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Coverage, quality, and cost of
cancer care under the Affordable
Care Act and Medicare reforms
Amy J. Davidoff, PhD
Cancer Outcomes, Public Policy and Effectiveness Research Center
(COPPER), Yale School of Medicine
Department of Health Policy and Management, Yale School of Public Health
[email protected]
Connecticut Cancer Partnership Annual Meeting
December 6, 2016
Disclosures
• Research funding from the Pharmaceutical
Research and Manufacturers of America
Foundation
• Consulting and research funding from
Celgene Pharmaceuticals (spouse)
Individuals may experience
multiple barriers to cancer care
access
• Poor access to screening
• Limited specialist access => delay in diagnostic confirmation,
staging, care planning
• Poor care coordination => patient slips between the cracks
• Patient delays or defers therapy due to cost, lack of
transportation, social supports
• Job loss, leads to insurance loss. Can’t buy private insurance.
• Early discontinuation of oral therapy due to out-of-pocket cost
• Financial toxicity
Outline
• Key objectives, provisions of the ACA
• Early evidence on ACA coverage
• Other provisions of the ACA, Medicare
reform
• Remaining gaps
• Discussion, next steps
Individual insurance
mandate
• U.S. citizens and legal residents must have
qualified insurance plan
• Tax penalty
– greater of $695 per year (up to three times that
amount per family) or 2.5% of household income.
– Phased in over time
• Exemptions: financial hardship, religious
objections, undocumented immigrants, prisoners
ACA improves insurance access
• Dependent coverage
mandate (2010)
• Eliminates health status
as barrier to coverage
• Employer mandate*
• Marketplaces: New
source of private
coverage
• Public coverage
expansions
* Implementation delayed until 2016
Buying insurance in the Marketplace
• Centralized market for purchase of private
insurance plans
• Plans
– cover essential health benefits
– 4 standard plans defined by actuarial value
• Bronze (60%) – platinum (90%)
• OOP caps
• No lifetime, annual coverage limits
• Premiums vary by policy type (single, family),
region, age, tobacco use
• No health status underwriting
• No pre-existing condition exclusions
Subsidies, extra protections available
for lower income
• Advanced premium tax credits to
subsidize premiums (100-400% FPG)
• Cost-sharing reductions (CSR)
– Lower caps on OOP spending
– Available for families at 100-250% FPG
• Eligibility for premium subsidies restricted
to individuals w/o “alternative source of
affordable coverage”
Medicaid expanded for working-aged adults
Income eligibility for insurance options Pre
and Post ACA -- Connecticut
Before ACA
Early
expansion
(2010)
After ACA (As
of June 2016)
Low-income
children aged 018
185%
185%
196%
Other children
aged 0-18
(CHIP)
300%
300%
318%
Pregnant women
250%
250%
258%
Parents of
dependent
children
201%
201%
155%
Childless Adults
N/A
56%
138%
Aged, aged, blind Detailed income
or disabled
and assets
people
criteria
Income eligibility for ACA insurance
options
Medicaid expansion states
M’caid preACA
Mcaid
expn
Marketplace
access w/o
subsidies
Marketplace premium tax credits
Affordable alternative coverage
States not expanding Medicaid
M’caid
pre &
post ACA
0%
Elig
gap
Marketplace
access w/o
subsidies
Marketplace premium tax credits
Affordable alternative coverage
100% 138%
400%
Adjusted Income as % Federal Poverty Guideline
Eligibility for Subsidized Coverage
Under the ACA
Working Aged Adult Cancer Survivors
100
90
Pre-ACA
Post ACA Implementation
80
62
Percentage
70
61
60
50
40
30
20
15
19
2
10
10
7
0
Medicaid, ESI offer,
CHIP
Medicare,
eligible
Tricare
Medicaid Alternative
Not
eligible coverage eligible
Premium Income >
tax credit 400% FPG
eligible
Source: Medical Expenditure Panel Survey, 2008-2010. Davidoff et al. JNCI 2015
Eligibility for subsidized coverage varies by
state Medicaid expansion status
Working Aged Adult Cancer Survivors
100
Pre-ACA
90
Post ACA Implementation
80
70
60
65
65
59
60
50
40
26
30
20
18
10
10
9
0
5
8
14
7
7
0
Medicaid, ESI offer,
CHIP
Medicare,
eligible
Tricare
Medicaid Alternative Not eligible Premium Income >
eligible coverage
tax credit 400% FPG
eligible
Expansion State
State Not Expanding
Source: Medical Expenditure Panel Survey, 2008-2010. Davidoff et al. JNCI 2015
Evidence of substantial coverage gains
for working-aged adults
• Between 2010 and March 2016
– 21.3 M fewer uninsured
– Uninsured rate declined from 22.3% to 11.9%
• CT uninsured at 5.7%
– Private coverage increased from 64.1% to 70.2%
– Public coverage increased from 15% to 18.9%
• Overall Marketplace enrollment, 2016
– 12.7 M enrolled
– 80% receiving advanced premium tax credits, with or w/o additional
OOP protections
Cohen et al., http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201609.pdf
ASPE issue brief, “HEALTH INSURANCE MARKETPLACES 2016 OPEN ENROLLMENT
PERIOD: FINAL ENROLLMENT REPORT .” March 11, 2016.
https://aspe.hhs.gov/sites/default/files/pdf/187866/Finalenrollment2016.pdf
Trends in insurance coverage for
working aged cancer survivors
80%
68%
70%
70%
68%
69%
60%
50%
40%
30%
20%
12%
13%
16% 16%
15%
9%
21%
6%
10%
0%
Uninsured
Private
2012
2013
2104
Source: NHIS 2012-2015. Davidoff et al., unpublished.
