ALEXANDRIA, VaOrganized opposition to the Health Care
Finance Administrations (HCFA) proposal to reimburse outpatient
Medicare cancer services according to ambulatory payment
classifications (APCs) now includes many of the major players in the
oncology community, reported Lee E. Mortenson, DPA, executive
director of the Association of Community Cancer Centers (ACCC),
Speaking at a plenary session of the ACCCs 25th Annual Meeting,
he said that with two independent analyses confirming an
initial HCFA finding that cancer centers would lose 30% of their
current reimbursement for chemotherapy, ACCC has mobilized a variety
of groups to speak with one voice on the issue.
What Are APCs
Ambulatory payment classifications (APCs) are a new method, proposed
According to HCFA, the payment amount is based on hospital costs, but
The oncology community also objects to the wide range of drugs
Analyses by ELM and the Lewin Group, which were hired to replicate
the HCFA database, also predicted significant losses for radiation
oncology and a complete loss of reimbursement for supportive care
should the proposal go into effect as currently written.
Groups now on board the opposition include the American
Hospital Association (AHA), the American Medical Association (AMA),
the American Society for Clinical Oncology (ASCO), the Cancer
Research Foundation of America (CRFA), and major groups representing
oncology nurses and patients.
In their draft comments to HCFA, Dr. Mortenson said,
ASCO noted that the proposal would result in sharp reductions
in payments to hospitals for oncology-related services. . . . ASCO
recommends continuation of the current reimbursement system.
The AHA holds that there are serious problems with the data
underlying the chemotherapy groups. It recommends that HCFA
carve out the costs for chemotherapy and chemotherapeutic
agents, and pay on a reasonable cost basis until the agency fixes the
underlying coding problems, collects new data, proposes new groups or
rates, and includes the results in a subsequent proposed rule.
In addition, AHA opposes the HCFA proposal to reimburse new
therapeutic agents at the lowest rates. Because new drugs and
technologies are generally both costlier and more effective than
existing ones, they should be totally excluded from budget
neutrality, the AHA asserts.
Turning to radiation oncology, Dr. Mortenson mentioned an ELM study
showing that the proposed payment rates will make it impossible for
providers to replace equipment without operating losses, a situation
that will strongly discourage use of the most effective therapies. In
its draft comments, ASTRO (American Society for Therapeutic Radiology
and Oncology) said it supports the coalitions position that
the proposed classification system . . . discourages the use of
clinically appropriate but costly therapies and encourages the use of
less expensive and less effective therapies.
A federal bill known as HR 1090 and introduced in the House of
Representatives by Rep. Gene Green, Democrat of Texas, would, if
passed into law, carve out from the APCs any outpatient drug or
biologic used as cancer treatment, supportive care, or both. It has
more than 20 co-sponsors from both parties and the support of a wide
range of organizations. Dr. Mortenson noted that copies of the
proposed legislation had been handed out to those attending the ACCC
meeting. He strongly encouraged all members of his audience to
contact their congressional representatives and urge them to become co-sponsors.
While Dr. Mortenson views passage of HR 1090 as very important, he
also noted that the oncology communitys strong condemnation of
the APC proposal has already forced HCFA to reevaluate at least parts
of its position. In a joint meeting of ACCC and AHA
representatives with HCFA officials, he said, the agency
admitted that it included in its database only medical bills to
patients listing a single procedure, a most unrepresentative sample
of cancer treatments. In fact, this action systematically excluded
the most representative multiprocedure bills.
Because of oncology community complaints, HCFA is now re-evaluating
the database on which it based the proposed system of APCs, Dr.
Mortenson observed, noting that HCFA has admitted, in the
agencys words, that we must make extensive revisions of
our databases in order to respond to the industry. Therefore, we are
reprogramming and documenting our databases in order to make
interaction with potential commentors more efficient.
This revision occurred, the agency statement said, because
numerous hospital industry groups . . . have requested
extensive comparison of their databases with those used to
create the HCFA proposal.
Dr. Mortenson pointed out that the comment period on the proposal,
first scheduled to end in September 1998, has been extended twice,
with a current deadline of June 30, 1999.