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Home > Press Room > Interviews & Features > 2001 M C & C Roundtable > Page 2

Pending Changes in Medicare (continued)

DR. GOODMAN: It sounds as though the oncology community, HCFA, and other stakeholders had in place a practical working agreement in which AWP minus 5% approximated the total expense of providing care. But when it became clear that this system did not reflect the true costs of the drugs, we had to revisit the arrangement. So are you saying now that the cancer community, including patients and oncologists, is welcoming the GAO study and would be willing to stand by its findings?

MS. DAVENPORT-ENNIS: Absolutely. We worked very hard with Congress last year to see that that would be the result. I don't think anyone wants to continue with an artificial system of AWP minus 5%.

MR. AULT: I agree with everything that Nancy just said. I would just like to add that I find the GAO study a little unsettling because of the way the language is written. GAO reports, and then HCFA has very broad discretion to implement whatever the GAO recommends or even to modify what GAO recommends without the need for further legislation. I find HCFA's broad discretion a little disconcerting.

MS. DAVENPORT-ENNIS: I would agree with Tom. I think the only solace that we can take is that members of Congress are acutely aware of this issue, and I think that they are poised to respond legislatively if HCFA tries to make a proposal that would threaten patient access and compromise the medical community at the same time.

MR. AULT: I'm not saying that HCFA would want to do that either, but I agree that the fact that Congress is going to be looking at this helps a lot.

MS. DAVENPORT-ENNIS: And they really are very keen about seeing the report. It's a routine question we get when we go into offices. "When is the GAO report coming out? What have you heard?" We heard most recently from Secretary Thompson that it is going to be out in advance of the September deadline-maybe as early as June or the 1st of July.

DR. GOODMAN: If the GAO study finds that the payment arrangement should be changed, and the effective reimbursement to the physicians becomes less than what they are getting now, who would be most at risk?

MS. DAVENPORT-ENNIS: From our perspective, the segment most at risk would he seniors who are 100% dependent on Medicare for any type of health-care access. Many are not in a position to purchase these products separately and don't have any other form of insurance coverage. Plus, so many of the plans that are secondary to Medicare are not going to pay for anything that the policy primary icy doesn't reimburse. And that's a huge problem.

DR. GOODMAN: Let's move to a related aspect of Medicare payment concerning some of the newer drugs in the pipeline. Most cancer chemotherapeutic drugs are delivered intravenously or in conjunction with physician care. Some of the newer drugs coming out will be oral anticancer drugs. Under Medicare, most oral drugs are not reimbursed. Nancy, I know that you are well aware of some important new drugs coming down the pipeline. Do you think that Medicare's traditional payment policies for cancer drugs may affect patient access to these newer drugs?

MS. DAVENPORT-ENNIS: I think it would certainly affect the access to these drugs if we're not successful in having Congress look at this issue and create a valid mechanism and process for reimbursement. I would like to clarify that currently, under Part B, we do have a select number of oral anticancer agents that are reimbursed. The problem is that they are only reimbursed if there is an IV equivalent. The newer drugs have been designed in such a manner that they cannot even be reproduced in an IV form. It's a problem. So once again, we're called upon to go back to Congress and say, "We've got to have a provision for reimbursement of these products, If you talk to the researchers, the research for cancer products has gone to the oral product because (1) you maintain dosing far more effectively, (2) you have fewer side effects, and (3) it allows for an enhanced quality of life and a more independent lifestyle during the time that you're taking these oral drugs.

DR. GOODMAN: So, the current Medicare Part B coverage for oral anticancer drugs does require there being an IV equivalent, and that provision in the coverage policy may hinder access to these new drugs that don't have IV equivalents.

MR. AULT: I think it's important to emphasize that the coverage for oral cancer drugs that have IV equivalents is provided through special legislation that Congress enacted a few years ago to override the fact that Medicare generally does not pay for oral drugs. Congress made an exception by law. In fact, HCFA has no authority given the way the laws are written now, so to cover these new oral drugs would require a change in legislation.

DR. GOODMAN: So it's not just a matter of HCFA's discretion; it would require further special legislation from Congress. Is that something that we think Congress would be willing to take on?

MR. AULT: I think it's awkward, because what Congress is considering this year, and what both parties have pledged to do something about, is a general prescription drug benefit under Medicare, which would solve this problem. It's awkward to talk about specific drugs such as oral anticancer agents right now.


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