The ACA fault line: Individual patient care vs. the insurer

According to cancer-patient advocate Robert Goldberg, “The latest innovation in cancer care isn’t a medical breakthrough but an app to ration new drugs. It’ll measure care in terms of what it costs health plans, instead of what it means for patients’ lives.” This “innovation” may be used to conceal the best-available cancer treatment options from...

According to cancer-patient advocate Robert Goldberg, “The latest innovation in cancer care isn’t a medical breakthrough but an app to ration new drugs. It’ll measure care in terms of what it costs health plans, instead of what it means for patients’ lives.”

This “innovation” may be used to conceal the best-available cancer treatment options from patients.

Rationing takes place in health care, as it does in every other product that is in limited supply. But in the case of the Affordable Care Act, or ACA, some oncology physicians may soon do the government’s and insurers’ bidding in rationing high-cost treatments and procedures.

Goldberg’s opinion article, as well as my own Washington Examiner piece, point out that a patient’s course of treatment could be pre-determined by an algorithm – rather than on the individual patient and their needs and preferences as determined by the physician.

Since the ACA has imposed out-of-pocket cost limits for patients, insurers may be taking a new approach: coercing physicians to ration care. Such rationing would come just before the insurers’ bailouts, provided by the ACA, end in 2016.

The insurance industry claims that new cancer treatment costs are bankrupting the health-care system. Newer cancer treatments, such as oral chemotherapy, can cost $75,000 or more, annually. As more medical breakthroughs occur, treatment costs for the newest approaches will certainly cost more. But Goldberg counters that insurers are ignoring the health savings that ultimately come from new innovations:

“Yes, spending on cancer treatments has climbed from $24 billion in 2004 to about $37 billion today. But that’s less than a half a percent of total U.S. health-care spending. More important: While expensive, since 2004 such innovations were largely responsible for a 40 percent increase in living cancer survivors, from 9.8 million to 13.6 million. The new therapies also saved $188 billion on hospitalizations.”

There is no doubt that insurers have been facing increasing pressure to cover higher-cost cancer treatments. Many insurers had been treating oral chemotherapy under prescription drug coverage rules, making the out-of-pocket costs too steep for many patients.

In response, patient advocates began lobbying state lawmakers to pass oral chemotherapy “parity” laws in 21 states where insurers are now required to cover the oral drugs in the same manner as traditional chemotherapy. But now that insurers are bound by the ACA rules limiting out-of-pocket expenses, they have sought a new avenue to limit claims.

Moving rationing decisions like these to the bedside means giving cover to government payers and insurers. This makes rationing less visible to public discussion and scrutiny since it won’t be explicitly stated policy, such as a prescription drug formulary list or pre-authorization for certain treatments. But the critical issue for patients is whether they will be kept in the dark about their treatment options.

Will your physician be providing their expertise and guidance in one of the biggest challenges you might face in your lifetime – a battle against cancer – or should you worry that your doctor is looking to cut corners for the sake of cost?

Physicians are now at an important juncture. They can either stop this proposal in its tracks, rescuing the profession from those who wish to deflect blame and scrutiny for denying care, or further compromise their patients’ trust.