NIH Public Access Author Manuscript Urol Oncol. Author manuscript; available in PMC 2015 February 01.
NIH-PA Author Manuscript
Published in final edited form as: Urol Oncol. 2014 February ; 32(2): 55–58.
Anticipating the Impact of the Patient Protection and Affordable Care Act for Patients with Urological Cancer Chandy Ellimoottil, MDa and David C. Miller, MD, MPHb aDepartment
of Urology, Loyola University Medical Center, Maywood, IL
bDepartment
of Urology, University of Michigan, Ann Arbor, MI
Abstract
NIH-PA Author Manuscript
The Affordable Care Act seeks to overhaul the US healthcare system by providing insurance for more Americans, improving the quality of healthcare delivery, and reducing healthcare expenditures. While the law’s intent is clear, its implementation and effect on patient care remains largely undefined. Herein, we discuss major components of the ACA, including the proposed insurance expansion, payment and delivery system reforms (e.g. bundled payments and Accountable Care Organizations) and other reforms relevant to the field of urologic oncology. We also discuss how these proposed reforms may impact patients with urological cancers.
Keywords Patient Protection and Affordable Care Act; Affordable Care Act; Urologic Oncology; Accountable Care Organizations; Bundled Payments; Health Care Reform
NIH-PA Author Manuscript
The Patient Protection and Affordable Care Act, often referred to as the Affordable Care Act (ACA), was signed into law on March 23, 2010. This legislation seeks to overhaul the US healthcare system by providing insurance for more Americans, improving the quality of healthcare delivery, and reducing healthcare expenditures. While the law’s intent is clear, its implementation and effect on patient care remains largely undefined. Herein, we discuss major components of the ACA, and consider how these may impact patients with urological cancers.
Insurance expansion Perhaps the most publicized aspect of the ACA is the expansion of insurance coverage, which will affect an estimated 32 million uninsured individuals by 2019. It is estimated that this legislation will increase the percentage of non-elderly insured individuals from 83% to 94%. There are multiple methods proposed in the law to achieve this laudable goal, including the individual mandate, state-based health benefit exchanges, tax credits, penalties to employers who do not provide coverage, expansion of Medicaid, and the protection of individuals with pre-existing conditions (including cancer).
Corresponding Author: Chandy Ellimoottil, Department of Urology, Loyola University Medical Center, 2160 S. First Avenue, Fahey Center, Room 261, Maywood, IL 60153, Tel: 708-216-5098, Fax: 708-216-1699, [email protected].
Ellimoottil and Miller
Page 2
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The impact of insurance coverage on the field of urologic oncology will depend on several factors, including whether or not states and individuals follow the law, and the demographics of the newly insured. Critics argue that the success of the individual mandate will be limited to some extent if individuals choose to pay a penalty rather than obtaining coverage, since the former may be less expensive than insurance premiums. [1] Additionally, while it is estimated that 16 to 20 million additional individuals will be insured by expanding Medicaid eligibility up to 133% of the federal poverty level, many states are reluctant to support the expansion, a fact that could limit greatly the impact of the ACA on access to care. [2]
NIH-PA Author Manuscript
Given that urologic malignancies represent 25% of all cancer diagnoses annually, if some or all of the insurance expansion policies are successful, there may be a significant increase in the number of patients diagnosed and treated with urologic cancer, including many more individuals presenting with early-stage disease. It is important to note, however, that 76% of the current 48 million uninsured are younger than 55 years of age (41.5% are less than 34 years old), and that most urologic cancers occur in older patients. [3] Based on the age demographics of the currently uninsured, therefore, it is anticipated that expanded insurance coverage may lead to greater demand for urological treatment of cancers that affect young patients, such as testicular cancer. While there may be an increase in the number of young patients treated for kidney, bladder, and prostate cancer, given the average age of onset of these cancers, the overall effect will likely be small, as was the case for breast cancer after the Massachusetts insurance reforms. [4]
NIH-PA Author Manuscript
Importantly, expanded insurance coverage may accelerate efforts to address both race/ethnic and socioeconomic disparities in cancer care. At present, race/ethnic minorities comprise a disproportionate fraction of the uninsured population in the United States, and expanded coverage through the ACA may yield greater access to screening and treatment of urological cancers for many historically-underserved communities. In the field prostate cancer, the positive effect of providing care to the previously uninsured and underinsured has been demonstrated through the Improving Access, Counseling and Treatment for Californians with prostate cancer (IMPACT) program. Since 2001, the IMPACT program has provided free treatment to men with prostate cancer and household incomes under 200% of the Federal Poverty Level. Despite the high quality care available to IMPACT patients, the men served by this program still have a higher incidence of metastatic and high risk prostate cancer at the time of diagnosis, which may reflect minimal access to early detection programs prior to enrollment. [5] By providing better access to primary care and early detection opportunities, provisions in the ACA may help narrow this disparity. While the insurance expansion does offer opportunities to improve access to care and reduce socioeconomic disparities, one consequent concern is whether or not the current urologic oncology workforce will be able to handle such increases in demand, particularly in regions that are already underserved by urologic oncologists. Accordingly, one potential unintended consequence of the insurance expansion could be longer wait times for appointments and surgeries. This effect could be offset by efforts aimed at augmenting the urological workforce including, for instance, increasing the number of urologic oncology fellowship
Urol Oncol. Author manuscript; available in PMC 2015 February 01.
