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Old 06-28-2013, 12:20 PM
gdpawel gdpawel is offline
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Default What's Really in the Affordable Care Act

John E. McDonough, DPh, MPA
Professor of Health Policy and Management
Harvard University School of Public Health
Boston, Massachusetts


The Patient Protection and Affordable Care Act (ACA) was signed into law on March 23, 2010 by President Obama. Some love it, others hate it, but many people have only a vague idea of what's in the almost 2000-page law. John McDonough, DPh, MPA, a Professor of Health Policy and Management at Harvard University School of Public Health, was invited by Senator Ted Kennedy to participate in the committee that helped draft the law. In his book, Inside National Health Reform, McDonough offers a look at the ACA many haven't seen. It breaks down the law according to the 10 Titles that comprise it, offering an easy-to-follow guide of the changes affecting the insurance and medical industries, as well as patients, and when these changes will happen. Here is an overview of the titles as explained in the book.

Title I. Quality, Affordable Health Care for All Americans

This title fundamentally changes the nature and operation of private health insurance in the United States. Beginning in 2014, no health insurer will be able to sell or rate coverage based on an individual''s medical history; most Americans will be required to obtain health insurance; and substantial financial subsidies will be available to low- and moderate-income Americans to help them afford the cost of health insurance. Most states will operate new "health insurance exchanges" to make shopping for health insurance easier. Small businesses and individuals can shop these insurance exchanges for competitive rates. Other important changes in health insurance, including the banning of lifetime and annual benefit limits, were implemented in 2010.

Title II. The Role of Public Programs

This title creates substantial changes to Medicaid, the federal-state program for many low-income persons. Beginning in 2014, all lower-income individuals will be eligible to enroll in their state's Medicaid program, not just those who fit into categories such as disabled, children, or parents. For the first time, Medicaid will become a more uniform national program with uniform eligibility and enrollment standards as well as quality improvement requirements.

Title III. Improving the Quality and Efficiency of Health Care

This title establishes new mechanisms to improve the quality of medical care in the United States by making it more efficient and effective, and more patient-centered. Medicare will be improved with the addition of new preventive benefits for enrollees; and the Medicare Part D drug benefit will be made more affordable by closing the coverage gap known as the "donut hole." Medicare's rate of growth will be lowered to provide about $450 billion in savings between 2010 and 2019, which should fund about half the cost of the ACA.

Title IV. Prevention of Chronic Disease and the Improvement of Public Health

Title IV is the most ambitious law ever passed to promote healthier lifestyles for all Americans and to prevent disease and disability. A National Prevention, Health Promotion, and Public Health Council will devise a national prevention strategy, backed up by a $13 billion Trust Fund. Evidence-based clinical preventive services will be provided in most public and private health insurance policies without cost-sharing. Chain restaurants will be required to post the calorie content of their foods.

Title V. Healthcare Workforce

This title establishes a National Healthcare Workforce Commission to analyze and plan for workforce needs and to make recommendations to congress and the administration. Support is provided to expand the healthcare workforce, especially in primary care. Major expansions for community health centers and the National Health Service Corps are funded.

Title VI. Transparency and Program Integrity

Title VI provides new authority to federal and state agencies to combat fraud and abuse in Medicare, Medicaid, and private health insurance. Drug companies and medical suppliers will report most gifts and other gratuities to physicians for public release on a federal Website. The Patient Centered Outcomes Research Institute is established as a public-private entity to support research on comparative clinical effectiveness. New transparency requirements on the nursing home industry will provide information to protect and empower patients and their families. The Elder Justice Act provides a national framework to combat violence, neglect, and financial exploitation of senior citizens.

Title VII. Improving Access to Innovative Medical Therapies

This title directs the US Food and Drug Administration to develop a regulatory pathway to permit the development, manufacture, marketing, and sale of biosimilar biologic products, generic-like versions of biopharmaceutical drugs. It also ends anticompetitive efforts to keep generic drugs off the market, and offers drug discounts to hospitals and communities that serve low-income patients.

Title VIII. CLASS: Community Living Assistance Supports and Services

This title authorizes a new national and voluntary long-term disability insurance program to provide workers with daily cash payments and support if they become permanently and temporarily disabled. People who enroll in CLASS must pay premiums for a minimum of 5 years. The funding is flexible and can be used for a range of services. No tax money will be used to fund this program. Its only permitted financing source -- enrollee premiums -- must be sufficient for at least 75 years if the Health and Human Services Secretary is to launch the program.

Editor's Note: The Obama administration announced on October 15 that it was abandoning plans for CLASS. Congress is expected to quickly draft legislation to repeal the provisions of this title.

Title IX. Revenue Provisions

This section covers the financing for slightly less than half the cost of the ACA. Key provisions establish new Medicare taxes on high-income wage earners, as well as new taxes on pharmaceutical manufacturers, health insurance providers, and medical device manufacturers. Also included is an excise tax on high-cost, employer-provided health insurance; changes to health savings accounts and other individual health accounts; and a 10% tax on indoor tanning services.

Title X. Strengthening Quality, Affordable Healthcare for All Americans

The final title in the act is the "Manager's Amendment," which includes amendments and additions to Titles I-IX, reflecting the unusual legislative process leading to passage of the ACA. Additional changes to Titles I-X were approved in a separate measure called the Health Care and Education Reconciliation Act (HCERA) signed into law by President Obama 1 week after he signed the base law on March 23, 2010. This title also reauthorizes the Indian Health Care Improvement Act, which provides healthcare to American Indians and Alaskan natives.

John E. McDonough, DPh, MPA, has disclosed no relevant financial relationships.

