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PHARMA/PHYSICIANS: Changing the Identity of Medical Oncology Under Medicare, by Gregory D. Pawelski

Here’s the first in a series of articles I have in the queue about the oncology market. The first is from Greg Pawelski:

Under the new Medicare Prescription Bill (MMA) medical oncologists will be reimbursed for providing evaluation and management services, making referrals for diagnostic testing, radiation therapy, surgery and other procedures as necessary, and offer any other support needed to reduce patient morbidity and extend patient survival.

The fact that medical oncologists received no reimbursement for providing oral-dose therapy to patients had been the principal barrier to the availability of oral-dose protocol. The advent of oral agents ultimately means that medical oncology will need to change its identity, prior to the chemotherapy drug concession. Because oral-dose drugs hold the promise of being more selective, harming fewer normal cells, reducing side-effects and work to improve the quality of life for people with cancer, they will rightfully gain their appropriate share of the marketplace, again.

The new Medicare Bill offers patients benefits they did not have before, mainly some coverage for oral chemotherapy drugs. Since April of 2004, $200 million was available so that some Medicare cancer patients would have transitional coverage for these drugs, until the bill goes into full effect in 2006. Although some benefit was realized, more might have been achieved if the American Society of Clinical Oncology and other groups had lobbied as much for the oral chemotherapy drug issue as they did for office-practice expense reimbursement. They fought long and hard to retain the Chemotherapy Drug Concession.

Increasingly, oral-dose anti-cancer drugs are found to treat cancer effectively and seen as a necessary part of a patient’s cancer care. A number of these breakthrough cancer drugs came on to the market that are only in oral form and previously not reimbursed under Medicare. Patients were being forced to compromise their cancer care due to Medicare not covering many of these life-saving therapies.

The new legislation started the process of providing access to a full range of the latest cancer-related prescription drugs at manageable costs to enhance the quality and standard of treatment for cancer. Medicare recipients were being relagated to treating their diseases with older, more toxic infusional chemotherapy agents at a time when new and more promising cancer drugs were reaching the market.

Compared to infusional therapy, oral-dose anti-cancer drugs can make receiving cancer treatment more convenient for patients by allowing flexibility in taking medication without disrupting work or other activities. They can often result in less time (or no time) spent in office-based oncology practices because of the absence of intravenous administration and its related side-effects.

Targeted cancer therapies will give doctors a better way to tailor cancer treatment. There are a multiple of different cancer drug regimens, all of which have approximately the same probability of working. Treatments may be individualized based on the unique set of molecular targets produced by the patient’s tumor, and these important treatment advances will require individualizing treatment based on testing the individual properties of each patient’s cancer.

What was needed, was to remove the profit incentive from the choice of cancer treatments, which were financial incentives for infusion therapy over oral therapy or non-chemotherapy, and financial incentives for choosing some drugs over others. Patients should receive what is best for them and not what is best for their oncologists.

The new system is clearly an improvement from the standpoint of cancer patients, taxpayers, and advocates of basing drug selection on individual tumor biology, rather than on a least common denominator approach which invites “conflict-of-interest medical decision-making.” I think it is time to set aside empiric one-size-fits-all treatment in favor of recognizing that many forms of cancer represent heterogenous diseases, where the tumors of different patients have different responses to chemotherapy. It requires individualized treatment based on testing the individual properties of each patient’s cancer.

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Mary Anne MartinOscar DeMariaJeetGregory D. Pawelski Recent comment authors
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Gregory D. Pawelski
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Gregory D. Pawelski

Report: Doctors’ $275M Study Questioned By KEVIN FREKING The Associated Press Tuesday, August 29, 2006 http://www.topix.net/content/ap/3252578919265568528409953178163644686735 In 2005, CMS initiated a one-year demonstration project for cancer patients undergoing chemotherapy. The demonstration focused on measuring patient outcomes in three areas of concern often cited by patients undergoing infusional chemotherapy: controlling pain; minimizing nausea and vomiting; and reducing fatigue. Oncology Practices reporting data on all three factors qualified for an additional payment of $130 per encounter for chemotherapy administration (a financial incentive to use infusional drugs over oral drugs). That included a $26 patient copay. A Republican, Senate Finance Committee Chairman Chuck… Read more »

Mary Anne Martin
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This blog posting was of great use in learning new information and also in exchanging our views. Thank you.
Mary Anne Martin
http://www.treatmentcancercenter.com

Oscar DeMaria
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Yes that is correct. I liked your comment. I too belong to the same profile and this was of great help.
Oscar DeMaria
http://www.treatmentcancercenter.com

Gregory D. Pawelski
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Gregory D. Pawelski

The PricewaterhouseCoopers study that the Community Oncology Alliance (COA) commissioned shows that an estimated $13 billion will be saved from Medicare spending for cancer care through 2013. This is $8.8 billion more than the original intent of Congress in passing the Medicare Modernization Act (MMA). There is at least one silver lining in the new Medicare bill. It offers patients benefits benefits they did not have before, some coverage for oral-chemotherapy drugs (full coverage in 2006). Compared to infusional-chemotherapy, oral-dose anti-cancer drugs can make receiving cancer treatment more convenient for patients by allowing flexibility in taking medication without disrupting work… Read more »

Jeet
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Jeet

some of these oral drugs will also be covered under the Part D benefit as well

Gregory D. Pawelski
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Gregory D. Pawelski

Neil Love, M.D. reports in a survey of breast cancer oncologists based in academic medical centers and community based, private practice oncologists. The academic center-based oncologists do not derive personal profit from the administration of infusion chemotherapy, the community-based oncologists do derive personal profit from infusion chemotherapy, while deriving no profit from prescribing oral-dosed chemotherapy. The results of the survey show that for first line chemotherapy of metastatic breast cancer, 84-88% of the academic center-based oncologists prescribed an oral dose drug (capecitabine), while only 13% perscribed infusion drugs, and none of them prescribed the expensive, highly remunerative drug docetaxel. In… Read more »