Medicare Drug Reimbursement Cuts Are Backdoor Rationing

Medicare Drug Reimbursement Cuts Are Backdoor Rationing

Imagine being denied treatment for cancer because Washington bureaucrats decided that a cutting-edge new therapy that could cure you just wasn’t “cost effective.”

That’s already happening in Britain under its government-run health care system, the National Health Service. And Medicare officials are poised to bring similar policies here.

The NHS’s “Cancer Drugs Fund” restricts physicians’ ability to prescribe half of all oncology medicines. If a medicine doesn’t extend the average cancer patient’s life span by a set length of time, which varies according to the medicine’s price, doctors can’t prescribe it for general use — even if they think would be the most effective treatment option.

In February, the NHS announced it would review existing general-use drugs in an effort to tighten prescribing restrictions. After the new review, the number of off-limits drugs is sure to rise. Patient groups predict the move will deny treatment to 22,000 cancer sufferers and “set cancer treatment back by a generation.”

A new proposal from the Center for Medicare & Medicaid Innovation, an arm of the federal agency that runs Medicare, could similarly tie American doctors’ hands. CMMI plans to slash physician reimbursements for medications administered in a doctor’s office or clinic under Medicare Part B. Doctors buy these medications upfront and receive reimbursement from Medicare.

The proposed reimbursement scheme, which CMMI innocently bills as a cost-control experiment, will prevent many doctors from breaking even on the most advanced, most expensive treatments. Essentially, CMMI will cut Medicare spending by forcing doctors to resort to cheaper drugs and second-tier treatments — or run the risk of having to close their practices.

Manipulating reimbursements to discourage physicians from prescribing certain medicines is a backdoor way to ration care. At least the British are straightforward about banning certain costly prescriptions.

Currently, Medicare reimburses physicians for chemotherapy and certain other medications at the drug’s average sales price (ASP) plus 6%. That add-on accounts for the fact that some doctors pay more than the average price. It also covers expenses associated with handling, storing and administering the drugs.

Often, that 6% makes the difference between a viable medical practice and one drowning in red ink.

Under CMMI’s proposed formula, Medicare would reduce reimbursements to ASP plus 2.5%, along with a flat fee of $16.80 per day. The formula makes generic drugs more economical to administer compared to pricier, cutting-edge treatments.

Most doctors already don’t receive ASP plus 6 percent., “sequestration” budget cuts effectively lowered reimbursements to ASP plus 4.3%.

Those cuts crippled many doctors’ abilities to care for their Medicare patients. Eighty percent of oncologists at community cancer clinics reported that their practices were affected by the cuts, and 50% had to send Medicare patients elsewhere — often to distant hospitals — for chemotherapy, which was too economically burdensome to administer at the reduced rates.

Now, analysts predict CMMI’s proposal will bring the effective reimbursement rate down to ASP plus 0.86% and a daily flat fee of $16.53.

If sequestration cuts forced doctors to turn away cancer patients, the new, even more drastic CMMI cuts could outright bankrupt many clinics. At the very least, many doctors will feel financial pressure to stock and prescribe cheaper treatments, even if they’re less effective.

Keeping Medicare spending under control is important. But reforms should incentivize providers to do so while improving care and keeping people healthy — which sometimes means paying more up front for higher quality treatments. CMMI’s proposal relies on the mindless bureaucratic logic that Britain’s NHS and other socialized medical systems use: Good care is expensive — let’s ban it.

Medicare might be ailing. But CMMI’s reimbursement scheme isn’t what the doctor ordered. It will only tie the hands of physicians and make them choose between running a profitable practice and providing the best care for their patients.