Citation: "What's Really in the Affordable Care Act." Medscape Oncology, John E. McDonough, DPh, MPA, June 27, 2013
Gregory D. Pawelski
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Old 06-28-2013, 12:28 PM
gdpawel gdpawel is offline
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Default Eric J. Topol, M.D. asks Kathleen Sebelius, MPA Five ACA Questions

Medscape Editor-in-Chief Eric J. Topol, MD, questioned Secretary of Health and Human Services (HHS) Kathleen Sebelius about the act's effect on medical technology, clinical trial participation, genetic testing, primary care, and patient safety.

Dr. Topol: We are experiencing a digital revolution in which technological advances are putting healthcare where it should be: in the hands of patients. How is the ACA helping to foster medical innovation?

Secretary Sebelius: A recent New York Times column, "Obamacare's Other Surprise,"[1] by Thomas L. Friedman, echoes what we've been hearing from healthcare providers and innovators: Data that support medical decision-making and collaboration, dovetailing with new tools in the Affordable Care Act, are spurring the innovation necessary to deliver improved healthcare for more people at affordable prices.

Today we are focused on driving a smarter healthcare system with an emphasis on the quality -- not quantity -- of care. The healthcare law includes many tools to increase transparency, avoid costly mistakes and hospital readmissions, keep patients healthy, and test new payment and care delivery models, like Accountable Care Organizations (ACOs). Health information technology is a critical underpinning to this larger strategy.

In May we reached an important milestone in the adoption of health information technology. More than half of all doctors and other eligible providers, and nearly 80% of hospitals, are using electronic health records (EHRs) to improve care, an increase of at least 200% since 2008. Also in May, we announced a $1 billion challenge to help jump-start innovative projects that test creative ways to deliver high-quality medical care and lower costs to people enrolled in Medicare and Medicaid, following 81 Health Care Innovation Awards that HHS awarded last year.

Dr. Topol: Physicians have long lamented the lack of participation by patients in clinical trials, but the ACA is opening the door for greater participation by allowing patients to keep their health insurance while participating in clinical research. Are patients even aware that this provision now exists? How do you see it affecting clinical trial participation in the future?

Secretary Sebelius: In 2014, thanks to the ACA, insurance companies will no longer be able to deny patients from participating in an approved clinical trial for treatment of cancer or another life-threatening disease or condition, nor can they deny or limit the coverage of routine patient costs for items or services in connection with trial participation. For many patients, access to cutting-edge medicine available through clinical trials can increase their likelihood of survival. This is an important protection for patients that not only could have a life-altering impact, but it's also one that serves to facilitate participation in research that is critical to expanding our knowledge base and finding cures and treatments for those illnesses that threaten the lives of Americans each day.

Dr. Topol: One of the intentions of the ACA is to increase the primary care workforce. This is critical as we approach 2014, when more Americans than ever will have either private insurance or Medicaid. Have you seen any movement in the primary care workforce? Are there concerns that there aren't enough clinicians available to meet the forthcoming patient load?

Secretary Sebelius: Primary care providers are critical to ensuring better coordinated care and better health outcomes for all Americans. To meet the health needs of Americans, the Obama Administration has made the recruitment, training, and retention of primary care professionals a top priority.

Together, the ACA, the American Recovery and Reinvestment Act of 2009, and ongoing federal investments in the healthcare workforce have led to significant progress in training new primary care providers -- such as physicians, nurse practitioners, and physician assistants -- and encouraging primary care providers to practice in underserved areas, including:

Nearly tripling the National Health Service Corps;

Increasing the number of medical residents, nurse practitioners, and physician assistants trained in primary care, including placing over 1500 new primary care providers in underserved areas;

Creating primary care payment incentives for providers; and

Redistributing unused residency positions and directing those slots for the training of primary care physicians.

Additionally, the ACA is modernizing the primary care training infrastructure, creating new primary care clinical training opportunities, supporting primary care practice, and improving payment and financial incentives for coordinated care.

Improving Hospital Safety

Dr. Topol: George Orwell once said that the hospital is the antechamber to the tomb. That was written decades ago, and unfortunately there's still truth to that today. One in 4 hospital patients in America have a problem with medical mistakes, contract hospital-acquired infections, and experience medication errors. The ACA last year began linking Medicare payments to quality of patient care, offering financial incentives to hospitals that improve patient care. How is this working? Have there been any meaningful care improvements over the past year?

Secretary Sebelius: The ACA includes steps to improve the quality of healthcare and, in so doing, lowers costs for taxpayers and patients. This means avoiding costly mistakes and readmissions, keeping patients healthy, rewarding quality instead of quantity, and creating the health information technology infrastructure that enables new payment and delivery models to work. These reforms and investments will build a healthcare system that will ensure quality care for generations to come.

Already we have made significant progress:

Healthcare Spending Is Slowing

Secretary Sebelius: Medicare spending per beneficiary grew just 0.4% per capita in fiscal year 2012, continuing the pattern of very low growth in 2010 and 2011. Medicaid spending per beneficiary also decreased 0.9% in 2011, compared with 0.6% growth in 2010. Average annual increases in family premiums for employer-sponsored insurance were 6.2% from 2004 to 2008, 5.6% from 2009 to 2012, and 4.5% in 2012 alone.

Health Outcomes Are Improving and Adverse Events Are Decreasing

Secretary Sebelius: Several programs tie Medicare reimbursement for hospitals to their readmission rates, when patients have to come back into the hospital within 30 days of being discharged. Additionally, as part of a new ACA initiative, clinicians at some hospitals have reduced their early elective deliveries to close to zero, meaning fewer at-risk newborns and fewer admissions to the NICU.

Providers Are Engaged

Secretary Sebelius: In 2012, we debuted the Medicare Shared Savings Program and the Pioneer Accountable Care Organization Model. These programs encourage providers to invest in redesigning care for higher-quality and more efficient service delivery, without restricting patients' freedom to go to the Medicare provider of their choice.