Public
2015
Reductions in the Uninsured by
Eligibility Category
Working Aged Adult Cancer Survivors
60%
50%
50%
42%
40%
30%
20%
10%
16%
6%
22%
27%
26%
30%
23%
8%
6% 4%
4% 3%
0%
Medicaid
Newly
Poor,
Premium
eligible pre- Medicaid
Medicaid subsidies &
ACA
eligible post- eligibilty gap
CSR
ACA
Pre-ACA
Premium
subsidies
only
Post-ACA
Source: NHIS 2012-2015. Davidoff et al., unpublished.
Alternative
Income
affordable >400% FPG
coverage
Half of previously uninsured remain
without coverage
– Many eligible, unenrolled
– Family affordability glitch
– Affordability an issue for Marketplace plans
• Premiums increasing
– Low cost plans have
• High deductibles
• Narrow networks
High, increasing prevalence of high
deductible plans
Chart Title
60
56.4
54.7
52.4
54.1
50.9
48
50
40
36.2
36.6
32
30
26.9
29.2
23.3
20
10
0
2010
2011
2012
Employer
2013
2014
Direct Purchase
Source: NHIS, 2010-2015. Cohen et al.,
http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201609.pdf
2015
Protection from financial “toxicity” in
Marketplace plans?
• Lifetime & annual $ coverage limits
eliminated
• Annual cost sharing capped, but can still
be substantial.
– Bronze plan: $5,950 for individuals and
$11,900 for families
– Even means-tested reductions in OOP
spending caps are high
• 100-200% FPL: $1,983/individual and
$3,967/family
Pause
• Clarifying questions?
The ACA also attempts to fix many coverage
& delivery system problems
Improved primary & preventive care
access
• Longer term – primary care workforce
development
• Enhanced primary care reimbursements under
Medicaid x 2 years
• Eliminated cost sharing for USPSTF
recommended preventive care, including cancer
screenings (2010)
• Early evidence mixed
States Required to Specify, Apply Essential Health Benefits
•
•
•
•
•
•
•
•
•
•
•
•
•
Primary Care Visit
Specialist Visit
•
Inpatient Services
•
Hospice Services
•
Infertility Treatment
•
Routine Eye Exam
•
Home Health Care Services
•
Emergency Room Services
Emergency Transportation/ Ambulance •
•
Skilled Nursing Facility
•
Mental/Behavioral Health
Inpatient/Outpatient Services
•
Substance Abuse Disorder
•
Inpatient/Outpatient Services
•
Generic/Preferred Brand/Non•
Preferred Brand/Specialty Drugs
Durable Medical Equipment
Diagnostic Test/Imaging
Preventive Care/ Screening/
Immunization
Nutritional counseling
Prosthetic devices
Off-label prescription drugs
Chemotherapy
Radiation
Reconstructive surgery
Clinical trials
Rehabilitative services
Bone marrow testing
Post-Mastectomy care
ACA mandates coverage of routine
care for clinical trials
• Goal = reduced financial barriers to clinical trial
participation
• How likely is the impact?
– 18 states already had similar mandates
• Ongoing issues
– Out-of-network coverage
– Delays in approval by insurers
Kircher SM, Benson AB 3rd, Farber M, Nimeiri HS. Effect of the accountable care act of
2010 on clinical trial insurance coverage. J Clin Oncol. 2012 Feb 10;30(5):548-53.
Jain et a. JOP 2016
Downstream availability of biosimilars
likely to impact cost of cancer therapy
• ACA authorized FDA to approve generic
biologic agents
• European Union experience suggests
development of both:
– “me too” biologics, slightly less expensive
– truly interchangeable biosimilars much less
expensive
• Ultimately U.S. implementation regulatory
process for biosimilars =>reduced cost
sharing to individuals with cancer
Megerlin F, Lopert R, Taymor K, Trouvin JH. Health Aff 2013 Oct;32(10):1803-10.