Ellimoottil and Miller
Page 3
positions. The ACA, however, does not provide any provisions to fund such expansions in post-graduate education and training.
NIH-PA Author Manuscript
Reimbursement and delivery system reforms The ACA also includes provisions and pilot programs that seek to reform both Medicare reimbursement and the organization of our healthcare delivery system. One high-profile pilot program involves the replacement of traditional fee-for service reimbursement with “bundled payments,” or single predetermined payments for all services (Medicare Part A and Part B) provided during and after an acute inpatient stay. The period covered by the bundled payment is defined as an “episode of care.” [6] At present, there are over 100 hospitals and healthcare systems participating in one of four different bundled payment pilot models. There are high expectations that bundled payment will provide new and powerful incentives for physicians to better coordinate care around hospitalizations, thereby lowering costs (e.g., by reducing duplicative services) and improving quality (e.g., by avoiding readmissions).
NIH-PA Author Manuscript NIH-PA Author Manuscript
While the value of this payment model is being tested through large-scale pilot programs, no urologic cancer surgeries and/or conditions are among the 48 selected to be included in these early assessments. If the bundled payment model is eventually extended more broadly, there could be significant implications for complex urological cancer surgeries such as radical cystectomy. Patients undergoing radical cystectomy tend to require long inpatient stays and have significant post-discharge care requirements. On the one hand, bundled payments may encourage clinicians to streamline care and reduce utilization of discretionary services for these patients. In a study of variation in Medicare payments for major inpatient surgical procedures, hospitals in the high cost quintile had payments that were 10–40% higher than the low cost quintile, even after adjusting for price differences and case-mix. [7] Postdischarge care made up a large portion of this variation in payments. Bundled payments may reduce this variation in unexplained costs by making providers more cost conscious. On the other hand, an unintended consequence of bundled payments could be a reduction in the use of necessary services. For example, use of inpatient consultants, home health care, and skilled nursing services—all of which may be useful for patients who undergoing major cancer surgery—may be discouraged by the bundled payment model. A reduction in postdischarge care can be especially challenging for elderly patients. Once data from the bundled payment pilot programs for similar surgical procedures becomes available, we will be able to better anticipate the net effect of these intended and unintended consequences on urologic cancer episodes. A second reform enacted by the ACA is the development of Accountable Care Organizations (ACO). As defined in the legislation, ACOs represent groups of physicians, hospitals, and/or healthcare systems that collectively accept responsibility for delivering care to a population of at least 5,000 Medicare beneficiaries, with the explicit goal of reducing cost and improving quality of care for these patients. While there is evidence that the greater provider integration promoted by this model can reduce costs and improve care for cancer screening and chronic disease management, these same benefits are not necessarily evident for more complex hospital-based care. [8] Assuming that they are implemented widely,
Urol Oncol. Author manuscript; available in PMC 2015 February 01.
