The passage of health-care reform-the Patient Protection and Affordable Care Act-is a "world historical event," having been attempted by five previous presidents over almost 100 years before being accomplished by the Obama administration, said Ezekiel J. Emanuel, MD, PhD, Special Advisor for Health Policy in the Office of Management and Budget, and Chair of the Department of Bioethics at the National Institutes of Health. But in spite of the legislation's promise to increase coverage to about 94% of the American populace, there are many criticisms and efforts to derail it, he said.

At the 2010 Breast Cancer Symposium, Dr. Emanuel, himself an oncologist who once taught at Harvard Medical School, discussed the key components of the Act and noted how "the common criticisms are wrong," including the following "myths":

Myth: The reform is 90% coverage and only 10% cost control.

"Many provisions will reduce the amount of spending on health care," Dr. Emanuel pointed out. The greatest reductions will come from the following reductions in spending:

• Cutting overpayment to Medicare Advantage ($136 billion)
• Reduction of payment update factor ($196 billion)
• Administrative simplification ($20 billion)
• Use of generic biologics ($7 billion)
• Enforcement of fraud and abuse laws ($3 billion)
• Payment change for complex imaging procedures ($1.2 billion)

In addition, other provisions will slow the growth rate in spending, including the "Cadillac tax" (an excise tax on high-cost insurance plans), patient-centered outcomes research, hospital 30-day admission policy (ie, penalties imposed when patients are readmitted due to inadequate care), reduction in hospital-acquired infections and other nosocomial conditions, and use of medical homes, accountable care organizations, and bundled payments.

Myth: Even if passed, the cost control provisions will not be implemented.

"Au contraire," Dr. Emanuel said, pointing out the following provisions:

• Reducing payment for high-cost imaging services is in the 2011 Medicare physician fee schedule
• Reducing payment updates for outpatient, hospital, and ambulatory surgical centers is in the 2011 Outpatient Hospital Prospective Payment Rules
• Pay-as-you-go (PAYGO) rules compel Congress not to add to the federal deficit when instituting new spending or tax changes.

Myth: Health-care reform will cost Americans.

"Reform will not add to the budget or budget deficit," he emphasized, citing over $100 billion in savings. He noted that unlike Medicare Part D, health-care reform is "completely, totally paid for" with new resources and offsets. "Health-care reform is likely to be even cheaper than anticipated if cost controls work and health-care inflation is lower, reducing Medicare and Medicaid outlays and subsidies," he added. "I think these reforms will have a synergistic effect."

Myth: All the important parts of reform do not happen until 2014 or later.

"This is partly true," Dr. Emanuel acknowledged. "But if hospitals, physicians, insurers, and others behave like my Harvard undergraduates, and wait until the night before the due date and pull an all-nighter, they will fail, and fail miserably." Changes, therefore, were gradually initiated even prior to the Act's passage.

What Health-care Reform Will Mean for Cancer Care

The transformation of the delivery system, including the field of oncology, will occur in three main areas: information (using new technologies, primarily financial incentives for installing electronic health records, and comparative effectiveness research), infrastructure (using medical homes and accountable care organizations), and incentives (using bundled payments and other financial and quality instruments).

Bundled payments may be the most striking change oncologists will experience, but Dr. Emanuel put this in positive terms. "We have lots of guidelines, which will be used to determine bundled payments. This gives you flexibility in managing patients as you see fit to provide optimal care," he said.

Reform will also ensure better coverage of breast, colon, and cervical screening tests with no copays, and will include a campaign for positive lifestyle changes. Patients with cancer will particularly benefit through the elimination of preexisting conditions exclusions and annual and lifetime limits. The Act also mandates coverage of routine costs of clinical trials.

The oncology community has a big role to play to enhance reform, Dr. Emanuel told attendees. "Oncologists should get their offices wired and use the financing that is available for installing electronic medical records," he said.

"Develop treatment guidelines and protocols that will assess therapeutically similar interventions by how they affect costs. And develop bundles for treating common cancers that can be used by payers." ■