New Orleans, LA—As reimbursement for services continues to decline, oncology pharmacists must be proactive and develop a strategy to minimize losses, said Steven L. D’Amato, RPh, a clinical pharmacy specialist with the Maine Center for Cancer Medicine, Scarborough, Me, at a presentation at the annual meeting of the Hematology/Oncology Pharmacy Association (HOPA).
“The landscape for oncology reimbursement presents challenges for clinicians and payers. Reimbursement for services is declining in both the hospital and private sectors as administrative burdens are increasing,” Mr D’Amato said. “These days we need to maximize efficiencies to make sure we get every dollar coming to us.”
Consultation code changes took effect January 1, 2010, and as Mr D’Amato noted, “billing and coding changes occur from year to year. If you don’t keep up, this can affect your bottom line.” The Centers for Medicare & Medicaid Services (CMS) eliminated the use of all consultation codes for various places of service except for telehealth consultation Gcodes. In place of the consultation codes, CMS increased the relative value units (RVUs) for new and established office visits, increased the work RVUs for initial hospital and initial nursing facility visits, and incorporated the increased use of these visits into the practice expense and malpractice calculations, he said. The proposed RVU cut of 6% for oncology will affect the bottom line, with reimbursement cut by 1% in 2010 and the 6% cut phased in over 4 years. A change in the sustainable growth rate has again been delayed, but when eventually implemented “it will mean a huge financial loss for private practices,” Mr D’Amato predicted, estimating a 25% reduction in payment for chemotherapy administration.
Regarding drug payments, CMS will no longer exempt 5-HT3 antiemetic products from standard packaging methodology. Drugs costing less than $65 per day are not reimbursed separately, while those costing more than $65 will continue to be paid separately. Separately billed drugs are reimbursed at average sales price + 4%.
Pharmacist involvement in the financial side of oncology is becoming increasingly important, Mr D’Amato told attendees. Institutions have contracting teams to identify issues pertinent to new or renewing contracts, and pharmacists should participate in these discussions.
Private payers are looking to control costs and spending through the use of specialty pharmacies, preauthorizations, and other mechanisms. In addition, payer requirements may slow patients’ access to care since treatments cannot begin until authorizations are received, and there is the additional administrative burden of managing denials. Pharmacists can weigh in on these issues, he said.
Participation in the Physician Quality Reporting Initiative (PQRI) is not a prerequisite for joining the electronic e-Prescribing Incentive Program in 2010. “The program requirements have been simplified, with a minimum of just 25 encounters for patients you have e-prescribed and for whom you utilized the G8443 code,” he said. CMS has expanded the reporting mechanism to be claims-based, registry-based, and electronic medical records-based.
“With the 2% PQRI incentive and 2% e-prescribing incentive, providers have the opportunity for a 4% increase in Medicare reimbursement,” he noted. By 2010, CMS will begin penalizing professionals who are not e-prescribers, reducing payments by 1%, then by 1.5% in 2013 and by 2% in 2014.
Medical oncology has become a new priority for managed care organizations (MCOs), based on the rise in cancer and cost of care. In 2008, new cancer cases numbered 1.437 million. Caring for these patients totaled $89 billion in direct costs in 2007 and $219.2 billion overall, once secondary costs and comorbidities were considered.
MCOs also are concerned about the cost of novel and new agents, especially oral oncolytics, and the evolving paradigm of cancer as a chronic disease. Other challenges for MCOs are the changing reimbursement model and new mandates to measure quality and performance.
“When you contract with MCOs, be creative,” he told oncology pharmacists. “For example, for anti-emesis you could agree to use the less expensive agent but asked to be paid more to offset what you would make instead on the more expensive agent. There are many opportunities to enhance reimbursement and reduce costs within MCOs (Table).”
Unfortunately, the future will be rife with other worries, Mr D’Amato predicted. There will be issues related to random audits from payers, for which pharmacists receive no payment; the Recovery Audit Contractor Program, which aims to identify potential overpayments and underpayments made to providers and are required in all states; coding compliance by physicians; the rise in underinsured and uninsured patients who need assistance in accessing care; the demand for Risk Evaluation and Mitigation Strategies; budget and staffing shortages; and competition by specialty pharmacies.
“As a profession,” Mr D’Amato concluded, “we have a lot to deal with outside of patient care.”