Ellimoottil and Miller
Page 4
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there are several potential implications of ACOs for the delivery and outcomes of urological cancer care, including initial treatment decisions, survivorship care, and end-of-life care. For example, with cost savings in mind, physicians in ACOs will be motivated to enhance communication and reduce unnecessary and duplicative diagnostic and surveillance imaging. At the same time, there are some concerns with the ACO model. For example, there may be new incentives for both primary care physicians and specialists to discourage the use of expensive technology and treatments, such as robotic surgery or novel therapies for castrate-resistant prostate cancer. Additionally, certain ACOs may limit access to expensive cancer-focused hospitals. It is well known that there is a wide variation in quality of care and outcomes for oncologic surgery across hospitals. Cancer-focused hospitals tend to have larger oncologic case volumes and more specialized expertise and resources that may ultimately translate into better clinical outcomes. If patients are restricted ACOs from obtaining care at a cancer-focused hospital, they may miss out on the potential benefits associated with treatment in such facilities. At present, it is unclear whether the benefits of the “focused factory” model outweigh the improved quality of care that may come from the greater local delivery system integration that will be encouraged by ACO formation. Similar to the bundled payment models, we will have to wait for data from the numerous ACO pilot projects in order to make this assessment. Another delivery reform included in the law is the establishment of Patient-Centered Medical Homes (PCMH). In this model, selected physicians are empowered with additional resources and incentives that support greater care coordination between specialists, physician extenders, and family members. [9] Pilot programs for PCMH have largely focused on primary care physicians as the logical center of care coordination efforts, and these programs have shown that PCMHs are efficient models for chronic disease management. PCMHs might benefit patients with urologic malignancies in two ways. First, seventy-five percent of Medicare patients have three or more chronic conditions, and better management of these conditions may yield longer overall survival for patients with urological cancers [10]. Second, it is plausible that interested urologic oncologists could play a role as the central PCMH physician in instances where a genitourinary cancer is the primary health problem for a patient (e.g. patients on active surveillance for prostate cancer or longitudinal care after radical cystectomy). [11]
NIH-PA Author Manuscript
Other reforms relevant to urologic cancer patients Several other reforms in the ACA are notable from the perspective of urologic oncology. First, starting in 2014, health insurers will be mandated to cover routine costs for oncology patients in clinical trials. By removing this financial barrier, the legislation will likely improve access to and enrollment in clinical trials, particularly for low-income populations. [12] Second, the ACA created new sources for research funding that could greatly advance the field of urological oncology. There is a strong emphasis on cost-effectiveness research (CER), which will help urologic oncologists and their patients make better treatment decisions. The Patient-Centered Outcomes Research Institute (PCORI) was developed and commissioned through the ACA and, currently, there are several funded projects investigating patient preferences, educational tools, and comparative effectiveness of treatments related to prostate cancer. Third, the ACA is focused on reducing cancer
Urol Oncol. Author manuscript; available in PMC 2015 February 01.
Ellimoottil and Miller
Page 5
NIH-PA Author Manuscript
disparities, with provisions to increase funding for community health centers that serve a high percentage of low income and minority patients. While this extra funding can improve care through cancer screening and identify patients with urologic cancers, it will be important for these centers to have access to specialty care to achieve optimal outcomes. [9] Finally, the ACA places an emphasis on public reporting of quality data. For example, the Hospital Value-Based Purchasing (VBP) program links hospital reimbursement with performance on clinical process and outcome measures, as well as patient satisfaction. Between now and 2015, approximately 26 measures will be introduced to better measure hospital performance as part of the VBP program. Furthermore, for cancer hospitals currently designated as Prospective Payment System (PPS)-exempt, the ACA mandates data submission for specific clinical process of care measures beginning in fiscal year 2014. While the current focus of the PPS-Exempt Quality Reporting program (PCHQR) is around patients with breast and colon cancer, similar quality measures will almost certainly be developed for patients with urological cancers. The public reporting of quality information may help patients with urological cancers make better informed decisions about where to obtain care.
NIH-PA Author Manuscript
Conclusion
NIH-PA Author Manuscript
Over the next several years, we will witness a broad range of changes to the current healthcare system as a result of the ACA: these changes are intended to create a healthcare system that delivers more accessible and higher value care. The provisions for insurance expansion will likely expand the pool of patients seeking urologic cancer care, however the anticipated volume of patients will depend on the whether patients obey the individual mandate and the demographics of the newly insured. The insurance expansion has the potential to reduce race/ethnic and socioeconomic disparities in cancer care. In addition, many hospitals and providers are already participating programs based on the payment and delivery system reforms in the ACA, including bundled payments and Accountable Care Organizations. It is too early, however, to predict whether or not these new models will lead to better clinical outcomes and greater cost efficiency than current models of care delivery. Finally, given the strong focus of the ACA on public reporting of quality and CER, we anticipate that the urologic cancer care (in and out of the hospital) will be increasingly evaluated by the government, patients and ourselves. While the net effect of all the changes implemented with the ACA is difficult to predict, its intentions are aligned with the goal of most urologic oncologists—to provide high quality, cost-effective and accessible care for our patients.
