By Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC
We’re on the countdown to ACCC’s Capitol Hill Day on March 31. ACCC members who join us will be visiting with congressional staff to speak out on major concerns affecting oncology care. Those on the front lines of cancer care can deliver a powerful, clear message on issues affecting cancer patients and providers. Patient access to care—in particular to anti-cancer medications—is a cross-cutting concern.
Where Things Stand in Congress—Two Bills
Many health insurance plans cover IV chemotherapy, injected anti-cancer medications, and oral anti-cancer drugs differently, causing patients to pay far more out-of-pocket for oral drugs than for IV chemotherapy or injected medications. With the ever rising cost of healthcare, insurers employ various methods to keep costs down, including increasingly shifting the cost of prescription drugs to patients. To help patients afford the life-saving medications they need, Congress has introduced two complementary—if not somewhat confusing—pieces of legislation: HR 1801 and companion bill S 1879 to lower the cost of prescription oral chemotherapy drugs, and HR 460, to limit cost-sharing requirements for prescription drugs on specialty tiers. Both bills aim to protect cancer patients in different ways.
Here’s a quick side-by-side comparison of the legislation. For ACCC members joining us for Capitol Hill Day, this snapshot can help you prepare for conversations with congressional staff.
Oral Parity (HR 1801/S 1879)
- Legislation would require insurers to provide coverage for orally administered anti-cancer medication under terms no less favorable than for medication administered intravenously. Insurers may not create parity by raising rates for IV infusions.
- Focus is on cost-sharing across prescription drug coverage and office visit coverage for anti-cancer medications only.
- Requirements: A physician must deem the treatment to be medically necessary for treating cancer, and the treatment must be clinically appropriate in terms of type, frequency, and duration.
- Types of insurance affected: Group and individual private plans and self-insured group plans regulated by ERISA that cover oral and IV-infused anti-cancer medications.
Specialty Tier (HR 460)
- Legislation would limit cost-sharing requirements applicable to prescription drugs in a specialty tier to the dollar amount of such requirements applicable to prescription drugs in a non-preferred tier.
- Focus is on cost-sharing in prescription drug coverage plans and formularies for any specialty-tier drug covered by the plan.
- Requirements: A health plan that provides coverage for prescription drugs using a cost-sharing structure shall not impose cost-sharing requirements applicable to prescription drugs in a specialty drug tier that exceed the dollar amount of cost sharing for drugs in a non-preferred brand tier.
- Types of insurance affected: Group and individual private plans that cover prescription drugs and use a formulary or other tiered cost-sharing structure. Bill language is unclear as to whether ERISA plans are affected.
Both bills help protect patient access to affordable prescription drugs. However, because oral parity legislation already has 67 co-sponsors in the House and a companion bill in the Senate, this will most likely move through Congress first. Therefore, ACCC will be advocating for oral parity (HR 1801/S 1879) in both chambers on Hill Day. In addition, we will be talking to our representatives about SGR reform, elimination of cancer drugs from the 2% Medicare sequester, and elimination of the prompt pay discount. Learn more about Hill Day 2014 and register today.
by Amanda Patton, Manager, Communications, ACCC
This week Health Affairs announced its 15 most-read articles of 2013. Topping the list: “What It Will Take to Achieve the As-Yet-Unfulfilled Promises of Health Information Technology” (January 2013). Authors Arthur Kellermann and Spencer Jones of the RAND Corporation re-visit a 2005 Health Affairs article from a team of RAND researchers that projected savings of more than $81 billion annually from rapid adoption of health information technology.
Seven years down the road—the picture is not so bright. Kellerman and Jones report that data show health IT’s impact on healthcare efficiency and safety is mixed and, meanwhile, annual expenditures on healthcare in the U.S. have grown by $800 billion. The authors cite a number of hurdles impeding progress toward realizing health IT’s full promise. These include selection of systems that lack interoperability and are not easy to use, along with failure on the part of providers and healthcare systems to re-engineer care processes to fully take advantage of the benefits of health IT.
