As the political
environment heats up in advance of the upcoming presidential
campaign season, many issues crucial to the oncology community are
being placed on the political chopping block as policymakers seek
ways to reduce the mounting debt and soaring health-care spending.
To help clarify some of the current policy concerns crucial to the
delivery of cancer care, The ASCO Post spoke with
Ms. Shelagh Foster, Director of Government
Relations for ASCO.
The SGR
Problem Resurfaces
As reported previously
inThe ASCO Post, a "patch" for the sustainable growth rate
(SGR)-the instrument used to calculate physicians' fee schedule-was
passed at the end of last year, averting a 23% cut in Medicare
reimbursement for physician services. However, if Congress does not
act by January 1, 2012, a 29.5% cut in physician reimbursement
could take effect. Congress faces a dilemma: A true SGR
fix-eliminating the problematic instrument-would cost taxpayers
well in excess of $300 billion.
"Current talks on the
Hill include a permanent fix to the SGR formula or a freeze of some
period to allow ample time for policymakers to develop a permanent
fix. However, these proposals do not outline what the fix will be,
and any solution will likely be tied to quality reporting," said
Ms. Foster. "ASCO continues to work hard with members of Congress
to include the SGR fix into any of the comprehensive budgetary
packages that are put forth," she added.
Cuts to
Medicare Reimbursement
The cancer community is expressing
deep concern over a proposed $3 billion cut in Medicare
reimbursement for oncology drugs. ASCO and other leading cancer
groups signed onto a letter, sent to the White House and
congressional leadership on July 14, urging both parties to oppose
a proposed $3 billion funding cut to Medicare reimbursement for
oncology drugs. While these cuts were originally proposed in the
debt ceiling negotiations, they will likely be on the table for any
Medicare reform or proposed SGR fix.
Ms. Foster explained that
cuts would shave another 2 points off the average sales price,
which is linked to the reimbursement rate, bringing it from 106% of
average sales price, down to 104%. "The message we impress on
policymakers is that many community practices are already
struggling to make up the shortfall from Medicare drugs currently
'underwater' [ie, insufficiently covered by current Medicare
payments], and cuts of this proportion would have a devastating
effect on access," said Ms. Foster.
She stressed that in the
grand scheme, the cuts to oncology being proposed have little
effect on the overall budget or Medicare, but will hamper an
already fiscally challenged cancer care delivery system.
Reporting
System Signals Change
In 2007, Medicare began
operating the Physician Quality Reporting System (formerly known as
the Physician Quality Reporting Initiative) on a voluntary basis.
The Centers for Medicare & Medicaid Services (CMS) program
provides incentive payments to eligible professionals who report
data on quality measures. Providers also receive confidential
feedback reports.
However, the Affordable
Care Act established penalties for providers who do not
successfully participate in this reporting system. That change in
the program-from bonuses for voluntary participation to reductions
in payment for nonparticipation-has increased the pressure on
physicians to participate. It is important for the oncology
community to keep abreast of how this program unfolds in the coming
months, in order to prepare for any changes that might affect the
delivery of care.
Prompt Pay
Hurts Community Practices
Another issue that has
been on ASCO's front burner for numerous legislative calendars is
the customary prompt pay discounts that are based on negotiated
terms between the manufacturer and the distributor for payment
within a certain time frame and represent the time value of money.
These discounts are typically not passed on to the physician
purchasing the drugs.
"Removing prompt pay from
the average sales price formula for physicians creates a more
accurate reimbursement for drugs, closer to the average sales price
plus 106%, which we should be getting based on the 2003 Medicare
Modernization Act, said Ms. Foster. She pointed out two bills
currently in Congress: H.R. 905 and S. 733. These bills are
bipartisan and were introduced by Representatives Al Green (D-TX)
and Ed Whitfield (R-KY) in the House and Senators Debbie Stabenow
(D-MI) and Pat Roberts (R-KS) in the Senate.
Cognitive
Services Still Underreimbursed
Under certain Affordable
Care Act provisions, Medicare will transition physicians to a
value-based purchasing reimbursement system using quality and cost
measures as calipers to gauge proper payment. Reimbursement will be
tied to CMS reporting on physicians' relative patterns of use-but
it is unclear how this will be implemented as a way to pay for
difficult-to-quantify oncology services.
To that end, Ms. Foster
addressed a long-standing problem for oncology providers-getting
proper compensation for cognitive services and other complex,
difficult-to-bill practices. "We need to look at the reimbursement
system differently. We should be paying oncologists for cognitive
services, such as treatment plans," said Ms. Foster.
Put simply, oncologists
are reimbursed for evaluation and management, for administering
chemotherapy drugs in the office setting (plus related services),
and for the cancer drugs they purchase and deliver. However, all
the other cognitive services, such as treatment planning, follow-up
care, and survivorship support, are not adequately reimbursed. ASCO
continues its efforts to educate lawmakers about the uncompensated
services that are delivered every day in community practices.
Cuts to
Oncology Impact Care
Ms. Foster acknowledged
that gaining headway on tough-to-sell political issues such as
adequate reimbursement for physicians is an uphill battle for the
oncology community. "It's not that we find policymakers
unsympathetic to our concerns; it basically boils down to taking a
back seat to the economic challenges of the day," Ms. Foster
explained.
In general, many of the
issues and challenges in today's tough environment have overlapping
problems and solutions. ASCO and other major cancer organizations
are working with bipartisan groups of policymakers to focus on
developing ways to fairly compensate oncologists for delivering
evidence-based, cost-effective quality care.
"We're cautioning members
from both sides of the aisle on the Hill that proposing wholesale
reductions in funding and reimbursement for oncologists as a way to
generate revenue will have the unintended consequence of hampering
access to care for the nation's patients with cancer," concluded
Ms. Foster. ■
Disclosure: Ms. Foster reported no
potential conflicts of interest.
SIDEBAR: Customary Prompt Pay
SIDEBAR: Letter to President
Obama
