January 2014 Edition Vol.8, Issue 1

2014 Forecast Series-Looking ahead with Matthew Farber, MA

2014 Forecast Series-Looking ahead with Matthew Farber, MA

Matthew Farber, MA, is the Director of Provider Economics and Public Policy at the Association of Community Cancer Centers (ACCC). For over seven years, he has worked with the Centers for Medicare & Medicaid Services, Congress, and other key policy makers in Washington, D.C., to help ensure patient access to quality cancer care in community cancer programs and in physician offices.

OBR: In order to talk about 2014, let’s talk about 2013 first. In your area of expertise, as it relates to community and academic oncology, what do you think were the top three issues that were critical for community oncology in 2013?

MF: First thing, probably sequestration had the most challenging impact. That, and the 2% cut in reimbursement on injectable drugs caused by sequestration had an impact on oncologists. We’ve seen reductions in services, cuts in staff, and the increased shifting of site-of-care for patients. All of these have been very difficult for our members and continue to be significant issues for community oncologists.

Another issue is for the patients signing up for insurance through the exchanges created by the Affordable Healthcare Act. They want to know if their physician and/or hospital will be in their network, and if their treatments will be covered. Even with attaining coverage, patients may experience significant out of pocket expenses. Some practices are looking at what plans to potentially participate in that might be offered through the exchanges.  

Third, I would say the increased attention to healthcare issues from the state level, including oral parity and biosimilar legislation, prior authorizations, Medicaid expansion and reductions in coverage. Across the country, different states are embarking on various healthcare civic legislation, which includes oncology, that really have to be paid attention to so as not to take anyone by surprise. 

OBR: Moving into 2014, how would you characterize sequestration in relation to community oncology?

MF: Well, I would say it adds to the pile, if you will. And many people have called sequester the last straw. When you look at the overall history of declining reimbursement and throw sequestration on top of that, it just makes it very difficult for practices, in some cases, to continue. Now, we’re not saying folks are going out of business, but they do have to come up with innovative ways to remain in business. Whether that’s trying out new patent models, cutting back on services, or having some kind of cooperative agreement with a hospital; we’re seeing lots of different things happening out there that are changing the dynamics of the community oncology market place.

OBR: Is it safe to say that quality of care is being jeopardized by sequester and the other things “in the pile” that you refer to?

MF: Not that the quality of care is being jeopardized, but certainly the quality of experience that the patient has throughout their treatment is being challenged. We know from membership surveys we’ve conducted that because of sequestration certain services like patient navigation, survivorship and nutritional counseling are being reduced. These are all non-revenue generating services, so while they benefit the experience of the patient and help with overall outcomes, when these types of services aren’t offered, the overall quality of the treatment experience for the patient, and by that I mean, the mental, physical, and spiritual side of treatment, may suffer.

OBR: Does ACCC deal with the patient perspective at all?

MF: Typically our primary representation is that of the providers. Many patient systems programs are marketed and directed to patients directly, but the folks most often walking the patients through those systems and programs are the providers, nurses, social workers, the financial counselors, and such. There’s definitely a degree of frustration we’ve seen with the exchanges, and anytime patients get frustrated, that spills over onto the providers. Not knowing all of a plan’s details makes it difficult to provide information on the best option for patients. Many of our members are being asked from their patients for guidance on the exchanges and what plans to choose so we’re trying to educate our members on the exchanges and the different plans that are being offered. So far, we’ve seen that many of the plans offered through the exchanges may require high out-of-pocket costs, or may leave certain physicians, treatments, or hospitals out of network. 

In conjunction with some wonderful organizations like the Patient Advocate Foundation and specific disease-state societies, we’ve created a great tool called the Cancer Insurance Check List for patients to navigate through. It’s geared to help cancer patients, potential cancer patients, and cancer survivors to compare plans, and the subsequent issues and costs that may come up with cancer treatment. The website has the checklist that can be downloaded along with other great resources that explain the basics of healthcare e.g., what a premium is or a co-pay, etc. A lot of people don’t know the level of basics, let alone whether one drug will be on a formulary or not. The checklist is free and can found at www.cancerinsurancechecklist.org.

OBR: So, in 2014, regarding the exchanges and the ACA, do you see them having any effect that we aren’t expecting?

