The Impact of the Affordable Care Act on Cancer Care
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Transcript of The Impact of the Affordable Care Act on Cancer Care
Overview and Key Considerations
The Impact of the Affordable Care Act on Cancer Care and
Prevention
Katie Horton, RN, MPH, JD
Cancer: Compelling Case for Health Reform
• No more compelling case for health reform than cancer treatment and survivorship– 12 million survivors in US– 1.6 million new cases of cancer diagnosed
annually– Cancer survivors living longer
• Need comprehensive follow-up care over longer period of time
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Cancer: Compelling Case for Health Reform
• Impact of cancer and its treatment difficult even for those with reasonable financial means and strong support network– 11 percent of all cancer patients under 65
are uninsured• Higher for members of racial and ethnic
minority groups– 1 in 4 struggle with under-insurance
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Cost of Cancer• Cancer costs climbing• Now estimated to cost $264 billion annually
including direct medical expenditures and lost productivity
• 33% of cancer patients have health care costs that are equal to or greater than 10% of annual family income
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Pre-ACA Health Care System
• ~ 50 million without coverage• Unstable insurance markets with
discrimination against persons needing health care
• Fragmented--care coordination often poor• Weak individual market• Challenges intensify for uneducated, poor,
uninsured and underinsured
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ACA Goals
• Establish near-universal coverage• Improve fairness, quality and affordability of
health insurance coverage• Improve health care value and efficiency• Strengthen primary care access• Make strategic investments in public’s health
(preventive care and community investments)• Law not “perfect”—corrections needed
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Where Are We Headed?Estimated Health Insurance Coverage in 2019
SOURCE: Kaiser Family Foundation analysis of Congressional Budget Office estimates, March 20, 2010
Total Nonelderly Population = 282 million
ACA Coverage Expansions
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By 2022, ACA Coverage Expansions will Reduce Uninsured by Approximately 32 Million
Medicaid Approximately 10-16 million additional individuals enrolled in Medicaid
Health Insurance Exchanges
Coverage for approximately 20-23 million individuals
Employer Coverage
Between 4-6 million fewer people estimated to have coverage through an employer
Uninsured Approximately 30 million will remain uninsured(8% of US population)
Source: Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision. Congressional Budget Office. July 2012. http://www.cbo.gov/sites/default/files/cbofiles/attachments/43472-07-24-2012-CoverageEstimates.pdf
Promoting Health Coverage
Medicaid Coverage
(up to 133% FPL)
Employer-Sponsored Coverage
Exchanges(subsidies 133-400%
FPL)
IndividualMandate
Health Insurance Market Reforms
Universal Coverage
Return to KaiserEDU Tutorials
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How Do We Get There?
• Individual responsibility• Employer responsibility• Insurance market reforms (individual and group
markets)• Exchanges• Medicaid
• Restructuring and expansion• Medicare
• Payment reform• Delivery system reform
• Tax reforms
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Shared Responsibility
• 2014: All individuals required to obtain coverage or pay a penalty unless they have a religious objection or face financial hardship
• 2014: Large employers (50+ employees) will be subject to fees if they do not offer affordable coverage and any employees receive subsidized coverage through a health insurance exchange
Market Reforms
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Key Insurance Market Reforms (2010)
• Health plans may not place lifetime limits on coverage, rescind coverage, or deny coverage to children with pre-existing conditions
• Dependent coverage to age 26
• Preventive services with no cost sharing (USPSTF, ACIP recommended immunizations, additional HRSA-recommended preventive care for women and children)
• Pricing transparency and medical loss ratio/rebates
• “Patient protections”
• Non network ED coverage
• Direct access to pediatric and ob-gyn services
• Internal and external appeals
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Key Insurance Market Reforms (2014)
• Adults with pre-existing conditions cannot be denied coverage or pay more based on their health status
• Rating limitations– Premium rates for qualified health benefits
plan can vary by only a few factors and with limitations
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“Grandfathered” Health Plans• Plans in place before passage of ACA, with no
significant changes to benefits/coverage or premiums/cost-sharing since that time
• Grandfathered plans exempt from certain market reforms (i.e. annual limits, preventive services, appeals, emergency services etc.)
• Number of plans meeting definition of “grandfathered” decreasing over time:
– 48% of covered workers enrolled in grandfathered plans in 2012, down from 56% in 2011
Source: Kaiser Employer Health Benefits Survey. 2012.
