Medicare Pricing Experiment Could Cost Seniors Access to Cancer Care
The Centers for Medicare and Medicaid Services want to impose a mandatory payment experiment that could burden both patients and providers.
Alan Marks, MD, is a board-certified oncologist practicing in Jacksonville, FL, and a member of the Alliance for Patient Access.
Senior citizens with cancer represent some of the most vulnerable patients in our health care system. Many rely on Medicare Part B for chemotherapy infusions at their physician's office or local hospital as part of their uphill battle to fight the disease. But now the Centers for Medicare and Medicaid Services (CMS) want to impose a mandatory payment experiment that could burden both patients and providers, hindering access to high quality, high value care.
While Medicare Part D covers most take-home prescription drugs for older Americans, Part B typically covers medications that are injected or infused under direct supervision of a health care provider.
In addition to infused chemotherapy medications for cancer, Part B also covers treatments for conditions such as rheumatoid arthritis, macular degeneration, and inflammatory bowel diseases.
To provide ready treatment for patients, doctors and their staff may maintain an inventory of these drugs at their clinic or hospital. Some of the treatments, such as cell-derived biological drugs, require refrigeration or special handling. Health care providers and staff must set aside time to receive, store, and prepare these drugs before administering them to patients. Medicare covers the cost by reimbursing physicians for the average list price of the drug plus an added payment to cover the cost of staff time in handling, preparing, and administering them.
Few would argue that physicians must be reimbursed for the time and resources required to provide sophisticated Part B drugs. But in recent years, CMS and others started to quibble about the amount of reimbursement—and how it is calculated. In 2011, Congress reduced reimbursement for Part B drugs as part of sequestration cuts, trimming the payment for handling and preparing the drugs from 6% of the drug's average list price down to 4%.
Now, CMS' proposed payment model would reduce the amount even further, down to 2.6% plus a nominal flat fee. It would also randomly select health care providers for mandatory participation in an experiment that imposes new payment methodologies.
The problem is a rather obvious one. These drugs are costly and time-consuming for providers. Thus, where reimbursement falls below what's required to store, track, and prepare these drugs, physicians and clinics will simply limit the number they use. Or, they'll stop providing them altogether.
Patients will encounter fewer choices for treatment. For example, when a patient and physician discover that the current treatment choice isn't working, the physician may have to send the patient elsewhere to get the desired alternative. Some community oncology practices may stop offering chemotherapy altogether, sending their patients instead to a hospital for treatment.
For any patient, having to change health care providers or to seek treatment at multiple centers rather than just one can be a burdensome nuisance. For senior citizens, it can be a significant barrier to care. Transportation challenges are real for these patients, who must often depend upon family members to drive them or must navigate public transportation alone. And, especially for those fighting cancer, a doctor's visit can be physically and emotionally draining. Multiplying the number of trips required is an unfair burden on these patients.
Cost-effectiveness and value in health care are laudable goals for the long-term viability of our nation's health care system. But experiments of the sort CMS wants to explore should begin smaller, with voluntary participation by health care providers and clinics that feel they can fulfill the goals of the program without compromising patient care.
CMS hopes to reduce drug costs for the Medicare program but, for patients, the cost of this pricing initiative is just too high.