As you know, CMS recently released a final rule (1429-FC) on elements of the physician fee schedule, which includes the recent Medicare coding changes and demonstration project for cancer care.  Attached you will find preliminary comments submitted by COA to CMS on this rule.  It includes a detailed analysis (recommendations, concerns, and questions) conducted by the COA Cancer Care Comprehensive Coding Task Force.  

The position we have on the rule and the Medicare changes is summarized as follows:

First, all the recent changes are a step in the right direction.  They acknowledge that community oncology clinics have been underpaid for all of the essential medical services required to treat cancer patients.

Second, the demonstration project is acknowledgment of the impact that cancer-related and chemotherapy-induced symptoms/toxicities have on cancer care.  It is another step in the right direction.  However, we believe that cancer patients should not have to pay $26 (20% co-payment) per assessment for a CMS demonstration project.  Medicare should absorb the total $130 per patient assessment.  We are also concerned about the logistics of implementing this program in so short a time.

Third, as the drug overpayment (based on the old AWP system) that subsidized the services underpayment is corrected, there are elements of essential cancer care that are still not paid or underpaid.  The Medicare coding system is simply not keeping pace with the increasing complexity and cost of delivering modern-day cancer care.

Fourth, and very important, the ASP-based drug reimbursement system is not ready to be implemented.  It does not adequately reflect realistic market pricing for most community oncology clinics and it is under-analyzed as witnessed by the fact that the new ASP calculation methodology employed by CMS for 3rd quarter will have no basis of comparison.

The bottom line is that we are rushing to implement historic reimbursement changes with more questions than answers, under-analysis, and unrealistic expectations.  In terms of impact, looking at the impact analysis performed by CMS (Tables 42 & 43 of the impact section of the rule, attached) overall there will be a 6% decrease in Medicare reimbursement to community cancer care.  This is a $350 million cut in Medicare (only) reimbursement to cancer care in 2005.  The impact will be approximately $1 billion to the extent private payers follow the Medicare changes, except that they will not adopt the demonstration project.

We sincerely appreciate all the effort that CMS has put into the Herculean task of preparing for the implementation of all of the Medicare changes mandated by the Medicare Modernization Act (MMA).  The coding changes and demonstration project are truly steps in the right direction.  We have pledged to work with CMS in any way possible and have tried to be responsive in providing recommendations and operational questions.  We have also already provided advice to practices on coding issues and will do so going forward.  There needs to be a continuous, positive dialogue among Congress, CMS, and the cancer community.   

The specific changes to Medicare cancer care reimbursement are truly historic in magnitude and scope.  They create overwhelming operational issues for CMS, carriers, and community oncology clinics.  With weeks left till implementation, there is simply little time to address every issue and have systems in place to operationalize the changes.

It is important for your Members of Congress to understand these critical issues.  Attached is a one-page summary (Cancer Care Status.pdf) that outlines the issues, as we see them. Most importantly, your Members need to hear from you about your issues.  Tell them about the impact, if any, of changes on your practice, including the specific cancer drugs that will be reimbursed under ASP in 2005 (based on 2nd quarter ASP-based rates published recently by CMS).  They need to be well informed IMMEDIATELY so that they can speak with the congressional leadership about this critical issue.

Congress is in session for this week before the Thanksgiving break and the likely end to the 108th session.  Many of you have already contacted your Members about the specific impact on your practice.  You can use your own analysis as well as the attached summary and attached comment letter to CMS as reference.

Once again, we believe that the solution is a transitional year in 2005 whereby changes are phased in, especially ASP, after additional analyses are available.  There needs to be a safety net in 2005 based on 2004 reimbursement.  This is the rational, prudent course of action.  The cost of this is a minimal $350 million to Medicare.  This far outweighs the risk of patient access problems.

We also encourage you to provide very specific comments to CMS.  These comments should relate to the impact of the rule on your individual practice.  For example, provide CMS with comments on some of the following questions:

• What drugs cost more than projected reimbursement for 2005?
• How do your specific costs compare with reimbursement rates for services such as drug administration?
• What essential services that you provide to your patients are not reimbursed?
• What essential services that you provide to your patients are not under-reimbursed (under-valued RVUs)?
• What actions are being taken by private payers as a result of Medicare changes?
• What problems do you encounter, if any, in collecting patient co-payments?

The specific procedures for submitting comments to CMS are contained in the final rule (posted on the COA Web site).  You need to follow these to the letter in order for your comments to be accepted by CMS.  The comment period expires on 1/3/05; however, we suggest that you provide comments IMMEDIATELY.

Many people, especially those on the COA Task Force, have spent uncounted hours analyzing these Medicare changes.  We have tried to make specific recommendations wherever possible. We are trying to provide as much data as possible to CMS and the Congress.  Most of all, we have trying to provide valuable data about the realities of delivering modern-day cancer care.

Once again, this now rests in your hands to positively reach out to your elected representatives (House and Senate) in Congress.  They need to hear your position.  Contact Dianne Kube (<dianne.kube@att.net>) or Steve Coplon (<scoplon@westclinic.com>) if you need any help.

The Community Oncology Alliance
http://www.communityoncology.org

For further information or comments, please contact Chief Administrative Officer Dianne Kube <dianne.kube@att.net>.

Community Oncology Alliance, 100 N. Humphreys Blvd., Memphis, TN, 38120