Dierdre Fuller, Oncology Roundtable
Open enrollment in health insurance exchanges starts in less than a month. We’ve spoken to several members to learn how they are preparing for coverage expansion.
Read on to learn how the Lacks Cancer Center at Mercy Health, Saint Mary's Hospital, is staying ahead of the game.
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Following months of uncertainty about the fate of the Affordable Care Act (ACA), yesterday the Supreme Court upheld the health care reform law, including the individual mandate that requires most Americans to purchase health insurance.
However, the Court did elect to limit the federal government’s ability to withhold funds from states for failing to expand Medicaid. It ruled that existing federal Medicaid funds cannot be taken away. As a result, expanding Medicaid eligibility for citizens up to 133% of the federal poverty level is now effectively optional for states. This will likely limit the degree to which the law expands access to health insurance as many states have already indicated they will opt out of the expansion.
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After the health reform legislation was officially signed into law, I put together a quick post outlining the key provisions and the implications for oncology-providers. In that post I didn't weigh in on "so what does this mean?" - that's what I hope to do with this post. We've been tracking what's going on with reform and it's potential implications for cancer providers for some time. When we put together that content it was hard to know for sure how reform would impact oncology because so much was uncertain - we weren't even sure the bill would pass. Now it's possible for us to weigh in with a bit more certainty, but we still must acknowledge that a lot remains up in the air - many of the bill's provisions are backloaded to five years from now (if not longer) and a lot can change. With this post I hope to do two things - one, discuss the big picture of health reform and how it relates to cancer care, two, provide a quick take on implications of key provisions for cancer providers. I won't go into depth on every cancer-related line item, as my previous post covered that, and many are self explanatory. Ultimately, this is too much to cover in one blog post, but I'll begin conversation and we'll keep you updated on what we learn.
Coverage Expansion - A Good Thing for Cancer Providers
The expansion of coverage to the uninsured is good news for cancer providers, particularly for managing bad debt. While the expansion is done largely on the back of Medicaid, low payment is better than no payment. Other good news includes the prohibition of denying patients coverage due to pre-existing conditions, and elimination of benefit caps. Many cancer patients have struggled for years to get their care needs met - this bill goes a long way towards addressing that.
Key Themes of Delivery Reform
First, let's acknowledge that there are not a lot of oncology specific provisions in the reform bill. That said, broadly speaking, when it comes to delivery reform (as opposed to coverage expansion) the key themes of the bill are all things we've been talking about in cancer care for a long time:
- Improve care coordination
- Provide care in accordance with national guidelines
- Ensure all who need care can access it
- Expand access to end of life care and advanced care planning
- Increase use of Health IT
- Increase team based care and provider accountability
Bending the Cost Curve Through Improved Accountability
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On Friday we reported that the new healthcare law had expanded the 340B program to provide discounts on inpatient drugs. A question from a member prompted us to look again at the text of the legislation. We discovered that while the Senate bill did expand discounts to inpatient drugs, the Reconciliation bill repealed that measure. You can see a section by section analysis of the Reconciliation bill here.
Note that the Senate bill's expansion of the program to allow participation by certain children's hospitals, cancer hospitals, CAHs and rural referral centers still stands.
While most of the provisions in the recently passed health reform legislation are broad, focused on expanding coverage and reforming the delivery system overall, there are a few items specific to cancer providers I wanted to bring to your attention - items covered include clinical trials, qualty reporting for cancer hospitals and payment for biologics. I've bulleted them out for you below. If you'd like to learn more about them, you can read the legislation in it's entirety here (the link at the top of the page has the full bill - you'll also need the reconiliation provisions, which can be found here).
With this post I am simply listing out the provisions of interest. In subsequent posts we will provide additional analysis, particularly for those provisions where the implications are not evidence (such as the advent of biosimilar biologics and the new cancer project proposed under the Center for Medicare and Medicaid Innovation - both referenced below).
Coverage For Individuals Particpating in Clinical Trials
- In Section 1013, they prohibit insurers from dropping coverage because an individual chooses to participate in a clinical trial
- Prohibit insurers from denying coverage for routine care that they would otherwise provide just because an individual is enrolled in a clinical trial
- This applies to all trials that treat cancer or other life-threatening diseases
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