Medicare facing cancer, cardiac care cuts

[Rich66]

http://www.commercialappeal.com/news...e/?partner=RSS

Medicare facing cancer, cardiac care cuts

Reimbursements for oncologists and cardiologists are on the federal government's chopping block in the next six weeks.

By Arie Szatkowski, Special to The Commercial Appeal
Tuesday, September 15, 2009
As the health care debate continues in Washington, lost in the controversy is a little-known change in Medicare policy that threatens efficient access to lifesaving medical services for millions of heart and cancer patients.
If enacted as scheduled on Jan. 1, 2010, policy changes recommended by the federal Centers for Medicare and Medicaid Services (CMS) -- the government's insurer for the elderly and disabled -- will severely cut current Medicare reimbursements to cardiologists and oncologists for critical care services that are provided to patients in physicians' offices or other out-of-hospital setting, such as chemotherapy to treat cancer, and various cardiac procedures to monitor and treat heart disease, such as nuclear imaging and heart catheterization.


These cuts will force cardiologists and oncologists to limit care to their Medicare patients, withdraw from treating Medicare patients altogether or require their patients to pay more out of pocket to make up the difference in the cost of these services.
Unless these proposed changes are rescinded, current and future cardiac and cancer care patients will suffer the consequences, especially in rural areas where the proportion of Medicare patients is exceptionally high and patients have fewer choices of health care providers.
The changes certainly will force the closing of outreach clinics in rural areas, leaving many people without easily accessible cardiac or cancer care. They will be forced to travel to hospitals, sometimes long distances from home, and to wait for hours, if not days and weeks, for the tests and services they need.
It is difficult to think of the emotional, physical and financial burden this will place on people already suffering from heart disease and cancer.
Yet the policymakers at CMS, who base their decisions on numbers and statistics, are unilaterally and dramatically changing the delivery of heart and cancer care by proclaiming that care for heart disease and cancer is too costly, while treatment for other diseases has greater value.
Such decisions are based on flawed and incomplete data. They disregard the fact that heart disease and cancer kill more Americans than any other disease, and that advances in heart and cancer care have led to a 25 percent reduction in deaths due to heart disease during the past decade, and a marked increase in survival of cancer.
With the U.S. population aging, along with an expected rise in the number of cases of heart disease and cancer, the ability to manage these diseases in a cost-effective manner while maintaining a high standard of care through the use of advanced therapies and tests will be critical for prolonged life. Studies have proved that people with heart failure have better outcomes when their illness is managed by cardiologists in an outpatient setting. Yet the changes proposed by those who run Medicare will disrupt much of the progress we have made.
Many oncologists and cardiologists -- myself included -- in Memphis and the Mid-South and throughout the nation, are faced with this difficult dilemma: How can we afford to treat our Medicare patients when the proposed Medicare reimbursements in some cases are less than the cost of providing medical services? As with all businesses today, the costs of running medical practices have increased.
While these changes will have serious financial impact on medical practices, they also will erode a doctor's ability to provide patients with the very best quality of care that has proved to be cost-effective and beneficial. They will erode a doctor's ability to provide the same level of care for people who live far away from medical centers such as Memphis. And they will lessen a doctor's ability to be the primary advocate for his patients, as opposed to a group of hospital administrators, bureaucrats and lawyers.
At this point, the proposed CMS policy changes remain just that: proposed changes. During the next six weeks, CMS officials will be reviewing them, and they'll likely be enacted unless the people most seriously affected -- patients and the doctors who care for them -- contact CMS officials and their congressional representatives to protest these proposed changes.
Otherwise, the day is coming when Medicare patients -- often the most vulnerable in our society -- will wake up and realize they no longer have access to the timely and often urgent medical care they need.
Dr. Arie Szatkowski is a cardiologist with The Stern Cardiovascular Center in Memphis.

[Rich66]

