The Affordable Care Act requires Medicare patients to pay out-of-pocket for colorectal cancer screenings if a polyp is found and removed. However, if no polyp is found, patients pay nothing. This creates a disincentive for screenings and is an unintended consequence that needs fixing. Earlier cancer detection through screening reduces costs and saves lives. Representatives need to be educated on this oversight so they can quickly correct the Medicare policy and remove barriers to important cancer screenings.
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Cecily Hall Call-on Congress 2012 Presentation
1. THE IMPACT OF THE
AFFORDABLE CARE ACT ON
COLORECTAL CANCER
SCREENING
Cecily Hall
Consultant and
Former Director of Employee Benefits,
Microsoft Corporation
2. Topics for Review
• Healthcare Coverage – basic
concepts
• The Affordable Care Act – coverage
for cancer screenings
• The Challenge
• Your Opportunity to Make a
Difference
4. Healthcare Coverage: The Payers
The Government, Insurers and Employers Play Big Roles
Source: Centers for Medicare & Medicaid Services, Office of the Actuary
5. Healthcare Coverage: The Enrollee
• Enrollee
– The patient who is eligible for coverage
under the employer’s, the government’s
or the insurer’s plan
– May also be referred to as the Member
or Plan Participant
6. Healthcare Coverage: Cost-
Sharing
• Why do cost sharing strategies exist?
• Two common approaches to cost sharing*
– Deductible: A fixed dollar amount that the
patient pays before their insurance makes
payments for covered medical services
– Coinsurance: Requires the patient to pay a
percentage of medical expenses after the
deductible amount is paid
*Both examples are triggered when care is delivered
7. The Affordable Care Act:
Coverage for Colorectal Screening
The Intent
• Remove cost barriers for Medicare
participants that are candidates for
colorectal screenings
– No out-of-pocket expenses for the patient
for colorectal screenings
8. The Problem
• The Affordable Care Act requires
Medicare patients pay for a portion of
their colorectal screening/colonoscopy if
a polyp is found and removed
• If a polyp isn’t found/removed during
screening, the patient isn’t required to
pay any out of pocket expenses for that
screening
• You said What...?
9. The Problem
• This problem is due to an oversight
that occurred when writing the
legislation
• The oversight impedes screenings
that would reduce the US healthcare
spend
• …AND save lives
11. Your Mission
• Educate Congressional Representatives
about this oversight
• Help them understand the unintended
consequences
• Arm them with relevant information so
they can educate others and quickly
correct this
12. Helpful, Important Facts
• Cancer is the leading cause of death for
people ages 20-65 (prime workforce ages)
• A 2006 Milliman Study revealed:
• Enrollees with cancer tend to make up 1.6% of the
employer/insurer population but generate ~10% of the
medical costs
• The average monthly cost to a payer for an enrollee
without cancer: $360
• The average monthly cost to a payer for an enrollee with
cancer: $2,390*
* Does not include disability costs, lost productivity and life insurance payment
13. Important Facts
• Medical literature demonstrates that screening leads to
earlier detection, lowering disease severity and resulting
in fewer deaths
• People with more advanced cancer cost more than
people with less advanced cancers
• People who die from cancer cost more than cancer
survivors (considers both medical and non-medical
insurance costs (disability and life))
Therefore, screening for cancer reduces costs
- and saves lives.
Source: 2005 Milliman report commissioned by C-Change and the
American Cancer Society
14. Your Mission
Help correct the oversight and these
these unintended consequences
currently part of the Affordable Care
Act Medicare Policy
Thank you!
Notes de l'éditeur
As the cost of healthcare continues to climb, the payers have asked enrollees/consumers to pay a higher portion of what services cost
This chart givesdetail on who pays the U.S. health care expenditures. As you can see the majority of expenditures are paid by the federal government (mostly Medicare and Medicaid) and by private insurance.
Typically in a plan yearPlans may have both per individual and family deductibles.Some plans may have separate deductibles for specific services. For example, a plan may have a hospitalization deductible per admission.Coinsurance: Once any deductible amount and coinsurance are paid, the insurer is responsible for the rest of the reimbursement for covered benefits Example: You might cover 20% of total costs while Medicare handles the rest.Not all procedures and care require costs sharing – this is determined by the payerThese are not the only ways the Insurer shares costs with the patients (co-pays at time of care and or on Rx, premiums - upfront payment as a requirement of coverage, etc.)
An enrollee with cancer costs the payer ix and a half times as much for healthcare costs aloneIn contrast, Maternity costs tend to range about 5% (500M x 10% $50M year)