The Affordable Care Act: Where Are We Now?

In 2014, the Ides of March mean more to healthcare than ever, as the nation approaches its first open enrollment deadline under the Affordable Care Act (ACA). Most experts do not expect the early goal of enrolling 7 million previously uninsured Americans on state- and federally run exchanges will be achieved by the deadline of March 31, 2014. Still, the law brings with it many changes that while outside the view of the average healthcare consumer are fundamentally altering the way care is delivered. Cliff Goodman, PhD, opened Friday’s panel by asking how the early days of the ACA are affecting cancer care delivery, or if that can yet be determined.

“So where are we now?” Dr Goodman asked. “How in particular is it affecting cancer care?” He asked the 2 payer representatives on the panel, Michael Kolodziej, MD, of Aetna, and Lee H. Newcomer, MD, MHA, of UnitedHealthcare, to weigh in on where cancer care ranks in overall spending in their plans. Both said it takes up 11% percent of overall spending, and Dr Newcomer commented that for UnitedHealthcare, cancer care is a growing piece, as the insurer is a large Medicare provider and also administers many self-insured plans for businesses.

“Who is walking through the door now who is different?” Dr Goodman asked. W. Thomas Purcell, MD, MBA, of the University of Colorado Cancer Center, said the nature of “narrow network” exchange means that as an academic medical center, his facility has historically dealt with many indigent patients, and many of those issues remain. Some of the newly insured are showing up with the same diseases, but new issues: It turns out being underinsured can pose as big a challenge as being uninsured. Many lower-income Americans, having not been insured, are selecting the lowest-priced option available, the bronze plan, which come with huge out-of-pocket costs in cancer care, as Dr Kolodziej and Dr Newcomer discussed.

“One big issue we don’t have a handle on are the large co-pays,” on the bronze plans, Dr Purcell said. “We are thinking strategically how to help them pay for these large out-of-pocket expenses.”

While several panelists said it was a little early to have a full grasp of how the ACA would affect cancer care, there was some sense that older, sicker patients were among the first to enroll.

Liz Fowler, PhD, JD, who previously worked for both the White House and the Senate Finance Committee to help pass the ACA, said this mirrors an earlier experience with a bridge program launched in 2010. When people who have been denied care have opportunities to enroll, they move quickly to do so. Christian G. Downs, JD, MHA, agreed. “We’ve seen cancer patients who have jumped right in. We probably have addressed some of the pent up demand.”

Dr Goodman asked if there were any early data to report about enrollment selection. John C. Winkelmannn, MD, said at this stage, there are more anecdotes than data, including a study that suggests that the political divisions that have surrounded the ACA extend into personal decisions about paying a penalty for not having a policy: Dr Winkelmann reported results that said 15% of uninsured Democrats would rather pay a penalty than enroll, but that share rose to 45% of uninsured Republicans.

Dr Goodman noted that with the technical problems of the rollout and continuing uncertainty, it appears plans are going to have to set premiums for another year without having a complete year’s worth of data. “Actuaries don’t like uncertainty,” he said.

Both Dr Newcomer and Dr Kolodziej said payers would manage as best they could, with Dr Kolodziej adding, “Independent of what the law is, reform in oncology was going to happen.” And he remained positive about the expansion of healthcare generally, despite the bumps. Patients who have not had access to care are gaining access. Dr Fowler, the veteran of crafting the healthcare law, said there are ways to make course corrections for risk if the numbers of young enrollees far short of projections. Downs concurred that patience is necessary.

“We are going to need to give it more time. It’s not something that’s going to be done in one year,” he said.

Dr Newcomer echoed Dr Kolodziej’s sentiment about the positive aspects of seeing coverage reach more Americans. But the technical challenges with the websites and the policy reversals have created unanticipated costs his company has had to absorb. “It’s been an extremely expensive product to roll out,” he said. “That said, getting to the point of usability will be a good thing for consumers.”

When asked what he sees in his practice, Mohammed S. Ogaily, MD, said patients still have trouble signing up for coverage. “We are delighted to see the opportunity (for patients) to get coverage, but process is slow.”

Dr Purcell said the changing nature of narrow networks makes it imperative that providers increase the ability to discuss financial issues with cancer patients. Said Dr Goodman, “So, we need to expend more resources to provide patient navigation?”

He then turned the discussion to payment models, including accountable care organizations (ACOs) and oncology medical homes, asking whether the panelists were seeing the emergence of these models as called for under the law.

“There’s some concern about providers going too quickly into models they don’t totally understand,” said Downs. The new models will work in some places but not in others, he said. Said Dr Ogaily, “The oncology medical home -- it is logically difficult to do, and there is not a lot of enthusiasm.”

Even a large academic center like Colorado finds the going slow, Dr Purcell said. But he thinks there are “some savvy practitioners” who will find a way to make new models work. Dr Goodman then turned the economic discussion form the practice level to the big picture: How does the ACA affect the financial outlook?

Dr Newcomer, of UnitedHealthcare, said the ACA is shifting financial pressure off government programs and on to private plans, which is having spillover effects. The uncertainty doctors and hospitals feel, which is triggering the rounds of hospital purchases of practices, is having a direct effect on what his company pays for cancer drugs. “We are seeing a 10-fold increase in the price of a drug if a hospital acquires a practice.”

Asked Dr Goodman, given United Healthcare’s size, isn’t a discount possible? “We are huge nationally, but not locally. In any given town, I’m not the biggest provider.” To which Dr Goodman said to Dr Fowler, “Is this what you had in mind?”

He then asked if the consolidations would ultimately affect drug pricing to the point where it affected demand for the products Johnson & Johnson makes and sells. Dr Fowler said she doesn’t see effects on the research side, but there is concern about what happens when drugs go to market: How affordable will they be?

Dr Goodman then took the discussion to a more practical level: With an aging population projected to produce more cancer cases, who will provide the care? Winkelmann quoted sobering data from the American Society of Clinical Oncology and the American Society of Hematology: a survey nearly 5000 practitioners found that 20-25% of those in clinical practice planned to retire in the next 5 years.

Dr Purcell said oncology faces a rising tide of “increasing volume, decreasing ability to make a margin, and resistance to change.” As a physician leader, he said, “I’m trying to create a platform to say, ‘we cannot wait or the tsunami to come.’ “Healthcare reform will bring winners and losers, but it must be managed to ensure there are enough providers, including physician extenders such as physician assistants and specially trained nurses, to meet demand in cancer care.

Dr Kolodziej wondered if critical issues like survivorship were best handled directly by oncologists, or whether others would perform those tasks better at a lower cost. Ms Downs worried more about competing for a limited pool of these specialty workers.

Dr Goodman ended the session with a question: “What’s missing?”

Dr Winkelmann said healthcare reform needs more explicit information on protected patient reimbursement during clinical trials. Dr Newcomer wants to see more done with medical necessity clauses to reduce waste and give payers the ability to take cost into account.

Said Dr Purcell, “We have to become experts in improvement science.”