Practice Management

The Medicare bill that Congress passed in December 2000 (H.R. 5661) didn’t help oncologists or any other medical specialty in terms of increasing payment in such pressing areas as chemotherapy administration. Instead, the bill gave big bucks

WASHINGTON-The Health Care Financing Administration (HCFA) has scrapped plans to significantly reduce payments in 2001 for therapies and technologies covered by Medicare under its Hospital Outpatient Prospective Payment System (HOPPS).

CHICAGO-Unless relative value reimbursement units for mammography services rise by a factor of three, the US health care system will not be able to keep up with the expected demand for diagnostic and screening examinations for breast cancer, a panel of radiologists said at the annual meeting of the Radiological Society of North America (RSNA).

Oncologists will get an average 6% increase from Medicare in calendar 2001. That puts them about midway amongst specialists, with optometrists getting a 12% hike and gastroenterologists coming out with a big goose egg.

The Clinton administration memorandum on coverage of Medicare patient costs in clinical trials, which drew concern from ASCO when the White House published its incipient statement last June, has apparently morphed into a “final national coverage decision”-announced in late September-that most groups are quite happy with. Ellen Stovall, president and CEO of the National Coalition for Cancer Survivorship, says her group is very happy with the coverage document published by HCFA. She does note, however, that there is a need to monitor the new rules HCFA will be developing for coverage of a subgroup of trials-so-called IND-exempt trials run by cancer centers and pharmaceutical companies-that are testing existing drugs for new uses. Some of these trials are extremely legitimate. Some are not. No one in the cancer community wants to see Medicare pay for clinical trials involving the use of tea leaves to cure colon cancer. However, in writing rules meant to exclude Medicare coverage of those kinds of questionable trials, Stovall indicates that it will be important to ensure that those rules, based on imprecise wording, don’t exclude Medicare coverage for legitimate trials.” We will be concerned with how the language develops,” she explained. One other area of possible concern is Medicare’s intention to pay only for trials that have a “therapeutic” objective. That would rule out some phase I trials designed to test the toxicity of a new medication.

The Health Care Financing Administration (HCFA) sent a letter to Medicare insurance carriers in September telling them not to cut reimbursement to oncologists for 14 oncology drugs that are administered in the oncologist’s office. This was a reversal of what HCFA said it planned to do, based on pricing data developed by the US Justice Department. Those data showed that drug manufacturers were reporting “average wholesale prices” (AWPs) to Medicare for those 14 drugs that were much higher than the actual AWPs. Medicare reimburses the oncologist for 95% of the AWP. The Justice Department alleges that the drug companies report a very high AWP and then actually sell the drug to the oncologist for a considerably lower price, allowing the oncologist to make a tidy profit after Medicare reimburses at the higher price. The American Society of Clinical Oncology (ASCO) argued that Medicare woefully under-reimburses oncologists for chemotherapy administration, and, therefore, any additional revenue the doctors can generate via AWP reimbursements is warranted. ASCO took that argument to Capitol Hill, and legislators brought pressure to bear on HCFA administrator Nancy-Ann Min DeParle. “We would like to acknowledge HCFA’s willingness to work with the cancer community on this important issue,” said Lawrence H. Einhorn, MD, president of ASCO. Of equal importance is DeParle’s commitment to increase practice expenses for the CPT codes for chemotherapy administration. That will be done in the summer of 2001, when HCFA publishes a proposed Medicare fee schedule for calendar year 2002.

WASHINGTON-The Health Care Financing Administration (HCFA) has backed off from plans to reduce Medicare payments for chemotherapy agents administered in outpatient settings.

The Health Care Financing Administration (HCFA) proposed increased reimbursement for two heavily used chemotherapy administration codes (90408 and 90410), but not nearly as much as ASCO had been pushing for. AMA’s relative value update committee (RUC) voted to accept ASCO’s data justifying an increase in the clinical staff time related to an oncologist’s expenses associated with both codes.This recommendation was forwarded to HCFA. Clinical staff time-the time a nurse or staff spends giving chemotherapy or educating a patient-is figured into the “practice expense,” which, with “physician work” (time spent face-to-face with the patient) and “malpractice expense,” is part of the formula for determining a CPT code’s relative value, which dictates reimbursement. However, HCFA slightly lowered the clinical staff times recommended by the RUC. Julie Taylor, deputy director of public policy for ASCO, says the group will be submitting comments to HCFA to accept the RUC recommendation. HCFA’s final decision will go into effect on January 1, 2001.

BETHESDA, Md-President Clin-ton’s executive memorandum directing Medicare to pay the costs of routine care delivered to beneficiaries who participate in clinical trials left some major questions unanswered, NCI director Richard D. Klausner told the National Cancer Advisory Board.

Donna Shalala, secretary of the Department of Health and Human Services (HHS), assured a key House Republican that Medicare and Medicaid are taking steps to cut their drug reimbursements. The two agencies-part of HHS’s Health Care

WASHINGTON-President Clinton has ordered Medicare to begin paying for the routine care of all its beneficiaries who participate in clinical trials. The president also directed that the Department of Health and Human Services (HHS) take other actions to promote the participation of older patients in clinical trials.

WASHINGTON-The Department of Health and Human Services (HHS) has awarded grants totaling $794 million to the 50 states, the District of Columbia, and two US territories, to improve access to primary care, support services, and medications for HIV-infected individuals and their families.

WASHINGTON-The National Institutes of Health (NIH) and the Food and Drug Administration (FDA) have made little progress in implementing recommendations to reform the Institutional Review Board (IRB) system to ensure the protection of patients participating in medical research, according to a new report by the Office of the Inspector General (IG) at the Department of Health and Human Services (HHS).

