Paul R. Helft, MD
David Eagle, MD
CancerNetwork discusses the recent Supreme Court ruling and its implications for oncology practices and cancer patients with two practicing oncologists—David Eagle, MD, a medical oncologist in North Carolina and president of the Community Oncology Alliance and Paul R. Helft, MD, director of the Fairbanks Center for Medical Ethics and associate professor at the Indiana University School of Medicine.
In a 5-to-4 vote announced June 28, the Supreme Court upheld the Affordable Care Act, keeping the majority of the law intact and establishing the individual mandate as constitutional. The mandate requires Americans to purchase health insurance or incur a fine, or as the high court interpreted it, a tax. The ruling, however, restricted the law's expansion of Medicaid and now individual states, if they choose, will have the option not to expand their Medicaid program without suffering any penalties.
CancerNetwork: Now that the law is upheld, what are the next steps? When can we expect the majority of the changes to occur? Dr. Helft, let’s begin with you.
Dr. Helft: Well, the interesting thing about it, is that whether the law was upheld by the Supreme Court or not, the changes that were in a sense spurred on by healthcare reform in general had already begun to affect the healthcare system. My organization, like most large healthcare systems around the country have already begun the process of adapting to a new healthcare payment environment in which everybody expects that payments and reimbursements will go down, and a new model of healthcare financing will be put into effect whereby we will be responsible for the healthcare of populations of patients rather than being paid for each individual patient care interaction.
So, I would like to argue that a lot of the momentum has already carried changes into place, and in fact most large healthcare systems felt these changes were inevitable. The actual changes according to the law, from my understanding, those will happen in the next couple of years.
CancerNetwork: So these changes you have described, is each individual state beginning to put these systems into place or is this happening on a more federal level?
Dr. Helft: My impression is that this is happening at a national level and that there are some variations state by state, especially with respect to how to manage each state’s Medicaid funding. But the idea of capitated payments, healthcare populations, accountable care organizations, quality incentives, and so forth—those are well underway—and I think that everyone is already in the process of preparing for those changes.
CancerNetwork: Dr. Eagle, do you have anything to add?
Dr. Eagle: To start with the initial question, I think the law is really implemented in phases. Some of the provisions have already been implemented such as allowing people to stay on their parents’ policy until the age of 26—2014 is a critical year. That year the individual mandate becomes enforced, Medicaid expansion was supposed to happen that year but that is no longer an issue since the Supreme Court has ruled on that. But a lot of administrative tasks have to be done too, which is getting the exchanges to operate, getting the rules and regulations for defining the private insurance market to function, and clarifying what are to be considered the essential health benefits. These are things we can expect to come.
I agree with Dr. Helft. I think people are preparing for a new payment model potentially, but in terms what exactly what that is going to be, I think it is still unclear. Massachusetts passed its healthcare law in 2006, which is similar to the Affordable Care Act, and is at its heart a coverage act. What it is struggling with right now is how to control the costs, and it is looking most strongly at fee-for-service and bundle payments, but that is taking 6 years just to get us started on that process. I think everybody expects something similar from the Affordable Care Act, but when and how that is going to happen is not clear. The Affordable Care Act lays groundwork for cost savings, bundle-payment initiatives, accountable care organizations, and the Independent Payment Advisory Board (IPAB), but exactly how that gets implemented remains to be seen.
Dr. Helft: Dr. Eagle’s comment is really a great summary. What I am hearing from people in administration in large healthcare systems is that what they are struggling with now is, in a sense, living with one foot in a small boat and one foot on the dock, because healthcare financing changes are happening yet we are still operating, basically, under the old model. So management is very complicated as we are trying to live in two worlds at the same time.
CancerNetwork: In terms of oncology, specifically, what are the fundamental provisions for cancer patients and those at high risk for cancer? Will these now reach more patients under the new act? Dr. Eagle, let’s start with you.
Dr. Eagle: The law does a lot of great things for cancer patients. Those eliminations of lifetime benefit caps, prevents from rescinding coverage, and probably one of the most important things it does for cancer patients is eliminates pre-existing conditions as a reason to deny someone healthcare. We are seeing many more former cancer patients move into survivorship mode of care, so this is really important for them. Lower prices for preventive services, such as cancer screening as well as routine cost of clinical trials. In the next few years, the amount of the doughnut hole will be phased down as well, and that is very important as some of the oncology agents we are using are very expensive, and we do have patients that have a very hard time accessing these therapies because they have a payment responsibility. So I think these are the things that can be very helpful for cancer patients.
CancerNetwork: Dr. Helft, do you have anything to add to that?
Dr. Helft: No, that was just a terrific summary of the specific provisions that affect cancer patients. To state the obvious, we believe that more patients in general will receive care and therefore will have access to primary care, basic screening, surveillance and so forth—I think that can’t be understated. It will have the effect it intended to.
CancerNetwork: In terms of oncology patients, do either of you see major changes in terms of the patient? We have already touched upon this, but is there anything specific in terms of screening or care?
Dr. Helft: This is already happening to a large degree, but the great focus on quality measures and outcomes will only be strengthened by the provisions of the act, by pay-for-performance measures, and I think that is already affecting oncology care and oncology practices.
Dr. Eagle: I agree with that. I am president of the Community Oncology Alliance, and we are taking a very active role in trying to define these quality measures. I think what you will probably see is the private sector taking the lead in trying to figure out the best way to operationalize quality metrics. We are working with payers in a multi-state initiative to do exactly what you propose, because I think there is an appetite within the Centers for Medicare and Medicaid Services (CMS) to look at pilot programs to figure out how to do that, but they will need the cooperation of the oncology community to do that.
Dr. Helft: Even prior to when it was popular to do so, we oncologists have always had a focus on end-of-life care because that is something that we deal with on a daily basis, but the way that the reform act changes the incentives I think will lead to an even greater focus on cost of care at the end of life. In particular, how cost effective many of the cancer therapies that we provide at the end of life in advanced cancer settings, how those are going to be utilized. So I think these will likely come under greater scrutiny.
