The Patient Protection and Affordable Care Act, known to most of us as the Healthcare Reform Bill, will change the face of healthcare for many generations to come. As the dust settles from the process of this bill becoming the law of the land, we start to explore what its provisions may mean for patients with cancer and for those who care for them. We do know that insurance reform of some kind was passed, but the actual details and ramifications will not be clearly understood or visible for some time to come.

The Good: More coverage for those who need it
The bill is reported to provide or subsidize healthcare coverage for 32 million currently uninsured people, or one tenth of the nation's population. Children with preexisting conditions, in cluding cancer, will no longer be able to be ex cluded from the coverage of their families' policies, starting in September 2010. Such protection for adults will not start until January 1, 2014. Current policies with such terms will have to rescind those restrictions by the effective dates. By January 1, 2014, workers are expected to have insurance options regardless of their employer offerings. Workers may purchase insurance on their own from new program offerings or seek insurance from their employer. Employers with fewer than 50 workers will not be required to offer insurance.

Employers with 50 to 200 workers may still choose whether or not to offer insurance, but at a cost. Employers with 50 workers or more that do not offer health insurance as a benefit but who have at least one full-time employee receiving a subsidy from the government to purchase health insurance on his or her own, will be subject to hefty fines—as much as $2000 for each full-time worker. Employers with 200 or more employees will be mandated to automatically enroll workers in their health insurance plan (but they may choose to opt out on their own).

The Bad: Benefits will be substantial, but at what cost?
The legislation includes guaranteed insurance coverage for persons participating in clinical trials; however, the details and impact of such coverage on premiums and benefit copays and coinsurance are not yet clear. One of the biggest challenges is that coverage is mandated, but the cost of such coverage to employers and individual patients is not yet addressed.

Insurers are mandated to cover preexisting conditions, but at some recognized cost. The delay for covering adults with preexisting conditions is intended to allow insurers to increase their rolls of insured patients.

Coverage does not equal access. The discussion about the national healthcare reform bill has focused largely on the increase in insurance options for individuals, but has not addressed how and by whom this new care will be provided. We have already seen that reimbursement reductions and public insurance plans that pay below the cost of care result in reduced access to care providers in oncology. We can probably expect that this situation will not be remedied, but exacerbated, under the national healthcare reform.

In the process of adding this coverage for millions, expectations are that the ranks of those served by Medicaid may swell by more than 10 million in the next 5 years. In many states, physician practices and hospitals are already scrambling to provide services to Medicaid patients in the face of significantly inadequate reimbursement rates. In Connecticut, for instance, local screening clinics for colon cancer had to close in early 2009 not because of a lack of people who needed screening, but because of a lack of resources for colonoscopy services; facilities could only afford to accept a limited number of patients with no reimbursement options. For oncology, the pressures posed by the healthcare reform bill are significant. Many physicians already care for as many Medicaid patients as they can afford in their offices, but have to refer increasing numbers of Medicaid patients to hospital services (which are now becoming more vocal about their funding and resource limitations for Medicaid services).

Recent state-based reforms in Connecticut and Massachusetts have demonstrated that increasing coverage does not equate to increased access. A new state-funded universal healthcare option in Connecticut failed when the option was unable to attract sufficient physicians and hospitals to enroll as providers, despite high numbers of en rolled potential patients. Expansion of the Medicaid program in Massachusetts has had a profound impact on local providers. According to Philip Betbeze, reporting for HealthLeaders Media, "Boston Medical Center, a hospital that was breaking even before [Massachusetts state health] reform, is now losing $12 million a month."¹

The healthcare reform bill provides subsidies for some of the expansion of Medicaid programs in states, but these subsidies begin to decrease starting in 2017, leaving states to fund the balances. Many states, including Virginia, Texas, and Mississippi, are already making public statements of concern about their ability to absorb the additional costs.

The Ugly: Medicare reimbursements are already a challenge for oncology
A recent study released by Avalere Health on the costs of cancer care and presented at the Community Oncology Alliance annual conference was summarized by that organization: "Medicare covers only 56% of the actual costs of administering chemotherapy and providing related infusion room services to seniors with cancer. The remaining costs—for essential services provided such as treatment planning, care coordination, and follow-up care planning—are not reimbursed by Medicare, causing many oncology practices to struggle to continue to provide under the Medicare program."²

A significant portion of the funding of the costs of the healthcare reform program is expected to be covered by savings (reductions), both from current Medicare payments and also from savings to be generated by reductions in the Medicare Advantage program. To the extent that "savings" mean direct reductions in payments to oncology practices for services incurred in treating Medicare patients (whether through Medicare directly or Medicare Advantage programs), practices and hospital centers may make difficult choices about their ability to continue to participate in the Medicare programs. Much is made of planned increases and support of primary care in the healthcare reform language, but most of those increases will come at the cost of reductions to specialists, like those who care for patients with cancer (new reductions, on top of existing 2010 Medicare cuts and reductions).

Medicare Advantage—or disadvantage? Medicare Advantage programs offer additional benefits outside of the basic Medicare options for patients, but those benefits also come with greater restrictions. Oncologists are seeing increasing numbers of patients who have converted to Medicare Advantage programs, only to find significantly higher copayments or formulary restrictions on the drugs needed to treat their cancer. Some oncologists in Florida have actually coined the phrase "grief counselors" to identify the additional challenges their financial counselors are finding when helping patients to navigate the consequences of insurance changes to Medicare Advantage plans. As healthcare reform reduces payments to Medicare Advantage insurers, it will be important to watch how those financial reductions translate into coverage changes for patients with cancer.

Healthcare reform—but probably not healthcare improvement for cancer care. Many aspects of the health insurance reform bill will make positive changes for Americans, but the implications for patients with cancer and those who care for them are fairly grim. When insurance expansion occurs in the sectors that already have proved to underreimburse complex cancer care, there will be an inevitable and direct effect on the resources available for cancer care. Neither physician practices nor hospitals, at this point, are anticipating any improvements in reimbursement under the healthcare reform bill and are definitely anticipating significant increases in volumes of patients covered under insurance plans they may not be able to continue to accept. If large numbers of physicians and hospitals are not able to provide services to these newly insured patients, how is that true health reform?

More details about the implementation and application of the healthcare reform bill are yet to be unveiled. This will definitely be an uphill struggle, no matter what your position is on the bill. For better or worse, nothing will ever be the same again.

References

1. Betbeze P. Hospital bailout? It could happen. March 26, 2010. HealthLeaders Media. www.healthleadersmedia.com/content/LED-248619/Hospital-Bailout-It-Could-Happen. Accessed March 31, 2010.
2. Community Oncology Alliance. Study: Medicare covers only half the cost of administering chemotherapy to seniors with cancer. February 4, 2010. PRNewswire. www.prnewswire.com/news-releases/study-medicare-covers-only-half-the-cost-of-administering-chemotherapy-to-seniors-with-cancer-83564552.html. Accessed March 31, 2010.