US Cardiologists in Short Supply, and the Problem Could Get Worse

Michael O’Riordan

September 14, 2009 (Washington, DC) — The demand for cardiologists in the US far exceeds the supply, and this shortage will continue to get worse with time, according to a new report published online September 10, 2009 in the Journal of the American College of Cardiology [1]. At present, there is shortage of more than 1600 general cardiologists and nearly 2000 interventional cardiologists, with electrophysiologists and pediatric cardiologists also in short supply.
More concerning, however, is that with an aging baby-boomer population, epidemics in obesity, and growing rates of the number of individuals with diabetes mellitus, as well as the fact that more patients with chronic heart disease are living longer, the number of practicing cardiologists will need to double by 2050 to keep up with the demand. If not, the US might find itself short approximately 16 000 cardiologists.
These are the conclusions of the American College of Cardiology Board of Trustees Workforce Task Force, which is headed up by Dr George Rodgers, a private-practice cardiologist in Austin, TX.
"The thought is that this is currently a problem, we have a huge gap," said Rodgers during a briefing with the media. "Our guess is that the deficit in the number of cardiologists is probably going to widen, even double, by the time we get to 2030 or 2050."
In their report, the task force noted that just 750 to 800 new cardiologists graduate from training programs each year. Rodgers pointed out that internal-medicine residents looking to do a cardiology fellowship don't always get the chance to become cardiologists because there are approximately 1200 applicants for 800 cardiology fellowship positions. Many institutions say they lack the funding to take on any more cardiology fellows, noted Rodgers.
The task force suggests that the current shortage is partially brought on by significant shortages in the number of women and minorities in cardiology. While women equal men in medical school, just 12% of the current cardiology workforce is female. Also, while African Americans and Hispanics constitute 25% of the US population, they represent just 6% of cardiologists in active practice. In addition, in 2006–2007, black and Hispanic fellows represented just 13% of internal-medicine residents and 10% of cardiology fellows.
Currently, more than 43% of US cardiologists are older than 55 years, notes the task force, and there are concerns that these doctors might retire early, especially with the proposed cuts to cardiology payments in the Medicare physician fee schedule for 2010.
During the media briefing, Rodgers said that one of the ways they are looking to make cardiology more attractive is by making the work environment more "sustainable and survivable."
"We need to see if we can work out a better kind of work-life balance," he said. "That's what we're hearing from the fellows coming out today, they're concerned about the work-life balance."
[ CLOSE WINDOW ]
References

1. Rodgers GP, Conti JB, Feinstein JA, et al. ACC 2009 survey results and recommendations: addressing the cardiology workforce crisis. J Am Coll Cardiol 2009; 54:1195-208. Available at: http://content.onlinejacc.org.

[Rich66]

http://www.news-medical.net/news/200...re-system.aspx

11. September 2009 01:49

The Community Oncology Alliance (COA), a national non-profit organization that represents oncologists and other cancer care providers, strongly opposes cuts in Medicare reimbursement for cancer care outlined by the Centers for Medicare & Medicaid Services (CMS). In spite of President Obama’s vow to protect Medicare in his speech to Congress last night, the new rules scheduled to take effect on January 1, 2010 specify an additional 21.5% decrease in all physician-related services payments by Medicare. These cuts, which include massive payment reductions for medical oncology, diagnostic imaging and radiation oncology, are scheduled to occur regardless of the outcome of the healthcare reform process.
Over the past five years, the cancer care system has already been severely strained by a series of cuts to Medicare reimbursement for drugs and services. The new cuts are especially alarming, given that almost 50% of all cancer patients are Medicare patients. While the healthcare plan the President presented last night included only a limited public option under his proposed insurance exchange, some proposals call for a public insurance plan based on Medicare rates, which would only compound and perpetuate the problem.
Based on data from community oncology practices across the nation, COA estimates that the new cuts will result in a staggering 38% annual average reduction in Medicare reimbursement for chemotherapy infusion services alone. As a result of these cuts, cancer patients across the nation will experience delays in diagnosis and treatment, face longer waiting times, be obliged to travel farther for care and in some cases be unable to find local access to cancer care.
“President Obama recommitted in his speech last night to building on what works and fixing what does not work,” said Patrick Cobb,M.D., president of COA and managing partner of Hematology-Oncology Centers of the Northern Rockies in Billings, Montana. “But the cancer care system is already broken after a steady series of cuts to Medicare reimbursement for drugs and services each year over the past five years. The Medicare reimbursement cuts planned by CMS will kill cancer care as we know it. Community cancer clinics have already had to close satellite facilities and cut staff. Smaller clinics are struggling to operate and more will close.”
To measure the likely impact of the Medicare cuts on actual reimbursement, COA developed a financial analytical tool based on the data provided in the proposed CMS rule outlining the cuts. Detailed financial data resulting from nearly 200,000 patient visits was submitted to a certified public accountant that aggregated the results.
“The magnitude of the proposed cuts in the reimbursement for administration of life-saving cancer drugs will be tremendously damaging to patients depending on quality, accessible cancer care,” said oncologist Dr. Mark E. Thompson of The Mark H. Zangmeister Center in Columbus, OH. “These cuts are not reflective of underlying market costs and will seriously impair our ability to continue to treat cancer patients.”
Dr. Thompson and his staff have already taken a number of steps in the past year to deal with cuts in reimbursement from Medicare and private payors. They have eliminated staff positions, reduced staff hours, initiated a wage freeze and referred Medicare patients with inadequate supplemental insurance coverage to hospital inpatient infusion centers.
“The patients do not receive the same level of care in hospital infusion centers, often waiting longer for lab tests and the preparation of their treatments for each chemotherapy visit, and the cancer care is ultimately at a higher financial cost than we can provide in the community oncology setting,” Dr. Thompson said.
Fact Sheet
Scheduled Cuts in Medicare Reimbursement for Cancer Care by Centers for Medicare & Medicaid Services (CMS)