References 1. Wilensky GR. The shortfalls of “Obamacare”. N Engl J Med. 2012 Oct 18; 367(16):1479–81. [PubMed: 23050511] 2. Sommers BD, Epstein AM. U.S. governors and the Medicaid expansion--no quick resolution in sight. N Engl J Med. 2013 Feb 7; 368(6):496–9. [PubMed: 23323866] 3. Audience Segmentation for the Emerging Health Insurance Marketplace. Centers for Medicare and Medicaid Services; Baltimore, MD: http://www.healthreformgps.org/wp-content/uploads/ cms-3-26.pdf [Accessed April 15, 2013]
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4. Keating NL, Kouri EM, He Y, West DW, Winer EP. Effect of Massachusetts health insurance reform on mammography use and breast cancer stage at diagnosis. Cancer. 2013 Jan 15; 119(2): 250–8. [PubMed: 22833148] 5. Miller DC, Litwin MS, Bergman J. Prostate cancer severity among low income, uninsured men. J Urol. 2009 Feb; 181(2):579–83. [PubMed: 19100580] 6. Albright HW, Moreno M, Feeley TW. The implications of the 2010 Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act on cancer care delivery. Cancer. 2011 Apr 15; 117(8):1564–74. [PubMed: 21472704] 7. Miller DC, Gust C, Dimick JB. Large variations in Medicare payments for surgery highlight savings potential from bundled payment programs. Health Aff (Millwood). 2011 Nov; 30(11):2107–15. [PubMed: 22068403] 8. Miller DC, Ye Z, Gust C, Birkmeyer JD. Anticipating the Effects of Accountable Care Organizations for Inpatient Surgery. JAMA Surg. 2013 Feb.20:1–6. 9. Moy B, Polite BN, Halpern MT, Stranne SK. American Society of Clinical Oncology policy statement: opportunities in the patient protection and affordable care act to reduce cancer care disparities. J Clin Oncol. 2011 Oct 1; 29(28):3816–24. [PubMed: 21810680] 10. Enthoven AC, Crosson FJ, Shortell SM. ‘Redefining health care’: medical homes or archipelagos to navigate? Health Aff (Millwood). 2007 Sep-Oct;26(5):1366–72. [PubMed: 17848447] 11. Sakshaug JW, Miller DC, Hollenbeck BK. Urologists and the Patient-Centered Medical Home. J Urol. 2013 Apr 9. 12. Keegan KA, Penson DF. The patient protection and affordable care act: The impact on urologic cancer care. Urol Oncol. 2012 Jul 21.
NIH-PA Author Manuscript Urol Oncol. Author manuscript; available in PMC 2015 February 01.
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NIH-PA Author Manuscript Strong emphasis on cost-effectiveness research (CER), which will help urologic oncologists and their patients make better treatment decisions The Patient-Centered Outcomes Research Institute (PCORI) provides funding for investigators interested in studying patient preferences, educational tools, and comparative effectiveness of treatments related to urologic malignancies
•
PCP as the center of care may be beneficial for patients with urologic malignancies who also have multiple comorbidities •
•
Pilot programs for PCMH have largely focused on primary care physicians as center of care, however oncologists and urologists may be able to serve as the center of care in select cases •
Health insurers are mandated to cover routine costs for oncology patients in clinical trials and they cannot deny insurance to patients who have cancer as a preexisting condition
ACOs may limit access to expensive cancer-focused hospitals, which may lead to worse oncologic outcomes •
•
There may be new disincentives for both primary care physicians and specialists to encourage the use of expensive technology and treatments, such as robotic surgery or novel therapies for castrate-resistant prostate cancer •
Other reforms relevant to urologic cancer patients
Selected physicians are empowered with additional resources and incentives that support greater care coordination between specialists, physician extenders, and family members
May help reduce duplicative diagnostic and surveillance imaging in the treatment of urologic cancers
Potential targets include costly inpatient procedures such as radical cystectomy and nephrectomy
•
•
Current BP pilots do not include urologic cancer surgeries and/or conditions
May reduce race/ethnic and socioeconomic disparities in cancer care
• •
Smaller impact in urologic oncology than other fields other fields because 76% of the current 48 million uninsured are younger than 55 years of age
Expected increase in the number of patients diagnosed and treated with urologic cancer, including many more individuals presenting with early-stage disease and cancers that young patients such as testicular cancer
•
•
Impact will depend on whether or not individuals follow the individual mandate and states expand Medicaid
•
Impact on urologic oncology
•
May motivate providers to enhance communication and reduce unnecessary and duplicative services
Pilot programs are currently being tested across the country
•
•
May reduce unnecessary and duplicative services, however, may also cause skimping of necessary services.
•
Group of physicians, hospitals, and/or healthcare systems that collectively accept responsibility for delivering care to a population of at least 5,000 Medicare beneficiaries
May provide incentives for physicians to better coordinate care, lower costs and improve quality
•
•
Lump sum reimbursement for an acute hospitalization and all charges up to 30 days after discharge
Mechanisms include individual mandate, state-based health benefit exchanges, tax credits, penalties to employers who do not provide coverage, expansion of Medicaid, and the protection of individuals with pre-existing conditions (including cancer)
•
•
25 million Americans are expected to gain insurance by 2017
•
Description
Patient-Centered Medical Homes (PCMH)
Accountable Care Organizations (ACO)
Bundled payments (BP)
Insurance expansion
Provision
Key provisions in the Affordable Care Act and potential implications for urologic oncology
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TABLE 1 Ellimoottil and Miller Page 7
Urol Oncol. Author manuscript; available in PMC 2015 February 01.
