Being Your Own Advocate

I had never thought of myself as a political operative. I’ve been an oncologist in Billings, Montana, since 1995. When I was younger, there wasn’t much concern about getting reimbursed; you billed and you were paid. As far as my political involvement, it was nearly nonexistent. I never expected to walk the halls of Congress, meet with more than 50 members, and talk to my colleagues about the importance of traveling to Washington, DC, to make sure that our voices were heard. (I remember once bumping into Sen. Max Baucus [D-MT], now chairman of the Senate Finance Committee, in a cafeteria when he was running for re-election in 1996. I had to ask someone, “Isn’t that Senator Baucus?”)

However, as the current chairman of the Policy Committee and 2008-2010 past-president of the Community Oncology Alliance (COA), which represents more than 2500 oncologists at community cancer clinics, I am now an expert on the advocacy process, and I travel each month to the nation’s capital to advocate on behalf of oncologists and our cancer patients.

Why do I do this? Seven years ago, Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), which changed how doctors are reimbursed by the Centers for Medicare & Medicaid Services (CMS). When payments for chemotherapy administration were reduced, it forced oncologists to take on a new active role. We then established COA to mobilize the oncology community, including physicians, patients, administrators, nurses, and other healthcare providers, to increase awareness on Capitol Hill about how the law was affecting the cancer care delivery system. This has become an increasingly critical role now as oncologists are fighting for the lives of their patients and their practices—community cancer clinics, which treat 84% of Americans with cancer.

As the World Health Organization predicted, this year cancer overtook heart disease as the leading cause of death. About 7.6 million people died of cancer in 2008, and about 12.4 million new cases are diagnosed each year, according to a report by the American Cancer Society.¹ The report further states that cancer costs more in productivity and loss of life than AIDS, malaria, the flu, and other diseases that are spread from person to person. Cancer’s economic toll was $895 billion in 2008, which is equivalent to 1.5% of the world’s gross domestic product.¹

Although cancer is the number one killer of Americans under age 85, the good news is that cancer survival rates in the U.S. continue to improve. The e number of Americans living with cancer is likely to increase with the aging population, more screenings leading to earlier detection, and current treatments allowing patients to live longer. As a result, more oncologists will be needed in the future to administer the treatments to the growing population of patients. It is estimated that by 2020, the country will be 4800 oncologists short.² Unfortunately, the state of physician reimbursement has disillusioned many practicing oncologists today about the Medicare system.

Physician reimbursement penalized

Congress has failed to address the Sustainable Growth Rate (SGR), the formula used to calculate payments to physicians annually based on the economy. The intended purpose of this formula was to place constraints on the growth of Medicare. However, it appears that physicians alone are being punished for the increases in Medicare spending, despite the fact that physician reimbursement is a very small part of overall spending. Congress has blocked the cuts each year, and, in December, the seven-month patch will end again.

For the past 6 years, the SGR has reduced Medicare reimbursement for some of the most expensive drugs and services used to care for cancer patients. The CMS Physician Fee Schedule for 2010 cuts even deeper, reducing payment for chemotherapy administration services an additional 5% annually, and up to 20% by 2013. There are additional cuts for cancer diagnostic imaging and physician consultation services. Medical practices cannot continue to provide care when they lose money.

Many community oncology clinics treat patients who cannot afford supplementary insurance and are solely dependent on Medicare. This alone causes financial pressure for oncologists who are already losing money from inadequate reimbursements for drugs and chemotherapy administration, as well as other overhead expenses.

Before the MMA was passed there wasn’t as much concern with access to chemotherapy treatments as there is now. That law radically changed how we were paid for delivering cancer care. Now we’re seeing the full impact of the law, with practices decreasing services and the flight of community oncology clinics to merge with hospitals and larger groups. For some practices, the situation has become even more dire. In the past 3 years, 166 clinics have closed. Since January 2010, 39 community cancer clinics in 15 states across the United States have closed or are in the process of closing because of financial pressures from severe cuts in Medicare reimbursement for cancer care. By the end of the year, the number of clinic closings could double. A cancer clinic serving Selma, Alabama, for nearly 25 years was forced to shut its doors. Now those patients must travel an hour to obtain treatment at a community oncology center in Montgomery.