• New rules by the Centers for Medicare & Medicaid Services (CMS) scheduled to take effect on January 1, 2010 specify an additional 21.5% decrease in all physician-related services payments by Medicare.
• Based on data from community oncology practices across the nation, COA estimates that the new cuts will result in a staggering 38% annual average reduction in Medicare reimbursement for chemotherapy infusion services alone. COA estimated the likely impact of the Medicare cuts on actual reimbursement using a financial analytical tool it developed based on the data provided in the proposed CMS rule. Detailed data from nearly 200,000 patient visits was submitted to a certified public accountant that aggregated the results.
• The cuts, which include massive payment reductions for medical oncology, diagnostic imaging and radiation oncology, are scheduled to occur regardless of the outcome of the healthcare reform process.
• The new cuts are especially alarming, given that almost 50% of all cancer patients are Medicare patients.
• Reimbursement cuts to oncologists for cancer drug administration have already occurred every year since 2003, with a total decrease in reimbursement from 2003 to 2009 of 68%. This means if an oncologist was reimbursed $100 in 2003 for the net profit or loss on a drug plus its administration, in 2009 he or she is being reimbursed $32.
• These numbers are applicable for Medicare reimbursements (often 50% or more for community oncology practices) as well as third party payors that follow Medicare guidelines.
• Additional data from COA showing that, on average, current Medicare payments to community oncologists cover only 55% of the costs of services associated with the delivery of cancer care. This data was obtained through COA’s “Components of Care” study, a survey of oncology practices across the nation that quantified the clinical and operational components and associated costs for delivering cancer care.
• The areas of underpayment include life-saving chemotherapy infusion services as well as other vital cancer care services such as treatment planning, treatment evaluation, testing, care coordination, supportive and palliative care, and patient counseling.
• For as many as 40% of all cancer drugs, the Medicare reimbursement is already less than the acquisition cost.
• The CMS cuts will also impact essential diagnostic imaging and radiation therapy services. Reimbursement cuts in these vital services are counter-productive to coordinated care and will place additional financial burden on community oncology practices.
• COA and many community oncology practices have submitted comments to the Centers for Medicare & Medicaid Services opposing the planned cuts.

http://www.communityoncology.org/

[Rich66]

http://www.helenair.com/news/opinion...cc4c03286.html

Support oncology amendment to bill

• Story
• Discussion

By Robert D. Pfeffer, IR Letter to the Editor | Posted: Sunday, September 27, 2009 12:00 am
I am an oncologist practicing in Helena. I am encouraging people to ask Sen. Baucus to support the amendment to the Senate health reform bill being offered by Sen. Lincoln. This addresses the shocking cuts in reimbursement for radiation oncology services contained in the CMS 2010 fee schedule proposed rule.
The proposed fee reductions will injure Montanans by removing the reimbursement for high technology medicine. High technology medicine is costly to install and maintain and must be supported by appropriate reimbursements. In my career, which began in 1990, I have seen tremendous improvement in the quality of radiation medicine in this state. Montana facilities in the early 1990s had to use equipment that was 15 years out of date. Montanans with means often left the state to go to Seattle or Salt Lake or Mayo knowing they could get better care out of state and Montanans without means stayed here and received lesser quality care.
Montana cancer care has gone from cobalt therapy to having the only Cyberknife between Seattle and Minneapolis. The old low-tech era is bygone but will certainly return after the proposed radiation oncology fee cuts go through.
As a senator with special standing regarding health care policy, Baucus can do much to help the ordinary Montanan continue to receive state-of-the-art cancer treatment at home. While the wealthy will always be able to jet off to Johns Hopkins, we want to provide technical excellence for the ordinary fellow and his family right here in Montana. The proposed 2010 fee schedule for radiation oncology services may once again force us to accept lesser quality cancer care than citizens of other states.
Robert D. Pfeffer, MD
5585 York Road

| (1) Comments

[Rich66]