FDA approved biosimilars to date
Date of FDA Approval
Biosimilar Product
Original Product
March 6, 2015
Filgrastimsndz/Zarxio
filgrastim/Neupogen
April 5, 2016
infliximabdyyb/Inflectra
infliximab/Remicade
August 30, 2016
etanerceptszzs/Erelzi
etanercept/Enbrel
September 23, 2016
adalimumabatto/Amjevita
adalimumab/Humira
• As of January 21, 2016, 59 proposed biosimilar products to 18
different reference products were enrolled in the Biosimilar
Product Development Program
• Likely next: rituximab, trastuzumab, bevacizumab, erythropoietin
Barlas, S., Early Biosimilars Face Hurdles to Acceptance: The FDA Has Approved Few, So Lack of Competition Is Keeping Prices High. P
T, 2016. 41(6): p. 362-5
Changes within Medicare
• Closing the Part D coverage gap
• Reducing excessive Medicare Advantage
capitation payments
• Improving patient safety through the
Partnership for Patients
• Cracking down on fraud and abuse in the
Medicare system
• Reforming provider payments incentivize
quality, efficiency
Prescription drug coverage essential
benefit for adults with cancer
•
•
•
•
Oral hormone therapy
Oral chemotherapy, targeted therapy
Supportive care medications
OOP burden from
– # medications
– Cost of medications
– Cost-sharing required
• ACA closes Part D coverage gap
The ACA initiated selected value-focused
reimbursement changes
• Established CMS Innovation Center
(CMMI)
• Charged with testing “innovative payment
and service delivery models to reduce
program expenditures …while preserving
or enhancing the quality of care” for those
individuals who receive Medicare,
Medicaid, or Children’s Health Insurance
Program (CHIP) benefits.
CMS/CMMI initiatives
• $ Penalties for hospital acquired
conditions
• $ penalties for “avoidable” readmissions
• Shared savings models
– Accountable Care Organizations
(ACOs)
• Bundled payment mechanisms
Medicare Care Choices Model
Demonstration
• Allows Medicare beneficiaries to receive
hospice-like support services from
certain hospice providers
• Concurrent with care provided by their
curative care providers
• Initiated January 2016. 140 participating
hospices.
– Regional Hospice and Home Care of
Western Connecticut
Oncology Care Model
Demonstration
• Defines episodes of care initiated by
chemotherapy
• Practices agree to financial and performance
accountability
– OCM participant implements QI plan
– Monthly payments to support enhanced quality,
coordination
– Potential for shared savings
– Quality metrics, CAHPS
• 195 OCM participants. Initiated July 2016.
OCM in CT
• Starling Physicians, Wethersfield, CT
• Yale Medical Group/Smilow, New
Haven,CT including Smilow Care Centers
• Eastern Connecticut Hematology and
Oncology, Norwich, CT
• Hematology Oncology PC, Stamford, CT
Medicare Part B Drugs Payment Model
(On hold)
• Tests $ incentives under Part B “buy & bill”
• Phase I= mandatory experiment w/2 arms:
– Current Average Sales Price + 6%
– ASP + 2.5% + $16.80/drug administered/day
• Phase II – value based drug pricing
– Patient cost sharing to incentivize preferred drugs
– Negotiated prices for drugs
• Indication-specific pricing
• Outcome-based pricing
Policy issues not addressed by ACA
• Cost sharing under Medicare Parts A & B
– Lack of coordinated incentives
– No OOP cap
• Poor coordination between Part B & Part
D drug coverage creates perverse
incentives
• Oral-parenteral cancer drug parity
Questions/Discussion
• What patient groups do you encounter who
remain without insurance?
• What strategies can be used in CT to further
expand coverage? Facilitate enrollment?
• How well do CT-Access plans meet the
needs of adults with cancer?
• How well does Husky D meet the needs of
enrolled adults with cancer?
• What resources are or should be available to
fill gaps in coverage, OOP spending?
Federal Poverty Guidelines
Family Size
1
Income at
100% FPG
$11,670
Income at
400% FPG
$ 46,680
3
19,790
$ 79,160
5
27,910
$111,640
Source: ASPE 2014 Poverty Guidelines
http://aspe.hhs.gov/poverty/14poverty.cfm
Uninsured less likely to receive recommended
cancer screenings
Receipt of colon cancer screening (FOBT past year or colonoscopy past 10 years)
Adults aged 50-64. NHIS 2003-2005. Ward et al. CA-Cancer J Clin 2008.
Uninsured more likely to be diagnosed
with late stage cancer
Adjusted Odds of Being Uninsured on Stage III/IV vs Stage I
0
0.5
1
Adjusted Odds
1.5
2
2.5
Breast
CRC
Kidney
Cancer Site
Lung
Melanoma
NHL
Prostate
Bladder
Uterus
Thyroid
Ovary
Pancreas
Source: NCDB 1998-2004. Halpern MT et al. Lancet Oncology 2008.
3
3.5
Uninsured less likely to receive definitive
cancer therapy, have worse survival
Among adults aged 20-40, being insured was
associated with:
• Higher odds of receiving definitive treatment
Adj OR: 1.95 (95% CI 1.52-2.5)
• Reduced mortality risk
Adj HR: 0.84 (95% CI 0.75-0.94)
Source: SEER, 2007-2009. Aizer AA et al. JCO 2014