Sen. Jeremy Nordquist of Omaha, who spearheaded the legislation in Nebraska, said the lack of parity in coverage between intravenous and oral chemotherapy medications is a growing problem. Some cancer treatments cost $5,000 to $10,000 a month, and some patients are being forced to pay high out-of-pocket costs for chemotherapy taken orally.
“This … will make life-saving cancer treatments more accessible and affordable for cancer patients,” he said. “The decision about the best course of treatment, whether it be IV chemo or chemo in a pill form, will be made between patients and their doctor, not dictated by their insurance company.”
Nordquist said research shows that when confronted with the reality of high out-of-pocket expenses, many cancer patients forgo expensive therapy and discontinue treatment, in part because they do not want to saddle their families with unmanageable debt.
And because oncologists know how expensive oral medications can be, he said, they often do not prescribe them — even when they think that would be the best option.
The actuarial and benefits consulting firm Milliman Inc. did a study in 2010 that estimated that requiring similar coverage for oral chemotherapy would cost less than $6 a year per person in most insurance plans.
Atrial fibrillation is the most common form of cardiac arrhythmia, better known as an irregular heartbeat. The disorder has significant health and cost concerns for the Medicare population because of its association with an increased risk for stroke and all-cause mortality.
Here is an excerpt highlighting key points from the study entitled “Utilization of Anticoagulation Therapy in Medicare Patients with Nonvalvular Atrial Fibrillation:”
• Patients with atrial fibrillation (AF) are at a significant, 5-fold increased risk for stroke and all cause mortality compared with those without AF.
• Oral anticoagulation therapy is recommended by national guidelines as the cornerstone for stroke prevention in patients with AF.
• Warfarin significantly reduces the risk for ischemic stroke; newer anticoagulant agents have shown even greater reduction of stroke risk compared to warfarin.
• Although AF risk increases with age, this present study shows that anticoagulation therapy is underutilized in Medicare beneficiaries who have nonvalvular AF (NVAF), resulting in an increase in ischemic strokes.
• These findings suggest the need to follow guideline-based anticoagulation recommendations in patients with NVAF to prevent strokes and the associated excess in healthcare costs, reduced quality of life, and even death.
• These findings also raise the need to investigate provider compliance with clinical guidelines regarding oral anticoagulation therapy for stroke prevention in older patients (aged >65 years) with NVAF.
PPACA focuses on expanding coverage and insurance reform, and in some cases it shifts costs from one party to another, but it does not directly affect the unit costs and utilization that are among the major underlying drivers of healthcare costs.
Certain aspects of PPACA have the potential to affect costs. The option to implement an accountable care organization (ACO)13 reprises the managed care movement of the ’80s and ’90s, but with better technology and information, and by transferring the financial risk onto the provider to create an incentive for efficiency. With many potential ACOs already establishing the tools required to succeed,14 this reinvigorated movement is already in motion. The nuts and bolts of an ACO are still the parts needed for a more efficient system.
Most of PPACA’s explicit ACO efforts center on Medicare, and while the Medicare Shared Savings Program (MSSP) and Pioneer Programs will continue, the potential for commercial ACOs15 may prove just as significant.
Accountable care is not a solution to everything that ails the entire healthcare system, but it offers some hope and, to the extent it can meaningfully control unit costs and utilization, it just may work.
People who get traditional IV chemotherapy on an outpatient basis often pay a flat co-payment that covers the drug as well as the cost of administering it. Annual out-of-pocket costs are also typically capped.
Oral anti-cancer medications, on the other hand, are generally considered a pharmacy benefit. Instead of a co-payment, plan members often pay a percentage of the drugs’ cost — up to 50 percent, in some cases — with no annual out-of-pocket limit. And these drugs are expensive, often costing tens of thousands of dollars a year.
In recent years, states have stepped in to address the problem. Since 2007,
19 states and the District have passed laws requiring insurers to provide coverage for oral cancer drugs that is equivalent to infusion drugs, according to the National Patient Advocate Foundation. Five states, including Virginia and Maryland, have passed laws in 2012 alone, and others are considering proposals, according to advocacy groups.
Is oral chemotherapy a cost-effective way to treat cancer? The article addresses this question:
But oral oncology parity laws don’t necessarily drive up costs. According to a 2010 study by benefits consultants Milliman, the estimated cost to most health plans for complying with oral oncology parity laws would be less than 50 cents per member per month.
In July 2012, New York state is scheduled to roll out a mandate that individuals receiving community-based long-term care services funded by Medicaid must enroll in managed long-term care (MLTC) plans. This mandate will be implemented gradually, starting with the five boroughs of New York City.
Provider organizations need to be aware that under this mandate managed long-term care plans are funded using a capitation mechanism in which they receive a lump sum per member from which they must pay most long-term care and other ancillary expenses. The risk shifts from the Medicaid program to the plan. Running a successful managed long-term care plan therefore requires significantly more investment in risk management, financial management, and strategic planning than do fee-for-service arrangements.
Health plans and home healthcare agencies that were successful under fee-for-service reimbursement need to understand and plan for these changes, which will ultimately result in reduced utilization per long-term care patient.
This paper discusses these and other issues pertaining to MLTC plans in New York.