ASCO clip on proposed Medicare cuts:

http://link.brightcove.com/services/...id=43015932001

[Rich66]

www.medscape.com




From Medscape Medical News

Current Estimates Predict Fewer and Younger MDs in the Future

Fran Lowry

October 20, 2009 — Estimates made using data from the US Census Bureau suggest that the future physician workforce may be younger and fewer in number, contrary to estimates made using the American Medical Association Physician Masterfile data, a source that is often used by workforce analysts to project changes in the supply of physicians, according to the results of a study published in the October 21 issue of the Journal of the American Medical Association.
"Recent projections indicate that the supply of US physicians may soon decrease below requirements, with some projecting a shortfall as high as 200,000 by 2020," write Douglas O. Staiger, PhD, from Dartmouth College, Hanover, New Hampshire, and the National Bureau of Economic Research, Cambridge, Massachusetts, and colleagues. "Although debate over potential shortages has focused largely on the number and type of physicians needed in the future, concerns have also been raised about data used in physician supply estimates and projections."
The Masterfile data have recently come under scrutiny because of concerns that the Masterfile overestimates the number of active physicians at older ages, the authors write.
The aim of this study was to compare physician workforce estimates and supply projections using Masterfile data with estimates and projections using data from the US Census Bureau Current Population Survey (CPS), a data source used extensively by the US Department of Labor.
Using annual data from the Masterfile and the CPS between 1979 and 2008, the investigators analyzed the number of active physicians by age and sex to estimate the annual number of physicians working at least 20 hours per week in 10-year age categories.
The authors found that in an average year, the CPS estimated 67,000 fewer active physicians (10%) than did the Masterfile (95% confidence interval [CI], 57,000 – 78,000; P < .001), almost entirely as a result of there being fewer active physicians aged 55 years or older.
They also found that the CPS estimated more young physicians (ages 25 – 34 years) than did the Masterfile, with the difference increasing to an average of 17,000 physicians (12%) during the final 15 years (95% CI, 13,000 – 22,000; P < .001).
The CPS estimates of more young physicians were consistent with historical growth observed in the number of first-year residents, and their estimates of fewer older physicians were consistent with lower Medicare billing by older physicians, the authors note.
Both databases projected that the number of active physicians will increase by approximately 20% between 2005 and 2020. However, the CPS data estimated that there will be almost 100,000 fewer active physicians (9%) than the Masterfile data (957,000 per CPS vs 1,050,000 per Masterfile). The CPS data also estimated that a smaller proportion of active physicians will be aged 65 years or older (9% vs 18%).
"The CPS-based projection indicates that 71% of active physicians will be younger than 55 years and only 9% will be older than 65 years, whereas the Masterfile-based projection indicates that 61% of active physicians will be younger than 55 years and 18% will be older than 65 years," Dr. Staiger and colleagues write.
In addition, the increasing proportion of female physicians had little effect on physician supply projections "because, unlike male physicians, female physicians were found to maintain their work activity after age 55 years," according to the authors.
The analysis was restricted to physician supply and projections of physician requirements also rely on estimates of the current number of physicians as a starting point for projections. "Thus, without more accurate estimates of the size and age distribution of the current workforce, projections of physician supply, requirements, and potential shortages may mislead policymakers as they try to anticipate and prepare for the health care needs of the population," the authors conclude.
In an accompanying editorial, Thomas C. Ricketts, PhD, MPH, from the University of North Carolina, Chapel Hill, writes that the controversy over the accuracy of the Masterfile data continues the "longstanding" debate over the supply of physicians and whether that number meets the US healthcare needs and promotes economic efficiency.
"The physician workforce is one of the most critical factors that must be considered in current health care reform and discussions," he writes. "Having accurate estimates for determining not only the number of physicians, but also current and future physician and workforce requirements and capabilities for delivering primary and specialty care, will be essential for achieving and sustaining effective health care reform."
Dr. Staiger and Dr. Ricketts have reported no relevant financial relationships.
JAMA. 2009;302:1674–1680, 1701–1702.
[CLOSE WINDOW]
Authors and Disclosures

Journalist

Fran Lowry

is a freelance writer for Medscape.




Medscape Medical News © Medscape, LLC
Send press releases and comments to news@medscape.net.

