By Sydney Abbott, JD, Manager, Provider Economics & Public Policy, ACCC
The bipartisan Congressional Budget Conference Committee came to an agreement on the federal budget on Tuesday, which is now scheduled to be voted on by all of Congress on Friday. The budget deal is not sweeping change, but it takes small steps towards compromise—something that has been eluding a gridlocked Congress for years. Some of the small steps include no new tax increases and a reconfiguration of part of the sequester that had significant impacts on domestic spending in 2013.
The good news: The deal funds the federal government through 2015. The bad news: Although it eliminates some of the cuts imposed by sequestration, the deal not only keeps the sequester in place for Medicare, it also proposes to extend the sequester for another two years. By doing this, the Conference Committee’s compromise budget would create about $28 billion in savings through 2023—just by keeping the 2% across-the-board Medicare sequester in place for two years longer than originally called for in the Budget Control Act of 2011. (The Budget Control Act was the law that enabled sequestration to be enacted when the bipartisan, bicameral debt “super committee” failed to agree on $1.2 trillion in savings.)
The possibility that the sequester may be prolonged is troubling news for community oncology, especially coming on the heels of newly released ACCC survey data showing the impact of sequestration on providers and their patients. This most recent survey of ACCC members shows that the sequester is affecting more cancer programs than initially thought, and is having an impact on all cancer patients.
But the struggle over the sequester is far from over. First, the budget must pass the House and Senate. And even if it does, ACCC is still continuing to fight for legislation that would exempt cancer drugs specifically from the sequester, HR 1416. This bill has gained much bipartisan support, and we will continue to work for the passage of this legislation.
All of this serves to underscore the importance of continued communication with members of Congress about how the sequester is affecting your cancer program and your patients. This is a developing issue so stay tuned for more information about the budget and other deals that are in the works for an upcoming congressional vote, like the SGR.
by Matt Farber, Director, Provider Economics and Public Policy, ACCC
The role of technology in healthcare—and the many headaches that can accompany the adoption of new technology—has been put under the microscope in recent weeks. Missteps and glitches during the roll-out of the new health insurance marketplaces’ online enrollment have some questioning broadly whether technologies designed to improve the healthcare system can actually achieve their goal.
The process may not be easy, but evidence shows that appropriate technology can improve efficiency and coordination in healthcare, whether it’s online insurance enrollment, electronic health records, or—as explored in a new white paper from ACCC—health information exchanges.
ACCC’s new white paper, “Cancer Care in the Age of Electronic Health Information Exchange,” discusses the potential impact of health information exchange on cancer care and the hurdles to adoption. It is the second white paper to come out of ACCC’s Institute for the Future of Oncology, with the first released in October.
Health information exchange describes two related concepts: the electronic sharing of health-related information among organizations, and the entities that provide services to facilitate this electronic information sharing.
“Cancer Care in the Age of Electronic Health Information Exchange” explores the current state of health information exchange adoption, the importance of HIE, and also the potential for improved quality of care and reduced costs that an HIE can provide.
The push for adoption and integration of electronic health records (EHRs) has been a first step toward realizing the capabilities and benefits of electronic health information exchange. Adoption of and engagement in HIEs, the organizations that enable electronic sharing of patient data across providers and healthcare organizations, is the next step—and in many areas of the country, this step is still out of reach.
The white paper reflects discussion and perspectives from participants in the Institute’s inaugural forum, which was held in late June 2013. Here is a snapshot of the white paper’s findings:
- HIE adoption is uneven.
- There is a lack of awareness around HIEs.
- HIE initiatives must focus on information standardization.
- HIEs can help benchmark interventions within patient populations.
- Providers must have input on the information released via patient portals.
The potential of HIEs to improve benchmarking, efficiency, and ultimately quality of care in oncology was universally agreed by participants at the Institute. However, the consensus was that many hurdles remain before the potential becomes reality.