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Published in final edited form as: Urol Oncol. 2014 February ; 32(2): 55–58.
Anticipating the Impact of the Patient Protection and Affordable Care Act for Patients with Urological Cancer Chandy Ellimoottil, MDa and David C. Miller, MD, MPHb aDepartment
of Urology, Loyola University Medical Center, Maywood, IL
bDepartment
of Urology, University of Michigan, Ann Arbor, MI
Abstract
NIH-PA Author Manuscript
The Affordable Care Act seeks to overhaul the US healthcare system by providing insurance for more Americans, improving the quality of healthcare delivery, and reducing healthcare expenditures. While the law’s intent is clear, its implementation and effect on patient care remains largely undefined. Herein, we discuss major components of the ACA, including the proposed insurance expansion, payment and delivery system reforms (e.g. bundled payments and Accountable Care Organizations) and other reforms relevant to the field of urologic oncology. We also discuss how these proposed reforms may impact patients with urological cancers.
Keywords Patient Protection and Affordable Care Act; Affordable Care Act; Urologic Oncology; Accountable Care Organizations; Bundled Payments; Health Care Reform
NIH-PA Author Manuscript
The Patient Protection and Affordable Care Act, often referred to as the Affordable Care Act (ACA), was signed into law on March 23, 2010. This legislation seeks to overhaul the US healthcare system by providing insurance for more Americans, improving the quality of healthcare delivery, and reducing healthcare expenditures. While the law’s intent is clear, its implementation and effect on patient care remains largely undefined. Herein, we discuss major components of the ACA, and consider how these may impact patients with urological cancers.
Insurance expansion Perhaps the most publicized aspect of the ACA is the expansion of insurance coverage, which will affect an estimated 32 million uninsured individuals by 2019. It is estimated that this legislation will increase the percentage of non-elderly insured individuals from 83% to 94%. There are multiple methods proposed in the law to achieve this laudable goal, including the individual mandate, state-based health benefit exchanges, tax credits, penalties to employers who do not provide coverage, expansion of Medicaid, and the protection of individuals with pre-existing conditions (including cancer).
Corresponding Author: Chandy Ellimoottil, Department of Urology, Loyola University Medical Center, 2160 S. First Avenue, Fahey Center, Room 261, Maywood, IL 60153, Tel: 708-216-5098, Fax: 708-216-1699, [email protected].
Ellimoottil and Miller
Page 2
NIH-PA Author Manuscript
The impact of insurance coverage on the field of urologic oncology will depend on several factors, including whether or not states and individuals follow the law, and the demographics of the newly insured. Critics argue that the success of the individual mandate will be limited to some extent if individuals choose to pay a penalty rather than obtaining coverage, since the former may be less expensive than insurance premiums. [1] Additionally, while it is estimated that 16 to 20 million additional individuals will be insured by expanding Medicaid eligibility up to 133% of the federal poverty level, many states are reluctant to support the expansion, a fact that could limit greatly the impact of the ACA on access to care. [2]
NIH-PA Author Manuscript
Given that urologic malignancies represent 25% of all cancer diagnoses annually, if some or all of the insurance expansion policies are successful, there may be a significant increase in the number of patients diagnosed and treated with urologic cancer, including many more individuals presenting with early-stage disease. It is important to note, however, that 76% of the current 48 million uninsured are younger than 55 years of age (41.5% are less than 34 years old), and that most urologic cancers occur in older patients. [3] Based on the age demographics of the currently uninsured, therefore, it is anticipated that expanded insurance coverage may lead to greater demand for urological treatment of cancers that affect young patients, such as testicular cancer. While there may be an increase in the number of young patients treated for kidney, bladder, and prostate cancer, given the average age of onset of these cancers, the overall effect will likely be small, as was the case for breast cancer after the Massachusetts insurance reforms. [4]
NIH-PA Author Manuscript
Importantly, expanded insurance coverage may accelerate efforts to address both race/ethnic and socioeconomic disparities in cancer care. At present, race/ethnic minorities comprise a disproportionate fraction of the uninsured population in the United States, and expanded coverage through the ACA may yield greater access to screening and treatment of urological cancers for many historically-underserved communities. In the field prostate cancer, the positive effect of providing care to the previously uninsured and underinsured has been demonstrated through the Improving Access, Counseling and Treatment for Californians with prostate cancer (IMPACT) program. Since 2001, the IMPACT program has provided free treatment to men with prostate cancer and household incomes under 200% of the Federal Poverty Level. Despite the high quality care available to IMPACT patients, the men served by this program still have a higher incidence of metastatic and high risk prostate cancer at the time of diagnosis, which may reflect minimal access to early detection programs prior to enrollment. [5] By providing better access to primary care and early detection opportunities, provisions in the ACA may help narrow this disparity. While the insurance expansion does offer opportunities to improve access to care and reduce socioeconomic disparities, one consequent concern is whether or not the current urologic oncology workforce will be able to handle such increases in demand, particularly in regions that are already underserved by urologic oncologists. Accordingly, one potential unintended consequence of the insurance expansion could be longer wait times for appointments and surgeries. This effect could be offset by efforts aimed at augmenting the urological workforce including, for instance, increasing the number of urologic oncology fellowship
Urol Oncol. Author manuscript; available in PMC 2015 February 01.
