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The Impact of the Affordable Care Act on Oncology Care

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Key Points

  • Over the next 10 years, the Patient Protection and Affordable Care Act will result in approximately 25 million newly insured individuals and 12 million more Medicaid beneficiaries through its Medicaid expansion provision.
  • The Affordable Care Act provides significant consumer protections important to oncology patients, including coverage of preexisting conditions and mandated coinsurance limitations that apply to all medical and pharmacy benefits.
  • There are several unresolved risks with the law, including the reliance on 50 state benchmark plan formularies rather than on the Medicare Part D protected class concept; no specified protections for physician-administered products; and inconsistent oncology protections that may result in variable coverage.

According to the Congressional Budget Office, over the next 10 years, the Patient Protection and Affordable Care Act will result in approximately 25 million newly insured individuals and 12 million more Medicaid beneficiaries through the the Medicaid expansion provision. While the law provides significant consumer protections important to oncology patients, including coverage of preexisting conditions and mandated coinsurance limitations that apply to all medical and pharmacy benefits, there are some unresolved risks with the law, found an analysis by Valerie A. Hutchins, MPH, and colleagues at HillCo Health. The report is published in the Journal of Oncology Practice.

One such risk, according to the authors, is the Affordable Care Act’s reliance on 50 state benchmark plan formularies rather than on the Medicare Part D protected class concept, which requires that all protected-class products be included on formularies. Another problem is there are no current rules or policies related to the coverage of new drugs or biologics, particularly oncolytics. In addition, should new oncolytics be approved in classes that previously had one product in them, it is unclear whether the qualified health plans would be required to afford coverage, because the benchmark would only have one drug in the class.

Other potential problems in the law include:

  • No specified protections for physician-administered products, so the definition of medical necessity and the application of compendia coverage will be extremely important regarding physician-administered products.
  • The potential lack of consistent oncology protections, which, according to the authors, may result in variable coverage and a widening list of prior authorization requirements and appeals that oncology practices must mange to ensure appropriate access to care for patients.
  • No clear pathway for universal coverage of compendia-listed anticancer indications; coverage relies on state-required benefits. As a result, in a state without a law requiring off-label drug coverage, a patient may not have access to a life-saving medication.
  • It is unclear how affordability and overall cost could affect the standards used to determine medical necessity. These standards could be less comprehensive than what physicians have become accustomed to under the Medicare and Medicaid programs.

Staying Vigilant

The provisions in the Affordable Care Act should enable more Americans to find affordable health care and have better health-care coverage and access to oncology care from qualified health plans sold in the marketplace exchanges, greatly reducing the risk of medical debt or personal bankruptcy, according to the report. However, it is important for all stakeholders—oncologists, practice managers, manufacturers, and patient advocates—to stay involved and advocate at the federal and state levels to ensure that patients with cancer have access to necessary services and quality treatment, said the authors.

The report recommends that at the federal level, ASCO and the Community Oncology Alliance direct such efforts and that ASCO, the Association of Community Cancer Centers, and ASCO state affiliates advocate on the state level to ensure that patient access to oncology care remains intact.

The study authors are employed by HillCo Health.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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