ACCC’s Institute for the Future of Oncology addresses key topics impacting oncology now and in the future. If you would like to get involved in upcoming forums of the Institute for the Future of Oncology, please contact Matt Farber at firstname.lastname@example.org.
By Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC
The federal government is back in business. On Wednesday evening of this week, the House and Senate passed a continuing resolution to fund the government through January 15, 2014, and raise the debt ceiling until February 7, 2014. So, the shutdown is over, but Congress essentially just kicked the can down the road—and not very far.
The good news? Funding for new clinical trials will be restored and the Centers for Medicare & Medicaid Services (CMS) will get back to writing the final rules for the 2014 Physician Fee Schedule (PFS) and Hospital Outpatient Prospective Payment System (OPPS). However, funding has been restored at post-sequestration levels, and the conversation continues about how this is impacting community cancer care. It’s also possible that the three-week government shutdown may cause a delay in CMS’s release of the final rules, which would mean less time for implementation of the new policies that go into effect on January 1, 2014.
What about hopes for SGR reform? With less than two months remaining in 2013 and Congress focused on little besides the budget and debt ceiling, hopes of passing reform this year are slipping away. This means we are looking at the probability of yet another last-minute “Doc Fix” to stave off the anticipated 25% cut to Medicare reimbursement created by the flawed SGR formula. This year, many in the advocacy community believed that the timing was ripe to finally do away with the SGR given the CBO’s low budget score and the fact that the House Energy & Commerce, Ways and Means, and Senate Finance Committees all drafted legislation. While there is an outside chance that SGR repeal could get looped into a larger budget deal, the current SGR repeal legislation is expected to cost $175 billion over 10 years and no offsets have yet been identified, so Congress will likely wait another day to take on that fight.
Déjà vu all over again? Come January we may see ourselves in the same situation from which we just emerged: partisanship and political gridlock threatening another shutdown. While the conversation on the Hill continues to be budget-driven, ACCC will continue to work with members of Congress to preserve provider reimbursement and access to care for patients. We will be participating in a Hill day next week with other members of the cancer advocacy community to request adequate funding for cancer research and other programs. Please stay tuned for updates.
By Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC
As you undoubtedly already know, we are in the third week of the government shutdown due to Congress’s inability to agree on a continuing resolution (CR) to fund discretionary spending. This means that discretionary spending has stopped, but mandatory spending for things that protect life, property, and entitlements continues on an automatic basis. What does this mean for cancer care providers?
1) At least in the short term, Medicare reimbursement will continue as usual (at post-sequestration levels).
2) The National Institutes of Health (NIH) will continue with clinical trials currently in progress, but will not begin any new trials until funding is restored.
3) The U.S. Food and Drug Administration (FDA) has furloughed a number of workers, which could slow the approval of new drugs if there is a prolonged shutdown.
The federal government is expected to hit the debt ceiling—the point at which the country cannot borrow new money—on October 17. Speaker Boehner has committed to not reaching the debt limit, even though the House and Senate are still unable to reach a deal that pleases everyone. Some members of the House Tea Party remain committed to only voting in favor of funding if implementation of the Affordable Care Act (ACA) is delayed. Current negotiations would fund the government through the middle of January, and raise the debt ceiling through the middle of February; barely enough time to catch a breath before the threat of shutdown is upon us again.
While Congress continues to negotiate the government’s budget and borrowing limit, other important legislation waits on the sidelines. The status of the sequester remains of specific interest to the oncology community. ACCC continues to support HR 1416, legislation that would exempt cancer drugs from the Medicare sequester. This legislation is becoming increasingly important not only because of its 108 bipartisan cosponsors, but because of the current political climate. Congress is in a deficit-reduction mindset. While they understand that the sequester is a blunt budgetary tool which impacts oncology providers in a particularly unfair manner, they are reluctant to eliminate the sequester because it is saving the government money. In other words, Congress views the sequester as the new normal and proved this by only introducing budget bills with post-sequestration spending levels.