Over 250 organizations are participating in Medicare ACOs, serving approximately 4 million, or 8%, of Medicare beneficiaries. As existing ACOs choose to add providers and as more organizations join the program, participation in ACOs is expected to grow. ACOs are estimated to save up to $940 million in the first 4 years.

Dr. Topol: The future of medicine is all about genetic testing and using genetic data to develop new and better treatments for patients. How does genomic medicine figure into the ACA? How is it helping to further personalized medicine for patients?

Secretary Sebelius: All marketplace health plans and many other private plans are required to cover recommended preventive services without charging you a copay or deductible. Genetic counseling and testing for the breast cancer susceptibility gene (BRCA) for women at higher risk for breast cancer is one of the free preventive services for women. Also covered without cost-sharing in many private plans are well-woman visits, where a woman can sit down, talk with her provider, and get the recommended preventive services that are age- and developmentally appropriate.

Dr. Topol: Thank you, Secretary Sebelius.

For more information on how the ACA is changing the practice of medicine, providers may visit

References: [1] Friedman TL. Obamacare's other surprise. The New York Times. May 25, 2013.

Citation: Eric J. Topol, Kathleen Sebelius. Topol Asks Sebelius 5 ACA Questions. Medscape. Jun 27, 2013.
Gregory D. Pawelski
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Old 06-28-2013, 12:33 PM
gdpawel gdpawel is offline
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Default Affordable Care Act: What Does it Mean for Oncologists?

The Affordable Care Act (ACA), passed in 2010 and still being debated, has led to a series of changes that will undoubtedly affect the way oncology is practiced.

The Act "is a big audacious complex piece of legislation that has been in place now for 3 years, and we still are still learning about the implementation of it," said William Charles Penley, MD, from Tennessee Oncology in Nashville. "The full impact has yet to be realized and it is still politically contentious. I can't pretend to know how this is going to play out."

The full impact on patients, coverage, and providers has also yet to be realized, said Dr. Penley, who chaired a session on the impact of the ACA on the practicing oncologist here at the 2013 Annual Meeting of the American Society of Clinical Oncology (ASCO®).

After giving a brief overview of the law and where it currently stands, Dr. Penley pointed out that there are "very few oncology-specific aspects of this law."

"What we know is that cancer survivors can't be denied coverage because of pre-existing illness," said Dr. Penley. "The Medicare Part D donut hole, which is a big factor for our patients who are prescribed expensive oral oncolytics, is supposed to be reduced and eventually eliminated."

In addition, children with cancer can't be denied coverage because of a pre-existing condition, lifetime limits will be eliminated by 2014, and coverage can't be rescinded on the basis of "technicalities," he explained. "There will also be increased access to preventative services, with the goal of decreasing the incidence of these illnesses."

There is no doubt that the legislation is complex. "Keeping up with the Affordable Care Act and trying to digest it all is like drinking from a fire hose," said Steven Stranne, MD, JD, who spoke on the panel.

Despite the complexity and the length of the ACA, it is really just a framework, said Dr. Stranne, who is from the law firm of Polsinelli Shughart PC, in Washington, DC. "There are gaps, there are conflicts, there are ambiguities and outright discretion that is granted to the secretary of the different agencies that implement the law."

"That's been playing out over the past 3 years, and that's what has been keeping everybody busy in Washington, just in case you were wondering," Dr. Stranne told attendees.

These laws are "not like the Constitution," which is difficult to amend. Rather, the ACA is going through constant revision; that is the process that is occurring right now, he said.

One of the key points of the ACA is expanded patient access, but even though the law takes effect in 2014, it doesn't mean "that everyone is going to be insured immediately."

An estimated 30 million people will gain access to insurance, 2 million of whom will be enrolled this year. By 2015, it is expected that 20 million will be enrolled, and by 2017, 27 million will be. One of the ways of expanding coverage to the uninsured is through expansion of the Medicaid program, which Dr. Stranne emphasized is up to the individual state, and not a mandate.

Although the ACA relies heavily on Medicaid to expand coverage, some stakeholders are concerned about the adequacy of coverage and reimbursement under this program. "One concern is that the outcomes for cancer patients with Medicaid are not much better than for the uninsured," he said. "But whether or not your patients are going to benefit from this expanded coverage depends on which state you live in."

There are important patient safeguards in the legislation that will affect cancer patients, one of which is the required coverage for routine clinical trials. "This is a great safeguard that has been added to the legislation, and one that will go into effect in 2014. I hope you all are able to take advantage of that with your patients," said Dr. Stranne.

"In general, policy makers are hesitant to limit or remove coverage, or use the "r" word — ration — under Medicare expressly on the basis of cost," explained Dr. Stranne.

The Center for Medicare and Medicaid Innovation (CMI), created as part of the Centers for Medicare and Medicaid Services (CMS), has "tremendous authority and discretion to test and implement new payment methods," he said.

The CMI has the authority to test and expand the use of innovative approaches to reimbursement under Medicare without further action by Congress. The emphasis is on integrated care, bundling payment for episodes of care, risk sharing among providers, improved coordination among providers, and the formation of networks.

"Congress has suggested evaluation of treatment planning in cancer care and addressing the gaps in cancer quality that ASCO has been highlighting for some time now," he said. Some of the oncology-focused evaluations underway involve a medical home initiative, palliative care, a radiation program, and comprehensive home care for advanced illness.

Every one of the pilot projects is 3 years long, and the projected savings exceed the funding that the federal government is putting into them, Dr. Stranne emphasized.

Dr. Penley noted that although ASCO doesn't have an ACA task force, they have a number of committees and task forces that are working on the care of cancer patients. "There is an oncology service provision that meshes very nicely with some of the components of the ACA," he explained. "We have a very robust quality program."