New Coverage Expansions
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Health Insurance Exchanges
• New market for individuals and small businesses/groups
• One stop shopping for insurance products that meet certain federal and state standards– Called “qualified health plans”
• Exchanges expected to assure quality of coverage, provide information and enrollment assistance, coordinate with Medicaid and calculate subsidy eligibility, among others
Health Insurance Exchanges
• Subsidies only in Exchanges• State administered/federal default• Critical issues for states include:
– Whether to operate at all– Adverse selection– Active purchaser vs. passive “shopping center”– Geographic size (state vs. regional)– Medicaid relationship– Governance
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Subsidies• Premium subsidies available for
individuals and families with incomes between 100% and 400% of the poverty level; subsidies on a sliding scale
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2012 Federal Poverty Level
Individual Family of Four
100% FPL: $11,170 $23,050
400% FPL: $43,320 $88,200
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Subsidies-Timeline
• 2010: Tax credits for small employers
• 2010: Temporary high risk pools (pre-existing condition coverage) for people with pre-existing conditions
• 2014: Premium and cost-sharing subsidies for low and moderate income individuals and families; premium assistance for small employers purchasing Exchange products
Essential Health Benefit Coverage
• All new qualified health plans (including health plans offered through the Exchange) must include the essential health benefit package– Will reflect standard employer-sponsored plan
—”typical employer coverage”• Coverage under the Medicaid Expansion will
also include the essential health benefit package
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Essential Health Benefit Coverage• 10 broad categories of coverage in ACA
– Ambulatory patient services– Emergency services– Hospitalization– Maternity & newborn care– Mental health and substance use disorder services including
behavioral health treatment– Prescription drugs– Rehabilitative and habilitative services and devices– Laboratory services– Prevention and wellness services and chronic disease
management– Pediatric services including oral and vision care
• Rules out for comment in December
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Source: Kaiser Family Foundation, December 10, 2012
• 18 States Declared State-based Exchange
• 6 States Planning for Partnership Exchange
• 6 States Undecided• 21 States Default to
Federal Exchange
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Medicaid
• Fundamentally restructures Medicaid to allow states to cover all non-elderly, non-disabled citizens and legal US residents with family incomes below 133% (approx. $30,000 for family of four)– Primarily assists adults who have never had
children or whose children are grown
• Benchmark coverage and preventive care for newly eligible persons– Benchmark coverage will resemble essential
benefits package (approximation of employer coverage)
Prevention
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Coverage of Preventive Services
• ACA requires new health plans to cover without cost-sharing:
(1) Evidence-based items or services rated A or B by the USPSTF
(2) ACIP-recommended immunizations
(3) Preventive care for infants, children, and adolescents recommended by HRSA, and additional preventive care and screenings for women recommended by HRSA
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Prevention in Medicare
• Sixty percent of cancer diagnoses occur among individuals age 65 or older
• Provides for annual wellness visit, health risk assessment and personal prevention plan
• Requires Medicare-covered services that are classified as A or B by USPSTF to be covered without cost-sharing (doesn't require Medicare to cover them all); also applies to colorectal cancer screening
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Prevention in Traditional Medicaid
• ACA expands the scope of “optional” preventive services under “traditional” Medicaid to include all USPSTF-, ACIP- and HRSA-recommended clinical preventive services required under Section 2713 (Effective January 1, 2013)– Additional 1% increase in FMAP percentage
for any recommended preventive service provided, so long as the state does not impose any beneficiary cost-sharing
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Public Health
• Sustained funding for prevention and public health (Prevention and Public Health Fund)
- $15 billion over 10 years
- Mandatory appropriation
- To invest in community prevention, core capacity and building the evidence
• National Prevention and Health Promotion Strategy (and Council)
Prevention and Public Health Fund
• $15 billion mandatory appropriation over 10 years ($2 billion a year beginning in FY 2015)
• Can fund any program authorized by the Public Health Service Act
• So far, the PPHF has been used to strengthen the health and public health workforce; expand existing Public Health Service Act programs; bolster public health infrastructure through grants to states; and create and maintain new health promotion programs
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Community Transformation Grants• New grant program for community prevention: supports
communities in creating comprehensive change in the factors that affect people’s health across multiple environments.
• 2011: $103 million to 61 state and local government agencies and nonprofit organizations in 36 states to improve the health of their communities– Focus is on obesity, nutrition, tobacco; but some may include
increasing access to broader set of clinical services
• 2012: $70 million awarded to 40 small communities (fewer than 500,000 residents) to implement broad, sustainable strategies that will reduce health disparities and expand clinical and community preventive services
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Other Payment, Coverage and Delivery System Reforms
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Clinical Trials• Beginning 2014, routine medical costs must
be covered for all individuals who are participating in clinical trials (excluding traditional Medicaid)– Routine costs include all costs typically
covered for an individual not enrolled in clinical trial
– Costs for specific investigational item or service excluded
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Clinical Trials
• Insurers are prohibited from dropping or limiting coverage for participants in cancer clinical trials
• Plan may compel patient to use a network participating provider for the trial– Trial costs must be covered even if
approved clinical trial is conducted outside the state of the patient’s residence
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Closes Medicare Doughnut Hole
• Provides immediate $250 rebate to seniors who hit the prescription drug coverage gap
• Coverage gap will be closed completely by 2020
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Payment and Delivery Reforms• Accountable Care Organizations (effective 1/1/12):
– New model of care in which groups of primary care providers work together to coordinate patient care and reduce costs while offering high-quality care to Medicare beneficiaries
• Medicaid Health Homes (effective 1/1/12):
– ACA gives states the option to create “health home” models in which a designated provider or team of health professionals will provide coordinated care to individuals with one or more chronic conditions; Oregon is including cancer
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Delivery System and Quality
• Multi-payer, national quality improvement strategy
• Continued movement toward provider reimbursement tied to quality outcomes
• Demonstration projects on medical homes, gain sharing, medical liability, bundling, geographic payment variation, accountable care organizations
Delivery System and Quality
• Patient-Centered Outcomes Research Institute
– Assists patient, clinicians and others with making informed decisions by identifying and analyzing national research priorities
– FY 2012, direct appropriations of $150 million
– FY 2013-2019, funding source sustained (trust fund plus per capita charges per enrollee from insurance plans)
– Restricts use of CER by public or private payers in coverage or reimbursement decisions
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Controlling Costs
• New Independent Payment Advisory board with expanded powers (IPAB)
• $15 million funded for FY2012
• In 2015, will make recommendations about Medicare spending if targets not met
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Controlling Costs
• Center for Medicare and Medicaid Innovation
• $5 million dollars for the design and implementation of models in FY 2010
• $10 billion funding for FY2011 through FY2019
• Numerous initiatives underway: bundled payments, value-based purchasing
• Medicare payments for diagnostic imaging reduced
Ten-Year Medicare Savings = $533.1 Billion
Source: Kaiser Family Foundation analysis of Congressional Budget Office (CBO) cost estimates as provided on March 20, 2010.Notes: *Savings include interactions with Medicare Advantage and TRICARE; spending includes implementation of Medicare changes, Part D interactions with Medicare Advantage
provisions, Part B interactions with Part D provisions, and Medicaid interactions with Medicare Part D provisions.