Cancer care providers, please complete ACCC’s follow-up sequester impact survey so we can show how the two percent Medicare sequester is impacting you and your ability to care for patients. As always, ACCC will keep members up to date on this important matter.
by Amanda Patton, Manager, ACCC Communications
An expert panel—representing the payer, private practice, hospital-based cancer program, academic medicine, and the patient advocacy perspectives—discussed Innovation: Value, Quality, and Technology on Thursday, Oct. 3, at the ACCC National Oncology Conference in Boston, Mass. Echoing keynote speaker Whitney Johnson’s theme of disruption and innovation, panelists identified major disruptors to the status quo and multiple constraints challenging oncology care delivery.
Disruption is not limited to oncology. “It’s our entire medical system,” said panelist Roy Beveridge, MD, Senior Vice President and Chief Medical Officer, Humana, Inc. “It’s a brave new world and the next five years will be very exciting.”
Specific disruptions cited by panelists included changing relationships between primary care providers and specialists, hospitals and payers, and providers and payers. Added to this are overarching uncertainties about reimbursement, how (or if) the sustainable growth rate (SGR) fix will be achieved, and the impact of the newly created health insurance exchanges on oncology providers and the patients they serve.
Panelist Al Benson, MD, FACP, Professor of Medicine, Northwestern University’s Feinberg School of Medicine, sees constraints ahead in three main areas: patients having to deal with fragmentation of services, workforces shortages, and technology-driven challenges. “Technology is really overwhelming, and I wonder how a general medical oncologist is going to adjust to these massive changes. With more diagnostic tools, it’s not only how we’re going to afford them, but how to integrate the technology into healthcare structures so patients can move through the system more efficiently.”
Nancy Davenport-Ennis, CEO of the Patient Advocate Foundation (PAF), shared the patient advocate perspective. “Disruption for patients begins the day their name and cancer is said in the same sentence,” she said. For her organization, a major challenge has been the accelerated growth of uninsured patients over the past year. Thirty-eight percent of patients served by PAF in 2012 were uninsured, she said.
Panelists also discussed the evolving provider-payer relationship. Quality care does not have to be expensive care, panelists agreed.
Partnering with a payer, a provider can demonstrate quality metrics and use of pathways, commented panelist Kim Woofter, RN, OCN, Chief Operating Officer, Michiana Hematology Oncology. Through participation in Health Information Exchanges (HIEs) practices can integrate with other providers to streamline patient enrollment in clinical trials, as well as partner with hospitals to reduce hospital re-admission.
Panel moderator Cliff Goodman, PhD, the Lewin Group, asked panelists to share innovations they’ve developed in response to these challenges.
Given the fragmentation of the current delivery system, Norma Ferdinand, Senior Vice President, Lancaster General Health, said her heath system is responding by supporting a culture of innovation and learning. The health system recently opened a new cancer center to centralize services with a patient-centered, rather than physician-centered design. The system is also participating an accountable care organization, among other initiatives.
Kim Woofter said her practice has taken ownership of care coordination in the period immediately after hospital discharge. A large triage staff handles the 48 hours post-discharge, following up with patients to ensure they have needed medications and resources. “We can affect return admission by interacting with that patient within the first 48 hours after discharge,” she said. Participation in a Health Information Exchange (HIE) is also facilitating the practice’s ability to demonstrate quality to payers.
Davenport-Ennis described a range of services PAF is providing including 24/7 patient portals, online easy-to-use tools for consumers, and more.
A key takeawy from the discussion: Innovation at the nexus of value, quality, and technology requires a patient-centered, data-driven, learning organization.
The new state-based Health Insurance Marketplaces are set to open next week, on Oct. 1. These Marketplaces—also known as insurance exchanges—have been created under the Affordable Care Act (ACA), with a goal of providing a simplified process to compare individual market health insurance plans and shop for health insurance coverage.