The Quality Oncology Practice Initiative is now considered a model for specialty quality registries. It is on track to be "deemed" a demonstration of practice quality reporting by the CMS. ASCO's CancerLinQ program is the next step in quality practice, Dr. Penley said, and the prototype is well on the way to successful completion.

He explained that ASCO has developed some "guiding principles of payment reform," which affirm that every patient has access to high-quality, high-value, evidence-based care, and that the wishes and needs of patients are protected through shared decision making with their physicians.

"We are going to support system-wide reforms and improvements that keep pace with the evolution of the healthcare system," Dr. Penley noted. "Things are changing quickly."

"However, ASCO will continue focus on quality, value, access to care, and innovation. I believe those things will position us very well, whatever happens on the political or implementation level," he noted. "We need to stay focused on the patient and the provision of high-quality cancer care."

Dr. Penley and Dr. Stranne have disclosed no relevant financial relationships.

2013 Annual Meeting of the American Society of Clinical Oncology. Presented June 3, 2013.

Citation: Affordable Care Act: What Does it Mean for Oncologists? Medscape. Jun 11, 2013.
Gregory D. Pawelski
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Old 06-28-2013, 12:44 PM
gdpawel gdpawel is offline
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Default Dollars for Doctors: Are Pharmaceutical Companies Paying Your Doctors?

With the Sunshine provision of the Affordable Care Act scheduled to go into effect next year, the American Law Journal discussed this issue on their weekly television program.


Physician Payments Sunshine Act

Open Payments Program

The Physician Payments Sunshine Act created the Open Payments Program, administered by the Centers for Medicare & Medicaid Services (CMS). The program is designed to create greater transparency around the financial relationships of manufacturers, physicians, and teaching hospitals.

The Sunshine Act requires certain pharmaceutical and device manufacturers to report payments or other transfers of value given to U.S. physicians and teaching hospitals. Reports will be made once a year and will be posted on a public website via the Open Payments Program after September 30, 2014. Data collection for reporting will begin on August 1, 2013. Physicians will have the ability to review their reports and to challenge those reports that are false, inaccurate, or misleading by registering at the CMS website.

Manufacturers will report all payments or transfers of value—including payments for research, travel, honoraria and speaking fees, meals, educational items like textbooks and journal reprints—whether made directly to a physician or teaching hospital or indirectly through a third party.


Gregory D. Pawelski

Last edited by gdpawel : 08-24-2013 at 07:17 PM. Reason: additional info
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Old 06-28-2013, 12:51 PM
gdpawel gdpawel is offline
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Default Curbing Overpriced Treatments for Cancer Care

Merrill Goozner
The Fiscal Times

Top health care experts meeting at the Institute of Medicine last week delivered a stern message to the nation’s 15,000 oncologists and their patients: Either learn to deliver care at lower costs or watch the government and insurance companies impose limits.

“If you think this is a tough reimbursement environment, just wait a year or two,” said Mark McClellan, who headed the Centers for Medicare and Medicaid Services during the George W. Bush administration. “Leadership is needed to show how to get to better care on a more sustainable fiscal path.”

The sentiment was echoed by Ezekiel Emanuel, an oncologist and top adviser to the Obama administration during the battle to enact the Affordable Care Act, which imposed a first round of payment restrictions on Medicare providers. “We can never get too much cost control,” he said. “There’s $700 to $800 billion of waste in the health care system. We have a long way to go.”

Oncology has become a focal point in the health care cost control debate because its claims are rising faster than other specialties. New drugs coming on the market, many of which only extend life for a month or two, now cost $100,000 a year or more. They have become a major driver of rising cancer care costs, especially when used in terminally-ill patients nearing the end of life.

A top official from UnitedHealthcare, the nation’s largest insurer, told the forum reimbursement for cancer care now accounts for 12 percent of all payments for patients not on Medicare and Medicaid. That’s up from 10 percent five years ago. Cancer care has now pulled even with cardiovascular care as the insurer’s biggest expense.

The company’s fastest growing expense within cancer care is drugs, which continue to rise at about 10 percent a year. While drug costs are about 10 percent of all health care costs, according to CMS, they account for about a quarter of all cancer care costs.

“There is no market. It is sellers dictating the price when a new drug comes out,” said Lee Newcomer, chief oncologist at UnitedHealthcare. “I don’t have a substitution effect I can enforce because just about every state in the nation requires that I pay for the latest drugs.”

With 80 to 85 percent of the 1.64 million Americans who get diagnosed with cancer every year receiving their treatment at community-based oncology practices, the IOM meeting focused on potential changes in those settings that might lower costs. Most practices pay the bills by selling chemotherapy treatments and charging Medicare and insurers a mark-up on the wholesale cost of the drugs – 6 percent in the case of Medicare and 20 to 40 percent for private insurers, according to one community oncologist at the meeting.

UnitedHealthcare has an experiment underway that would get rid of the cost-plus model because it provides a powerful incentive for oncologists to use not only more drugs, but the most expensive drugs. It has signed contracts with five community practices where the insurer now pays for drugs directly while the oncologists get paid extra for adhering to agreed-upon treatment strategies and drug regimens that clinical practice guidelines say will deliver the best outcomes. The approach not only eliminates the incentive to prescribe more drugs, it eliminates variations in care that provide no benefit or, in some cases, cause harm.

“We need standard approaches,” Newcomer said. “Where we can shift to the less expensive therapies that have no difference in outcomes, we should do that.”

Peter Bach, an oncologist at Memorial-Sloan Kettering Cancer Center in New York and former CMS official, offered an alternative model. He suggested Medicare and insurers could shift to a system where oncologists are paid for episodes of care – a bundled payment – rather than fees for the various services. Besides eliminating the incentive to order duplicative or unnecessary tests, imaging and office visits, it encourages physicians to use the most cost-effective chemotherapy regimens that deliver comparable results.

