The Lynx Group

Implications of Healthcare Reform for Oncologists and Cancer Care

July 2011, Vol 2, No 4

Q: What concerns do you have about how healthcare legislation might affect oncology?
Dr Bailes: The healthcare reform legislation involves many potential issues that can affect oncology, for example, how minimum benefits are defined. First, there are required minimum benefits that all health plans and other insurers have to meet, and we have to make sure that cancer care is included.

Second, the group called the Independent Payment Advisory Board (IPAB) has the ability—the way the law is set up—to make recommendations that could be implemented in Medicare through the Centers for Medicare & Medicaid Services (CMS), unless Congress overrides these recommendations.

Third, the reform bill relies on Medicaid expansion to a great extent; and because Medicaid is a joint federal/ state program, Medicaid expansion means more pressure on states. State budgets are already under pressure, and we worry about adding potential barriers to access. These barriers would require patients with cancer to jump through hoops and perhaps not get needed therapy.

Those are just some of the big issues that those involved in oncology care are worried about within the context of the healthcare reform bill.

Q: What do you see as some of the positive things in the healthcare reform bill?
Dr Bailes: There are many positive things in the healthcare reform bill, especially for individuals with serious diseases, such as cancer. There is the elimination of preexisting conditions, so patients can get any insurance, regardless of whether they have cancer or have had cancer. There is the elimination of lifetime caps on insurance; if patients have a serious illness or have to have a transplant, they won’t face being told they can’t have further care because they have reached their lifetime maximum benefits.

There is also the elimination of what is known as rescissions, where people are denied coverage because of something on an insurance application from previous years. In addition, there is coverage for patients’ costs that are associated with participation in clinical trials in private insurance.

Q: Do you think the provision will ultimately lead to lower costs for the healthcare system overall?
Dr Bailes: Ultimately, yes. If we look at malignancy, the most expensive treatment is when it is diagnosed late or not diagnosed correctly. If we screen early, we find cancers at a stage where they are treatable. That is where the treatment is cost-effective for the individual, because the patient is treated and is back to work. There are a lot of benefits to the system in being able to access the healthcare system early and get the appropriate treatment.

Q: Will the IPAB committee—that is going to make recommendations to Medicare—include an oncologist?
Dr Bailes: The IPAB is set up by the healthcare reform bill to replace the Medicare Payment Advisory Com mit - tee. It will be able to make recommendations within certain parameters that are in the law that CMS could then implement, unless Con gress stopped it. There is no explicit provision to require an oncologist on the IPAB.

Q: Do you think the debate over healthcare reform may hurt the ability of an oncologist to talk about terminal care with patients?
Dr Bailes: I do not think it will hurt, but the unfortunate thing about the debate was that it got off topic from what is important, that is, the need for oncologists, patients with cancer, and their families to have a candid discussion about the benefits, or lack of benefits, of a particular therapy at a specific time. We saw that in the rule when that part of the proposed physician fee schedule was decided.

I believe we got off on a tangent in that case and lost sight of what was important. Many organizations—the American Society of Clinical Oncologists among them—have guidelines and much background material on how to speak with individuals who have a terminal illness and evaluate with the individual and the family which therapy makes sense. That is the responsibility of the oncologist and the health oncology team. The more we can do to help the oncology team with that, the better.

Q: Do you think some oncologists hesitate following parts of the law that are already in practice because it is being disputed in the courts?
Dr Bailes: I do not think that is an issue right now. Oncologists are dedicated individuals, and they see there has been a lot of publicity about the positive parts of the healthcare reform law. And many of the other parts have not been implemented yet.

Q: What are some improvements that you would make to the bill?
Dr Bailes: There needs to be a little more flushing out of what the patientoriented research authority—the comparative effectiveness research group— does, and what their authority is. Those in charge of benefit design in health plans need to make sure that there is input from all parties involved, such as patient advocates, physicians, specialty societies, policymakers, and states.

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