The Affordable Care Act (ACA) is still relatively new, but it’s already changing the way patient populations gain access to healthcare coverage. This has important implications for oncology, according to Burton VanderLaan, MD, FACP, medical director for Priority Health.
VanderLaan delivered the afternoon keynote—the payer perspective—on November 14 at Patient-Centered Oncology Care 2014, and he offered an early view of how the payer mix is changing as the ACA takes hold. In looking at the population of Michigan, where Priority Health is based, VanderLaan presented data showing that 900,000 people joined the ranks of the insured, while Medicaid enrollment grew by 600,000. “Some of the movement into Medicaid is from employers, but most of it is from the newly insured,” he said (Figure 1). Many who signed up on the health insurance exchange websites were able to do so because of “the attractiveness of the subsidies,” which held down the cost, VanderLaan said.
As a group, those signing up for insurance on the exchanges tend to be older—most of those who signed up in Michigan were between the ages of 45 and 64 years. Data from Priority Health’s pharmacy benefit managers show those who signed up also tended to be sicker, based on the number of prescriptions they were having filled. “Many had some prior insurance, but because they were able to get a premium subsidy, there was an impetus to move to the exchanges,” VanderLaan said, asking, “What are the implications of that? Think of those implications to an oncology practice.”
VanderLaan walked the audience through projections, showing that eventually up to two-thirds will be covered as individuals, not through their employers (ie, through a group plan). As a group, those with individual coverage are less likely to pay premiums on time, less likely to buy full coverage, and more likely to change coverage frequently. “An individual is more likely to miss a payment than a corporation,” VanderLaan said. “For terms of the ACA, if an individual doesn’t pay, the insurer honors the claims for 30 days. If you’re that provider seeing that patient, you see them for 30 days; then it pends for 60 days. It raises the whole issue of bad debt that might be injected into the system.”
VanderLaan is not the first to raise this issue. Groups, including the Community Oncology Alliance, along with oncologists from academic medical centers who spoke last spring at the National Comprehensive Cancer Network annual meeting, raised the specter of challenges from the “underinsured.” This group, distinct from those who are known upfront to need charity care, might have some coverage but face steep deductibles or co-payments for cuttingedge therapies. “Lower cost plans come with a lot of cost sharing,” he said.
With the ACA Silver plans being the most popular, the out-of-pocket costs when a patient faces a cancer diagnosis might be more than the person can handle. “Most Silver plans come with a $3000 deductible,” he said. “Out-of-pocket maximums may offer some protection, but that may be in-network only.” (Figure 2.) Thus, VanderLaan raised another emerging issue: “narrow networks,” which are efforts by exchanges in some states to limit where patients seek care, all done in an effort to control costs. “Academic medical centers and cancer centers are particularly vulnerable,” he said. VanderLaan discussed an Associated Press survey that found only 4 of 19 nationally recognized cancer centers reported that patients had access to care through their exchanges.1
“There has been a backlash,” he said. "CMS has definitely had a backlash.” Indeed, VanderLaan cited outcry in California over access-to-care issues, which that state’s exchange said it tried to address by adding more choices for consumers in 2015. With an aging population, oncology is going to face ever-increasing demands. “It’s unclear where this is going to end up,” VanderLaan said.
1. Bernard-Kuhn L. Health plans may omit top cancer hospitals. Cincinnati.com. http://www.cincinnati.com/story/news/2014/03/27/acacancer-obamacare/6957237/. Published March 28, 2014. Accessed January 19, 2015.