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The preservation of affordable cancer care
“We cannot solve our problems with the same level of thinking that created them.”
–Albert Einstein
In a 6-month period characterized by political chaos, there have been plenty of reasons to become disheartened by the apparent lack of dialogue, cooperation and thoughtfulness among our administration.
Particularly distressing are examples of ill-considered, politically motivated posturing, which have the potential to cost lives or profoundly affect vulnerable citizens. Attempts to deconstruct the Affordable Care Act without thoughtful consideration for those likely to suffer the most has been at one level depressing and at another, just ridiculous.
On Oct. 12, President Donald J. Trump signed an executive order that will bypass some provisions of the ACA and allow for an expansion of low-cost insurance policies with fewer benefits and fewer protections — characterized by some commentators as “junk insurance.”
Reaction has been swift and, among health care organizations, largely negative. But — as has so often been the case in recent months — the rush to score political “wins” seems to have taken the place of a constructive analysis of the potential impact of this change.
Strengths of the ACA
Having read some very early analyses of Trump’s executive order, I am left in confusion over what this will mean for the health insurance market and, more importantly, for our patients.
At one level, that’s OK — these are complex issues and it’s difficult to predict the unintended consequences — and we should wait to hear what the real experts think are the likely consequences. That’s the point; the stakes are very high for many of our patients and we need thoughtful input on the strengths and weaknesses of the ACA and how sensible changes might lead to improved health outcomes, more comprehensive coverage, and less stress and anxiety for those who need cancer care.
Signs of the positive impact of the ACA for those affected by cancer have been emerging for several years. At my own center, we have seen a steady increase in patient volumes over the last 4 to 5 years, accompanied by a steady reduction in the number of uninsured and underinsured patients. Although anecdotal, it’s hard to find another explanation for this trend.
On the other hand, we have also seen an increasing trend in denials from certain payers, suggesting that narrowing networks may be reducing access to our center and limiting patient choice.
There are emerging data to suggest that both of these impressions — positive and negative — are true.
Chino and colleagues conducted an important study — presented at the ASTRO Annual Meeting — that investigated insurance rates among patients undergoing radiation therapy for newly diagnosed cancer (see article here). Researchers compared insurance rates before and after Medicaid expansion and, using SEER data, also explored the effect in expansion and nonexpansion states.
The uninsured rates dropped in both expansion and nonexpansion states, although the effect was much larger in expansion states. Also of note, the uninsured levels fell regardless of race, with a higher impact in high-poverty areas — both compelling illustrations of how to address disparities in cancer care. Researchers did not observe the same effects on disparities in nonexpansion states.
Remarkably similar findings have been reported in a study published in September in Journal of Clinical Oncology (see article here). Jemal and colleagues used the National Cancer Data Base to investigate changes in insurance coverage and stage at diagnosis after the introduction of the ACA among adults aged 18 to 64 years. The researchers reported an increase in insurance coverage for newly presenting patients with cancer in all states examined, although the magnitude of the increase was higher in expansion states.
The largest increase occurred in low-income areas of expansion states — again showing that this legislation has at least begun to address some disparities in care. Also of note, the study showed small shifts toward earlier stage at diagnosis for some cancers, including colorectal, breast, pancreas and melanoma. Whether this represents increased access to screening is unclear but the trend is gratifying, if relatively small.
It’s reasonable to conclude that early data show a positive impact of the ACA on access to cancer care, especially for those typically underserved populations. Whether this will translate into better outcomes is not clear. Time will tell.
Negative consequences
Perhaps not surprisingly, the impact of the ACA on cancer care has not been universally positive.
Recent data suggests that one of the unintended consequences of the ACA — narrowing of networks — has adversely affected patient access to cancer providers. So, although many patients now buy insurance coverage from the exchanges, some of these policies are limiting the hospitals and physicians included in their plans.
Cancer care is, of course, very expensive, and as health care consolidation increases and institutions and systems gain more bargaining power, there is a tendency for insurers to exclude high-cost organizations. Evidence that this trend is more than anecdotal is now available from a couple studies.
One such report surveyed standalone cancer centers that are members of the Alliance of Dedicated Cancer Centers to determine whether they were being excluded from exchange insurance plans. Of the 11 member centers, four reported that they were excluded from exchange plans and, interestingly, four others reported that they had no way of tracking whether their patients’ plans were being purchased on the exchanges.
Consistent with this, a study from researchers at University of Pennsylvania — published in September in Journal of Clinical Oncology — showed insurers in areas that include an NCI-designated cancer center or National Comprehensive Cancer Network-member institution offered narrower provider networks on the exchange than those in areas without an NCI-designated cancer center.
In balance to this, the overall density of covered oncologists remained the same in all areas, suggesting that patients had approximately equal access to a cancer specialist in all the investigated regions, but that NCI-designated cancer centers appear to be specifically excluded in some.
What’s not clear from these data is whether the apparent exclusion of these centers has any effect on outcomes and whether patients are disadvantaged as a result of being excluded from large centers. Evidence is conflicting. Although there are some studies that suggest superior outcomes for patients with cancer treated in large academic centers, there are others that suggest equivalent quality in academic and community settings.
Additionally, some studies suggest that narrower networks will drive patients toward low-cost, high-quality systems, improving outcomes and value in cancer care. This, of course, is a complex issue that has many confounders, including patient volumes, case mix, demographics and so on.
Although we can’t conclude that narrow networks mean lower quality care, we can conclude that they limit patient choice and that increased transparency might help patients purchase the plan that best fits their needs. Information regarding in-network facilities and quality metrics for those facilities should be readily available to those who are making coverage choices.
‘Fixable’ problems
There is little doubt that the ACA has improved access to cancer care, may be improving outcomes and is certainly reducing some long-standing disparities.
There also is little doubt that the effects on patients with cancer have not been universally positive, with restricted access to large centers for insurance bought on the exchanges as one example of an unintended consequence.
But, the problems are fixable.
Although there are many critics of the ACA, I think most would acknowledge that it was developed with thoughtful input from a broad base of stakeholders, sought solutions to complex problems of access and costs of health care, placed new emphasis on value and has helped many vulnerable citizens get affordable cancer care. Fortunately, the bipartisan bill introduced by senators Lamar Alexander, R-Tenn., and Patty Murray, D-Wash. — conceived in the same spirit — has given many at least a temporary reprieve from this latest attack.
To echo Albert Einstein’s observations, solutions to the problems of the ACA will need even higher levels of thoughtfulness and cooperation — surely a better approach than the recent debacles, which have gotten us nowhere and haven’t helped any of our patients affected by cancer.
References:
Chino F, et al. Abstract LBA-15. Presented at: American Society for Radiation Oncology Annual Meeting; Sept. 24-26, 2017; San Diego.
Jemal A, et al. J Clin Oncol. 2017;doi:10.1200/JCO.2017.73.7817.
Schlelcher SM, et al. JAMA Oncol. 2016;doi:10.1001/jamaoncol.2015.6125.
Yasaitis L, et al. J Clin Oncol. 2017;doi:10.1200/JCO2017.73.2040.
For more information:
John Sweetenham, MD, FRCP, FACP, is HemOnc Today’s Chief Medical Editor for Hematology. He also is senior director of clinical affairs and executive medical director of Huntsman Cancer Institute at University of Utah. He can be reached at john.sweetenham@hci.utah.edu.
Disclosure: Sweetenham reports no relevant financial disclosures.