Ellimoottil and Miller
Page 3
positions. The ACA, however, does not provide any provisions to fund such expansions in post-graduate education and training.
NIH-PA Author Manuscript
Reimbursement and delivery system reforms The ACA also includes provisions and pilot programs that seek to reform both Medicare reimbursement and the organization of our healthcare delivery system. One high-profile pilot program involves the replacement of traditional fee-for service reimbursement with “bundled payments,” or single predetermined payments for all services (Medicare Part A and Part B) provided during and after an acute inpatient stay. The period covered by the bundled payment is defined as an “episode of care.” [6] At present, there are over 100 hospitals and healthcare systems participating in one of four different bundled payment pilot models. There are high expectations that bundled payment will provide new and powerful incentives for physicians to better coordinate care around hospitalizations, thereby lowering costs (e.g., by reducing duplicative services) and improving quality (e.g., by avoiding readmissions).
NIH-PA Author Manuscript NIH-PA Author Manuscript
While the value of this payment model is being tested through large-scale pilot programs, no urologic cancer surgeries and/or conditions are among the 48 selected to be included in these early assessments. If the bundled payment model is eventually extended more broadly, there could be significant implications for complex urological cancer surgeries such as radical cystectomy. Patients undergoing radical cystectomy tend to require long inpatient stays and have significant post-discharge care requirements. On the one hand, bundled payments may encourage clinicians to streamline care and reduce utilization of discretionary services for these patients. In a study of variation in Medicare payments for major inpatient surgical procedures, hospitals in the high cost quintile had payments that were 10–40% higher than the low cost quintile, even after adjusting for price differences and case-mix. [7] Postdischarge care made up a large portion of this variation in payments. Bundled payments may reduce this variation in unexplained costs by making providers more cost conscious. On the other hand, an unintended consequence of bundled payments could be a reduction in the use of necessary services. For example, use of inpatient consultants, home health care, and skilled nursing services—all of which may be useful for patients who undergoing major cancer surgery—may be discouraged by the bundled payment model. A reduction in postdischarge care can be especially challenging for elderly patients. Once data from the bundled payment pilot programs for similar surgical procedures becomes available, we will be able to better anticipate the net effect of these intended and unintended consequences on urologic cancer episodes. A second reform enacted by the ACA is the development of Accountable Care Organizations (ACO). As defined in the legislation, ACOs represent groups of physicians, hospitals, and/or healthcare systems that collectively accept responsibility for delivering care to a population of at least 5,000 Medicare beneficiaries, with the explicit goal of reducing cost and improving quality of care for these patients. While there is evidence that the greater provider integration promoted by this model can reduce costs and improve care for cancer screening and chronic disease management, these same benefits are not necessarily evident for more complex hospital-based care. [8] Assuming that they are implemented widely,
Urol Oncol. Author manuscript; available in PMC 2015 February 01.
