Medicare Part B… Ware

Medicare seeks to ensure Americans over age 65, and younger people with certain disabilities, have affordable health care. This Federal health insurance program is particularly important for our community, as colon cancer disproportionately impacts older adults. Most people are familiar with Medicare Part D, which provides coverage for prescription drugs patients buy at the pharmacy; lesser known is Part B, which covers prescription drugs administered in a physician’s office or hospital outpatient department, such as most medications that treat colon cancer.

On March 8, the Centers for Medicare and Medicaid Services (CMS) announced a proposed rule to test changes to Part B coverage. Acting Administrator for CMS Andy Slavitt said, “These proposals would allow us to test different ways to help Medicare beneficiaries get the right medication and right care…this is consistent with our focus on testing value-based care models.” The CMS-proposed tests come in two phases: the first changes how physicians are reimbursed under Part B and will start later this year, while the second will test a variety of pricing strategies in 2017.

The phase one test will change the reimbursement rate for Part B drugs. Originally, doctors received the average sales price of the drug plus 6 percent for administering it; in 2013 that was reduced under sequestration to 4.3 percent. Now, CMS proposes to make it 2.5 percent plus $16.85, to be reduced even further under sequestration. Presumably, CMS believes doctors are being incentivized to use more expensive drugs and this will fix it by using a flat rate.

So what does this mean for patients? Well, if the change in 2013 is any indication, it is not good news.  The American Society of Clinical Oncology (ASCO) did a study of its members to gage the reimbursement reduction’s impact; almost half of the doctors reported they would reduce or stop caring for Medicare patients unless they had supplemental insurance and half stated they would send patients elsewhere for chemotherapy—generally to large hospital centers. It is clear that rural and smaller community practices are disproportionately impacted by these cuts and their Medicare patients either can’t get care or have to travel great distances for treatment. This is certainly one of the reasons the Community Oncology Alliance has already issued a letter in vehement opposition to the CMS plan.

In phase two, CMS will test a host of what they call “value-based care models.” These vary from reference pricing where all similar drugs have the same price; indication pricing where the cost is based on CMS’ assessment of the clinical effectiveness, risk sharing agreements, elimination of patient cost sharing; and creation of clinical decision support tools where CMS advises the doctor on the best treatment.

Here CMS is following the trend forged by private health insurers of using reimbursement models designed to improve outcomes while lowering costs. Our reaction to these phase two tests is much the same as our view of clinical pathways in the private health insurance market place. We support both provider networks and payers giving doctors evidence-based guidance that will improve outcomes for patients, but we strongly oppose their use to restrict access to treatments based solely on costs or other non-clinical reasons. With the proliferation of clinical pathways, some doctors have wondered why they bothered going to medical school since it is now the insurance company that decides your cancer treatment. We encourage CMS to use the phase two tests to best support your doctor’s judgement—not replace it.

CMS has assured us there will be an opportunity for public comment on the proposed changes to Medicare Part B, and we encourage you to share your views when that is available. In the meantime, tell us what you think of the proposed changes. Let your voice be heard this Colon Cancer Awareness Month—leave a comment to Speak Up, Speak Out on how these changes will affect you and your loved ones.

Speak Up, Speak Out is an advocacy series where we bring you the information you need to know every third Tuesday of the month. Don’t forget, the Colon Cancer Alliance serves as a source of information about colon health. If you have questions or are in need of support, please contact our free Helpline at (877) 422-2030.

3 replies
  1. Shawn
    Shawn says:

    Acting Administrator for CMS Andy Slavitt said, “These proposals would allow us to test different ways to help Medicare beneficiaries get the right medication and right care…this is consistent with our focus on testing value-based care models.” What he means is they value money over people getting what they need.

  2. Zona Spaeth
    Zona Spaeth says:

    An issue my daughter who has colon cancer that has now recurred in her lymph glands and lungs and has been in chemo-treatment for that for a year, is hydration. I go with her often to her doctor appointments and we live in the same house, so I witness her struggles. Her Cancer treatment clinician told her she did not support my daughter having an at home hydration by an RN which can be done. And that if my daughter (Amelia) could not drink enough water then maybe she should not be in chemo treatment (what the P.A. said was “Maybe I should not be giving you chemo therapy.”) Is this cost control? My daughter is receiving treatment under Medicare, Special Help, and State of Washington Medicaid..Apple program.

    Sincerely, Zona

  3. Mary Bowman
    Mary Bowman says:

    Having been exposed to the term “outcome based decision making’ the term “value-based care” gives me some insight as to what is actually going to happen. CMS already has the results they desire formed. They only allow the testing and then use the information to fit into the desired result. This gives CMS control over what it is they want. Why not let the tests be done real time and not fit them into what the CMS people want to happen. This way some accurate decisions can be made to benefit people who need medication.


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