CMS Medicare Part B Drug Payment Model: What Does It Mean for Seniors?

​What is the CMS Medicare Part B Drug Payment Model?

Many of our friends in the community onocology world who treat more than 70% of cancer patients in this country say it’s another cut to cancer care for seniors. We happen to agree.

What exactly does this proposal mean for your health or the health of the seniors you love?

We took it upon ourselves here at Patients Rising to ask that question because it is very clear no one was asking it at the Centers for Medicare & Medicaid Services (CMS).

This week our friends at the Community Oncology Alliance (COA) sent a letter to HHS Secretary Burwell and CMS Acting Director Slavitt regarding the recently released CMS Medicare Part B Drug Payment Model. To say it sets a dangerous precedent for the care of our senior patients — especially cancer patients — is an understatement. From where we stand, anything that undermines the sanctity of the doctor-patient relationship is simply wrong, and this new payment model takes perfect aim right between the patient and their doctor.

“The CMS Medicare Part B Drug Payment Model is an inappropriate, potentially dangerous, and perverse experiment on the cancer care of seniors who are covered by Medicare,” says the letter, signed on behalf of the COA Board of Directors by Bruce B. Gould, MD, president of COA and a practicing community oncologist with Northwest Georgia Oncology Centers in Marietta, Ga.

This proposal was announced in passing to Medicare contractors last month. As far as we can tell, no one has ever announced it to you, the patient, nor asked your opinion or taken your care into careful consideration. When patients are left out of the equation, we take notice. This is what drug rationing and price controls look like — and from where we sit it is morally and ethically the wrong direction for our seniors.

For those of you unfamiliar with Medicare Part B, it does not cover most prescription drugs you would administer at home, but rather a limited number of outpatient prescription drugs under limited conditions.  Intravenous drugs.  Mainly those given to cancer patients. For a full list of what is covered under Part B click here.

According to the Community Oncology Alliance, “the proposal – which was rushed through review without physician or patient input – lays out an experiment, not based on quality metrics, that is simply intended to decrease the cost of drugs purchased under the Medicare Part B program. The CMS Medicare Part B Drug Payment Model intends to drive the selection of cancer drugs towards the CMS definition of “value,” rather than the most appropriate treatment determined by oncologists in close collaboration with their patients.”

The most appropriate treatment for a patient should be determined by the patient and their doctor. Period. If a value payment model of any kind does not put that relationship and decision making process at the top of the pyramid then it is a failure.

Dr. Bruce Gould’s letter goes on to state: This experiment is saying that CMS believes it knows better and intends to dictate drug treatment choice rather than the patient’s treating oncologist. As practicing physicians, we are in the best position to determine the care our patients should receive in close consultation with them; not federal government regulators. This experiment is a misguided government intrusion on the treatment of seniors with cancer and a very dangerous precedent in severing the sacred physician-patient bond. And make no mistake about it – CMS has designed the Medicare Part B Drug Payment Model not as a model of quality cancer care, like the OCM (Oncology Care Model), but as a blind experiment to force cancer treatment to meet CMS’ definition of value; not the best, most appropriate cancer treatment as determined by oncologists in collaboration with their patients. 

“It is an understatement to say that this latest CMS initiative is misguided and a perilous cancer care policy,” says Ted Okon, executive director of COA. “It will only serve to accelerate the consolidation of cancer care into the more expensive hospital setting and undermine the physician-patient collaboration on the treatment of cancer. I thought we were at war on cancer, not cancer care.”

“For the sake of all of our patients, we simply cannot let CMS proceed with the dangerous Medicare Part B Drug Payment Model, which is not a true ‘model’ in the CCMI legislative charter but simply another disguised cut to Medicare Part B reimbursement for cancer care. It is very revealing that CMS did not engage any patient and provider stakeholders in developing this perverse experiment, but is now seeking comment at the 11th hour,” says Dr. Gould.

It is our belief at Patients Rising that when we get so focused on cost at the exclusion of all other factors, we lose sight of the patient’s best interest. When we lose sight of the patient’s value and best interest, we have failed.

Let’s not fail our seniors.

Terry Wilcox is the Co-Founder and Executive Director of Patients Rising and Patients Rising NOW.  She is the former Executive and Creative Director of Vital Options International and the creator of the web series Understanding Cancer. Her passion is challenging the entire health care system to think broadly about the system challenges while always remaining focused on the patient and the sanctity of their relationship with their doctor. 

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