Officials at the Centers for Medicare and Medicaid Innovation (CMMI) recently proposed a major change to the way Medicare pays for advanced cancer medicines. Unfortunately, the changes threaten cancer patients’ access to lifesaving care.
Many people are familiar with Medicare Part D, which covers prescription drugs that beneficiaries purchase at pharmacies. Part B, however, is less well known. It covers drugs for illnesses such as cancer, rheumatoid arthritis, and immune diseases that are administered at clinics or outpatient hospitals.
CMMI believes doctors prescribe expensive drugs, rather than clinically appropriate drugs, because under Part B doctors receive a percentage of the drug’s price to cover the cost of administering it. While there is no evidence doctors prescribe the wrong drug so they make more money, CMMI nevertheless proposes to “fix” this supposed problem by altering physicians’ reimbursements.
Doctors who administer a drug under Part B were traditionally reimbursed the average sales price of the medicine plus 6 percent. Following budget cuts in 2013, Medicare officials reduced that rate to about 4.3 percent. Now, they’re proposing to cut it to 2.5 percent, but add a flat fee of around $17 each time doctors administer a medicine.
CMMI ignores the impact this change will have on patients. Smaller community practices and those in rural communities will drop patients that lack supplemental insurance or send them to major hospitals for treatment; this occurred in 2013 with the “sequestration” budget cuts. CMMI’s latest cuts will force more providers to turn away patients.
And if making patients potentially drive hundreds of miles each week for chemotherapy wasn’t enough, CMMI proposes to test a host of “value-based care models.” For example, in one model officials would compare a drug’s average life expectancy gains to its cost. If the drug doesn’t meet an arbitrary dollars-to-days ratio, it’s considered a bad bargain for the Medicare.
Some countries, like Britain, already use cost-effectiveness metrics to restrict doctors’ ability to prescribe advanced drugs. Unsurprisingly, cancer survival rates are lower in those nations than in countries that don’t interfere in doctor-patient treatment decisions.
That begs the question: who receives the “value” from these models? Is it patients, who potentially lose access to the most innovative, life-saving treatments? Or is it Medicare, which saves money by denying payments for treatments the government decides aren’t “cost-effective.”
The health of tens of millions of Americans hangs in the balance. Men have a fifty-fifty chance of developing cancer in their lifetimes; for women it is one in three. Given that cancer disproportionately impacts older adults, it is likely that if a person develops cancer, he’ll rely on Medicare Part B to cover treatment costs.
Americans must ask themselves: when they or their loved ones develop cancer, do they want to receive the treatment their doctors say will provide the best chance of survival and quality of life? Or do they want to receive only the medicines that government officials deem cost-effective?
Patient health is not something to be toyed with. It’s time for the government officials who tinker with reimbursement formulas to realize that their fiddling has consequences for real people.
Eric Hargis is Senior Policy Advisor for the Colon Cancer Alliance.Posted - Copyright © 2022 Eastern Group Publications, Inc.