Sunday, April 7, 2013

Obamacare and Cancer

I’ve been asked to discuss these subjects.

·       The Affordable Care Act – its potential effects on inpatient and outpatient treatment of cancer patients.

Cancer accounts for 23% of deaths and 12% of all health costs. Because of our aging population, advances in technology, and expensive anti-cancer drugs, its costs are rising at 20% a year.   Because of Obamacare, physicians and hospitals are rapidly consolidating into large integrated organizations to deal with federal regulations, administrative demands, costs of installing information technologies, and demands for value-evidence-based approaches to contain costs and offer more systematic team based approaches to care.    Cancer treatment has improved.  There are now 11 million cancer survivors.  Many are elderly and expect the best care modern medicine can offer.

The effects of this will be multiple.   Inpatient care  or care dictated by large organizations will grow,   costs will increase, cancer departments within hospitals will proliferate,  protocols to treat cancer will become the norm,    demands by patients to be referred to leading cancer centers (Sloan-Kettering, Smile at Yale,  Boston-based teaching centers, MD Anderson in Houston) for comprehensive  centers that  treats all aspects of cancer, second opinions,  comparative statistics, and access to the latest technologies and teams of experts, will become a growth industry.  Palliative care will become a medical specialty, and subspecialties – oncology nurses, oncology pharmacists – will be much in demand.

·     Specific issues being faced by physicians in the field of oncology particularly in hospital and managed care settings.

These issues will include: 1) how to coordinate care with other doctors (primary care, diagnostic and radiation oncologists, social workers, home care nurses, and hospice-based nurse practitioners, to name but a few), 2) how to deal with the political controversies surrounding “death panels” and end of life counseling; 3) whether to become an employee of the hospital or large cancer organization. 4) how to facilitate the entry of patients into clinical trials, so that patients can afford anti-caner drugs;   5) when and how to tell patients  to withdraw treatment and to refer them for palliative care; and  most immediately, 6) how to survive in practice with the latest sequester,  which calls for 2% Medicare cuts.  These cuts are across the board and apply to the basic Medicare fee plus the cost of anti-cancer drugs and the 6% added to cover the average cost of drugs.  Oncologists are saying these amounts to an overall cut in their Medicare fees.   Since the typical oncologist has 300 to 350 Medicare patients and this cut reduces their revenues by $400 per patient, many oncologists say they cannot afford to treat new patients and are turning away thousands of Medicare patients.  The choice is between seeing Medicare patients or staying in business.

Beyond this there are the problems of primary palliative care and specialty palliative care, as outlined in the March 28 NEJM (“Generalist plus Specialty Palliative Care – Creating a More Sustainable Model”) outlined as follows.

Primary Palliative Care

1.      Basic management of pain and symptoms

2.      Basic management of depression and anxiety

3.      Basic discussions about – prognosis, goals of treatment, suffering, code status.

Specialty Primary Care

1.      Management of refractory patina or other symptoms

2.      Management of more complex depression, anxiety, grief, and existential distress.

3.      Assistance with conflict resolution regarding goals or method of treatment – within families, between staff and families, among treatment teams.

4.      Assistance in addressing causes of near futility


·     The role of pharmacists in care of cancer treatments, particularly in serving as members of multidisciplinary care team.

Make no mistake about it.   The role of pharmacists in cancer care is growing.   This is because of the expense of drugs and safety issues – 1) drug interactions with other drugs, over the counter medications, herbal medications, dietary supplements.  Many pharmacists have computer programs for tracking these interactions; 2) compliance issues – pharmacists are in a position to know if patients are filling their prescriptions  and may be of help in facilitating  access to these drugs or negotiating discounts.   A new specialty, board certified oncology pharmacists, now exists.  About 1% of the nation’s 250,000 pharmacists are now board certified in this specialty.   These new specialists are now much in demand in hospitals, cancer centers, oncology practices, and in nursing homes,   all of whom are trying to reduce costs and enhance effectiveness.  There is even a new journal The Journal of Oncology Pharmacy Practice.
The Triple Aim
The goals of managed cancer care are called “the triple aim”- to create a positive patient experience, to optimize outcomes, and to reduce costs.  To accomplish these aims, the cancer community and payers will increase guidelines and protocols, focus on evidence based care, utilize case management techniques, aggressively manage drug sales prices, aggressively contract for best prices and best practices, call for more appropriate uses of imaging and radiation modalities, and explore the possibilities of bundled care for specific cancers and episodes of care.

Tweet:  The effect of Obamacare on treatment of cancer patients has been profound because it focues on economic rather than clinical issues.



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