According to a Department of Health and Human Services (HHS) report released earlier this week, in states where HHS will run or partially run the Marketplace, individuals will have an average of 53 qualified health plan choices.
For those whose lives have been touched with cancer, understanding the coverage for cancer-related health services is crucial for making educated decisions based on their healthcare needs and budgets.
A new tool, launched this week by the Cancer Support Community in partnership with the Association of Community Cancer Centers and 17 other cancer and patient advocacy organizations, is designed to help people with cancer, a history of cancer, or a risk for cancer choose insurance plans in the Marketplaces. The Cancer Insurance Checklist is designed to be used while evaluating insurance plans and also when discussing them with a navigator or healthcare provider, and includes a worksheet to help the consumer detail the costs associated with each plan.
People with cancer concerns or healthcare professionals assisting patients with the Marketplaces can download and print the Cancer Insurance Checklist free of charge by visiting CancerInsuranceChecklist.org, where they’ll also find a comprehensive list of additional resources and glossary of terms related to insurance coverage decisions.
A central focus of ACCC’s advocacy efforts is elimination of the federal spending sequester. As you know, the sequester, a $1 trillion dollar, across-the-board budget cut set up by Congress in 2011 as a deadline to encourage a successful negotiation of a $4 trillion spending cut by April 1, 2013, has now been in effect for several months, with no end in sight. Starting April 1, the Centers for Medicare & Medicaid Services (CMS) initiated a 2% cut in reimbursement to all Medicare claims.
In June, ACCC released the results of its survey on the impact of these cuts to its membership. Nearly 200 survey respondents, encompassing hospitals, physician offices, and shared operations, were asked if they had made any changes in care due to sequestration. Fifty-eight percent of respondents said yes. Of those, 78% said they were reducing operating expenses, including staff reductions, while 35% said they were referring patients to other sites of service. A full 61% reported that all patients, regardless of insurance, had their care impacted by these changes. ACCC is not alone in reporting that sequestration has negatively affected patient care. In a similar survey conducted by the American Society of Clinical Oncology (ASCO) 80 percent of survey respondents said that the sequestration cuts have affected their practices and nearly 50 percent reported not being able to continue caring for Medicare patients unless they have supplemental insurance.
Many members of Congress are aware of the grave problem these spending cuts pose for oncologists and patients alike. Central to the discussion during the June 28 Energy and Commerce Health Subcommittee hearing was HR 1416, the Cancer Care Patient Protection Act recently introduced by Congresswoman Renee Ellmers. This bill, which already has 91 House cosponsors from both parties, would eliminate sequestration on necessary chemotherapy drugs administered in the physician office setting and repay providers for any reduced payment since April 1. Chemotherapy is one of the services most heavily affected by sequestration. In ACCC’s survey 64% of respondents reported patients’ chemo infusions being affected. This bill would only remove the cuts to the fixed costs associated with Part B chemotherapy drugs, while leaving the cuts to more general services provided to cancer patients untouched.
ACCC proudly supports Representative Ellmers’ bill, and is actively working to introduce companion legislation in the Senate. In addition, we will continue to advocate for elimination of the sequester so that oncologists get the reimbursement they need to continue to provide quality care for all of their patients. Treating cancer is hard enough. We must end government sequestration as soon as possible and find solutions to the nation’s financial dilemma that do not penalize providers or patients.
Please urge your representative to support HR 1416 and let your senators know you want companion legislation introduced in the Senate. Please take a few minutes to send a letter using ACCC’s template to members of Congress on how these cuts are impacting care. ACCC will also continue to keep members informed of new developments.
If your cancer program is feeling the impact of sequestration, let us know. Contact Sydney Abbott at email@example.com.
Theo Salem-Mackall is the policy intern at the Association of Community Cancer Centers.
