ASCO statement on Medicaid reform reflects physicians’ professional responsibilities

Issue: February 25, 2015

ByDerek Raghavan, MD, PhD, FACP, FRACP, FASCO

ASCO recently issued its policy statement on Medicaid reform, published Dec. 20 in Journal of Clinical Oncology.

A working party led by Blase N. Polite, MD, MPP, a HemOnc Today Editorial Board member, proposed the following key points:

No patient with cancer should lack health insurance that guarantees access to high-quality cancer care delivered by an oncologist;

Patients with cancer on Medicaid should receive care equivalent to that received by those with private insurance;

Medicaid payments should be sufficient to ensure high-quality care; and

Patients with cancer on Medicaid should not face insurance barriers to clinical trial participation.

Derek Raghavan

In addition to these important key precepts, ASCO suggested a series of policy recommendations.

They included: expansion of insurance coverage for those below the poverty level; parity for coverage for oral and IV medications for Medicaid patients; expansion of clinical trial coverage for Medicaid patients to be commensurate with national insured standards; improved coverage for screening, diagnostics and genetic testing; a refocusing of 340B drug pricing to benefit the key target population; elimination of variation between Medicare and Medicaid reimbursements; tying state flexibility to quality metrics; and allowing oncology practices to be designated as medical homes and provide support for related functions.

Professional responsibilities

The whole issue of our nation’s responsibility to under-insured and uninsured patients who face life-threatening diseases is a vexed one, with many socio-political ramifications.

My own view is that, as physicians, we should focus on our professional responsibilities, as an extension of the Hippocratic Oath. Physicians with strong political views are at liberty to exercise them through due political process, but it behooves our professional societies to reflect our professional responsibilities.

I believe that ASCO has done that with this declaration. It is consistent with its stance on other professional responsibilities, such as taking a leadership role in the Choosing Wisely campaign to reduce unnecessary expenditure without loss of quality in cancer care.

Similarly, ASCO has signaled the importance of creating strategies to overcome disparities in cancer care, improving access for patients with cancer to palliative care as part of a broader treatment algorithm, and overcoming conflicts of interest with the pharmaceutical industry.

Of course, ASCO has produced a panoply of position papers on various aspects of routine diagnosis and treatment of cancer.

Whether one takes the humanist/medical professional stance or thinks in simple pragmatic, fiscal terms, it makes the most sense for our nation to support early diagnosis and management for indigent, uninsured and under-insured populations. There is clear evidence that it is cheaper to manage cancer with curative intent!

Equivalent care

We should focus on an important point in the ASCO position paper — specifically that Medicaid patients should be entitled to care that is equivalent to that of insured patients. Once again, it is the “right” thing to do, but it also makes the most financial sense, as cure is more cost-effective than palliation.

Some years ago, Siran M. Koroukian, PhD, and I studied more than 12,000 Medicaid patients and compared outcomes to those of patients with private insurance. We focused on eight curable malignancies, and we documented that patients on Medicaid had statistically inferior outcomes compared with those who had private insurance.

To our surprise, patients newly recruited to Medicaid as part of their cancer diagnosis had inferior outcomes to those who had been covered by Medicaid for long periods. We were not able to investigate the basis for this, but we hypothesized that it might reflect problems associated with the time it takes for patients to understand and successfully negotiate government health insurance coverage.

We live in one of the wealthiest nations, notwithstanding the potential of some of our current social and political imperatives to change that.

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In the domain of cancer care, it just makes sense to rationalize our approaches — to educate the public to have realistic expectations, to reduce the level of hype and promissory notes while replacing the rhetoric with evidence-based practice, to accept that some patients will succumb to their disease and that it may be much more humane and more cost-effective to introduce palliative and hospice care instead of blindly continuing the pathway of active cytotoxic treatment.

That said, it also makes sense to give the indigent and under-insured the opportunity of the same outcomes as Caucasian college-educated males. Cure is cheaper than palliation at so many levels, and it is time that we predicated health delivery on that simple construct!

References:

American Society of Clinical Oncology. J Clin Oncol. 2013;31:2037-2042.

Goss E. J Clin Oncol. 2009;27:2881-2885.

Koroukian SM. Cancer. 2012;118:4271-4279.

Moy B. J Clin Oncol. 2011;29:3816-3824.

Partridge AH. J Clin Oncol. 2014;32:3330-3336.

Polite BN. J Clin Oncol. 2014;32:4162-4167.

Schnipper LE. J Clin Oncol. 2012;30:1715-1724.

Schnipper LE. J Clin Oncol. 2013;31:4362-4370.

For more information:

Derek Raghavan, MD, PhD, FACP, FRACP, FASCO, is HemOnc Today’s Chief Medical Editor, Oncology. He also is president of Levine Cancer Institute at Carolinas HealthCare System. He can be reached at derek.raghavan@carolinashealthcare.org.

Disclosure: Raghavan reports no relevant financial disclosures.