By Chad Knight, MSHA
Zimmer Cancer Center
New Hanover Regional Medical Center
This week actress Angelina Jolie’s New York Times op-ed piece, “My Medical Choice,” focused enormous media attention on genetic testing for breast cancer and treatment options. By sharing her story, Jolie hopes to raise awareness. She writes:
For any woman reading this, I hope it helps you to know you have options. I want to encourage every woman, especially if you have a family history of breast or ovarian cancer, to seek out the information and medical experts who can help you through this aspect of your life, and to make your own informed choices.
At our cancer center, requests for information from local media and the public were immediate and compelling. In response to multiple requests from media outlets and to proactively answer questions from the community, our cancer program scheduled a press conference with the primary goal of educating our community on the importance of cancer screenings, including genetic counseling and testing.
Jolie’s announcement presents the oncology community with an opportunity to raise local awareness of the importance of access to genetic testing and counseling to help with informed, patient-driven decision making. In fact, I agree with Dr. Isabelle Bedrosian of MD Anderson who in a follow-up article expressed her hope that Jolie’s announcement will “focus women on the value of genetic counseling and making informed decisions.”
With opportunity comes challenge. Rest assured we will continue to field questions and address concerns, especially those from patients with a known family history. The challenge will be how we, with limited resources, ensure that our community is informed such that they can make educated decisions about their own health. How do we expand reimbursement models for more genetic counseling and testing and other cancer screenings? How do we make certain our medical community is collaborative and adhering to the most current evidence-based guidelines? Our challenges are great, but our opportunities are greater.
Chad Knight, MSHA, is Administrator, Oncology Services, at ACCC member New Hanover Regional Medical Center, Zimmer Cancer Center, in Wilmington, N.C.
For more on how ACCC member cancer programs responded this week, read “Angelina Jolie, BRCA1 and the Power of Celebrity” from Seattle Cancer Care Alliance.
By Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC
As more oral anti-cancer regimens become the most appropriate form of treatment for cancer patients, the inequality in coverage for oral prescriptions compared with their IV-infused counterparts is becoming clearer. Because health insurance plans cover oral anti-cancer drugs differently than IV chemotherapy and injected anti-cancer medications, patients have to pay far more out-of-pocket for oral drugs than for IV chemotherapy or injected medications. The phrase “oral parity” refers to legislative initiatives intended to protect patients with cancer from the high cost-sharing requirements that are sometimes associated with oral cancer drugs under health insurance plans.
ACCC continues to support oral parity laws in the states, as well as federal legislation. At the state level, efforts by ACCC members and other organizations are having an impact. So far this year, three additional states have passed parity legislation: Massachusetts, Utah, and now, this week, Florida, where legislation is awaiting the Governor’s signature. This brings the tally of states with oral parity legislation to 23* plus the District of Columbia.
The oral parity issue is really a case of technology outpacing policy. As therapies become more targeted, reliance on oral anti-cancer treatments will only increase. Patients receiving IV-infusions through the physician office setting are covered under the medical benefit of their insurance plan, generally requiring about a $30 co-pay. However, patients on an oral regimen are covered under their pharmacy benefit, which often requires a cost-sharing component that is some percentage of the total cost of the drug. In the case of oral anti-cancer medications, that can be thousands of dollars out of pocket every month.
ACCC is proud to support the oral chemotherapy parity bills that recently passed in Massachusetts, Utah, and Florida, and will continue to support federal efforts to pass legislation covering all 50 states. Stayed tuned for an update on federal oral parity legislation.
*Oregon (2008), Indiana (2009), Iowa (2009), Hawaii (2009), District of Columbia (2009), Vermont (2010), Connecticut (2010), Kansas (2010), Colorado (2010), Minnesota (2010), Illinois (2011), New Mexico (2011), Texas (2011), New York (2011), Washington (2011), Nebraska (2012), New Jersey (2012), Maryland (2012), Virginia (2012), Delaware (2012), Louisiana (2012), Massachusetts (2013), Utah (2013), Florida (2013 – pending Governor’s signature)
by Matt Farber, MA, director, Provider Economics and Public Policy, ACCC
In the past week, two bills important to oncology care have been introduced in the United States Congress. The first, introduced by Reps. Israel (D-NY) and Tiberi (R-OH), is HR 1661. This bill would provide reimbursement for a one-hour chemotherapy teaching session by nurses in the physician-office setting. This legislation has been introduced in previous Congresses, with the primary support of the Oncology Nursing Society (ONS). ACCC has supported this legislation in the past and will be supporting it again this year.
