2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

HEALTH CARE REFORM AND ONCOLOGY
development and implementation of cancer survivorship
care plans. 11
Cancer Clinical Trials
The ACA mandates coverage of routine costs for patients
who participate in cancer clinical trials. Insurers are prohibited
from dropping or limiting coverage for participants in
cancer clinical trials.
Improving Quality and Lowering Costs
The ACA establishes a national pilot program to encourage
hospitals, doctors, and other providers to work together
to improve the coordination and quality of patient care.
Under payment bundling, hospitals, doctors, and providers
are paid a flat rate for an episode of care such as a cancer
diagnosis, rather than the current fee-for-service system.
The entire oncology team is compensated with a “bundled”
payment that provides incentives to deliver health care
services more efficiently while maintaining or improving
quality of care. Bundled payments may be the most striking
change resulting from the ACA that oncologists will
experience.
ACA Impact on Oncology
The stated goals of ACA are to expand access and control
health care costs. However, although the expansion of access
is relatively easy to quantify, the impact on health care costs
is less clear. On the surface, increasing demand for any good
or service typically results in higher costs in a free market
unless supply is similarly increased. Both expanded coverage
through the ACA and the projected increase in cancer
cases as a result of demographic shifts in the U.S. population
(e.g., aging) are likely to increase demand for oncology goods
and services over time. In contrast, on the supply side, an
oncology physician workforce shortage is projected, 12 novel
drugs with complex production requirements may be scarce
after initial approval, 13 and shortages of commonly used
generic drugs are already widespread and projected to
increase over time. 14 One of the key questions then is how,
in this context, the impetus to control costs will affect care in
the clinic.
To the extent that the ACA provides oncologists with more
resources to care for patients, the ACA may ease ethical
tensions. An oncologist faced with a patient in clinic with a
treatable disease or symptoms has an ethical obligation to
provide care or to help the patient obtain care elsewhere.
Oncology practices are currently faced with the dilemma of
how to care for patients without adequate resources. 15 Few
would argue that such differences in access or outcomes on
the basis of ability to pay alone are morally acceptable.
However, there is legitimate debate regarding how society
KEY POINTS
● The ACA contains provisions that are relevant to
oncology.
● Health care reform poses ethical implications for
oncology providers.
● Specific stakeholders in the oncology community will
face a variety of relevant issues.
can best address such disparities and the extent to which the
ACA will really help. At the center of the decades-old
controversy over health care reform in the United States
is the question of whether the goals of providing access
and improving health outcomes are best achieved through
a) government-provided health care, as is the dominant
model in the British National Health Service, b) governmentfinanced
health care, as in Canada, c) increased government
regulation of health care and health insurance, as established
by the ACA, or d) deregulation and greater freedom
within the medical care and medical insurance market
place, as proposed by some critics of the recent health care
law.
At the level of the individual provider, regardless of the
basis for insurance coverage, any increase in the amount of
resources available to care for an individual patient presenting
with cancer should provide a greater opportunity to meet
our ethical obligation to provide care. There are several
other features of the new law that will enhance our opportunity
to provide cancer care. As described herein, insurers
will be unable to refuse coverage to patients with preexisting
conditions and there will be no lifetime cap on coverage—
critical issues for patients with cancer. There will be no cost
sharing for recommended cancer screenings such as mammography
and cervical cancer screening. In addition, in a
provision that has received little attention, the law establishes
a federal right to timely independent external appeal
of adverse coverage decisions. This could be particularly
important for patients with rare cancers or rare presentations
of cancer requiring off-label therapy.
Ethical Challenges in Cost Control
The predominant ethical challenges facing oncologists will
likely come from increasing pressure on oncologists to act
both in their patient’s interest and simultaneously, in the
interest of society, the government, the insurer, or the
accountable care organization (ACO) in helping control
costs. These pressures are likely to be most acute in the
newly established ACOs, in which there are direct financial
incentives for controlling the cost of health care, but will
likely extend to consideration of care for all patients. Not
only is the entire success of this experiment in expanded
health care coverage dependent on financial sustainability,
but oncologists are likely to directly feel the impact of any
ongoing failure to shift the cost curve.
The law establishes a new Independent Advisory Board
charged with controlling Medicare spending. Given that
most potential remedies for rising costs are explicitly prohibited,
such as rationing, cuts in services, cost sharing, or
changes in hospital reimbursement, it appears likely that
rising costs will be met with cuts in reimbursement to
providers. One of the issues likely to face providers is simply
how (and whether) to practice in an era of lowered reimbursement.
Will we protect revenue at the expense of time
with patients or provision of ancillary services? Will this
affect individual treatment decisions? There may be very
personal answers to these questions for each oncologist.
The goal, of course, is to provide higher-quality care at
lower cost by focusing on the value of the care we provide. 16
In one of few studies to demonstrate this potential, Neubauer
and colleagues found that adherence to lung cancer
guidelines can reduce costs substantially with no detriment
in survival. 17 The potentially high costs associated with
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