Changing the Identity of Medical Oncology under Medicare

[gpawelski]

The new Medicare Modernization Act of 2003 changed how the CMS pays for doctor-administered drugs to a system based on doctors' costs for the drugs from one based on average wholesale price. Medical oncologists will be reimbursed for providing evaluation and management services, making referrals for diagnostic testing, radiation therapy, surgery and other procedures as necessary, and offer any other support needed to reduce patient morbidity and extend patient survival.

According to the Government Accountability Office (GAO), oncologists will see a net increase in Medicare revenue for oncology drugs, their preparation and their administration in 2004 and 2005, despite reduced payments for certain drugs. Providers feared the change would represent significant reimbursement cuts. However, the GAO said that in a review of 17 drugs, Medicare rates would exceed physician costs by 22% in 2004 and by 6% in 2005.

The fact that these medical oncologists received no reimbursement for providing oral-dose therapy to patients had been the principal barrier to the availability of oral-dose protocol. The advent of oral agents ultimately means that medical oncology will need to change its identity, prior to the chemotherapy drug concession. Because oral-dose drugs hold the promise of being more selective, harming fewer normal cells, reducing side-effects and work to improve the quality of life for people with cancer, they will rightfully gain their appropriate share of the marketplace, again.

The new Medicare Bill offers patients benefits they did not have before, mainly some coverage for oral chemotherapy drugs. Since April of 2004, $200 million was available so that some Medicare cancer patients would have transitional coverage for these drugs, until the bill goes into full effect in 2006. Although some benefit was realized, more might have been achieved if the American Society of Clinical Oncology and other groups had lobbied as much for the oral chemotherapy drug issue as they did for office-practice expense reimbursement. They fought long and hard to retain the Chemotherapy Drug Concession.

Increasingly, oral-dose anti-cancer drugs are found to treat cancer effectively and seen as a necessary part of a patient's cancer care. A number of these breakthrough cancer drugs came on to the market that are only in oral form and previously not reimbursed under Medicare. Patients were being forced to compromise their cancer care due to Medicare not covering many of these life-saving therapies.

The new legislation started the process of providing access to a full range of the latest cancer-related prescription drugs at manageable costs to enhance the quality and standard of treatment for cancer. Medicare recipients were being relagated to treating their diseases with older, more toxic infusional chemotherapy agents at a time when new and more promising cancer drugs were reaching the market.

Compared to infusional therapy, oral-dose anti-cancer drugs can make receiving cancer treatment more convenient for patients by allowing flexibility in taking medication without disrupting work or other activities. They can often result in less time (or no time) spent in office-based oncology practices because of the absence of intravenous administration and its related side-effects.

Targeted cancer therapies will give doctors a better way to tailor cancer treatment. There are a multiple of different cancer drug regimens, all of which have approximately the same probability of working. Treatments may be individualized based on the unique set of molecular targets produced by the patient's tumor, and these important treatment advances will require individualizing treatment based on testing the individual properties of each patient's cancer.

What was needed, was to remove the profit incentive from the choice of cancer treatments, which were financial incentives for infusion therapy over oral therapy or non-chemotherapy, and financial incentives for choosing some drugs over others. Patients should receive what is best for them and not what is best for their oncologists.

The new system is clearly an improvement from the standpoint of cancer patients, taxpayers, and advocates of basing drug selection on individual tumor biology, rather than on a least common denominator approach which invites "conflict-of-interest medical decision-making."

It is time to set aside empiric one-size-fits-all treatment in favor of recognizing that many forms of cancer represent heterogenous diseases, where the tumors of different patients have different responses to chemotherapy. It requires individualized treatment based on testing the individual properties of each patient's cancer.

[gpawelski]

The fact that medical oncologists received no medicare reimbursement for providing oral-dose therapy to cancer patients had been the principal barrier to the availability of oral-dose protocol. Patients were being forced to compromise their cancer care due to Medicare not covering many of these life-saving therapies. The advent of oral agents ultimately means that medical oncology will need to change its identity.

The new Medicare Bill offers patients benefits they did not have before, mainly some coverage for oral-chemotherapy drugs. The new legislation started the process of providing access to a full range of the latest cancer-related prescription drugs at manageable costs to enhance the quality and standard of treatment for cancer.

Compared to infusional therapy, oral-dose anti-cancer drugs can make receiving cancer treatment more convenient for patients by allowing flexibility in taking medication without disrupting work or other activities. They can often result in less time (or no time) spent in office-based oncology practices because of the absence of intravenous administration and its related side-effects.

These targeted cancer therapies will give doctors a better way to tailor cancer treatment. Treatments may be individualized based on the unique set of molecular targets produced by the patient's tumor, and these important treatment advances will require individualizing treatment based on testing the individual properties of each patient's cancer.

What was needed, was to remove the profit incentive from the choice of cancer treatments, which were financial incentives for infusion-therapy over oral-therapy or non-chemotherapy, and financial incentives for choosing some drugs over others. Patients should receive what is best for them and not what is best for their oncologists.

[cindi o'h]

Thank you.

Always enjoy your posts. Now here is a man with a mission.

