Medicare Compliance & Reimbursement

CMS refuses to recognize program's administrative burden.

The Centers for Medicare and Medicaid Services is doing its best to make the Competitive Acquisition Program for Part B drugs attractive to physicians, but many practices say it won't be worth the hassle of dealing with private vendors.

"I'm still not convinced that a lot of people are going to sign up for the CAP," says Sam Shepard, director of health policy with the American Association of Clinical Urologists. Even with rock-bottom drug payments, it's hard to see any incentives to join the program. But Shepard welcomes the omission of leuprolide, because he believes urologists would be better off obtaining it directly.

"There's too much at risk with the patients" to sign up for the CAP, says Carolyn Davis, director of reimbursement with Oncology Hematology West in Papillion, NE. If the patient has a reaction or isn't responding to a drug, and the oncologist needs to change the treatment plan completely, it would be a nightmare changing the treatment plan with the CAP vendor. "There would be a lot of rescheduling the patient,"  says Davis.

In the new interim final rule, CMS states that if a patient is unable to pay his or her copayment and can't obtain assistance from a charitable foundation, "then the vendor can cut off chemotherapy for the patient. I think that is reprehensible," says Albuquerque, NM oncologist Barbara McAneny.

This policy could deny potentially life-saving medications to patients. It also shows more concern for the profitability of vendors than for physicians who've struggled with bad debt. The vendor may make the decision to cut a patient off, but "I have to be the person who tells the patient, 'I'm sorry, you're cut off. You have to die now,'" says McAneny.

It's unclear from the 457-page regulation who pays if a physician has to send an unused or defective dose of medication back to the vendor. CMS states at one point that the vendor owns the drug until the physician administers it, and advises physicians to call the vendor and ask what to do with the unused medication. Like many other parts of the regulation, McAneny says this will be an administrative nightmare.

Practices that choose to sign up for the CAP program should expect to hire at least one extra person to deal with the bureaucracy at the vendors, McAneny advises.