[Rich66]

Proposed Payment Reductions Squeeze Oncologists

2009 Oct 28, Lee Schwartzberg, MD, PhD, Editor-in-Chief

This grim economic year has affected every health care sector, and oncology practices are no exception to this rule. In my recent travels around the country, I’ve witnessed clinics that have had to lay off staff, close satellites, sell their assets to hospitals, merge with competitors, and reduce office hours. Yet these changes may well represent just the tip of the iceberg.
Currently, 3 independent, but related, initiatives affecting the way physicians are paid are being hotly debated in Congress. These 3 concentric rings are tightening around oncologists, and unless favorable action occurs to loosen any (or all) of these belt-tightening initiatives, it is not a stretch to say that medical oncology as we know it may be irrevocably altered.
Proposed administrative pay cuts by CMS
The most oncology-specific issue is a proposed administrative pay cut by the Centers for Medicare & Medicaid Services (CMS) in services for chemotherapy administration, diagnostic imaging, and therapeutic radiation oncology. Such cuts in reimbursement could have potentially devastating effects on patient care. The origin of Medicare’s proposal stems from data provided by an American Medical Association (AMA) practice expense survey requested by the Medicare Payment Advisory Commission (MedPAC). The data used to justify such cuts is inherently flawed and misrepresentative of community oncology, given that only 50 oncologists responded to the AMA survey, and the mix of respondents was never characterized with respect to type of practice. It is a given that CMS reimbursement for chemotherapy administration is currently inadequate, and many constituent groups have replied to Medicare protesting these cuts.
Outpatient diagnostic radiology services
But what about diagnostic radiology services, which have been increasingly adopted in outpatient community offices? We incorporated computed tomography (CT) scanning into my own practice 20 years ago, and I still view this as the single best patient care decision we’ve ever made. Today, we have a full-service diagnostic radiology department, with the capability of performing the full spectrum of imaging studies, including CT, positron emission tomography (PET), magnetic resonance imaging (MRI), and ultrasound.
Having this radiology department at our clinic allows me to review every CT scan with our staff radiologists, who have vast experience in the presentation of various cancers. Not infrequently, such consultations lead to an alteration in a differential diagnosis, the suggestion for an alternative test, or a change in therapeutic approach. Wait time for patients to receive results is minimized, quality care is maximized, and productivity losses are greatly reduced. The reasons for these positive outcomes seem obvious: The on-site radiology department allows patients to receive all of their diagnostic and therapeutic care in a single facility, obviating the need for patients to schedule separate appointments in geographically remote facilities, where tests will likely be conducted by physicians who know nothing about their particular case or who have minimal insights into their specific circumstances.
Thus, the key question for me is: Will reducing reimbursement to outpatient radiology facilities, which will only serve to drive patients back to the hospital for testing, really decrease the cost of medical care? Or will this proposed reimbursement cut merely serve to lower the quality of such care?
Impact of proposed cuts, according to ASTRO survey
Moreover, the CMS rule proposes to cut radiation oncology services delivered in outpatient facilities by between 19% and 30%. A survey commissioned by the American Society for Therapeutic Radiation Oncology (ASTRO) demonstrated that two-fifths of respondents would actually close their practices if cuts in the 30% range were implemented. Half of rural practices would shut their doors under these circumstances, and the majority of practices that did manage to stay open would limit or no longer accept new Medicare patients.
Such cuts would have a huge impact on cancer care delivery in our country. Whether or not cuts of this magnitude will be implemented by CMS remains to be seen, however, so there is still opportunity for the oncology community to respond. Comments to CMS and unflagging communication with elected officials are absolutely critical to prevent these disastrous changes from being implemented on the basis of flawed information. A letter with bipartisan authorship signed by 32 senators protesting the cuts to radiation oncology was recently sent to Health and Human Services Secretary Kathleen Sebelius. The oncology community needs to maintain this type of pressure on our elected officials and the administration in the ensuing weeks.
Modifying the SGR formula