The second bill is the “Patient Centered Quality of Life Act” (HR 1666). This bill would support the growing demand for palliative care, which is specialized medical care that focuses on care coordination and relief from pain, stress, and other symptoms of treatment for a life-threatening disease such as cancer. The bipartisan bill, co-sponsored by Reps. Cleaver (D-MO) and Bachus (R-AL), would facilitate and expand federal research into palliative care; support training for nurses, nurse practitioners, and other allied health professionals to effectively practice palliative care; and convene health professionals, patients, public and private payers, and state and federal health officials for a national summit to develop tools and model best practices for providing palliative care.
Both pieces of legislation support oncology care and would improve the overall quality of care that patients receive. These bills address issues that have been identified as key to ensuring quality care as part of ACCC’s Grassroots Advocacy Campaign. ACCC is working with advocacy organizations, such as ONS, the American Cancer Society Cancer Action Network (ACS CAN), and other organizations to increase the support for these bills. We encourage you to write and call your elected officials and ask them to support these important measures. Visit ACCC’s Legislative Action Center.
by Matt Farber, MA, Director, Provider Economics and Public Policy, ACCC
Sequestration dealt cancer care another blow yesterday when all Medicare payments were reduced by two percent. These cuts to physician reimbursement are the third cuts due to the sequester that will impact cancer care. On March 1, the budgets of the National Institutes of Health (NIH) and the Food and Drug Administration (FDA) were each reduced by more than five percent. The funding reduction to NIH will have a significant impact on clinical trials, as well as other research projects. And, with a five percent lower budget for the FDA, which translates into a reduction of staff, the drug approval process will quite possibly be slowed.
The across-the-board 2% reduction of Medicare payments that kicked in on April 1 applies to all services billed to Medicare, including E&M codes, chemotherapy administration, hydration, and drugs and their overhead costs. Drug reimbursement will drop from ASP+6% to ASP+4.3%.
Why is drug reimbursement being reduced by this amount?
For example, consider a drug with an average sales price (ASP) of $100.
At ASP+6%, reimbursement = $106. The beneficiary pays 20% = $21.20 and Medicare normally pays 80% = $84.80.
Under sequestration, Medicare will pay $83.10 (98% of $84.80). Medicare’s share plus the beneficiary’s share after sequestration = $83.10 + $21.20 = $104.30, or ASP+4.3%.
With this change going into effect on April 1, practices and hospitals will begin to see these reductions by mid-April, when they start to get payments for services provided at the beginning of the month (CMS claims can often take 10 days to process).
For more information on these cuts, read “FAQs on the 2013 Sequestration,” just released by the American Medical Association (AMA).
More than 60% of cancer patients in the U.S. rely on Medicare. If you haven’t already done so, you should be preparing your cancer center for these reductions.
ACCC is working diligently with Congress and other advocacy organizations to try to roll back these cuts. For now, however, the 2% reduction is underway.
ACCC asks its member programs to keep track of how these cuts are impacting your ability to treat your patients and let us know. Contact Matt Farber at email@example.com.
Yesterday, Congress passed legislation to keep the federal government funded through September. In a rare act of bipartisanship, Congress avoided the potential government shutdown with a 318-109 vote in the House and a 73-26 vote in the Senate. The measure now awaits President Obama’s signature.
Even though this legislation funds federal agencies through September, the impact of the sequester is still very real. Medicare, the National Institutes of Health (NIH) , the National Cancer Institute (NCI), and the Food and Drug Administration (FDA) are all seeing significant cuts. However, this budget deal does provide supplemental funding to NIH of about $70 million to offset some of the cuts to research and clinical trials and an additional $74 million to the FDA, which may help the agency adhere to its current drug approval timeline—certainly bright spots in the gloomy sequester landscape.
It is important to note, though, that this is a pivotal year for implementation of the Affordable Care Act (ACA), which could lead to problems in an already too-tight budget. More states than previously expected have elected to let the federal government run their health insurance exchanges. This makes budgeting for these costs more difficult than initially predicted, and could lead to underfunding of the exchanges.
Certainly more debate on the federal budget and funding for healthcare reform is to come. As always, ACCC will keep its members updated on new developments.
by Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC
The Congressional Budget Office (CBO) has lowered the expected 10-year cost to replace the sustainable growth rate (SGR) formula from $245 billion down to $138 billion, a reduction of more than 40 percent. In its annual report on the federal budget and economy issued Feb. 5, CBO attributed the significant decrease in cost to the slow down in healthcare spending in recent years. This is largely due to the decreased use of medical services as a result of the recession, as well as the more efficient and appropriate use of medical procedures and other delivery system changes.
Meanwhile on Capitol Hill, in a bi-partisan effort, Representatives Allyson Schwartz (D-PA) and Joe Heck (R-NV) have reintroduced the Medicare “doc-fix” bill without the war savings offsets seen in the previous bill to attract more support. The Schwartz/Heck bill will eliminate the present fee-for-service system in favor of a system developed and tested by the Centers for Medicare & Medicaid Services (CMS) over the next five years. Physicians opting to remain with the current system would face increasing cuts to reimbursement, unless they are close to retirement.
