Medicare Compliance & Reimbursement

Docs won't know details of looming treatment cuts until late this year.

The suspense is killing oncologists. So far, the Centers for Medicare & Medicaid Services has released incomplete and out-of-date information on the fate of a thousand cuts it will to deal to cancer treatments next year.

For one thing, CMS included first-quarter numbers for average sales price, according to Deborah Kamin, senior director of cancer policy and clinical affairs with the American Society for Clinical Oncology (ASCO). The actual payment rates for oncology drugs will be based on 106 percent of third-quarter ASP numbers, not first-quarter numbers.

Also, CMS only released a partial list of projected rates for cancer drugs. "The ones they included account for around 70 percent of the Medicare expenditure for cancer drugs," Kamin explains. Oncologists are waiting to find out how hard CMS will hit the other 30 percent. CMS apparently didn't have enough data for those drugs at the time.

The sooner CMS can release complete third quarter data, the better it'll be for oncologists. But either way, the uncertainty will remain until providers learn what, if any, relief they're likely to get next year. In the meantime, oncologists may be reluctant to start patients on a year-long treatment regimen that they may not be able to afford to finish, says Kamin.

ASCO is still gathering data on the whole complex of services that have grown up around chemotherapy administration as it has migrated in recent years from the hospital to the physician office setting, says Kamin. These outcroppings include things like nutrition counseling and social services that might have been available as part of a hospital infrastructure and needed to be available in the doctor's office. They also include on-site pharmacists mixing drugs and social workers helping patients navigate through the system.

"It's a big problem," says Rise-Marie Cleland, cofounder of coding consulting firm Oplic Oncology in Lawton, OK. Besides not knowing the reimbursement levels of 30 percent of drugs, "we have no idea yet how we're going to be reimbursed for the services, so how we can prepare?"

The main hope for a legislative fix for oncologists at this point is a bill sponsored by Sens. Kay Bailey Hutchison (R-TX) and Deborah Stabenow (D-MI), which would extend this year's 32-percent administrative add-on for an extra year. ASCO would rather see a longer than one-year breathing space and worries that one year wouldn't allow enough time for the congressionally mandated studies of oncology reimbursement by the General Accountability Office and others. But oncologists would certainly welcome this bill as the best alternative, Kamin says.