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 AmyDavidoffyaleedu ID: 760036
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Slide1
Coverage, quality, and cost of cancer care under the Affordable Care Act and Medicare reforms
Amy J. Davidoff, PhDCancer Outcomes, Public Policy and Effectiveness Research Center (COPPER), Yale School of Medicine Department of Health Policy and Management, Yale School of Public HealthAmy.Davidoff@yale.edu
Connecticut Cancer Partnership Annual Meeting December 6, 2016
Slide2Disclosures
Research funding from the Pharmaceutical Research and Manufacturers of America Foundation
Consulting and research funding from Celgene Pharmaceuticals (spouse)
Slide3Individuals may experience multiple barriers to cancer care access
Poor access to screeningLimited specialist access => delay in diagnostic confirmation, staging, care planningPoor care coordination => patient slips between the cracks Patient delays or defers therapy due to cost, lack of transportation, social supportsJob loss, leads to insurance loss. Can’t buy private insurance.Early discontinuation of oral therapy due to out-of-pocket costFinancial toxicity
Slide4Outline
Key objectives, provisions of the ACA
Early evidence on ACA coverage
Other provisions of the ACA, Medicare reform
Remaining gaps
Discussion, next steps
Slide5Individual 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 timeExemptions: financial hardship, religious objections, undocumented immigrants, prisoners
Slide6ACA improves insurance access
Dependent coverage mandate (2010)Eliminates health status as barrier to coverageEmployer mandate*Marketplaces: New source of private coveragePublic coverage expansions
* Implementation delayed until 2016
Slide7Buying 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
Slide8Subsidies, 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”
Slide9Medicaid expanded for working-aged adults
Slide10Slide11Income eligibility for insurance options Pre and Post ACA -- Connecticut
Before ACA
Early expansion (2010)
After ACA
(As of June 2016)
Low-income children
aged
0-18
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 or disabled people
Detailed income and assets criteria
Slide12Income eligibility for ACA insurance options
Mcaid expn
Affordable alternative coverage
Marketplace premium tax credits
Marketplace access w/o subsidies
M’caid pre & post ACA
Marketplace premium tax credits
Affordable alternative coverage
Marketplace access w/o subsidies
Adjusted Income as % Federal Poverty Guideline
0%
100%
138%
400%
Medicaid expansion states
States not expanding Medicaid
M’caid
pre-ACA
Elig
gap
Slide13Eligibility for Subsidized Coverage Under the ACA
Source: Medical Expenditure Panel Survey, 2008-2010. Davidoff et al. JNCI 2015
Slide14Eligibility for subsidized coverage varies by state Medicaid expansion status
Source: Medical Expenditure Panel Survey, 2008-2010. Davidoff et al. JNCI 2015
Slide15Evidence of substantial coverage gains for working-aged adults
Between 2010 and March 201621.3 M fewer uninsuredUninsured 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, 201612.7 M enrolled80% 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
Slide16Trends in insurance coverage for working aged cancer survivors
Source: NHIS 2012-2015. Davidoff et al., unpublished.
Slide17Reductions in the Uninsured by Eligibility Category
Source: NHIS 2012-2015. Davidoff et al., unpublished.
Slide18Half 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
Slide19High, increasing prevalence of high deductible plans
Source: NHIS, 2010-2015. Cohen et al., http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201609.pdf
Slide20Protection 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
Slide21Pause
Clarifying questions?
Slide22The ACA also attempts to fix many coverage & delivery system problems
Slide23Improved 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
Slide24States 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
Slide25ACA mandates coverage of routine care for clinical trials
Goal = reduced financial barriers to clinical trial participationHow likely is the impact? 18 states already had similar mandatesOngoing issuesOut-of-network coverageDelays 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
Slide26Downstream availability of biosimilars likely to impact cost of cancer therapy
ACA authorized FDA to approve generic biologic agentsEuropean 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.
Slide27FDA approved biosimilars to date
As of January 21, 2016, 59 proposed biosimilar products to 18 different reference products were enrolled in the Biosimilar Product Development ProgramLikely next: rituximab, trastuzumab, bevacizumab, erythropoietin
Date of FDA ApprovalBiosimilar ProductOriginal ProductMarch 6, 2015Filgrastim-sndz/Zarxiofilgrastim/NeupogenApril 5, 2016infliximab-dyyb/Inflectrainfliximab/RemicadeAugust 30, 2016etanercept-szzs/Erelzietanercept/EnbrelSeptember 23, 2016adalimumab-atto/Amjevitaadalimumab/Humira
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
Slide28Changes 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
Slide29Prescription 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
Slide30Slide31Slide32The 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.
Slide33CMS/CMMI initiatives
$ Penalties for hospital acquired conditions
$ penalties for “avoidable” readmissions
Shared savings models
Accountable Care Organizations (ACOs)
Bundled payment mechanisms
Slide34Medicare 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
Slide35Oncology 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.
Slide36OCM 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
Slide37Medicare 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
Slide38Policy 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
Slide39Questions/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?
Slide40Slide41Federal Poverty Guidelines
Family SizeIncome at 100% FPGIncome at 400% FPG1$11,670$ 46,680319,790$ 79,160527,910$111,640
Source: ASPE 2014 Poverty Guidelines
http://aspe.hhs.gov/poverty/14poverty.cfm
Slide42Uninsured 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.
Slide43Uninsured more likely to be diagnosed with late stage cancer
Source: NCDB 1998-2004. Halpern MT et al. Lancet Oncology 2008.
Slide44Uninsured 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 treatmentAdj OR: 1.95 (95% CI 1.52-2.5)Reduced mortality riskAdj HR: 0.84 (95% CI 0.75-0.94)
Source: SEER, 2007-2009.
Aizer
AA et al. JCO 2014