Additionally, Kevin Brady (R-TX), is expected to introduce an alternative legislation that would allow for the continued use of the fee-for-service system on a modified basis by offering additional reimbursement for providers increasing efficiency. Congressman Brady’s proposal is also designed to encourage physician involvement in the replacement payment mechanism.
While we still await the introduction of Brady’s bill, the fact that both parties agree that the SGR must be fixed is promising. While Congress must still find a way to pay for the repeal, the lowered CBO score makes this task more palatable. With all the talk around the SGR in Congress, now is the time to reach out to your representatives and encourage them to act on this issue. Let them know why it is important to you and your patients that the SGR be repealed and permanently fixed. Visit ACCC’s Legislative Action Center for tools to help you make your voice heard.
By Sydney Abbott, JD, Policy Coordinator, ACCC
The long-held understanding that a pharmaceutical representative may not discuss any off-label use of an FDA-approved drug with a provider has been turned on its head by a federal appellate court in Manhattan. The controversial decision to allow pharmaceutical sales representatives to promote drugs for off-label use was recently determined in a 2-1 decision by a three-judge panel in the Court of Appeals for the Second Circuit, in United States v. Caronia. This ruling could have specific ramifications for ACCC members.
The way sales representatives may communicate with providers could change in the future. The federal appellate court ruling overturned a lower court’s decision on the basis of free speech. Leaning on recent precedent calling pharmaceutical use of prescription data for marketing purposes free speech, the court determined that pharmaceutical representatives are exercising their right to free speech when promoting the off-label use of an FDA (Food and Drug Administration) approved drug, so long as the use is supported by compendia.
This ruling is a complete reversal of the way FDA views the issue. Therefore, the government will likely appeal the ruling to the U.S. Supreme Court. If the ruling is upheld, the Supreme Court could address the slippery slope issue of defining parameters for promotion. What constitutes compendia? Ultimately, this decision could be a game-changer in the way pharmaceutical representatives interact with providers. And, it could have far-reaching impact beyond drugs, possibly into anything the FDA has its hand in, like medical devices, diet aids, or tobacco.
Most importantly, though, know that no change in your interaction with pharmaceutical representatives is likely in the near-term. First, the appellate court’s decision is limited to the Second Circuit’s jurisdiction – New York, Connecticut, and Vermont. In every other state it is still the law that no discussion of off-label uses is permitted by drug representatives. And, even with this decision, companies are unlikely to change their policies before a final decision on the matter is made by the U.S. Supreme Court.
For the full decision, please see United States v. Caronia.
By Matt Farber, Director Provider Economics and Public Policy, ACCC
By now most of you know that the House of Representatives passed a bill late last night averting the so-called “fiscal cliff,” stopping massive tax hikes, and delaying spending cuts. Within this bill are a few key provisions related to healthcare that are worth taking note of:
- Congress voted to delay the sequestration cuts for two months. This means that the two percent cut to Medicare payments will be put off until early March, as will the cuts to the National Institutes of Health, the Defense Department, etc. Ultimately, Congress acted to buy itself more time on this issue. Now, Congress will have to deal with both the sequestration cuts and the budget in the first two months of the year.
- Congress included a one-year patch to the sustainable growth rate (SGR), averting a 26.5 percent cut to the conversion factor. Once again, Congress has opted for a “doc-fix,” and once again we would have preferred that the “fix” be long-term instead of yet another “band-aid.” But as in past years, the price tag for a long-term fix has proven to be too big a stumbling block. To pay for this one-year fix Congress will again make cuts to other areas of healthcare as it did in 2012. This time the cuts will come from Disproportionate Share Hospital (DSH) payments, other payments to hospitals, cuts to imaging payments, and cuts to ESRD payments and to some diabetic pharmacy supplies. (ACCC will prepare a full summary of the bill with complete details. Stay tuned to the ACCC website for more information).
So Congress has prevented a fall off the cliff—for the time being. In the end, this is a mixed bag for oncology providers. Avoiding the two percent cut and 26.5 percent cut are good things; however, both are only temporary. The two percent sequestration cuts are postponed for two months, while the SGR “doc fix” lasts for one year but comes with cuts to other areas of the healthcare sector that will impact oncology.
These developments underscore the importance of building relationships with your members of Congress. What would a two percent across-the-board reduction in Medicare reimbursement mean to you and your ability to see patients? Let your senators and representatives know how this will affect patient access—and jobs—in your area. This is especially important for those in states with newly elected members of Congress.
