The Lynx Group

Defining the Role of Government in Future Oncology Care

September 2013, Vol 4, No 7

Hollywood, FL—Regardless of one’s personal opinion of the role of government in healthcare, the Affordable Care Act (ACA) will be implemented, which means government will be playing a more significant role, as 2 speakers pointed out at the Third Annual Conference of the Association for Value-Based Cancer Care.

The Centers for Medicare & Medicaid Services (CMS) has tremendous authority to implement the provisions that Congress has written. Beyond the ACA, Medicaid expansion, and healthcare exchanges, many other government activities dramatically affect cancer care because of the wheels that have been in motion for years under Medicare Part B and in the payer sector, said Jayson Slotnik, JD, MPH, Partner, Health Policy Strategies, LLC.

“What’s going on in the coverage world on a national level is interesting, yet not unpredictable,” Mr Slotnik said. CMS currently has few resources at the national level; it has lost staff that, because of sequestration, cannot be replaced. The agency is overworked and morale is very low, and CMS is “going after the low-hanging fruit,” he said.

“Given the resources, given the political environment, given where the agency is focused,” change within CMS, as it relates to cancer care, may come about slowly, Mr Slotnik predicted. “That having been said, CMS has local contractors that administer the plan, and that is where the action is.”

Denise K. Pierce, President and Chief Executive Officer, DK Pierce and Associates, agreed that there are many stressors at the national level, but “the machine” still runs at the local level.

“It is the local implementation of healthcare that all of us feel, and this differs across the United States. For example, when a new oncology drug comes to market, not every contractor deals with that drug in the same manner,” Ms Pierce pointed out.

Approaches vary regarding how coverage is established and the expectations for claims processing. This all impacts oncology practices.

For example, a change is occurring in the criteria for drug coverage. “Previously, many of the contractors would have very specific criteria for covering cancer drugs. You knew the particular indications of use and where the drug would be covered. Over time, many contractors have gone to a global coverage and are not being very distinct with the coverage criteria,” she noted.

Although this may indicate that providers are being trusted to utilize drugs appropriately, it could also make providers nervous about the possibility of a claim being rejected. There has also been a shift to more high-cost claim audits. “You know that if you’re looking at a high-dollar claim audit, notoriously, oncology drugs are ending up under that category,” she said.

Medicaid: Local Concerns

The expansion of Medicaid under the ACA will undoubtedly mean that more patients with cancer will be treated under Medicaid. Different Medicaid agencies are taking different actions, “because they are already in dire straits with their budgets,” Ms Pierce said.

An extreme example comes from Oregon, where Medicaid has established a marginal benefit for a high-cost policy that ties coverage of high-cost drugs to the patient’s life expectancy. A treatment will not be covered if a patient has an expected survival of <6 months; this patient will be referred for palliative or hospice care. For patients with an expected median survival of 6 to 12 months, the treatment must be expected to increase survival by 50%. For those expected to live at least 12 months, the treatment must provide a 30% improvement in survival.

“Whereas Medicaid, in the past, had not paid much attention to oncology drugs and never really established coverage criteria, we have now seen Medicaid agencies establishing very distinct clinical criteria and prior authorization approaches. These are going to be evolving over time, not only because of the ACA and the Medicaid expansion, but because the increased cost of care impacts their budgets and they must find ways to manage them,” Ms Pierce said.

Call to Action: Get Involved

Mr Slotnik urged stakeholders “who are in the know, who see patients, who make the drugs, who manage the dollars,” to get involved in setting policies regarding what society should pay for healthcare, what guidelines should be set, and what outcomes should be expected. “The people who actually pay to provide the care, in my opinion, are better positioned to engage, communicate, educate, and ultimately decide what role the government should have in healthcare,” he maintained.

Whereas the United States has shied away from a public discussion focused on substantial change, England did not, and their discussion led to the creation of the National Health Service. “Perhaps we are going to have that conversation soon,” Mr Slotnik added. “To me, at the end of the day, it’s up to each individual to voice their opinion…though some opinions will hold more water,” he offered.

Craig K. Deligdish, MD, Hema­tologist/Oncologist, Oncology Re­source Networks, Orlando, FL, and Co-Chair of the meeting, asked what will happen if the government avoids this larger discussion, or if novel programs being rolled out do not prove capable of improving quality and reducing cost. The options may be to ration healthcare, as Oregon is essentially doing, or to globally reduce payments for healthcare, Dr Deligdish said.

Ms Pierce pointed out that costs have been growing astronomically for a long time, but what is new is the conversation about cost and its impact. The conversation now revolves around how to create value propositions for caring for patients, how to use data, and how to identify solutions.

“Now, there are different organizations all working to identify options that can reduce the need for a drastic systemwide change,” she said, adding that the Oregon example, although objectionable on many levels, may trigger more conversation toward rational solutions.

Mr Slotnik predicted that it will be years before big changes are obvious. What will happen depends on the state of the economy, which party rules Congress, who the president is, and whether there is a major international crisis between now and then. The potential changes constitute a “laundry list” from interested parties, including price reductions, tax increases, changes in Medicare eligibility, elimination of employer-based insurance, and much more.

“But yes, something is going to happen. The question is, do you want to be under the bus or driving the bus?” Mr Slotnik asked.

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