Ellimoottil and Miller
Page 4
NIH-PA Author Manuscript NIH-PA Author Manuscript
there are several potential implications of ACOs for the delivery and outcomes of urological cancer care, including initial treatment decisions, survivorship care, and end-of-life care. For example, with cost savings in mind, physicians in ACOs will be motivated to enhance communication and reduce unnecessary and duplicative diagnostic and surveillance imaging. At the same time, there are some concerns with the ACO model. For example, there may be new incentives for both primary care physicians and specialists to discourage the use of expensive technology and treatments, such as robotic surgery or novel therapies for castrate-resistant prostate cancer. Additionally, certain ACOs may limit access to expensive cancer-focused hospitals. It is well known that there is a wide variation in quality of care and outcomes for oncologic surgery across hospitals. Cancer-focused hospitals tend to have larger oncologic case volumes and more specialized expertise and resources that may ultimately translate into better clinical outcomes. If patients are restricted ACOs from obtaining care at a cancer-focused hospital, they may miss out on the potential benefits associated with treatment in such facilities. At present, it is unclear whether the benefits of the “focused factory” model outweigh the improved quality of care that may come from the greater local delivery system integration that will be encouraged by ACO formation. Similar to the bundled payment models, we will have to wait for data from the numerous ACO pilot projects in order to make this assessment. Another delivery reform included in the law is the establishment of Patient-Centered Medical Homes (PCMH). In this model, selected physicians are empowered with additional resources and incentives that support greater care coordination between specialists, physician extenders, and family members. [9] Pilot programs for PCMH have largely focused on primary care physicians as the logical center of care coordination efforts, and these programs have shown that PCMHs are efficient models for chronic disease management. PCMHs might benefit patients with urologic malignancies in two ways. First, seventy-five percent of Medicare patients have three or more chronic conditions, and better management of these conditions may yield longer overall survival for patients with urological cancers [10]. Second, it is plausible that interested urologic oncologists could play a role as the central PCMH physician in instances where a genitourinary cancer is the primary health problem for a patient (e.g. patients on active surveillance for prostate cancer or longitudinal care after radical cystectomy). [11]
NIH-PA Author Manuscript
Other reforms relevant to urologic cancer patients Several other reforms in the ACA are notable from the perspective of urologic oncology. First, starting in 2014, health insurers will be mandated to cover routine costs for oncology patients in clinical trials. By removing this financial barrier, the legislation will likely improve access to and enrollment in clinical trials, particularly for low-income populations. [12] Second, the ACA created new sources for research funding that could greatly advance the field of urological oncology. There is a strong emphasis on cost-effectiveness research (CER), which will help urologic oncologists and their patients make better treatment decisions. The Patient-Centered Outcomes Research Institute (PCORI) was developed and commissioned through the ACA and, currently, there are several funded projects investigating patient preferences, educational tools, and comparative effectiveness of treatments related to prostate cancer. Third, the ACA is focused on reducing cancer
Urol Oncol. Author manuscript; available in PMC 2015 February 01.
Ellimoottil and Miller
Page 5
NIH-PA Author Manuscript
disparities, with provisions to increase funding for community health centers that serve a high percentage of low income and minority patients. While this extra funding can improve care through cancer screening and identify patients with urologic cancers, it will be important for these centers to have access to specialty care to achieve optimal outcomes. [9] Finally, the ACA places an emphasis on public reporting of quality data. For example, the Hospital Value-Based Purchasing (VBP) program links hospital reimbursement with performance on clinical process and outcome measures, as well as patient satisfaction. Between now and 2015, approximately 26 measures will be introduced to better measure hospital performance as part of the VBP program. Furthermore, for cancer hospitals currently designated as Prospective Payment System (PPS)-exempt, the ACA mandates data submission for specific clinical process of care measures beginning in fiscal year 2014. While the current focus of the PPS-Exempt Quality Reporting program (PCHQR) is around patients with breast and colon cancer, similar quality measures will almost certainly be developed for patients with urological cancers. The public reporting of quality information may help patients with urological cancers make better informed decisions about where to obtain care.
NIH-PA Author Manuscript
Conclusion
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Over the next several years, we will witness a broad range of changes to the current healthcare system as a result of the ACA: these changes are intended to create a healthcare system that delivers more accessible and higher value care. The provisions for insurance expansion will likely expand the pool of patients seeking urologic cancer care, however the anticipated volume of patients will depend on the whether patients obey the individual mandate and the demographics of the newly insured. The insurance expansion has the potential to reduce race/ethnic and socioeconomic disparities in cancer care. In addition, many hospitals and providers are already participating programs based on the payment and delivery system reforms in the ACA, including bundled payments and Accountable Care Organizations. It is too early, however, to predict whether or not these new models will lead to better clinical outcomes and greater cost efficiency than current models of care delivery. Finally, given the strong focus of the ACA on public reporting of quality and CER, we anticipate that the urologic cancer care (in and out of the hospital) will be increasingly evaluated by the government, patients and ourselves. While the net effect of all the changes implemented with the ACA is difficult to predict, its intentions are aligned with the goal of most urologic oncologists—to provide high quality, cost-effective and accessible care for our patients.
