CEO of Patient Advocate Foundation Cites Increase in Patients Steered from Community-Based Settings to Hospitals Due to Inadequate Reimbursement
Washington, DC – National Patient Advocate Foundation (PAF) Founder and CEO Nancy Davenport-Ennis testified today before the Energy and Commerce Health Subcommittee on the impact cuts to Medicare Part B drugs could have on patient access to critical community-based cancer care, as well as difficulty patients continue to have with Medicare co-pays.
Specifically, Davenport-Ennis pointed to a notable rise in appeals to PAF’s call centers from both Medicare beneficiaries and cancer doctors regarding difficulty accessing certain cancer drugs from their clinic in the community-based setting, where most patients receive their cancer care. As a result, patients have to seek cancer treatment in the hospital setting to access their life-saving cancer medicines; this displacement disrupts their continuum of care, is inconvenient, and can be more costly to the Medicare program.
“The stories we’re hearing from around the nation are startling and heartbreaking - and not just for the patients,” said Davenport-Ennis. “Doctors and nurses, who are committed to saving lives, are now being forced to do the unthinkable and turn sick and elderly patients away from their clinics to hospitals. We knew this day was coming, but that doesn’t make the reality of what’s happening any easier to bear. “
Upon further investigation and inquiries to both patients and cancer care providers in states like Georgia, New Mexico and Ohio, PAF case managers were able to confirm inadequate Medicare reimbursement for many leading cancer drugs as the sole reason for this trend.
A large regional cancer clinic in Columbus, Ohio, went so far as to forewarn all cancer patients in a letter that the sequestration cuts are affecting their ability to provide treatment options for their Medicare patients as a result of the drop in reimbursement. The result has been patients flocking to nearby hospitals, some of who are now experiencing a two-week delay in receiving chemo treatments, or four to six patients per day being denied services in the community-based setting.
In another case, Northeast Georgia Diagnostic Clinic, whose care team sees 200-250 patients a day, is being forced to send cancer and arthritis patients who need infusion medications to hospitals.
“I can attest with certainty that patients who struggle to make their copays while managing chronic, debilitating and life-threatening diseases require consistency in who is managing their disease condition and where,” said Davenport-Ennis. “Reductions in Medicare reimbursement to physicians over the past several years have made it very difficult to maintain their practices in the critical community-based setting, where most patients receive their care. This cannot happen to our cancer delivery system.”
Health officials throughout the cancer community attribute this growing trend to both the effects of the sequester and reduced reimbursement for Medicare Part B drugs. Effective April 1, the federal sequester reduced reimbursement for Medicare Part B cancer therapies from the current Medicare payment rate of the “average sales price” (ASP) plus 6 percent to just ASP plus 4.3 percent, resulting in severe financial losses for practices that treat cancer patients in the community. Even before this change, community-based cancer clinics maintained that drug reimbursement rates failed to adequately pay for the acquisition and related costs (such as storage, inventory, waste disposal, pharmacy and admixture facilities and staff) of life-sustaining cancer drugs.
The result, according to cancer community representatives, is that many critical cancer drugs are reimbursed below cost, and many are consolidating, merging with hospitals, or closing. The additional sequester-related cuts mean that unless cancer doctors personally fund a portion of each Medicare patient’s treatments for drugs, patients must look elsewhere for care.
Some of the drugs cited by community-based cancer clinics as having Medicare reimbursement levels below the actual cost it takes to acquire and administer the drug include Taxotere, Taxol, Cytoxan, 5FU, Dextran-high, Iron Chelation, Iron Dextran, Adriamycin, Carbotaxol, Aredia and certain drug “cocktails” – or combinations.
The impact of redirecting patients away from community-based clinics to hospital settings is shown to impact patients directly through higher copayments, longer travel times and increased travel expenses, visits to multiple providers and locations for care and services, and delays seeking treatment even as cancer progresses. All these factors result in disruption in the continuity of care, less streamlined care, increased chances for complications, and duplicative tests or procedures.
At the conclusion of her testimony, Davenport Ennis made the following plea:
“These Medicare cancer patients need Congress’ help to ensure that the health care they require is as conveniently located as possible. Congress must correct the way the sequester is applied to Medicare Part B drug reimbursements and eliminate these cuts that cruelly punish cancer patients. Further, Congress should enact H.R. 800, which removes prompt pay discounts from the calculation of Medicare reimbursement rates to make the ASP formula more closely resemble average costs. Additionally, Congress must stop incentivizing the shift to the hospital outpatient department setting. ASP can work only if it is fair and accurate, and it is up to Congress to ensure that this is the case.”