Bach cited the example of the initial chemotherapy regimen for patients diagnosed with lung cancer, which will account for 226,000 or 14 percent of all new cancer cases this year. Lung cancer, which is caused by smoking in about 80 percent of cases, is still America’s number one cancer killer.

There are seven approved chemotherapy regimens for the first round of treatment, which range in price from less than $1,500 to over $7,000. The guidelines produced by the National Comprehensive Cancer Network, which brings together experts from across the country to evaluate best practices, say there is no material difference in outcomes between the various regimens, although they do have different side effect profiles.

By having the bundled price for the episode include the average price of the different possible regimens, oncologists will be incentivized to use the lower-priced drugs. “Episode-based payment is all about shifting risk,” Bach said. “It puts the provider – the oncologist – at risk for performance. This is very different from fee-for-service, where the only risk is if someone doesn’t pay you.”

In his keynote address, McClellan lauded the growth of accountable care organizations (ACOs) and bundled payment pilot projects set up under the ACA. He expressed hope that they would be rapidly expanded after the election.

“We don’t have five years to see if these work,” he said. When asked what would happen if Obamacare is repealed because Republicans win the White House and both houses of Congress, he said “I don’t see that going away. There has been past Republican support for ACOs and bundled payments.”

Gregory D. Pawelski
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Old 06-28-2013, 12:57 PM
gdpawel gdpawel is offline
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Default A hospital says no to an $11,000 a month cancer drug

Ed Silverman

With all the talk of rising prices for cancer medications, the cost of healthcare and comparing the value and benefit of competing drugs, Memorial Sloan-Kettering Cancer Center has decided not to use a newly approved treatment for metastatic colorectal cancer. Specifically, the cancer center will not give patients Zaltrap, which is marketed by Sanofi and Regeneron Pharmaceuticals.

Why? The price tag. “The reasons are simple: The drug, Zaltrap, has proved to be no better than a similar medicine we already have for advanced colorectal cancer, while its price — at $11,063 on average for a month of treatment — is more than twice as high,” write three doctors from the cancer center in an opinion piece in The New York Times.

In explaining their case, they note that FDA, Medicare and organizations that set physician guidelines pay attention to effectiveness; private insurers then follow suit, since they are expected to be held to the same standard. “Ignoring the cost of care, though, is no longer tenable,” they write, adding they feel obligated to consider financial strains that result.

“This is particularly the case with cancer, where the cost of drugs, and of care over all, has risen precipitously,” they continue. “The typical new cancer drug coming on the market a decade ago cost about $4,500 per month (in 2012 dollars); since 2010 the median price has been around $10,000. Two of the new cancer drugs cost more than $35,000 each per month of treatment.”

“In 2006, one-quarter of cancer patients reported that they had used up all or most of their savings paying for care; a study last year reported that 2 percent of cancer patients were driven into bankruptcy by their illness and its treatment. One in 10 cancer patients now reports spending more than $18,000 out of pocket on care,” they continue.

As for Zaltrap, they explain that the drug offers the same survival benefit as Roche’s Avastin, which has a similar mechanism of action. “When compared with the standard chemotherapy regimen alone, adding either medicine has shown to prolong patient lives by a median of 1.4 months. Major clinical practice guidelines, like those from the National Comprehensive Cancer Network, agree that Zaltrap is no better than Avastin in this setting,” they write.

But Avastin offers some advantages – a monthly cost of $5,000, which is less than of the cost for Zaltrop, and it is takes less time to administer, while side effects are roughly equal. They then note that “an older colorectal cancer patient without extra insurance would have to pay more than $2,200 out of pocket for a month’s treatment with Zaltrap.”

The problem, they say, is that the “medical culture equates new with better, which can make a decision not to cover Zaltrap seem out of step. And they then complain that “political rhetoric today is similarly slanted. Our refusal to adopt this remarkably expensive therapy risks being labeled rationing, not rational.”

They recognize that the decision may not have any meaningful effect, given that health care spending is so high and Zaltrap sales in the US are expected to amount to 0.005 percent of all dollars spent on health care next year. “But it is a step in the right direction — one of many we need to take,” they conclude.

Such sentiments are hardly uncommon these days, but they note that the rhetoric over health care explains why the Affordable Care Act precludes Medicare from changing its coverage or payment amounts based on cost comparisons. Comparative effectiveness has become a nasty phrase in some quarters and few insurers are willing to openly discuss the issue.

Gregory D. Pawelski
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Old 07-04-2013, 06:27 PM
gdpawel gdpawel is offline
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Default If you have cancer, you may be eligible for Social Security Disability Benefits

Herman Kattlove, M.D.

There are two programs you may qualify for. These programs are known as 1) Social Security Disability Insurance (SSDI) and 2) Supplemental Security Income (SSI).

To qualify for either program, you must prove to the Social Security Administration that you suffer from a disabling condition that completely prevents you from performing any type of work activity whatsoever. Almost all cancers qualify. For a complete list of all conditions that qualify for disability, visit the SSA’s blue book:


In order to prove your case, you need to submit as much medical proof as possible. This includes clinical histories, lab results, imaging results, and treatment histories. In addition to proving that you are indeed disabled according to SSA standards, you must also meet other qualifying criteria for each program.

Qualifying for SSDI In addition to proving you are disabled, in order to qualify for SSDI you must have earned enough work credits in order to qualify for benefits. As a general rule, you must have worked 5 of the past ten years in order to qualify. If you are not old enough to have worked ten years, you must have worked at least half of the time that you were able to since turning 18.