Still, the authors are optimistic that the original promise of health IT can be realized. However, they say for this to happen we need standardized, easy to use systems; more interoperability; increased patient control of their healthcare information; and providers to re-engineer their care processes to fully benefit from the efficiencies offered by health IT.
Health Affairs is offering free access to all of its top 15 articles until January 28.
On the theme of the yet-to-be-realized potential of health IT, ACCC’s white paper Cancer Care in the Age of Electronic Health Information Exchange offers oncology-specific perspective on adoption and integration of health information exchanges (HIEs), a key component of health IT. Developed through ACCC’s Institute for the Future of Oncology, the paper reflects a forum discussion of current barriers and successes in adoption of HIE. Among the key findings:
- HIE adoption is uneven. Despite the potential that HIEs have to improve patient care, reduce redundancies, lower costs, and demonstrate quality—for example, by allowing participating providers to benchmark interventions within their own patient populations—the oncology community is experiencing patchy adoption and implementation, with the potential being realized in some areas but not others.
- There is lack of awareness around HIEs. There are many known benefits to participation in an HIE, but information about these benefits needs to be more widely disseminated.
- HIE initiatives must focus on information standardization, so that data can be easily exchanged by providers and viewed by patients.
- Challenges remain as to how to achieve interoperability so that data can be exchanged seamlessly across large geographic areas while best ensuring privacy and security.
- Providers must have input on the information released via patient portals. Patient portals can contribute to patient empowerment, but protocols must be put in place so that providers have input on the information released and the timing of that release, and have the opportunity to answer patient questions.
It’s no surprise that many of the issues identified in ACCC’s white paper—the need for standardization, interoperability, ease of use, and provider involvement in health IT processes—resonate with the findings of Kellerman and Jones. While remaining optimistic, there is consensus that much work remains to be done.
by Amanda Patton, Manager Communications, ACCC
Saturday January 11 marks the 50th anniversary of the first Surgeon General’s Report on Smoking and Health. This landmark report was an opening salvo in a sustained fight to reduce smoking and curb its devastating effects. While we’ve made remarkable progress—smoking rates among U.S. adults have been cut in half since 1964—tobacco use is still the leading preventable cause of disease, disability, and death in the U.S.
A study in this month’s Journal of the American Medical Association provides perspective on the powerful impact tobacco control efforts have had on public health in this country. In the decades since the Surgeon General’s first report, the study estimates 8 million premature deaths from smoking have been avoided.
And yesterday’s report from the Centers for Disease Control and Prevention (CDC) on the decrease in new lung cancer rates among men and women in the United States from 2005 to 2009 is more good news.
Still, the fight goes on. Here are some sobering facts from the CDC on the economic costs of smoking:
- During 2000–2004, cigarette smoking was estimated to be responsible for $193 billion in annual health-related economic losses in the U.S. (nearly $96 billion in direct medical costs and an additional $97 billion in lost productivity).
- Cigarette smoking results in 5.1 million years of potential life lost in the U.S. annually.
- Each day in the U.S., nearly 4,000 people younger than 18 years of age smoke their first cigarette
- An estimated 1,000 youth in that age group become new daily cigarette smokers.
The 50th anniversary of the first Surgeon General’s Report is a renewed call to action on this public health issue. Community cancer centers are important partners in the fight to end smoking and its negative health effects. Across the country, community cancer programs are participating in outreach education to schools and communities on the hazards of tobacco use, as well as providing lung cancer screening, diagnosis, treatment, and smoking cessation support. The recent U.S. Preventive Services Task Force Recommendation for lung cancer screening for those at high risk will further enable community cancer centers to identify and treat tobacco-related lung cancers.
Next week, a 50th Anniversary Surgeon General’s Report (SGR) on smoking and health is slated for release. This new report will highlight the progress that has been made in tobacco control and prevention, present new data on the health effects of tobacco use, and detail initiatives that can end the tobacco use epidemic in the U.S.
The Association of Community Cancer Centers will continue to support its membership in this fight by providing practical resources and peer-to-peer learning opportunities. Look for an upcoming article in Oncology Issues on implementing the latest lung screening recommendations in the community setting.
We can all hope that this fight will not last another 50 years.
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 email@example.com.
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.