Legislative Changes and Their Impact on Community Oncology Care

Several critical issues are impacting cancer care policy and practice, particularly concerning legislative changes being made in Washington, D.C. According to Ben Jones, key issues include physician reimbursement, Medicare reform, value-based care, and the government's response to the Change Healthcare cyber attack.

During the 2024 Community Oncology Conference (COA), Jones, vice president of government relations and public policy for McKesson, The US Oncology Network, presented “The Politics of Oncology: Legislative Updates & Predictions from Capitol Hill,” where he discussed the government’s response to these recent events and more.

These issues and more are creating financial strains on community oncology practices, with Medicare reducing provider reimbursement at a time when costs are increasing. Jones emphasized the need for Congress to address these disparities and level the playing field between physician and hospital reimbursement.

In an interview with Targeted Oncology^TM, Jones identified the key challenges community oncologists are facing due to legislative changes in cancer care policy.

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Targeted Oncology: Can you provide a brief overview of what you discussed at the COA meeting?

Jones: We had a conversation about what is happening in Washington, D.C. and how it relates to cancer care policy. There [is] a pretty wide range of issues ranging from physician reimbursement, Medicare reform, value-based care, how the government responded to Change Healthcare’s cyberattack, enhancing drug rights and policies that are starting to filter through but are focused on the implementation of the Inflation Reduction Act, and how Congress plans to respond to the increasing pressure for greater transparency of pharmacy benefit manager.

Could you elaborate on the potential impact of these issues on the daily practice of community oncologists?

One of the biggest issues that we have started to see a little bit of traction on, but we will likely continue to see more, is around provider reimbursement. At the crux of it, CMS [Centers for Medicare & Medicaid Services] finalized last year a reduction to provider reimbursement in the physician fee schedule. That reduction was going to be about 3% down. It is happening at a time when practices are under significant financial restraints. Everything that they need to run a practice is costing more money, whether that is equipment, servicing, etc. The salaries of these clinical employees just continue to increase. But what we saw was Medicare almost looked at that and said, sorry, we are still going to cut reimbursement.

Now, they did [create] a new set of codes for complexity of care and are testing weight screening, even some level of patient navigation, but at the core of it, they are reducing reimbursement at a time when costs are increasing. There are a couple of things that were happening. One is that Congress passed legislation to mitigate a piece of that, about 1 and a quarter percent instead of a 3 and a half reduction. Provider reimbursement would have been up to about 1 and a quarter or so percent, but still, a 10% reduction. Conversely, in the hospital setting, reimbursement has actually increased. We know that there is this unlevel playing field in reimbursement where hospitals, historically, can get 3 times as much. We are delivering the exact same care; that disparity has just been widening. The more that the physician fee schedule is reduced, OPPS [Hospital Outpatient Prospective Payment System] of the hospital increases.

We are glad that they were able to mitigate a piece and finalize reductions. We think they need to go 1 or 2 steps further. They need to consider an inflationary update or something that ties physician reimbursement to inflation that they are experiencing. At the same time, they need to figure out how to level the playing field. We have seen some progress in physician reimbursement, ongoing conversations around whether or not or how to implement an inflation adjustment for the fee schedule. That is still going on. As these conversations go on around payment reform, we will want to level the playing field across settings where we could see some movement towards the end of this year. They did include a provision to level reimbursement of drug administration codes, and that provision will be included in a bill, The Lower Costs, More Transparency Act. That has started to move in Congress and in the House [of Representatives], and we are waiting to have action from the Senate. We could see some action or activity on that toward the end of this year.

How might these legislative changes disproportionately impact certain patient populations?

At the core of it, it is potentially limiting because what we are seeing is practices under intense financial distress because of the cost and chaos that is happening inside and outside of reimbursement. We do not even have to look further than the Change Healthcare cyberattack that dried up a lot of practice. This means cash flow [is not] coming in, but [we are] still seeing patients and incurring all of the costs. Eventually, something is going to break. This is at a time when they start to ratchet down reimbursement. The biggest fear is that that causes a number of practices to close. They can no longer afford to keep them open because they are either not getting any revenue because of the change outage, or they are getting a reduction in reimbursements when costs are increasing. All of that [prevents] access to care in 1 of 2 ways: They either shut the door or they are forced to consolidate and sell to a hospital system. If they do that, patients will maintain that, but now all of a sudden, their care increases 2% to 3% or 2 to 3 times.