ACCC is undertaking a new grassroots effort to educate Congress about the issues impacting community cancer care. Please visit our the advocacy section on the ACCC website to learn more about the issues and how to contact your members of Congress. In ACCC’s Legislative Action Center you will find an easy-to-send letter on stopping the sequestration cuts.
As always, ACCC will keep members up-to-date on all new developments. Congress needs to hear from you, and ACCC is here to help.
If we need a reminder of the impact of the cost of cancer care on patients, a compelling opinion piece in the New York Times takes us step by step through the maze of trying to unravel exactly what the author’s cost will be for an anticancer drug in 2013. By the numbers: 70 phone calls to 16 organizations over the course of a few weeks. The answer: Still TBD.
And this is the experience of a former business journalist.
The cost of cancer care is a challenge for patients, providers, and payers.
According to ACCC’s 2012 Cancer Care Trends in Community Cancer Centers survey, 95% of respondent hospital-based cancer programs are seeing more patients without insurance or with inadequate insurance, and most respondent cancer programs are providing some type of financial counseling.
Community cancer centers have an important resource in ACCC’s “Financial Information and Learning Network” , which offers resources including webinars, online courses, workshops, and tools, to help providers help their patients with the complex financial issues surrounding their cancer diagnosis and treatment.
By Matt Farber, Director of Policy & Provider Economics, ACCC
The last few weeks have been busy for oncology healthcare policy. Last week the Centers for Medicare & Medicaid Services (CMS) released its final 2013 Physician Fee Schedule and Hospital Outpatient Prospective Payment System rules. Then, on Tuesday, the citizens of the United States went to the polls, shaping the course of government for the next two years and beyond. So, what happens now?
First, let’s cover what we know. The final Medicare rules for 2013 tell us:
- Drug reimbursement in the hospital outpatient department (HOPD) will increase to ASP+6% as proposed.
- Many chemotherapy administration APC reimbursement rates will increase as proposed.
- The overall impact (not counting the SGR or sequestration) on medical oncology in the PFS will be a 2% increase in reimbursement, as opposed to the proposed 1% decrease.
- The cuts to radiation oncology will be 7% in 2013, as opposed to the proposed 15% reduction.
These figures prove a very important point: having your voice heard by policymakers and legislators is more important than ever. CMS received a flurry of comments from across the healthcare spectrum on the negative impact the proposed 15% reductions in reimbursement would have on radiation oncology patients and practices. The agency heard stakeholder concerns and reduced its proposed cuts by half. While ACCC believes that the 7% reduction is still too steep, we are pleased that CMS has recognized our comments and those of other stakeholders and rolled back some of the cuts.
As for the results of Tuesday’s election, it seems like we’re in a position very similar to where we were before the election. President Obama has been re-elected, the GOP retains control of the House, and the Democrats remain in the majority in the Senate. Though this seems like a recipe for continued gridlock, Congress will be very active during December’s lame duck session. Congress must, and we believe will, halt the looming cuts to physician reimbursement due to the SGR. A short-term fix is probably all we will see, but a “doc fix” is very likely. Congress must also act to halt the cuts due to sequestration and the tax increases due to the expiring Bush-era tax cuts. If Congress does not act, the country faces the “fiscal cliff” that is being widely discussed in the news media.
Interestingly enough, although the balance of power after the election looks much as it did before, the election results may make a difference here. The President likely feels emboldened by the election results and so may take a stronger stance, essentially drawing a line in the sand on his position to match spending cuts with revenue increases (tax increases on the wealthy). It is possible that Congress may be unable to stop the tax increases and we might see these instituted on January 1. Then, the President and the Democrats in Congress would draft a bill to cut taxes on all but the wealthiest Americans, daring Republicans to vote against such a bill. It will be interesting to see how this plays out over the next two months.
Finally, there’s the Affordable Care Act (ACA) to consider. What do the election results mean for healthcare reform? Simply put, the election tells us that the ACA will live on. Its insurance reforms and other payment reforms will move forward over the next two to five years as planned. There is one caveat however. During the upcoming sequestration and debt ceiling negotiations, it is likely that EVERYTHING will be on the table in the search for programs to cut to offset the automatic cuts. That may mean that parts of the ACA, such as PCORI, the CMS Innovation Center, or subsidies for participants in exchanges, may end up on the chopping block. So if you are concerned about a program you support or think will help your patients, be sure to have your voice heard. Tell your elected officials to protect those programs, and protect oncology care. Not sure where to start? Come to the ACCC 39th Annual Meeting, and participate in our Capitol Hill lobby day on March 6. We are here to help.
ACCC’s Regional Meetings are here! ACCC members get complimentary registration for these meetings, focused on current policy and legislative issues, billing and coding updates, tools for improving patient financial assistance programs, and more. Attend a regional meeting in Jersey City on November 28, Louisville on December 5, or Denver on December 13. Learn more today!