MF:  I’ll say two things about this.  One, I think that the general concern is that we’re replacing a lot of uninsured patients with a lot of underinsured patients. However, if those people are buying the lower level plans, i.e., the bronze level plans or the silver level plans through an exchange, it may not be adequate coverage enough to truly help a patient through a treatment process, especially if it’s in oncology where costs can be incredibly high.

On the other hand, let’s say patients who are cancer survivors who have been denied coverage because they had a previous condition prior to 2013. Before, maybe they could only get one plan with a very high premium or maybe they could only get through a high-risk pool. Now, they will have more choices. Whether they are survivors or people with other pre-existing conditions, or it’s the young adult who’s rolling off their parent’s plan at 27 years old and doesn’t know what to do, and she or he has a family history of cancer and a new job doesn’t offer insurance, or something like that, the options available to people in these situations will be much greater. We kind of have dual sides of the coin in looking at the coverage picture, especially for people purchasing through an exchange. A lot of them may get coverage that didn’t have it before, but will it be enough coverage?

OBR: Do you think sequestration will continue well into 2014?

MF: As far as sequester, 2014 will be a pivotal year, because this would be the first full year of its enactment, whereas last year it only existed for three quarters. Many are wondering if life with the cuts is the new normal. Our hope is that it certainly is not. We are working to make sure that that’s not the case, however, whether we can exempt drugs from the cuts, the same issue is going to come up—how are we going to pay for them? That’s the real sticking point. Even though Congress is rolling back many of the sequestration cuts, drugs are not included in those rollbacks. Therefore, the 2% reduction to Medicare payments will remain. ACCC and other organizations are ramping up efforts to have drugs removed from the sequester cuts.  

OBR: What about the SGR? Do you think we’ll see SGR legislation in 2014?

MF: Three congressional committees have introduced SGR-fix legislation, and two committees have passed their proposed legislation with overwhelming support. Still, cost remains the sticking point, and the question of how Congress will pay for a long-term fix remains as yet unanswered. Latest indications are that Congress is going to pass a permanent fix at the beginning of 2014, perhaps in late January or in February. Different options are floating around, but the ultimate hurdle is that we have to get SGR reform passed. I am optimistic about that, because I truly believe that Congress does not want to continue dealing with this issue year after year. 

OBR: Tell us a little bit more about how in 2014 you think States will play a more active role in legislation.

MF: A lot of states are starting to bring up healthcare related bills and laws in their state legislation, that’s not new, we’ve seen this before with coverage of clinical trials, and coverage of off-label therapies, but it just seems like more and more states are getting into different issues that are important to oncology. We saw this increase before the ACA was passed. States are always looking for places to save money and with healthcare as one of the biggest spenders it’s a prime target. Oral parity I think will continue, it’s in over half of States now and efforts in other states will certainly continue. The next step with oral parity will move from trying to get laws passed into insuring that providers actually are abiding by the new laws; however, there are some question marks around implementation of the actual parity laws.

Biosimilars is another area that’s going to only increase in states. We’ve already seen laws introduced in Virginia, Illinois, and California – some have passed; some have not.  So efforts at legislation will definitely increase as the universe of biosimilars grows in the United States. As more and more drugs get close to that patent cliff, and as more companies are actively working on producing biosimilars, we know that this issue is only going to grow.

Prior authorizations are another big issue. We’ve seen some states that have passed standardization of prior authorizations, which is a good thing. With so many different prior authorizations out there, the administrative burden is a headache, to say the least. If there is a more standardized form then it could ease the process for some of our providers, but then we also have to be cognizant of some laws that were passed in 2013 where it would require prior authorizations for all treatments given to the state’s Medicaid population and that is certainly disconcerting, because certain procedures and certain treatments shouldn’t need that.

OBR: How important is to be active in state legislature from a community practice perspective?

MF: Being active with your state legislature, whether it’s on the local or national level, is of incredible importance. For instance, we met with an elected official in Washington, recently, and discussed sequester cuts. We showed data from our surveys how the cuts are affecting our members, and the response was, “Well, that’s funny, because we never heard from any of our constituents telling us any of this.” We, as a national organization, can do what we can, but elected officials also need to hear from their constituents as well. Moving forward, I think 2014 will be an exciting year for the oncology community, and ACCC will continue to provide resources to its members and be their voice with lawmakers in Washington. 

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