In 2010, Congress passed (and the President signed into law) comprehensive healthcare legislation called the Patient Protection and Affordable Care Act (PPACA), or as it is more commonly known, the Affordable Care Act (ACA).1 This legislation provides a health insurance exchange in which individuals and small businesses can purchase qualified health plans (QHPs). According to a report by the US Department of Health & Human Services (HHS),2 more than 8 million people enrolled in the health insurance marketplace by the end of the initial enrollment period (October 1, 2013–March 31, 2014). This total includes activity associated with individuals who qualified for a special enrollment period that was reported through April 19, 2014.
The goal of the ACA is to insure the uninsured and protect patients with chronic illnesses who are in the greatest need of quality care. However, this legislation is not perfect, and an important question to ask is whether it is going to benefit patients with cancer. The answer depends on who you ask. Each state’s QHP must offer, at minimum, the essential health benefit package,3 as defined by the HHS. Unfortunately, as was discussed in a previous article in Conquering the Cancer Care Continuum™ (“Access to Quality Care: A Nurse’s Perspective”), many patients with previously “good” insurance feel that the new plans leave them relatively underinsured. Is it true that some insurance is better than no insurance? Let’s review some of the ways in which the ACA will affect patients with cancer.
Improved access to care. More patients who are uninsured will have access to cancer care under the ACA, despite the presence of a preexisting condition. In addition, children who are cancer survivors are covered until they are 19 years of age, and patients cannot be dropped from insurance when they become sick. This access to care is critical for individuals with cancer.
No more doughnut holes. The ACA provides a rebate to seniors who hit the coverage gap in Medicare’s Part D prescription drug program. Although individuals will often need to tap into additional resources, such as the chronic disease fund, patient access network, and individual pharmaceutical companies, out-of-pocket copayments for oral medications and various services will tend to be less. However, oncologists should be cognizant of prescribed medications so that patients are not placed in a financially disadvantaged position.4
No capitation of coverage. In the past, companies could set a lifetime limit on coverage. These limits on insurance are not allowed under the ACA.
Clinical quality measures will be enhanced with penalties for hospital readmissions. The Centers for Medicare & Medicaid Services is revising its payment structures and mandating better quality measures for patients (including those with cancer) so that hospitals can be reimbursed for services. Quality of services with measurement of these services will be closely evaluated and additional training will be mandated at the graduate level for providers.5
Penalties for hospital readmissions may occur and impact the organization more than the patient. For patients with multiple symptom and side-effect management issues, it may be challenging to prevent hospital readmissions. However, many centers have addressed the risk of financial penalties for hospital readmissions. At our center, we have created acute care clinics, which are run by advanced practice nurses (APNs) or physician assistants (PAs) in an effort to prevent admission to the hospital. Patients who come to the clinic with a symptom to be managed, such as nausea and vomiting, can be seen by a midlevel provider and given appropriate hydration and antiemetics to prevent hospital admission. A call-back system by a nurse navigator, an APN, or a PA has been implemented to address symptom management and provide outpatient treatment versus readmission to the hospital when appropriate.
With the passing of the PPACA, the United States has been given an opportunity to transform its healthcare system. As key members of the cancer care team, nurses need to address the increasing demand for safe, high-quality, efficient care. Future directions should be aimed at meeting the challenge of new and expanding responsibilities, educating patients on the intricacies of the new legislation, and assuming leadership roles to create better-integrated, patient-centered healthcare services.
- Patient Protection and Affordable Care Act of 2010. Public Law 111-148, 124 Stat 119, 2010.
- Office of the Assistant Secretary for Planning and Evaluation. US Department of Health & Human Services. Health insurance marketplace: summary enrollment report for the initial annual open enrollment period. May 1, 2014. http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib_2014Apr_enrollment.pdf. Accessed October 23, 2014.
- Hutchins VA, Samuels MB, Lively AM. Analyzing the Affordable Care Act: essential health benefits and implications for oncology. J Oncol Pract. 2013;9:73-77.
- Zhang SQ, Polite BN. Achieving a deeper understanding of the implemented provisions of the Affordable Care Act. Am Soc Clin Oncol Educ Book. 2014:e472-e477.
- Centers for Medicare & Medicaid Services. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and fiscal year 2015 rates; quality reporting requirements for specific providers; reasonable compensation equivalents for physician services in excluded hospitals and certain teaching hospitals; provider administrative appeals and judicial review; enforcement provisions for organ transplant centers; and electronic health record (EHR) incentive program. Final rule. Fed Regist. 2014;79:49853-50536.