The second concentric circle relates to the long-standing need to modify the sustainable growth rate (SGR) formula. This formula, conceived to keep physician payments consistent with changes in the gross domestic product (GDP) over the years, has been a boondoggle requiring a temporary fix applied legislatively by Congress for each of the last several years to prevent huge and unsustainable cuts in physician payments. This issue was supposed to be resolved once and for all in 2009. Senator Debbie Stabenow (D-Mich) introduced legislation to alter the SGR formula and thereby correct the inequities. The bill, estimated to cost $240 billion over 10 years, was not accompanied by offsets in costs from other parts of the budget, however, and therefore actually added to the cost of Medicare—an approach that is very unpopular in Washington these days. This bill was soundly defeated on the Senate floor last week.
The Senate Finance Committee health reform bill does contain a 1-year SGR fix, which is fully offset by other reductions and therefore potentially more palatable. Nonetheless, even that potential solution does not provide a real fix for the SGR problem.
But if SGR is not fixed or if a comprehensive health reform bill does not pass, what’s in store for 2010? The most likely result will be a 21% reduction in Medicare fees. Such a drop in physician reimbursement would undoubtedly cause many, if not most, physicians to abandon Medicare. In the case of oncologists, for whom Medicare represents 45% of all patients, the ability to care for older individuals will become virtually impossible. And, if only a 1-year fix passes again, there is little realistic expectation that a fair solution to the SGR problem will survive the legislative process in 2010—especially after the exhausting year of debating health care reform that is now coming to a close. Still, this problem cannot be put off forever.
Health care reform bill
The third and widest initiative is, of course, the overall health care reform bill. Few would argue against the need for some form of health reform legislation, and signs still look good for a broad-based bill to pass Congress, even though it’s unclear whether a final bill reconciling the House and Senate versions will be brought to a final vote before the end of 2009. If this process extends into the early part of 2010, there are clear-cut political consequences for all Congressional representatives who are running for reelection, not to mention the impact on the President’s ambitious agenda beyond health care.
To date, the biggest sticking point between the Senate and House versions of health reform legislation is the public health plan option. Speaker of the House Nancy Pelosi (D-Calif) plans to keep the public option in the House version because of increasing pressure from liberal Democrats to do so. On the other side, the Senate seems strongly inclined to vote against any bill that includes a public option.
If a public plan is implemented, the greatest source of concern for oncologists is how well it is funded. The 2 basic proposals that have been advanced are as follows: (1) to pay providers at Medicare rates, or (2) to negotiate rates with providers, as would be done by private insurance companies. Most analysts believe any public plan would compete favorably with private payers and, in a few years, could be a dominant force in the non-Medicare market. If so, oncology providers paid at Medicare rates for their services could not afford to stay in business, since the current payment schedule is at or below cost and therefore is unsustainable. In my opinion, a public plan that negotiates with providers is a valid option, however. I believe that negotiating rates will ultimately drive down costs to patients in the private health insurance market. It should be noted that insurance premiums are rising significantly again this year, and are unsustainable for companies that provide health care insurance. A solution to the high cost of insurance premiums is necessary, but not on the backs of the providers.
Communication with elected officials is still key
So we head toward the holiday season with apprehension about what’s in store for Medicare, particularly with regard to oncology. However, uncertainty should not be confused with hopelessness or helplessness. Our elected officials do listen to their constituents. It’s incumbent upon all oncology practices and their patients to communicate with their elected representatives, and to explain what the stakes are for making decisions that fail to recognize the complexity of modern cancer care. Today’s oncology practitioners must not only plan treatment, assess treatment response, and provide coordination of care, but also offer disease surveillance, provide supportive and palliative care, and manage end of life. Most recently, we also have been charged with providing financial counseling to our patients who undergo expensive cancer treatments.
Current codes being used by the federal government fail to reimburse physicians for any of these services. Reach out to your representatives and ask them to support appropriate coding modifications that reimburse oncologists fairly for the work they do each day. Only by such outreach efforts will we be able to preserve access to the world’s best cancer care delivery system.