For example, if you are 22 you must have worked for 2 years in order to have enough work credits to qualify for SSDI. Qualifying for SSI Unlike SSDI, SSI is a needs-based program. In order to qualify for this program you must meet certain income and asset eligibility criteria.

In order to qualify under this program, your income cannot exceed $710 per month as an individual or $1,066 per month as a couple. You must also have no more than $2,000 in assets as an individual or $3,000 in assets as a couple. How do you know you qualify?

The SSA looks at everything from the point of view of whether or not it prevents you from working on a consistent basis. For example, if undergoing therapy prevents you from working, then you would qualify for SSD. However, if you can still continue to work while undergoing therapy then you do not qualify.

The SSA explains in detail in the blue book how severe every condition must be in order to qualify. Submitting Your Application You can submit an application for disability either online

[url] or at your local SSA office. When you file your application, make sure you provide detailed medical evidence proving the severity of your condition. Lab results, treatment histories, and written statements from treating physicians can help your claim be approved more quickly and without the need for an appeal.

The Compassionate Allowances Program Under the compassionate allowances program, some of the more severe and aggressive forms of cancer can qualify an individual for Social Security Disability benefits in less than two weeks.

To find a list of all conditions that qualify for this expedited process, please visit:


Article by Ram Meyyappan Social Security Disability Help For more information on Cancer and Social security Disability, please visit:

Gregory D. Pawelski
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Old 08-17-2013, 11:37 AM
gdpawel gdpawel is offline
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Default The ACA and Physician Reimbursement

As the Affordable Care Act (ACA) moves toward its key implementation phase next year, this massive law is starting to affect physicians' incomes in a variety of ways.

In January 2014, the ACA will carry out the largest insurance coverage expansion since 1965 and make historic changes in the way that insurers operate. Other changes that affect physicians have already been initiated, and more will follow.

Here are 8 ways that the ACA is likely to affect physician income:

More Covered Services

The new law removes some major impediments in insurance coverage for your patients and mandates some extra services that your payers may not have covered previously.[1]

"There are strong feelings for and against the ACA, but this group of provisions has broad support," said Jeffrey Cain, MD, President of the American Academy of Family Physicians (AAFP). He added that these reforms would help physicians because "patients who have insurance and access to primary care have better health outcomes."

In 2011 and 2012, the ACA required insurers to cover 63 different preventive services without requiring an out-of-pocket payment from patients.[2] The services include blood pressure and mammography screenings, a variety of immunizations, childhood behavioral and autism screenings, and -- controversially -- access to contraception. Practices can expect reimbursement for these services without needing to collect any money from patients.

Then, on January 1, 2014, individual and small group plans will have to cover specific services, called "essential health benefits," including maternity care, mental health services, medications, rehabilitation services, and chronic disease management. Again, insurers will have to pay physicians and other providers for these services.

Also, plans will be barred from discriminating against people for pre-existing conditions, and they cannot set annual or lifetime limits on coverage. These provisions will be important to your patients with chronic conditions who currently can lose coverage when they switch jobs and may have bills that exceed their insurance limits.

More Patients With Coverage

Also next year, millions of newly insured Americans will be looking for a primary care physician and eventually specialists as well. Enrollees in the new health insurance exchanges will be mostly low-income people who will get subsidies to buy coverage and pay out-of-pocket charges.[3]

The other sector of newly covered Americans will be part of the ACA's expansion of Medicaid coverage to those living at 138% of the federal poverty level. This will be crucial for low-income childless adults, who currently have little or no coverage. However, the Supreme Court last year allowed states to reject the Medicaid expansion. Even though they would not have to pay anything for the first 3 years of the expansion, approximately half of the states are refusing to participate.

Dr. Cain said that coverage through the exchanges and the Medicaid expansion will be a boon for family physicians, who see an average of 8 patients a week on a discounted or free basis. "This new coverage will mean that family physicians can have a financially viable practice," he said.

Exchange plans have not yet announced reimbursement rates for physicians, and it's not clear yet whether rates would be lower than those of other commercial plans. Because exchange plans serve a low-income population, they are under a great deal of pressure to keep premiums affordable. To keep costs down, many exchange plans have won discounts from hospitals by excluding high-priced hospitals from their exchange networks and rewarding in-network hospitals with higher volume.

The Game May Play Out Differently

Exchange plans' discounts-for-volume tactic may not work on physicians. Many practices already have full appointment books and are not interested in getting more patients. In fact, there are signs that a large proportion of physicians will refuse to join exchange plans, which would mean that exchange plans would have to offer reasonable rates just to have enough physicians in their networks.

Some exchange plans, concerned that their networks do not have enough physicians for the new enrollees, are reportedly pressuring more physicians to sign up. Physicians who already have contracts with an insurer in the exchange may have an "all-products" clause requiring them to take the exchange product, too.

Louis J. Goodman, PhD, President of the Physicians Foundation, which has been polling physician attitudes, said that many physicians think the exchanges won't open on time or will be very disorganized. "A lot of practices are thinking twice about joining exchange plans," he said. "They are going to wait and see." He said that uninsured patients who enroll in the exchanges will not be familiar with insurance ID cards, paying deductibles, and coverage limits, and may need some education.

However, even in full practices, physicians who have a lot of elderly Medicare patients may want to change their payer mix. Accepting exchange patients is a way to get younger patients, according to Jim Walton, DO, CEO of Genesis Physicians Group, an independent practice association in Dallas. He said that lots of younger patients, who need fewer healthcare services than older patients, are expected to go on the exchanges.

Also, physicians signing on to an exchange plan will have no idea how many patients they will get from the plan until after enrollment starts on October 1, 2013. Will they have enough time to expand their operations to meet the extra demand by January 1, 2014?

