Comment: Drug pricing rule threatens cancer centers, patients

The Biden administration should reconsider a rule change that would cut medication reimbursements.

By Barbara Jensen and Krista Nelson / For The Herald

Ruth is a 67-year-old woman living with metastatic lung cancer. She receives care at a treatment center near her home in rural southern Illinois. There are larger hospitals over an hour away in St. Louis, but she doesn’t have the time or financial resources to travel there as often as she would need to.

Fortunately, the cancer center near Ruth’s home boasts excellent staff; including her oncologist, experienced nurses, a pharmacist, and a social worker. The center also has a financial navigator who guides Ruth through Medicare benefits and a nutritionist who helps boost her caloric intake when treatment side effects decrease her appetite.

There are more than 2,100 community cancer centers just like Ruth’s across the country; many located outside of urban centers. For decades, these centers — and their multidisciplinary staff — have played an integral role in helping Americans fight cancer. Unfortunately, fulfilling their mission is about to get harder; as is life for patients.

In November, the Centers for Medicare and Medicaid Services issued a new statute, known as the Most Favored Nation rule. This MFN rule was supposed to take effect on Jan. 1, but a federal judge temporarily blocked it. With President Biden now in office, the rule’s fate is unclear. If the new administration implements the rule, it will drastically affect how cancer centers operate; and determine when, whether and how Medicare beneficiaries like Ruth receive care.

In theory, the MFN rule is supposed to lower costs for patients on Medicare. In reality, the new rule will reimburse cancer centers for less than they pay for necessary medications, such as chemotherapy, unless these cancer centers renegotiate drug prices with their suppliers. This presents an enormous administrative burden on cancer centers.

The new rule, if implemented as written, will likely put cancer centers out of business. As a result, countless more patients like Ruth will lose access to quality care in their communities.

Many of the support services provided by nurses, pharmacists and social workers at cancer treatment centers are not covered by Medicare. Cancer centers use reimbursement funds to cover these services for the benefit of their patients.

Clinics purchase their medications up front. Once oncologists administer the drugs to patients, the clinics bill Medicare for the cost of the drug itself, plus a small additional fee of 6 percent. This 6 percent fee helps cover the cost of services that are considered “extra” yet well known to improve patient outcomes, such as nutritional counseling, medication side-effect teaching by nurses and pharmacists, and psychosocial intervention from social workers. Elimination of these types of services hurts our most vulnerable patients.

The MFN rule will drastically cut drug reimbursements. It’s estimated that community oncology practices will suffer a 52 percent loss of Medicare drug revenue, on average, once MFN is fully implemented, according to the American Society of Clinical Oncology.

The impact of the rule will be especially acute in rural communities around the country, where community centers are prevalent, and Medicare is the largest health insurer. Clinics will have little choice but to cut staff and services.

And if care centers cut services or close altogether, it will make life that much more challenging for cancer patients. For many, the logistics of getting to and from chemotherapy will get harder and more expensive. Some will forego treatment altogether.

Shockingly, that is exactly what the Center for Medicare and Medicaid Services seems to expect. In the rule, the agency observes that some of the savings it hopes to achieve will be “attributable to beneficiaries not accessing their drugs through the Medicare benefit.”

As professionals who work with cancer patients every day, we find this unconscionable. We support payment reform that makes quality cancer care more attainable and equitable for all. The MFN rule, however, does not help but harms the ability of cancer centers to provide this care for patients. If the MFN rule goes into effect in 2021, it will cause devastating repercussions immediately on patients like Ruth.

Barbara Jensen, a registered nurse, works as the regional director of oncology and palliative care at Skagit Valley Hospital in Mount Vernon. Krista Nelson, a licensed clinical social worker and practicing oncology social worker, works at Providence Health and Services in Portland, Ore. Both serve on the board of trustees for the Association of Community Cancer Centers.

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