Practices depend on payments from private insurers to support their business. The COA conducted a study that showed that Medicare reimburses less than half of the cost of providing cancer treatment for patients. Practices take a financial loss every time they give a Medicare patient chemotherapy because of this poor reimbursement. This is not a sustainable business model. We need advocates to help convey to Congress that the cancer delivery system that has been built over the past two decades is quickly falling apart.

The mission of the Community Oncology Alliance

Meanwhile, there are a lot of conflicting and competing pressures. There is pressure from the government to hold down costs, and in the private sector, more pressure from insurance companies to contain costs. Oncologists, like other physicians, are frustrated by the entire process. Therefore, we must become our own biggest advocates. Someone has to stand up for patients’ access to chemotherapy drugs and the state of cancer care. The best ones to do that are physicians. In the last 7 years since COA was founded to advocate for patients and providers in community oncology clinics, there is a growing number of us who are doing just that.

This brings us to the core of COA’s mission. While it is true that oncologists first, and foremost, are responsible for diagnosing and caring for patients with cancer and hematologic disorders, and second, for continuing to increase our knowledge about the disease through clinical and laboratory research, we now have another obligation that is equally as important: We must educate medical students, residents, fellows, and other trainees about how to advocate on behalf of our cause. This includes not only advocating for patients and their families, but advocating for our practices so that we can continue to save the lives of our patients.

COA’s mission is to protect patients’ access to quality, affordable cancer care across the country. We want to ensure that the nation’s cancer care delivery system remains the best in the world. Since COA was established, we have rallied the cancer community—physicians, staff , and patients—to take our message to Capitol Hill. Through political advocacy, we have made an impact.

It is vital that physicians take a leadership role when Medicare or Congress comes out with new rules that affect patient care. We must meet with our local officials and members of Congress. Elected officials, from the U.S. Congress to the state capitals, have a lot on their plates. They cannot be experts on every topic, particularly when it comes to healthcare concerns such as Medicare. They are looking to their constituents for advice, and who better to advise them on healthcare issues than physicians. We must speak up for our patients; if we don’t, no one else will.

Of course, here in Montana, it’s a lot easier to gain access to members of Congress because they have far fewer constituents than the more heavily populated states. We have senators who are willing to sit down over coffee and talk about the issues. But now I go to Washington, DC, practically every month to meet with members of Congress about issues that impact COA members across the country. I walk the halls of Congress to bring attention to COA’s causes.

Get involved in your community

To be an advocate, you don’t have to travel to the nation’s capital every month. There are many ways that an oncologist can help. COA has a petition, “Stop Cancer Care Cuts,” that was distributed to all of the offices of COA members for their patients, administrators, and staff to sign. Then they were to encourage their friends and families to sign. Another COA initiative, “Sit in My Chair,” has been embraced by oncologists. Oncologists invite their members of Congress to come to their clinics and observe patients being treated in an outpatient setting while actually sitting in the doctor’s chair. It is a very powerful tool. No single act drives home the importance of community cancer care than being there and seeing firsthand how patients are cared for.

To quote Bush Foundation vice president Pamela Wheelock as she spoke of the mission of their leadership program for medical fellows in October 2009, “Physicians have always been at the forefront of confronting community problems, whether it was by keeping its residents healthy through their daily work of seeing patients or by instituting new community programs—both related to health and with a broader emphasis… [fellows] “must put their courageous leadership skills to work on the questions that face our communities today and in the future.”³

It is easy to become politically involved in your own community, ranging from attending meetings with congressional staffers and political fundraisers to talking with your patients, family, friends, and neighbors about how the law is affecting Medicare reimbursement. We must spread the word about the negative impact that the MMA is having on cancer patients and their doctors. We must be our own best advocates

This edition of Oncology Fellows is supported by Genentech, a member of the Roche Group.