Judith Aburmishan, a partner in charge of healthcare consulting services at FGMK LLC in Bannockburn, Illinois, advises physicians to proceed in steps. "When your volume grows, the first step is to add on hours," she said. "Later you might hire a new doctor or a nurse, or you might weed out the poor payers and drop your worst-paying insurance plan."

Physicians Have to Deal With Higher Out-of-Pocket Payments
The ACA and the exchanges follow a rising trend toward higher out-of-pocket charges, which is forcing practices to rethink payment policies for patients.

According to surveys by the Kaiser Family Foundation,[4] the percentage of covered employees having a deductible for single coverage rose from 52% in 2006 to 72% in 2012. In 2012 the average general annual deductible for this population was $1097, an 88% increase since 2006, the Foundation reported.

Health insurance exchange plans will have relatively high out-of-pocket payments. In the benchmark "silver" plan on the California exchange, for example, an enrollee with a $45,000 annual income would have a $2500 deductible and copays of $45 to $65 for an office visit.[5]

Deborah Walker Keegan, PhD, President of Medical Practice Dimensions, a consultancy in Asheville, North Carolina, said that high out-of-pocket payments have the biggest impact on specialists with expensive services, such as orthopedic surgeons, but they can also be a problem for primary care practices because they can add up quickly.

Keegan added that it's difficult for a practice to calculate how much the patient owes at any given time, because the deductible changes each time the patient pays for care, although some payers provide real-time information on members' out-of-pocket levels.

To make sure that the out-of-pocket charge is collected, Keegan said that a practice has to collect these charges up front, prior to providing care. "If patients don't have the payment at the time of service, then you might ask them to agree to a budget plan and set up credit card payments," she said.

Aburmishan, the Illinois consultant, says that some practices are asking patients to provide their credit card number and give permission to draw payments from it. If the practice's first attempt to file a claim is denied, it would charge the card for smaller bills; for larger bills, it would take $500 off the credit card each month, she said.

Primary Care Gets a Boost

"The ACA is increasing the prestige of primary care," said AAFP's Cain. He noted that many key aspects of the law favor primary care, such as enhanced reimbursements under Medicare and Medicaid, new models of care like the patient-centered medical home, and preventive and wellness services covered under the "essential health benefits."

Specifically, Medicare is paying primary care physicians a 10% bonus for primary care services from 2011 through 2015, and primary care physicians' Medicaid reimbursements for evaluation and management services and vaccinations are being raised to Medicare rates in 2013 and 2014. Due to start-up problems, the Medicaid payments are just beginning to come through.

Dr. Cain also pointed to new programs by commercial insurers oriented to primary care. WellPoint, for example, has increased reimbursement to primary care physicians for services such as "nonvisits" over the phone and will award them up to 50% more than they had been earning for reducing medical costs while maintaining quality.[6]

Dr. Cain said that a key outcome of the ACA's emphasis on primary care is that it "puts more emphasis on the need for these kinds of doctors."

New doctors have been heeding the call, partly due to new subsidies for primary care training. The number of medical students committing to primary care programs in the Match has increased every year since the ACA was passed in March 2010.[7]
Gregory D. Pawelski
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Old 08-17-2013, 11:39 AM
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Physicians Head for Larger Entities

Even before the ACA, hospitals were beginning to buy up physicians' practices. Michael La Penna, a healthcare consultant based in Grand Rapids, Michigan, said that the trend has stayed strong, partly due to the law's strong endorsement of Accountable Care Organizations (ACOs), which bring together the whole spectrum of providers.

"Solo practices need to align with someone bigger," he said, citing falling reimbursements, increasing regulations, the cost of installing electronic health record (EHR) systems, and worries that shifting referral patterns will exclude them.

Scott Gottlieb, MD, Resident Fellow at the American Enterprise Institute, a conservative thinktank in Washington, DC, said that hospitals buying physicians' practices is bad for both sides, because physicians will work less as paid employees and hospitals will reduce their pay to match the lower productivity.

Dr. Gottlieb recalled that hospitals went on a practice-acquisition spree in the 1990s, but it imploded because they couldn't manage outpatient care and lost a lot of money. Spun off by the hospitals, these physicians quickly returned to private practice. This time around, however, Dr. Gottlieb said that any physicians who were spun-off would have a harder time restarting their private practices. Reimbursements are lower than in the 1990s and it's harder to get bank loans.

His advice: "Resist being consolidated as long as you can. Buy yourself some time." And if you do need the protection of a larger entity, Dr. Gottlieb suggested joining an independent practice association (IPA) instead, though he conceded that it might be more difficult to find IPAs in parts of the Northeast and Midwest.

La Penna suggested that small practices form loose information-sharing collaborations. Each practice manager could become an expert on a certain topic. They could also share very basic market intelligence. With rapid changes in the market under way, "it is essential that physicians know what is going on in their community," La Penna said.

New Payment Methods May Zap Fee-for-Service

The ACA has built upon a new trend that is replacing straight fee-for-service payments with new payment methodologies based on outcomes, such as bundled payments, patient-centered medical homes, and shared savings in ACOs.

Although the new federally recognized ACOs and the government's Center for Medicare & Medicaid Innovation are taking their first cautious steps with new payment methodologies, many commercial payers are moving ahead at a fast clip, according to Keegan, the North Carolina consultant.

She pointed to Cigna's collaborative accountable care (CAC) program with primary care providers, which is using "care coordinators" -- CAC-paid nurses who make sure that patients are getting follow-up care. Cigna runs 28 patient-centered initiatives in 17 states, involving more than 4000 physicians.[8]

Keegan said that practices should take advantage of the extra funds and services that payers are currently offering in such programs, because they may not last. For example, as physicians become more efficient in shared savings programs in ACOs, the base payment rate will decline.

