Gastroenterologists are calling on the Centers for Medicare & Medicaid Services to withdraw a proposed Part B drug payment demonstration and collaborate with physicians and patient groups to find a more equitable solution.
In March, the CMS proposed changing the current payment scheme by which physicians are reimbursed for administration of certain drugs at average sales price (ASP) plus 6%; instead, the agency proposes to test reimbursing physicians at ASP plus 2.5% and provide them with an additional flat fee of $16.80. The proposed rule also calls for testing value-based purchasing tools during a second phase of the overall 5-year demonstration project.
Participation in the test would be mandatory for physicians in 49 states (Maryland is excluded as it is part of another ongoing demonstration project), and physician practices would receive either the full current reimbursement or the proposed reduced percentage plus the flat fee.
The American Gastroenterological Association noted in comments with the agency that drug prices “are not set by physicians” and if the CMS “is searching for new methods to control costs, this is not the way to achieve those goals.”
“If you’re going to drop the margin from 6% to 2.5% plus a flat fee of $16.80, your ability to successfully economically provide that service starts to really go away,” Dr. Rajeev Jain, practice councillor at AGA, said in an interview.
Dr. Rajeev Jain
He added that it could force patients to get their infusions in a hospital outpatient department. “Those are reimbursed at a much higher rate, and that is a much greater cost to Medicare and the health care system in general. In the office, we’re providing a very cost-efficient, patient-friendly way of providing these medications. … These kind of draconian cuts will make it less and less likely that the private practitioner will provide this additional service to their patients, and it will force them to get more of their care in HOPDs [hospital outpatient departments], which increases the cost plus is less efficient and less patient friendly.”
Dr. Jain also suggested that implementing such a change could put smaller practices out of business or at the very least limit the services they provide.
With “what’s going on now, this sort of evolution in the health care field with the Affordable Care Act and all these other economic pressures, physicians are either flipping and being bought by health care systems or they are merging themselves into consolidated larger practices to have these economies of scale,” he said. “But if you are just a three- or four-person GI practice and your overhead is substantial and because you are small, you’re not getting the best price on the medications. Your margins are probably slim, and this may just tip it enough where it’s not economically viable to give those infusions.”
The AGA joins a chorus of other physician groups who have called upon the CMS to withdraw its proposal.
“We are deeply concerned that because the new methodology will frequently not properly cover the cost of physician administration of infused drugs, they will be forced to stop offering patients the ability to receive infusion treatments,” the American College of Rheumatology wrote in its comments.
Likewise, the Coalition of State Rheumatology Organizations (CSRO) called for the withdrawal of the proposal.
The CSRO “must oppose the Part B drug payment model as it suffers from serious procedural and substantive flaws that we believe render it unworkable – and it does nothing to actually address drug prices,” according to the coalition’s comments.
The AGA voiced concern that the CMS did not consult with physicians and patient advocates on crafting the proposal before releasing it.
“The AGA urges CMS to withdraw this proposal and instead, bring physicians and patient groups together to work on substantive solutions to the problems CMS hoped to address with these payment models,” the organization said in its comment letter. “We believe that a collaborative effort will benefit everyone involved.”
The lack of collaboration on a solution was a key point at a House Committee on Energy and Commerce health subcommittee hearing to review the CMS’s proposal.
Witnesses called into question one of the CMS’s primary reasons for the proposal – that the current ASP formula is leading doctors to choose medications based on cost.
The “CMS has yet to produce any evidence indicating that physician prescribing patterns show any correlation to that of choosing higher-priced drugs as opposed to appropriate therapeutic treatment for patients,” said Dr. Debra A. Patt, vice president of Texas Oncology. Dr. Patt testified on behalf of the American Society of Clinical Oncology, the Community Oncology Alliance, and the U.S. Oncology Network. “Additionally, there is no evidence that the payment changes contemplated by CMS’s model will improve the quality of care, or for that matter, ensure patients have access to the same level of care they are currently receiving.”