Cindi o'h

[gpawelski]

The Medicare Rights Center’s report Heightened Anguish: Medicare Payments for Life-Saving Drugs is available online at

http://www.medicarerights.org/partbdrug ... meset.html

[gpawelski]

Oncologists are among the most highly-paid of the internal medicine sub-specialties. Office chemotherapy has made thousands of oncologists not just prosperous but rich. Office chemotherapy has served as an incentive to overtreat with infusion chemotherapy and to encourage the patient to receive 2nd, 3rd, and 4th line chemotherapy, regardless of the likelihood of meaningful benefit.

The system creates a hopeless conflict of interest, in that certain forms of chemotherapy are much more remunerative than others. ASCO and other fraternal organizations have never felt the need to perform clinical trials to determine whether or not treatment outcomes and patient satisfaction are altered by profit incentives.

The much needed reforms to the system, which are currently ongoing, are occurring over the fight to the death opposition of a profession which is vastly more concerned with protecting the selfish monetary interests of its members than in promoting the well-being of its patients.

The new medicare bill virtually changes nothing. If anything, it's worse. The only thing it does is to give the government a little bit of protection against being egregiously gouged on individual drugs. It doesn't change the basic incentives to give chemotherapy, whether or not chemotherapy is in the best interests of the patient, and to base drug selection on the "spread" between reimbursement and cost, which will continue to differ marketly between different drugs.

The law requires drug manufacturer's to provide quarterly reports of "actual average" sales costs. Average sales costs do not include prices to hospitals, HMOs, government entities, etc., it only includes prices actually charged physicians. Reimbursement level is this average selling price plus 6%, except if the oncologist documents that he/she actually had to pay more than the official reimbursement rate, he/she will then be reimbursed for his/her actuall cost.

In addition, the oncologist will be reimbursed for all bad debt, including uncollectible deductibles and co-pays. They will be reimbursed for associated drug administration services, chemotherapy support services, physician "supervision" time, and so on, and so forth. Thus, the oncologist remains incentivized to treat, rather than counsel, and they are incentivized to treat with certain "deal of the month" drugs.

It is illegal for physicians to refer patients for laboratory studies to centers in which they hold a financial interest. This is a sensible regulation against self-referral for perhaps unnecessary services which remunerate the referring physician, who then becomes the providing physician. The ideal would be if patients received chemotherapy at some treatment center which wasn't involved in the decision to treat or not to treat and in which the oncologist didn't have a financial interest.

There is no proven "standard" first line therapy which has been shown to be superior to the many other choices which exist. The same situation exists in the setting of 2nd, 3rd, 4th line therapy. The therapies are equivalent on a "population" basis, but not on an "individual" basis. Proven by the large number of patients who have progressive disease on 1st line therapy but who have good responses to 2nd or 3rd line therapy. These patients should have received the "correct" treatment in the first line setting. This can be accomplished by individualizing cancer treatment based on testing the cancer biology.

[endangered but surviving]

thank you

i appreciate how much you work on this stuff, have no idea how you guys do it but your are great.

joyce

[gpawelski]

Medicare Drug Plan Helps Patients Fight Cancer

By Steven Reinberg

HealthDay Reporter

http://www.hon.ch/News/HSN/534871.html

A National Coalition for Cancer Survivorship (NCCS) poll found that 89% of Americans said that the distinction between oral and intravenous applications should be abolished so that Medicare beneficiaries can have access to the best drugs to treat their form of cancer.

Apparently, Medicare has gone far in accomplishing that task. Nearly all generic cancer drugs and 70% of brand-name cancer drugs are covered by the Part D plans. Most of the brand-name drugs not covered had generic equivalents that are covered. And a number of trusted, old (generic) agents have been found to be just as effacious as the more expensive brand name ones.

Many infusional therapies are typically biotechnology drugs made of complicated proteins that are injected. This makes them several times more expensive than traditional pill-form pharmaceuticals.

More chemotherapy is given for breast cancer than for any other form of cancer and there have been more published reports of clinical trials for breast cancer than for any other form of cancer. So, according to NCI's March 31, 2006 official cancer information website on "state of the art" chemotherapy for recurrent or metastatic breast cancer, it is unclear whether single-agent chemotherapy or combination chemotherapy is preferable for first-line treatment.

At this time, no data support the superiority of any particular regimen. So, it would appear that published reports of clinical trials provide precious little in the way of guidance. There are many cancer drug regimens, all of which have approximately the same probability of working. The tumors of different patients have different responses to chemotherapy. It requires individualized treatment based on testing the individual properties of each patient's cancer.

Cancers that can be treated with oral chemotherapy include, breast cancer, colon and colorectal cancer, Leukemia, chronic myeloid leukemia, chronic lymphocytic leukemia, acute promyelocytic leukemia, acute non-lymphocytic leukemia, Lymphoma, cutaneous T-cell lymphoma, small cell lung cancer, non-small cell lung cancer, Kaposi's sarcoma, prostate cancer, multiple myeloma, ovarian cancer, brain tumours.

Oral chemotherapeutic agents are easy to use and offer the promise of less frequent visits to oncology-based offices and their infusion rooms. This promise is not trivial, especially as we have come to realize that many forms of cancer may be managed with these drugs, especially when they offer the equivalent outcome as intravenous drugs.