FORT LAUDERDALE, FlaTime is running out for lobbying against
the Health Care Finance Administrations (HCFA) proposed
Medicare hospital outpatient fee schedules, based on ambulatory
payment classifications (APCs). The deadline for comments is June 30, 1999.
If your hospitals have not written to the American Hospital
Association saying this is a problem, you need to do something about
it, Joseph Bailes, MD, said at the National Comprehensive
Cancer Network (NCCN) conference. He told the audience they can base
their letters on ASCOs draft comments on the issue.
Dr. Bailes is national medical director for Physician Reliance
Network, a physician practice management company focused on oncology
care. He is also ASCOs president-elect.
Using APCs, HCFA projects (based on what Dr. Bailes called
almost incomprehensible data) a 9% payment reduction for
major teaching hospitals, and a 29% payment reduction for the
Prospective Payment System (PPS) exempt cancer hospitals.
The structure of APCs is different from the older DRGs
(diagnosis-related groups), he said. Some 7,000 HCFA codes have been
compressed into 346 APCs. The payment amount is based on hospital
costs from the cost report.
The plan proposes three APCs for outpatient delivery of
chemotherapyintramuscular subcutaneous, push infusion, and
pump. So when an individual presents for chemotherapy to a
hospital outpatient department facility, he or she would be assigned
to one of these three APCs with a dollar amount, he said.
There are four APCs for chemotherapy drugs, grouped by the cost of
the quantity specified in each J-code. In other words, he
said, within a specific category of chemotherapy drugs, there
is absolutely no relation of one drug to another as far as cost.
Dr. Bailes foresees a number of potential problems. First is
the lack of separate payment for supportive care drugs, he
said. Currently, there is no separate billing for
nonchemotherapy drugs, including growth factors and antiemetics.
Second, he said, the bundling into a single APC of drugs of widely
varying costs creates undesirable incentives. Paclitaxel (Taxol), for
example, is in a category that reimburses $90, whereas fluorouracil
(5-FU) is in a category that reimburses $50. You can see that
there is a potential incentive for physicians to use the lower cost
drugs, he said.
Patient co-insurance payments are also an issue. For some of
these drugs, the patient co-insurance will be substantial, he
said. For example, the patient co-insurance for 500 mg of
fluorouracil could be as high as $45.
What to Do?
Dr. Bailes said that ASCO has been extremely active in combating the
use of APCs. Weve met with HCFA and with the American
Hospital Association. We have issued draft comments, which can be
obtained from the ASCO office, suggesting several ways to handle this.
First, he said, ASCO believes that chemotherapy drugs need to be
reimbursed on a fee schedule as in the past. We think that the
HCFA cost data for major teaching hospitals, and certainly for cancer
hospitals, are wrong, he said. HCFA even admits it is
wrong on this, but doesnt know how to fix it.
ASCO also believes that because of these inaccurate data, the cancer
services themselvescancer services in the hospital outpatient
departmentought to be kept separate (carved out), at
least for some period of time.