May 2014 Edition Vol.11, Issue 5

Newfound Risk that Providers, Payers, and Patients Are Navigating with the Implementation of the Affordable Care Act

Newfound Risk That Providers, Payers, and Patients Are Navigating With the Implementation of the Affordable Care Act

By John McCleery

At the recently held National Comprehensive Care Network (NCCN) annual conference, Clifford Goodman, PhD, The Lewin Group, moderated a diverse panel of distinguished guests that included, Christian G. Downs, Executive Director, Association of Community Cancer Centers; Liz Fowler, VP, Global Health Policy at Johnson & Johnson; Michael Kolodziej, MD, National Medical Director, Aetna; Lee H. Newcomer, MD, MHA, UnitedHealthcare; Mohammed S. Ogaily, Medical Director for the Oakwood Center, Hematology-Oncology, Detroit, MI; W. Thomas Purcell, MD, Executive Director at University of Colorado Cancer Center; John C. Winkelmann, MD, Oncology Hematology Care, Inc. based in Cincinnati OH, and Councillor, American Society of Hematology. The symposium was titled, “Affordable Care Act: Where Are We Now?” and the panel discussed how in particular the Affordable Care Act (ACA) and reform in the United States is affecting cancer care.

One of the first questions that were asked of the panel was: “Due to the ACA, who is now presenting with cancer? Who is walking through the door and is there a difference between patients since the ACA implementation?”

At the University of Colorado Cancer Center, Dr. Purcell said, “Currently, I haven’t noticed a difference. We’re not seeing a dramatic shift yet, but it’s still too early.”

He described the state-run exchange which, according to him, had roughly 220,000 people who signed up in the exchange, with about 140,000 of those being new Medicaid patients, and 80,000 participating in the narrow-network exchange. He said patients receive care at the academic center and the community center. What they don’t have a handle on yet, Dr. Purcell said, “is those people who have large co-pays and how to manage them, particularly those in the the Bronze plans. We’re thinking more strategically about how to help these patients pay for their much larger out-of-pocket expenses.”

Plans are primarily separated into 4 health plan categories — Bronze, Silver, Gold, or Platinum — and the percentage the plans will spend on overall cost of providing essential health benefits to members are 60% (Bronze), 70% (Silver), 80% (Gold), and 90% (Platinum).

At Aetna, Dr. Kolodziej thought it was too early to tell if there is a difference in patients presenting since ACA implementation. “In oncology, we just don’t know yet. We base our data on claims, and we’re not even at 90 days yet, so we just don’t know.”

In Kentucky, Dr. Winkelmann offered that there’s a very well-run and aggressive state exchange. “So we are seeing people come in without insurance and we help them sign up and get coverage.” Due to the success of the state-run exchange and Medicaid expansion in Kentucky, patients are now going to their doctors, and as a result of routine cancer screenings, oncologists in the area are experiencing an increase in newly insured patients.

An issue raised by Dr. Winkelmann is the polarizing affect the ACA has on the general population across political parties. Citing a recent article, he said, “Of uninsured Democrats, 15% said they’d rather pay a penalty than get insurance; of uninsured Independents, 31% said they’d rather pay a penalty, and of Republicans, 45% said they’d rather pay the penalty.”

Addressing the risk pool factor, Liz Fowler, who worked at the White House prior to her current position at Johnson & Johnson and participated in the drafting of the legislation of the ACA, shared that the intent of the ACA was that 40% of the initial enrollment would be the under 35 years of age population, a much less riskier population than their older counterparts. “But what we’re seeing is that [the percentage] is closer to 25%-27%.”  

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