By Chad Knight, MSHA
Zimmer Cancer Center
New Hanover Regional Medical Center
This week actress Angelina Jolie’s New York Times op-ed piece, “My Medical Choice,” focused enormous media attention on genetic testing for breast cancer and treatment options. By sharing her story, Jolie hopes to raise awareness. She writes:
For any woman reading this, I hope it helps you to know you have options. I want to encourage every woman, especially if you have a family history of breast or ovarian cancer, to seek out the information and medical experts who can help you through this aspect of your life, and to make your own informed choices.
At our cancer center, requests for information from local media and the public were immediate and compelling. In response to multiple requests from media outlets and to proactively answer questions from the community, our cancer program scheduled a press conference with the primary goal of educating our community on the importance of cancer screenings, including genetic counseling and testing.
Jolie’s announcement presents the oncology community with an opportunity to raise local awareness of the importance of access to genetic testing and counseling to help with informed, patient-driven decision making. In fact, I agree with Dr. Isabelle Bedrosian of MD Anderson who in a follow-up article expressed her hope that Jolie’s announcement will “focus women on the value of genetic counseling and making informed decisions.”
With opportunity comes challenge. Rest assured we will continue to field questions and address concerns, especially those from patients with a known family history. The challenge will be how we, with limited resources, ensure that our community is informed such that they can make educated decisions about their own health. How do we expand reimbursement models for more genetic counseling and testing and other cancer screenings? How do we make certain our medical community is collaborative and adhering to the most current evidence-based guidelines? Our challenges are great, but our opportunities are greater.
Chad Knight, MSHA, is Administrator, Oncology Services, at ACCC member New Hanover Regional Medical Center, Zimmer Cancer Center, in Wilmington, N.C.
For more on how ACCC member cancer programs responded this week, read “Angelina Jolie, BRCA1 and the Power of Celebrity” from Seattle Cancer Care Alliance.
By Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC
As more oral anti-cancer regimens become the most appropriate form of treatment for cancer patients, the inequality in coverage for oral prescriptions compared with their IV-infused counterparts is becoming clearer. Because health insurance plans cover oral anti-cancer drugs differently than IV chemotherapy and injected anti-cancer medications, patients have to pay far more out-of-pocket for oral drugs than for IV chemotherapy or injected medications. The phrase “oral parity” refers to legislative initiatives intended to protect patients with cancer from the high cost-sharing requirements that are sometimes associated with oral cancer drugs under health insurance plans.
ACCC continues to support oral parity laws in the states, as well as federal legislation. At the state level, efforts by ACCC members and other organizations are having an impact. So far this year, three additional states have passed parity legislation: Massachusetts, Utah, and now, this week, Florida, where legislation is awaiting the Governor’s signature. This brings the tally of states with oral parity legislation to 23* plus the District of Columbia.
The oral parity issue is really a case of technology outpacing policy. As therapies become more targeted, reliance on oral anti-cancer treatments will only increase. Patients receiving IV-infusions through the physician office setting are covered under the medical benefit of their insurance plan, generally requiring about a $30 co-pay. However, patients on an oral regimen are covered under their pharmacy benefit, which often requires a cost-sharing component that is some percentage of the total cost of the drug. In the case of oral anti-cancer medications, that can be thousands of dollars out of pocket every month.
ACCC is proud to support the oral chemotherapy parity bills that recently passed in Massachusetts, Utah, and Florida, and will continue to support federal efforts to pass legislation covering all 50 states. Stayed tuned for an update on federal oral parity legislation.
*Oregon (2008), Indiana (2009), Iowa (2009), Hawaii (2009), District of Columbia (2009), Vermont (2010), Connecticut (2010), Kansas (2010), Colorado (2010), Minnesota (2010), Illinois (2011), New Mexico (2011), Texas (2011), New York (2011), Washington (2011), Nebraska (2012), New Jersey (2012), Maryland (2012), Virginia (2012), Delaware (2012), Louisiana (2012), Massachusetts (2013), Utah (2013), Florida (2013 – pending Governor’s signature)