What are some of the biggest challenges you foresee for oncology care in the coming years?

The political climate is 1 of the big shows. We have been facing a number of issues, whether it is provider reimbursement or expansion to value-based care and investment in value-based care, ongoing restrictions that limit the ability of practices to deliver drugs to a patient's home and when they are needed, will not let their family member come and pick up the medication. All of this needs to be addressed. Unfortunately, the political environment has become slow, and it has become difficult to get alignment and flow because of that. Now, some of that is to be expected, because we are in a presidential election event. That typically slows things down a little bit. But this year, it is amplified more than the rest. That is a big obstacle. It is why we are seeing so much focus on state governments, because the federal government has been slow on a number of issues, and states are looking at this and saying, we are not standing by, and we will not take it.

What are some priorities that oncologists or patient advocacy groups should focus on to ensure continued access to quality care?

One of the biggest issues of concern is around ensuring access to timely care and making sure that that timely care is protecting the physician and patient. Some of that is being disruptive because of utilization management protocols from the meeting rooms, oftentimes steering them to their own specialty pharmacy, formulary control, pushing a white bag of drugs and medication. As background, white bagging is forcing a practice to order these medications and drugs from their own specialty pharmacy. They then receive the product after maintaining it in a separate inventory, wait for the patient to come in, and then administer it.

The problem is that it almost flies in the face of personalized care because if a patient comes in and has their labs drawn and something indicates a mean for a dose adjustment, they are having a reaction so there has to be a change in therapy, none of those adjustments or changes under a white bagging arrangement where it will be stored will occur. They order the drug at a specific time, store it specific to the patient, and only have the ability to use what they had stored for that patient. It truly does disrupt the continuity of care. It acts as a burden for patients that need that personalized approach to treatment.

What should a community oncologist take away from this discussion?

Stay involved, make sure your voice is heard, engage with your local representatives, and be prepared to get educated. We did not even talk about drug pricing. A lot of these practices have likely seen some mandates and they need to know that there is an avenue to push back on something. There is an avenue to say, wait a second, this is not the right thing to do for our patients, and I am not going to sit by and let this happen. We have seen tremendous progress in states around white bagging around anti steroid legislation. Texas passed a white bagging prohibition bill last session and Oregon this session, so we have got some progress in a number of other states where they are coming in and seeing the application. Missions, practices and providers need to understand the issues and get engaged in the process and stand up for their patients when their care is being disrupted.

Then, make sure we are looking around the corner as well. As the Inflation Reduction Act reaches full implementation, it is going to impact how practices operate today. Under the Inflation Reduction Act, HHS [the Department of Health and Human Services] will select a certain number of drugs, negotiate those drugs, and that negotiated price will take effect on part D drugs. In a year and in 2026 it will be part B drugs. So, it is coming right around the corner, and it is something that we need to be aware of. It will make sure that policymakers understand the impact this will have because it will impact how products enter the market, and the research dedicated to expanding indications for those products that are already on market.

Are there any other updates or predictions you would like to discuss?

We are still in the middle of the disruption caused by the Change Healthcare cyberattack, and I do not think we should focus on the what ifs right now. But very soon, this is going to be right for a postmortem conversation, what went right and what went wrong. Candidly, the federal government did not rise to the occasion. They looked at this outage, and I fundamentally believe that they viewed it almost through the lens of COVID. They saw anything in a dire situation, and they remembered it was only a few years ago when they were hearing some of the same things from providers in response to COVID. There was a difference during COVID where practices were under significant distress because volumes reduced so much, we had additional space and additional costs, etc.

This is a different conversation than what is happening now with the Change cyberattacks. What we are seeing now is that volumes are actually the same, maybe even increasing, but revenue and cash flow has dropped because claims are taken to be processed. We are seeing patients, and candidly, a lot of it has been shifted into more manual workflow, which puts more stress on the staff. So, the staff is working longer, oftentimes working overtime, volumes are remaining the same, if not increasing, so the practice is busier than ever and stretched to the brink. They are just not getting any cash flow from it to help pay for these increased costs.

I think that the federal government failed to rise to the occasion here and recognize the difference. Do not just treat this as COVID 2.1 because it was completely different. I think that is going to be the biggest kind of follow-up item here. Once the dust settles, we have to figure out how to make sure we are not almost deserted if there is a next time, which we think there could be.