[Rich66]

ASCO prez responds to cuts:
http://www.asco.org/ASCOv2/Press+Center/Latest+News+Releases/American+Society+of+Clinical+Oncology+(ASCO)+State ment+on+Cuts+to+Cancer+Care+in+2010+Medicare+Physi cian+Fee+Schedule

[Rich66]

Ugggg..
http://weisenthalcancer.com/Professi...surancepro.htm
"Medical Insurance Coverage Insurance coverage for Functional Tumor Cell Profiling varies depending upon the reimbursement policies of the patient's insurance carrier and the provisions of his or her specific insurance policy. Many insurance carriers cover most or all of the testing fees, excluding normal co-payments and deductible amounts. However, other insurance carriers pay for only a portion of the costs and some carriers may deny claims completely. Patients will be billed for any co-payments, deductible amounts, or other balances that are not paid by the patient's carrier. As a courtesy to your patient, we gladly will submit insurance claims to the carrier before requesting payment from the patient. We will also assist in appealing an unfavorable coverage decision in the event that an insurance claim is denied. Our collections policy is liberal and humane. We always allow ample time for insurance claims work their way through the system, including carrier information requests and appeals when necessary

Effective July 1, 2008, Weisenthal Cancer Group elected voluntarily to opt-out as a Medicare provider owing to excessive delays in receiving payments and also due to Medicare's erratic coverage patterns, despite the fact that an exhaustive technology review by Medicare resulted in what was supposed to have been routine coverage for Medicare beneficiaries for functional tumor cell profiling beginning in February of 2007. We regret that Medicare's slow and inconsistent payment policies along with its lack of responsiveness to our inquiries necessitated this action on our part. This does NOT mean that we do not perform testing for Medicare beneficiaries. We offer our testing services equally to all patients. However, it means that Medicare beneficiaries assume financial responsibility for their testing services in the same manner as non-Medicare beneficiaries. "

[gdpawel]

Only physicians and suppliers can decide not to accept assignment. If your physician or supplier does not accept assignment for covered services, your physician or supplier may require that you pay most or all of the bill at the time you receive services or supplies. However, the physician or supplier is still required to file a Medicare claim on your behalf. Medicare then pays its share of the bill directly to you.

[Rich66]

I thought opting out of Medicare assignment meant not having to operate according to Medicare guidelines. Or are you saying there are laws forcing them to file to any and all insurance entities?
If that's true, it's good information to know in the case of Medicare approved services. Maybe one could negotiate a good "pay as you go" discount with the provider and get full coverage upon Medicare reimbursement.

I think the Weisenthal statement indicates Medicare doesn't , or doesn't always, consider their services appropriate for coverage.

" erratic coverage patterns"

So filing might not guarantee reimbursement.

[gdpawel]

Accepting assignment means they will bill the Medicare contractor directly and receive reimbursement from the Medicare contractor.

Not accepting assignment means, although they may require you pay most or all of the bill, they are still required to file a Medicare claim on your behalf, and the Medicare contractor pays its share of the bill directly to you.

Medicare does consider the services appropriate for coverage. In 2006, Medicare officially recognized cancer chemosensitivity tests as a special test category in Federal Regulations (42 CFR 414.510(b)(3), 71 FR 69705, 12/01/2006). The are now known as Oncologic In Vitro Chemoresponse Assays.

As with any other laboratory tests in cancer medicine, the determination of the efficacy of chemoresponse assays is based on clinical correlations (comparisions of laboratory results with patient response). The "standard" of retrospective correlations between treatment outcomes and laboratory results is sufficient in the case of ALL laboratory tests. It is what established FDA-approval for the test kit.

Two Medicare contractors (NHIC Medicare Services and Highmark Medicare Services) established reimbursement coverage policies for these tests, the same way that the Oncotype DX assay is being covered. Medicare bills for chemoresponse testing, from any Medicare patients, anywhere in the United States, are billed through NHIC and Highmark Medicare Services because the test is conducted by approved laboratories in Southern California and one in Pennsylvania.

The decision had been made that the assay is a perfectly appropriate medical service, worthy of coverage on a non-investigational basis. What is of particular significance is that they abandoned the artificial distinction between "resistance" testing and "sensitivity" testing and are providing coverage for the whole FDA-approved kit. Drug "sensitivity" testing is merely a point a little farther along on the very same continuum which "resistance" testing resides.

Cell-based assay tests based on "cell-death" have proven very effective in identifying novel treatment combinations for a variety of cancers. The value of cell-death assays is that they can and do accurately predict clinical outcomes and define novel chemotherapeutic synergies. It can help see what treatments will not have the best opportunity of being successful (resistant) and identify drugs that have the best opportunity of being successful (sensitive).

The current clinical applications of in vitro chemoresponse testing is ever more important with the influx of new "targeted" therapies. Given the technical and conceptual advantages of "functional profiling" of cell-based assays together with their performance and the modest efficacy for therapy prediction on analysis of genome expression, there is reason for renewed interest in these assays for optimized use of medical treatment of malignant disease.

This pre-test can help see what treatments have the best opportunity of being successful for "high" risk cancer patients. The test measures the response of "live" tumor cells to drug exposure. Following this exposure, the assays measure both cell metabolism and cell morphology (functional profiling). The integrated effect of the drugs on the whole cell, resulting in a cellular response to the drug, measuring the interaction of the entire genome. Assays based on "cell-death" occur in the entire population of tumor cells.

This cell-based assay technology has been clinically validated for the selection of optimal chemotherapy regimens for individual patients. It is a laboratory analysis based on tumor tissue profiling that uses "fresh" human tumor biopsy or surgical specimen to determine which drugs or combinations of chemotherapeutic agents have the highest likelihood of response for individual cancer patients.