References 1. Wilensky GR. The shortfalls of “Obamacare”. N Engl J Med. 2012 Oct 18; 367(16):1479–81. [PubMed: 23050511] 2. Sommers BD, Epstein AM. U.S. governors and the Medicaid expansion--no quick resolution in sight. N Engl J Med. 2013 Feb 7; 368(6):496–9. [PubMed: 23323866] 3. Audience Segmentation for the Emerging Health Insurance Marketplace. Centers for Medicare and Medicaid Services; Baltimore, MD: http://www.healthreformgps.org/wp-content/uploads/ cms-3-26.pdf [Accessed April 15, 2013]
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4. Keating NL, Kouri EM, He Y, West DW, Winer EP. Effect of Massachusetts health insurance reform on mammography use and breast cancer stage at diagnosis. Cancer. 2013 Jan 15; 119(2): 250–8. [PubMed: 22833148] 5. Miller DC, Litwin MS, Bergman J. Prostate cancer severity among low income, uninsured men. J Urol. 2009 Feb; 181(2):579–83. [PubMed: 19100580] 6. Albright HW, Moreno M, Feeley TW. The implications of the 2010 Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act on cancer care delivery. Cancer. 2011 Apr 15; 117(8):1564–74. [PubMed: 21472704] 7. Miller DC, Gust C, Dimick JB. Large variations in Medicare payments for surgery highlight savings potential from bundled payment programs. Health Aff (Millwood). 2011 Nov; 30(11):2107–15. [PubMed: 22068403] 8. Miller DC, Ye Z, Gust C, Birkmeyer JD. Anticipating the Effects of Accountable Care Organizations for Inpatient Surgery. JAMA Surg. 2013 Feb.20:1–6. 9. Moy B, Polite BN, Halpern MT, Stranne SK. American Society of Clinical Oncology policy statement: opportunities in the patient protection and affordable care act to reduce cancer care disparities. J Clin Oncol. 2011 Oct 1; 29(28):3816–24. [PubMed: 21810680] 10. Enthoven AC, Crosson FJ, Shortell SM. ‘Redefining health care’: medical homes or archipelagos to navigate? Health Aff (Millwood). 2007 Sep-Oct;26(5):1366–72. [PubMed: 17848447] 11. Sakshaug JW, Miller DC, Hollenbeck BK. Urologists and the Patient-Centered Medical Home. J Urol. 2013 Apr 9. 12. Keegan KA, Penson DF. The patient protection and affordable care act: The impact on urologic cancer care. Urol Oncol. 2012 Jul 21.
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NIH-PA Author Manuscript Strong emphasis on cost-effectiveness research (CER), which will help urologic oncologists and their patients make better treatment decisions The Patient-Centered Outcomes Research Institute (PCORI) provides funding for investigators interested in studying patient preferences, educational tools, and comparative effectiveness of treatments related to urologic malignancies
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PCP as the center of care may be beneficial for patients with urologic malignancies who also have multiple comorbidities •
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Pilot programs for PCMH have largely focused on primary care physicians as center of care, however oncologists and urologists may be able to serve as the center of care in select cases •
Health insurers are mandated to cover routine costs for oncology patients in clinical trials and they cannot deny insurance to patients who have cancer as a preexisting condition
ACOs may limit access to expensive cancer-focused hospitals, which may lead to worse oncologic outcomes •
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There may be new disincentives for both primary care physicians and specialists to encourage the use of expensive technology and treatments, such as robotic surgery or novel therapies for castrate-resistant prostate cancer •
Other reforms relevant to urologic cancer patients
Selected physicians are empowered with additional resources and incentives that support greater care coordination between specialists, physician extenders, and family members
May help reduce duplicative diagnostic and surveillance imaging in the treatment of urologic cancers
Potential targets include costly inpatient procedures such as radical cystectomy and nephrectomy
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Current BP pilots do not include urologic cancer surgeries and/or conditions
May reduce race/ethnic and socioeconomic disparities in cancer care
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Smaller impact in urologic oncology than other fields other fields because 76% of the current 48 million uninsured are younger than 55 years of age
Expected increase in the number of patients diagnosed and treated with urologic cancer, including many more individuals presenting with early-stage disease and cancers that young patients such as testicular cancer
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Impact will depend on whether or not individuals follow the individual mandate and states expand Medicaid
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Impact on urologic oncology
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May motivate providers to enhance communication and reduce unnecessary and duplicative services
Pilot programs are currently being tested across the country
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May reduce unnecessary and duplicative services, however, may also cause skimping of necessary services.
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Group of physicians, hospitals, and/or healthcare systems that collectively accept responsibility for delivering care to a population of at least 5,000 Medicare beneficiaries
May provide incentives for physicians to better coordinate care, lower costs and improve quality
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Lump sum reimbursement for an acute hospitalization and all charges up to 30 days after discharge
Mechanisms include individual mandate, state-based health benefit exchanges, tax credits, penalties to employers who do not provide coverage, expansion of Medicaid, and the protection of individuals with pre-existing conditions (including cancer)
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25 million Americans are expected to gain insurance by 2017
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Description
Patient-Centered Medical Homes (PCMH)
Accountable Care Organizations (ACO)
Bundled payments (BP)
Insurance expansion
Provision
Key provisions in the Affordable Care Act and potential implications for urologic oncology
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