Opinion: Medicare pilot will hurt seniors

In an effort to pay less for prescription drugs, the Federal agency that oversees Medicare is pursuing an ill-advised plan to cut Medicare reimbursement for cancer drugs. In the process, it could disrupt care for many thousands of cancer patients – especially those in small towns and rural communities.

Physicians who provide cancer care strongly oppose the initiative. We urge the Centers for Medicare & Medicaid Services (CMS) to scrap it in favor of comprehensive payment reform based on years of work by my organization and many others in the cancer community.

Far from a pilot project, CMS' new Medicare Part B proposal is a nationwide experiment that will potentially affect more than half of all Medicare patients. Doctors will have no choice but to participate, and there are currently no safeguards in place to ensure that patients will not be adversely affected.

In the first phase of the plan, CMS plans to lower the amount paid to doctors for administering drugs, with the intention of reducing incentives to prescribe more costly treatments. But in cancer care, CMS is making a dangerously flawed assumption – that patients typically have multiple, equivalent drug options and that their oncologists choose the most expensive.

On the contrary, there is typically only one suitable treatment for a given patient, based on their tumor's location and stage, their health and, increasingly, the molecular profile of their tumor. Take Herceptin, for example. It is the only approved drug for certain breast and stomach cancers, and is life-saving for many patients. There is also only one treatment, Rituximab, for B Cell lymphomas. Both drugs are expensive, necessary and, under the
new plan, would be reimbursed at a much lower rate than they are today.

This matters because Medicare currently offers little or no payment for most of the care cancer patients need. That includes everything from pain management and blood tests to coordination with other healthcare providers to patient and family education. Ideally, doctors can make up the difference with reimbursement on chemotherapy drugs.

In reality, though, Medicare often covers less than what practices pay to acquire these drugs. This is especially common for smaller oncology practices, which have less purchasing power and pay more for drugs. On any given day, a typical practice pays more than Medicare reimburses for many cancer drugs. Doctors lose money every time they provide one of these "underwater" drugs, making it harder if not impossible to cover other essential patient services.

The Part B proposal will make the situation even worse. In practices recently surveyed by my organization, the new program will lead to a nearly 40 percent increase in the number of cancer drugs that will be underwater. A typical 15-physician practice stands to lose at least $560,000 annually – money that would otherwise be used to subsidize patient care.

Oncologists will always put patients first. In practices with too many underwater drugs, we will still prescribe the appropriate treatment. Many patients, though, will be forced to go to hospitals to receive it. This is not a mere inconvenience; it can be a major disruption in care for older, critically-ill patients, especially if they live outside of a major urban center and have to travel longer distances for treatment.  

What's more, it will also have the effect of driving up costs. Research shows that administering chemotherapy in a hospital costs about 30 percent more than in a private practice. This will likely offset the very cost savings CMS hopes to achieve.

In short, this proposal won't fix our country's irrational payment system. But a number of well-considered alternatives already exist. Thousands of doctors are already in the midst of preparing to implement the Medicare Access & CHIP Reauthorization Act (MACRA), a bill passed last year that would move us more quickly toward high-value care.

And my organization has developed a model to better align cancer care payments with the services our patients need.  We believe any reform should be based on a set of core principles: reimbursement should be focused on the full scope of therapies and services cancer patients need; oncology practices should not be rewarded for choosing a more expensive drug if a less expensive and medically appropriate alternative is available; and practices should not be forced to lose money providingappropriate treatment for their patients.

All of us – CMS, patients, and doctors – want high-quality cancer care at the lowest possible cost. We urge CMS to abandon its piecemeal response to rising drug prices, and work with us on comprehensive approaches that ensure Medicare patients receive the care they need and deserve.

Julie Vose, MD is president of the American Society of Clinical Oncology (ASCO). Founded in 1964, ASCO is the world's leading professional organization representing physicians who care for people with cancer.

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