• Health reform and oncology: A question for TIE readers

    Swag Central

    Swag Central

    Yesterday morning at 6:30, I found myself driving around the labyrinth of Chicago’s McCormick Place trying to find a shortcut from Lake Shore Drive to the parking structure. The tour didn’t go well, but I did get a fascinating look at where the busses let people off and the forklifts operate far from where the general public is supposed to be.

    Fortunately I encountered no homeland security agents, and (more frighteningly) no Chicago traffic personnel bearing thick ticket pads. I parked without incident—unless you count the $21 parking fee.


    I was there for the annual meeting of the American Society of Clinical Oncology. It’s an amazing affair with something like 25,000 attendees. I spoke on a panel at the invitation of my colleague William Dale. My assignment was to discuss the implications of the Affordable Care Act for geriatric oncology. Twenty minutes before our session was scheduled to begin, you can see that the excitement in the hall was palpable.

    We actually had a nice turnout and a nice session, which touched on some key issues:

    • Importance of universal coverage for cancer patients
    • Elimination of preexisting condition clauses and lifetime caps
    • The role of comparative effectiveness research and PCORI
    • Efforts to redress an unbalanced system that reimburses highly cost-ineffective proton beam therapies while leaving more valuable and basic services uncovered, particularly for older patients with comorbidities and patient needs.
    • The need to modify the strange economy and incentives in cancer care exemplified by the “chemotherapy concession.
    • Overuse of costly support therapies such as Epogen.
    • The complex political economy influenced by ill-understood measures such as the 340(b) program.

    ASCO2I didn’t talk about some other issues that bear discussion, including the fundamentally flawed and under-funded Preexisting Condition Insurance Plans or the need for appropriate public and private insurer coverage of participation in clinical trials (h/t @donaldhtaylorjr on that last one).

    I still found it a humbling experience. Oncology is a $125+ billion business. Health reform will have a significant impact on cancer care.  Covering health reform and participating in the 2008 and 2012 campaigns, I met more than a few cancer patients who desperately needed basic health one sought to provide.

    Yet as I prepared to speak, I was struck by how little I knew about the huge, but insulated world. I’ve seen one instant classic essay by Smith and Hillner on bending the cost curve in cancer care.  I’ve otherwise seen surprisingly little about the specific implications of ACA for cancer care.

    Hence my question to the TIE community: What should I be reading in this area?


    • I would send an email to E. Emanuel, I believe he is still at Penn, and ask him.


    • If I have renal failure, a government program pays for my dialysis. If I have leukemia, there’s no government program to pay for my chemotherapy, or a bone marrow transplant. Why the difference? Cancer at one time was a death sentence. Not anymore. Cancer is for most a chronic, treatable condition. But the treatment has be extremely expensive, with OOPEs running into hundreds of thousands of dollars over time even with very good health insurance. ACA will help somewhat, by removing the caps, but ACA will not solve the dilemma of enormous OOPEs. Indeed, the health care crisis is mostly attributable to chronic illness, including old age (it’s chronic because there’s no cure). And ACA does not solve that crisis.

      • If I have breast or cervical cancer and it is diagnosed at a CDC-sponsored screening center then I am eligible for Medicaid for the duration of my illness. http://www.cdc.gov/cancer/nbccedp/about.htm

        I find this one of the more ironic examples of disease-specific policy interventions. For what reason (other than politics and interest groups) would we offer treatment for breast cancer but not leukemia or melanoma?

    • I find seniors worried about news that oncologists will stop seeing cancer patients on Medicare as a result of lower reimbursement on chemotherapy drugs.
      Any insight or response to this from the the physicians in attendance?

      • At one time, provision of chemotherapy drugs was enormously profitable. Back in the good old days mark-ups of 30-40% were allowable. This happened concurrently with major scientific advances which meant new and highly expensive drugs such as monoclonals and stem cell stimulators. Around 1999, it was possible for an oncologist to make a lot of money by giving people Procrit for Anemia without having to do much work. Medicare grew aware of this and saw no reason why oncologists should be making more than neurosurgeons. A period of various cutbacks ensued resulting in essentially making drug provision nonprofitable. During the late 2000’s income fell by about 35% for oncologists. Typical comments I heard from colleagues around the country was that their personal income had fallen from 700 kilodollars to 400.
        Medicare led this, but the effects were across the board because the majority of patients were of medicare age and the private insurances soon followed with medicare like policies.
        As a result most oncology practices around the country have joined with hospitals. Hospitals are allowed to charge more for the same drug or service as free standing facilities under 340B rules of Medicare.
        I think that in larger urban centers the oncologists are likely to be sheltered from Medicare payment schedules by being part of 340B eligible organizations which are certainly including their satellite facilities even in remote parts.
        Short answer: the gravy train ride is over. We oncologist will continue our ride in a limo!

        • Oops, I forgot the Sustainable Growth Act which was passed in 1997 and would cut payment for office visits if the act were to be enabled. Every time it looked like the SGA was about to kick in, a bill was passed delaying the enactment and even on some occasions raising conversion rates. I forgot about it because if you cry wolf too often, people will tune you out.
          Short answer remains I doubt that oncologist will cut off ~50% of their patient panel; especially, now that many are in 340B organizations.
          We haven’t heard much from the people who said that they’d leave the country if Bush or later Obama was elected.

    • In the event you study our healthcare care system you will find you will find many well being issues we suffer from that we do not have a remedy for, the typical cold being just 1 of them. Also you will find many well being problems we do have drugs for but these drugs do not remedy but merely manage the symptoms. Asthma and diabetes are a couple and individuals with those problems are usually on a lifetime of medication which is good company for the companies that are supplying the drugs.If we weren’t trying to create a profit from cancer we would have a cure for it tomorrow because nature features a cure.