Mandatory HIV testing of newborns has not become a routine practice in the United States, Donna E. Shalala, Secretary of Health and Human Services (HHS), has ruled.

here has been some private sector momentum on the issue of insurance company reimbursement of patient care costs in cancer clinical trials. Now the spotlight may shift to Medicare reimbursement, especially since the Institute of Medicine

Oncologists will see about a 5.5% increase in pay for CPT codes that they bill Medicare for in the year 2000. Actually, all physicians will get that same “update.” But other specialties will have that increase either boosted or shaved based on changes in the Medicare fee formula for 2000. Medicare is transferring malpractice relative value units (RVUs) from a historical charge to an actual cost basis, and is continuing to do the same to practice expense RVUs, although the latter change will not occur until 2002. Those changes will have no impact on either hematologist/oncologists or radiation oncologists, but some surgical specialties and anesthesiologists will lose upwards of 10%.

ALEXANDRIA, Va-The failure of the National Bipartisan Commission on the Future of Medicare to issue a report resulted from complex political calculations made by various players in the process. “Behind the political differences lies a legitimate difference on the role of the government in health care,” Washington attorney John S. Hoff said at the 25th Annual Meeting of the Association of Community Cancer Centers (ACCC).

ALEXANDRIA, Virginia-Careful and correct coding has become crucial for oncology practices that wish to maximize reimbursement and minimize their chances of a Medicare audit, said Roberta Lee Buell, MBA, president and chief executive officer of Intake Initiatives, Inc./Documedics, San Bruno, California.

WASHINGTON-Cigars should carry health warning labels similar to those on cigarettes and other tobacco products, the inspector general (IG) of the Department of Health and Human Services (HHS) has concluded. Inspector General June Gibbs Brown also urged the federal government to develop a public awareness campaign aimed specifically at explaining the adverse health effects of cigar smoking.

WASHINGTON-A data manager has been disciplined by the Department of Health and Human Services (HHS) for falsifying data on three patients involved in studies conducted by the National Surgical Adjuvant Breast and Bowel Project (NSABP). The data problems were discovered in 1996 by NSABP as part of its quality assurance audits.

WASHINGTON--More of those long-secret tobacco industry documents that have come to light as the result of recent lawsuits will be coming to a website near you. President Clinton has ordered the Department of Health and Human Services (HHS) to take the steps necessary for making the documents more accessible to the public.

WASHINGTON--The Department of Health and Human Services (HHS) says it is making progress with the Year 2000 computer problem. Known to technowonks as the Y2K problem, it stems from the simple fact that most older computers are programmed to recognize years by their last two digits.

WASHINGTON--Health plans may now apply for certification as Medicare+Choice plans. The Department of Health and Human Services recently released regulations that outline the standards that health plans and organizations must meet to become part of the new program.

WASHINGTON--Medicare now has its own website on the Internet. Among the information available at www.medicare.gov is the "Who to Contact" section, which provides listings, including telephone numbers, where people can obtain answers to questions about receiving Medicare, understanding Medicare bills, Medicare rights and benefits, dealing with complaints and appeals, and managed care issues. Other topics covered include Medicare eligibility requirements and enrollment procedures; managed care options; reporting suspected fraud or abuse; and wellness issues of particular concern to older people.

WASHINGTON--The Department of Health and Human Services (HHS) has announced a new program to reward citizens who alert Medicare to acts of fraud and abuse. The Incentive Program for Fraud and Abuse Information, starting in January 1999, will pay 10% of a recovered overpayment up to a maximum of $1,000.

WASHINGTON-New cancer-screening benefits for Medicare patients took effect on Jan. 1. They include:

WASHINGTON-The Department of Health and Human Services wants to change the rules that govern hospital participation in Medicare and Medicaid programs. Whereas existing regulations focus on whether hospitals have systems or procedures in place, the proposed new rules would emphasize a hospital’s actual delivery of care, its overall performance, and the impact of its treatment on the state of patients’ health.

ATLANTA-A local effort by a state Medicare director to restrict Medicare reimbursement for use of epoetin-alpha (recombinant erythropoietin, Epogen, Procrit) in chemotherapy-induced anemia has now become nationwide policy, even though it contradicts current practice, LaMar S. McGinnis, MD, of the American Cancer Society, told Oncology News International in an interview.

WASHINGTON-In the waning weeks of the 1997 congressional session, the House and Senate passed, and President Clinton signed, several pieces of legislation of significance to the oncology community, including the National Cancer Institute appropriation bill and the Food and Drug Administration “reform act.” But the Congress left some tough issues, including legislation to implement the proposed tobacco settlement, until it returns in 1998.

Optimal dosing and scheduling are among the most important issues being addressed in clinical studies of the taxanes. The results to date indicate that there may not be a single administration schedule that produces optimal antitumor efficacy. Instead, the specific doses of the taxanes relative to each schedule and the overall aggressiveness of the dosing schedule should be considered. There appears to be a threshold taxane dose or concentration below which only negligible antitumor activity is observed, as well as a plateau dose or concentration above which no further antitumor activity occurs. The doses at which both threshold effects and plateauing of dose-response curves occur seem to be inversely proportional to the duration of the administration schedule. For paclitaxel (Taxol), it appears that comparable antitumor effects are achieved with both short (1- and 3-hour) and prolonged (24- and 96-hour) schedules as long as equitoxic dosing regimens are used. The majority of clinical studies with docetaxel have used a somewhat aggressive dosing schedule, 100 mg/m² over 1 hour, which marks the outer edge of the dosing envelope, but nonrandomized trial results suggest a dose-response relationship in the 60- to 100-mg/m² dosing range. [ONCOLOGY 11(Suppl):7-19, 1997]