Troubles Ahead

Raoul S. Concepcion, MD

Over the past few months, an alarming number of events have surfaced that we, as providers of oncologic urology care, should take notice. For starters, January 1, 2017 will be upon us very quickly. And what you may ask is the significance of that date for physicians?

That is when CMS, outlined in the Medicare Access and CHIP Reauthorization Act (MACRA) passed in 2015, will begin keeping scorecards on all of us in the transition to value/ performance based medicine. If you have been trying to keep up and stay abreast of this legislation that is succinctly distilled in a mere 900+ page document, there are many unknowns and questions that await us. But again, make no mistake, this will be upon us quite soon.

To compound our potential woes and challenges, potentially this fall, 75% of the country will be partaking in the Medicare Part B 5-year pilot program to test a new delivery for prescribed drugs to determine if this will result in better patient outcomes (see my prior missive in the last publication).

However, how does one measure patient outcomes when none of the endpoints of this “experiment” include any sort of quality metrics? It’s the government….I can’t make this up! The government wants to spend less money and will go through very circuitous paths to achieve this goal. It touts this as budget neutrality. See Tables 1 and 2, courtesy of Deepak Kapoor, MD, in New York, chairman of LUGPA Health Policy.

As you can see, in order to stay budget neutral, the cuts with the biggest downside will be for the most part agents we use for management of advancing prostate cancer, offset by many non-oncolytic drugs. For the ever increasing number of groups that have taken on this essential role of providing the continuum of care for prostate cancer, this will be devastating for our patients.

In another interesting ruling, it was announced by Caremark CVS and Express Scripts, that beginning January 1, 2017, they will consider the physician’s in-office dispensing (IOD) pharmacies that many specialties have set up, including urology, to be out of network. Although this ruling is not as harmful across the board for our specialty, it does impact the business model of integrated care that many of us have built.

This is analogous to some employer (primarily hospital systems) insurance plans that mandate use of their own facilities for certain out-patient services, rather than allowing the patient go to a more efficient, cost-effective center of excellence, in order to drive and maintain their profits. The results are the same: more expensive healthcare at the expense of patients and physicians.

Finally, it was recently brought to my attention that the government is looking into contributions by the pharmaceutical industry that subsidize patient assistance foundations (http://www.bloomberg.com/news/articles/2016-05-19/the-real-reason-big-pharma-wants-to-help-pay-for-your-prescription).

As those of you that have set up advanced prostate cancer centers for the management of our castration-resistant prostate cancer (CRPC) patients, these entities provide often times much needed financial assistance for many of our patients, many of whom are on fixed incomes, have no secondary coverage or, at times, no coverage whatsoever. With the explosion of new therapies over the past 6 years, it is very likely that a patient will receive a minimum of at least 2 to 3 of these agents before succumbing to CRPC. At a price of five to six figures per drug, many people would be forced to go without treatment or be thrust into financial distress if there were not funds available to help them with co-pays. It has been documented that patients with cancer are about 2.5 times more likely to declare bankruptcy than non-cancer patients, who may in fact have an increased mortality rate (https://www.fredhutch.org/en/ news/center-news/2016/01/cancer-bankruptcy-death-studyfinancial- toxicity.html).

As we move into a more advanced role in the management of all GU malignancies (and possibly embrace the oncology care model as outlined by the Center of Medicare and Medicaid Innovation (CMMI), that may have us assume some element of financial risk), it is imperative that we track, monitor and be proactive in fighting some of these changes in order to protect our patients and our specialty. Otherwise, all the great therapies recently brought to market, with many more on the horizon, that have extended survival will all be for naught.