She warned, however, that the transition from fee-for-service to new payments might be bumpy. During the next 5 years, "physicians will be living in 2 worlds" -- fee-for-service and the new payments -- "and it will be very, very confusing," she said. "Your whole revenue cycle gets affected."

The new payment methodologies also require sophisticated IT systems, a great deal of data-reporting, and shared networks, according to Dr. Walton at the Genesis IPA.

He said that physicians have to go through "a cultural transformation" to deal with the new methodologies. "They have to learn how to work in a team and share clinical decisions with other caregivers," he said.

Genesis, which is applying to start a Medicare ACO, is asking its physicians to engage patients through new technologies, such as text messaging and email. "You don't have to be face-to-face to ask a question," Dr. Walton said. "In fact, the new reimbursement system will not reward you for a face-to-face visit."

Rising Penalties Will Reduce Reimbursements

As the ACA is further implemented, the Centers for Medicare & Medicaid Services (CMS) is beginning to reduce payments to practices that do not comply with various CMS initiatives.

In 2012, CMS started imposing a penalty on physicians who do not meet e-prescribing (eRX) levels.[9] The eRX penalty started in 2012 at 1% and increases to 2% in 2014. In 2015, CMS will begin imposing penalties for not complying with EHR implementation standards, following up on "meaningful use" incentive payments for EHRs.

Also in 2015, CMS will begin levying penalties based on its Physician Quality Reporting System (PQRS), in which physicians report quality measures that they select from a CMS list.

Right now, Keegan said, the penalties do not exceed 1.5%, which is still relatively low on a practice's pain scale. But when the PQRS and EHR penalties begin in 2015, physicians could receive a maximum total fine of 4.5%, which would rise to 6% in 2016 and 7% in 2017. Those levels would have a significant impact on practices, Keegan said.

The PQRS penalty, called the "value-based modifier," follows up on a voluntary reporting program that most practices did not participate in. A CMS report found that only 1 in 5 physicians and other eligible health professionals reported PQRS quality measures to CMS in 2009, and only a little over half of those participants scored well enough to receive an incentive payment.[10]

Physicians who will be affected by the value-based modifiers in 2015 have been receiving a preview of their scores. "These numbers can help physicians prepare," Keegan said. "This is a great opportunity for higher payments down the road."

New Ways for Patients to Rate Physicians

"Consumers are doing more shopping, and we're seeing a greater demand for information," La Penna said.

The new insurance exchanges are supposed to be the next step in healthcare consumerism. Enrollees can compare insurance plans side by side, based on cost and other features, which can't be easily done in the current insurance market.

Healthcare consumers can also pick a physician by going to the Physician Compare Website, which CMS rolled out in December 2010 and significantly upgraded this past June. Consumers can now search for physicians by name, medical group, hospital affiliation, address, ZIP code, and proximity to a shopping center or other landmark. They can also look for physicians who are board-certified or participate in the meaningful use program.

In 2013, Physician Compare was supposed to add quality data gathered by PQRS, but that has been postponed until next year, according to an email from a CMS spokesperson. In early 2014, he said, the site will include 2012 PQRS data from group practices and ACOs. CMS has agreed to a 30-day preview period for physicians to view their information before it is posted.

In a recent letter to CMS, the American Medical Association (AMA) criticized the updated Website.[11] The AMA's concerns about Physician Compare included "inappropriate results when searching in a specific medical practice" and use of CMS specialty categories rather than physicians' own categories.

Keegan says that physicians are right to be nervous about what will be posted on Physician Compare, because it will become a very useful consumer tool. "You would want to make sure that your performance on the site is competitive," she said.

La Penna said that when Physician Compare begins including quality information next year, it will be a significant improvement over physician-ratings Websites like Yelp, HealthGrades, and Angie's List, which are very subjective. "Angry people go to these sites and make a comment," he said.

Accepting the Future of the ACA

Until last year, many physicians expected that the ACA could easily be repealed and they might never have to deal with it.

Then came the Supreme Court decision upholding most of the law, followed by President Obama's reelection, and the outlook changed. A 2013 survey by Deloitte[12] found that 8 in 10 physicians thought the law would continue as planned.

Even Dr. Gottlieb, who does not like the new law, thinks it is here to stay. "I don't think the ACA will get repealed," he said. "Once all those subsidies are in place, they are going to stay."
Gregory D. Pawelski
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Old 08-17-2013, 11:46 AM
gdpawel gdpawel is offline
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Default References

1. Centers for Medicare & Medicaid Services. The Center for Consumer Information & Insurance Oversight. Health Insurance Market Reforms.


2. Preventive Services Covered Under the Affordable Care Act.


3. Kaiser Family Foundation. A profile of health insurance exchange enrollees. March 2011.


4. Kaiser Family Foundation. Snapshots: the prevalence and cost of deductibles in employer sponsored insurance. November 2, 2012.


5. California Health Benefit Advisers. Covered California: cost-sharing reductions.


6. WellPoint. WellPoint launches innovative reimbursement initiative, partnering with primary care to improve quality and reduce medical costs. [Press release] January 27, 2012.


7. National Resident Matching Program. NRMP Match Day 2013 results: More U.S. students choose primary care. March 15, 2013.


8. Cigna Network News. Cigna's approach to collaborative accountable care. July 2012.


9. Centers for Medicare & Medicaid Services. Electronic prescribing (eRx) incentive program.


10. Centers for Medicare & Medicaid Services. 2010 reporting experience, including trends (2007-2011). February 22, 2012.


11. American Medical Association. AMA letter to CMS on Physician Compare. July 17, 2013.


12. Deloitte. Deloitte 2013 Survey of U.S. Physicians. Physician perspectives about health care reform and the future of the medical profession.


Citation: 8 Ways That the ACA Is Affecting Doctors' Incomes. Medscape. Aug 15, 2013.
Gregory D. Pawelski
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