Following the collection of "fresh" tumor cells obtained from surgery or tru-cut needle biopsies, a cell culture assay is performed on the tumor sample to measure drug activity (sensitivity and resistance). This will pinpoint which drug(s) are most effective. Tissue, blood, bone marrow, and ascites and pleural effusions are possibilities, providing tumor cells are present. At least one gram of fresh tissue is needed to perform the tests, and a special kit is obtained in advance from the lab. The treatment program developed through this approach is known as assay-directed therapy.

Effective September 2, 2008, Palmetto GBA (instead of NHIC, Corp.) is the Medicare Administrative Contractor for Jurisdiction 1, which includes California, Nevada, and Hawaii.

[gdpawel]

Despite the endless rhetoric from United States politicians, the results of study published in the November 30 Annals of Oncology, indicate private and government sponsored health programs have achieved extremely similar results in the reduction of cancer.

In a comparison of public and private insurance and cancer rates, a study of European cancer rates showed marked parity with very similarly constructed reports from the American Cancer Society.

Cancer mortality in Europe, 2000-2004, and an overview of trends since 1975. Annals of Oncology. doi:10.1093/annonc/mdp530

http://annonc.oxfordjournals.org/cgi/reprint/mdp530

http://www.cancer.org/downloads/STT/..._2007_rev2.pdf

http://www.cancer.org/docroot/stt/stt_0.asp?from=fast

[Rich66]

"they are still required to file a Medicare claim on your behalf"
Who/what requires this?

[gdpawel]

http://www.medicare.gov/basics/fac.asp

[Rich66]

If they accept the medicare patient, that would apply. If they don't want the hassle, they can limit Medicare patients from making appointments. I know one cancer treatment facility that accepted Medicare patients up until they were 50% of their patients.

Many people, just as they become eligible for Medicare, discover that the insurance rug has been pulled out from under them. Some doctors — often internists but also gastroenterologists, gynecologists, psychiatrists and other specialists — are no longer accepting Medicare, either because they have opted out of the insurance system or they are not accepting new patients with Medicare coverage. The doctors’ reasons: reimbursement rates are too low and paperwork too much of a hassle. …
In a June 2008 report, the Medicare Payment Advisory Commission, an independent federal panel that advises Congress on Medicare, said that 28 percent of the Medicare beneficiaries it surveyed who were looking for a primary care doctor had a problem finding one to treat them, up from 24 percent the year before. And a 2008 survey by the Texas Medical Association found that while 58 percent of the state’s doctors took new Medicare patients, only 38 percent of primary care doctors did.

[gdpawel]

I've observed incessant complaints on various cancer blogs and discussion boards about BC/BS (Blue Cross/Blue Shield) "denial of coverage" on the backs of injured and diseased human beings during their fight with the great crab.

In one case, a patient was denied a Cat scan. The poster said, "because BC/BS is practicing medicine and deciding that such a thing is not medically necessary." The physician wasn't allowed to make a diagnosis based on the best available technique.

Another poster said that BC/BS had decided not to cover a Pet scan, even against the physician protest. And another said that BC/BS had denied covering treatment because it was just too expensive.

One poster goes on to say, "It would appear to me that we in the USA are rapidly closing in on having all of the drawbacks of socialized medicine, with none of the purported benefits." The controls are mostly privately financed, but are given over to remote corporate bureaucrats who determine who shall live and who just isn't worth it.

Evidence-based medicine has morphed into pharma-based medicine and HMO-based medicine. Evidence is based on data from medical journal articles, epidemiology and economics, which relies on randomized clinical trials, which doesn't even require a medical education.

Nonphysicians trained in social science, science or even public policy analysis, have judgement over medicine. Where doctors used to define the "standard of care," now payers redefine the standards for appropriate medical care, encouraging doctors to act in ways to promote their financial interest when they make medical decisions.

America has granted private insurance companies the right to create bottlenecks in the financing of health care in order to extract profits out of the suffering of ordinary people, without providing any actual health care whatsoever.

[Rich66]

I thought we were talking about issues within Medicare, a public system. I too would like improved health care options. I think it's worth honestly looking at what's good and bad about the various approaches and figuring out how to proceed.

[gdpawel]

We hear complaints about publicaly run health programs and privately run health programs. According to the research published in the Annals of Oncology, private and government sponsored health programs have achieved similar results (for example) in the reduction of cancer. I agree, it is worth honestly looking at what's good and bad about both approaches and figuring out how to proceed.

[Rich66]

Mayo Clinic in Arizona to Stop Treating Some Medicare Patients

http://www.bloomberg.com/apps/news?p...d=aHoYSI84VdL0