Sources of Savings
•Provider payments, including DSH and home health - $219 billion
•Medicare Advantage – $136 billion
•Income-related premiums – $36 billion
•New Independent Payment Advisory Panel – $16 billion
•Delivery system reforms and hospital readmissions – $12 billion
Health Reform: Medicare Savings
Medicare Advantage
Payment Reforms25%
Annual Provider Payment Updates
29%
Part D Enrollment/ Consumer
Protections 1%
Delivery System
Pilots 1%
Reducing Hospital Readmissions 1%
Fraud, Waste, Abuse 1%
Part D Premiums 2%
Part B Premiums 5%Independent
Payment Advisory Board
3%
Disproportionate Share Hospital (DSH) Payments
4%
Annual Provider Payment Updates 29%
Home Health Payments 7%
Medicare Advantage Payment Reforms 25%
Exhibit 8
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Other Provisions
• Understanding Health Disparities– All Federally-funded health programs must
collect and report data on race, ethnicity, sex, primary language and disability status• Oct. 2011: ASPE issued implementation
guidance
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Other Provisions
• National Center for Health Workforce Analysis– HRSA
• $7.5 million through FY2014, Additional $4.5 million per year through FY2014
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Other Provisions
• Hospital Readmissions Reduction Program– Reduces Medicare payment to hospitals
with high readmissions for certain conditions
– Final rule for FY 2012 released on Aug. 18, 2011
• Quality reporting and pay for performance pilots for PPS exempt cancer hospitals
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Health Reform Implementation TimelineFigure 16
Return to KaiserEDU Tutorials
Paying for Health Reform
• ACA estimated to cost $938 billion over a decade – Because of higher taxes and fees and
billions of dollars in Medicare payment cuts to providers, the package will narrow the federal budget deficit by $143 billion over 10 years, according to the Congressional Budget Office
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Paying for Health Reform
• Starting in 2013, individuals with earnings over $200,000 and married couples earning more than $250,000 will pay a Medicare payroll tax of 2.35 percent (up from 1.45 percent)
• High income taxpayers will pay a 3.8 percent tax on unearned income (dividends)
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Paying for Health Reform
• Starting in 2018, imposes a 40 percent excise tax on the portion of most employer-sponsored health coverage (excluding dental and vision) that exceeds $10,200 a year for individuals and $27,500 for families
• Law raise the threshold for deducting unreimbursed medical expenses from 7.5 percent of adjusted gross income to 10 percent
• Limits to FSA applied
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Future Directions
• Continued consolidation likely to result from delivery system reforms and other provisions
• Current model of oncology care will change– Further focus on quality benchmarks,
outcomes, efficiency and reduction of duplicative services
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Future Direction• Increased bundling of payments• Disease pathways, assessments of episodes
of care and clinical decision supports applied more by payers
• Greater focus on shared decision-making with patient, value in care and use of evidence based care
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Outstanding Considerations
• Over 25 million likely to remain uninsured• What impact of fiscal cliff, sequestration and
debt discussions on ACA and other discretionary funding?
• Will states expand Medicaid (optional post supreme court ruling)?
• What impact to cancer care of $500 billion Medicare cuts in ACA?
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Outstanding Considerations
• What impact on employer-based insurance?• Will essential health benefits package provide
for adequate cancer prevention, treatment and other services?
• End of life care not addressed in ACA• ACA doesn’t require insurers to cover follow
up diagnostic exams/biopsies if abnormality found during preventive service
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Outstanding Considerations
• Who will care for the newly covered individuals?
• Workforce challenges remain
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Resources
• HHS Key provisions by date:
http://www.healthcare.gov/law/timeline/full.html• Kaiser Family Foundation Implementation
Timeline
http://healthreform.kff.org/timeline.aspx
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