Healthcare Reform and Its Effects on Cancer Care

• Patients/survivors with existing insurance will have more adequate coverage, e.g., no lifetime limits, fewer annual limits, no rescissions, retiree reinsurance, first dollar coverage of screenings and other preventive services
• More insurance options available for cancer patients and survivors
• Subsidized high-risk pools at age adjusted standard premiums
• Access to parents’ plans for dependents up to 26
• Improved information about value of available options; more standardized information
• Some pressure on insurers to keep premium increases more moderate; minimum loss ratios and rate reviews

• Insurance will be available regardless of health status; guaranteed issue and renewability; adjusted community rating; no pre-existing condition exclusions for adults and children
• Insurance may be more affordable (Expanded Medicaid eligibility, private insurance premium and cost-sharing subsidies for those below 400 percent of the federal poverty level, exchanges that will provide for more affordable and accountable insurance options)
• Insurers have to compete more on basis of price and service than on risk selection
• Insurance may be more adequate, especially in individual and small group markets (essential benefit packages meeting defined actuarial values, first dollar coverage of preventive services)
• Some potential challenges and drawbacks: Some may still find insurance unaffordable especially if costs not contained much; state-based exchanges may be too small to create sustainable risk pools and states may not provide aggressive oversight needed to ensure fair competition; employer wellness incentive programs may penalize employees for poor health status

• Beginning in FY 2013, 1 percent of hospitals' base DRG payments are set aside for VBP program, with payments based on performance in 2012 (excludes IME, DSH, outliers, special rural payments; phases up to 2 percent in FY 2017 and thereafter
• Initial measures are ones currently reported, including patient perception of care
• Beginning 2013, outcome measured to be risk-adjusted and all measures endorsed by NQF (with possible exception); beginning 2014, efficiency measures to be added, including spending per beneficiary
• VBP payments are based on performance measured by a single composite score; adjustment is applied to all DRGs
• VBP payments are determined by performance against standards established in advance by the Secretary, no VBP payment for hospitals below minimum threshold
• Program is budget neutral: all incentive pool funds must be paid out to hospitals in year they are withheld

• Quality Reporting: Makes Physician Quality Incentive Program (PQRI) permanent
• Provides 1 percent bonus in 2011 based on successful reporting in designated period and provides a bonus of 0.5 percent in 2012-2014
• Imposes 1.5 percent penalty in 2015 for failure to report successfully; penalty increased to 2 percent in subsequent years
• Beginning in 2011, allows registry reporting through a Maintenance of Certification program operated by a specialty body of the Board of Medical Specialties
• Provides an additional 0.5 percent in 2011-2014 for participation in qualified specialty Maintenance of Certification (MOC) programs
• Requires timely feedback on likelihood of receiving incentive payment and an appeals process
• Requires plan from Secretary to integrate clinical reporting with electronic health records (EHR)
• Physician Feedback Program: Requires confidential feedback reports to physicians comparing their performance on quality and efficiency to peers
• VBP for Physicians: Adjusts 1 percent of physician payment based on value index (quality and efficiency) beginning 2015

Imposes new standards for the tax exemption of nonprofit hospitals.

• Requires that a hospital complete a community needs assessment once every three years
• Requires hospitals to adopt and publicize a financial assistance policy
• Prohibits billing patients who qualify for financial assistance the top rates
• Prohibits a hospital from taking extraordinary collection actions if the hospital has not made reasonable efforts to notify patients of its financial assistance policy

• 2010 Physician Fee Schedule Final Rule reduces payment for services that require the use of “expensive” equipment (>$1 million) by increasing the equipment utilization assumption in the practice portion of the physician fee schedule from 50 to 90 percent over 4 years; redistributes savings to other services such as primary care; final rule exempts therapeutic services and applies only to MRI and CT

• Health Reform: beginning 1/1/2011, sets the equipment utilization assumption equal to 75 percent for expensive equipment (>$1 million); beginning in 7/1/2010, increases the multiple imaging discount for certain procedures involving contiguous body parts from 25 to 50 percent; excludes reduced expenditures from calculation of budget neutrality