Skip to main content

Essential Health Benefits, Comparative Effectiveness Research, Payment Models All Play a Role in the ACA

August 2013 Vol 6, No 6 Special Issue

Chicago, IL—Although cancer care is not at the front and center of the Affordable Care Act (ACA), oncology experts pointed out significant aspects to monitor as time goes on during a discussion of the topic at ASCO 2013.

A key element of the ACA is that the number of covered lives would expand by 38 million people by 2022 through the individual coverage mandate. The majority of the expansion will be through the Medicaid program and the establishment of health insurance exchanges, which, starting in October 2013, will offer an insurance option for individuals and families who are unemployed, work for small businesses, or are not offered insurance through their employer. Premium and cost-sharing subsidies are available for individuals who are less able to afford insurance coverage.

ACA Action Plans
The ACA is designed to encourage innovation through comparative effectiveness research (CER), alternative payment models, and accountable care organizations.

One oncology expert, William Charles Penley, MD, Medical Oncologist, Tennessee Oncology, Nashville, spelled out some of the ACA’s action plans:

  • Prohibit discrimination based on sex or preexisting condition
  • Eliminate annual limits on coverage
  • Prohibit dropping or limiting coverage because of choosing to participate in clinical trials for cancer or for other life-threatening diseases
  • Offer tax credits for people with income 100% to 400% above the federal poverty level
  • Set up a health insurance marketplace.

So far under the ACA, 32 million Medicare beneficiaries have used a free preventive service; 50,000 uninsured individuals with preexisting conditions have gained health insurace; and 3.6 million Medicare beneficiaries have saved $2.1 billion on prescription drugs (

“Regarding the ACA, there’s not a lot written in the law specifically about cancer care. However, for example, we know that based on the patient bill of rights, cancer survivors can’t be denied coverage because [cancer is] a preexisting illness,” Dr Penley said.

Additional ACA components of relevance to oncology include:

  • Children with cancer cannot be denied coverage because of a preexisting condition
  • Medicare Part D “donut hole” is reduced and will eventually be eliminated
  • Lifetime coverage limits will be eliminated by 2014
  • Coverage cannot be rescinded
  • Access to preventive services is increased.

ASCO’s Priorities
Dr Penley, who serves on several ASCO committees, said that although it does not have an ACA task force, ASCO has committees that are dedicated to working on the care of patients with cancer, especially in the way of a robust quality program. He mentioned the Quality Oncology Practice Initiative (QOPI) and its 300,000 patient data sets.

“CancerLinQ will take QOPI to the next level with real-time data for a prototype,” Dr Penley said.

ASCO has also developed its “Guiding Principles of Payment Reform,” which advocates:

  • Every patient having access to high-­quality, high-value, evidence-based care
  • Protecting patients’ needs and wishes through shared decision-making with physicians
  • Further developing and upholding the practice standards for the medical profession
  • Supporting systemwide reforms and improvements that keep pace with the evolution of the healthcare system.

“ASCO’s priorities are to address disparities—offer quality cancer care for all, that is, affordable care with no barriers to insurance coverage and no geographic barrier to high-quality cancer care. We also want to define value as it pertains to cancer care delivery,” Dr Penley said.
He concluded that the “ACA is complex legislation. Its full impact is yet to be realized. There are few oncology-specific components. In the meantime, ASCO’s focus is on quality, value, access to care, and innovation to serve patients and oncologists well.”

Medicaid Expansion
Steven K. Stranne, MD, JD, Shareholder, Polsinelli PC, a law firm in Washington, DC, participated in the discussion. He said that the focus of recent legislation, including the ACA, is multifaceted, including expanding access to care, offering patient safeguards and prevention, enhancing CER, innovation and bending the cost curve, and promoting quality.

Medicaid expansion under Medicare refers to extending eligibility for most nonelderly adults aged <65 years with income below 138% of the federal poverty level, with a 100% federal match until 2017 and with a 90% match in 2020 and after.

One major concern is the adequacy of Medicaid coverage, said Dr Stranne. “ACA relies heavily on Medicaid to expand access to coverage, although some stakeholders worry about the adequacy of coverage and reimbursement under Medicaid,” he noted. Dr Stranne stated that the medical literature suggests that clinical outcomes for Medicaid enrollees with life-threatening diseases, such as cancer, may not be better than for the uninsured.

Essential Health Benefits
Defining the essential health benefits helps to establish the minimal level of coverage under the state health insurance exchanges.
“The vision when this law was passed was that the Department of Health and Human Services and the Centers for Medicare & Medicaid Services [CMS] would offer great specificity on patient safeguards, such as minimum coverage, through essential health benefits. Yet, administration and CMS’ overarching concern is to avoid raising premiums. Therefore, there’s limited specificity in the definition of essential health benefits,” Dr Stranne said.

Of note, there is a clinical trials safeguard in the essential health benefits. Coverage is required for routine costs of clinical trials. Also, there are safeguards for prescription drug access, although they are not the same as under Medicare Part D.

CER Gets a Nod
Dr Stranne noted how there is a new infusion of federal funding devoted to CER. There is a linkage to this type of research and to efforts to reduce the cost of care, he said.

“CER is viewed by policymakers as a way to fill gaps in scientific evidence used to guide prescribers to high-value, cost-effective options,” Dr Stranne said. “CER advocates see the opportunity for dramatic savings in the future based on linking CER results with coverage policies and reimbursement incentives.”

Payment Models
The Center for Medicare & Medicaid Innovation tests and implements new payment models for healthcare delivery. Its authority is “extremely” broad, according to Dr Stranne, meaning that it can test and expand the use of innovative approaches to reimbursement under Medicare without further action by Congress.

Last modified: August 30, 2021