Ruth is a 67-year-old woman living with metastatic lung cancer. She receives care at a treatment center near her home in rural southern Illinois. There are larger hospitals over an hour away in St. Louis, but she doesn’t have the time or financial resources to travel there as often as she would need to.
Fortunately, the cancer center near Ruth’s home boasts excellent staff — including her oncologist, experienced nurses, a pharmacist and a social worker.
There are more than 2,100 community cancer centers just like Ruth’s across the country — many located outside of urban centers. For decades, these centers — and their multidisciplinary staff — have played an integral role in helping Americans fight cancer. Unfortunately, fulfilling their mission is about to get harder — as is life for patients.
In November, the Centers for Medicare and Medicaid Services issued a new statute, known as the most-favored-nation rule. If the new administration implements the rule, it will drastically affect how cancer centers operate.
In theory, the MFN rule is supposed to lower costs for patients on Medicare. In reality, the new rule will reimburse cancer centers for less than they pay for necessary medications, such as chemotherapy, unless these cancer centers renegotiate drug prices with their suppliers.
Many of the support services provided by nurses, pharmacists and social workers at cancer treatment centers are not covered by Medicare. Cancer centers use reimbursement funds to cover these services for the benefit of their patients.
Clinics purchase their medications up front. Once oncologists administer the drugs to patients, the clinics bill Medicare for the cost of the drug itself, plus a small additional fee of 6%. This 6% fee helps cover the cost of services that are considered “extra” yet well known to improve patient outcomes, such as nutritional counseling, medication side effect teaching by nurses and pharmacists, and psychosocial intervention from social workers.
The MFN rule will drastically cut drug reimbursements. It’s estimated that community oncology practices will suffer a 52% loss of Medicare drug revenue, on average, once MFN is fully implemented, according to the American Society of Clinical Oncology.
The impact of the rule will be especially acute in rural communities around the country, where community centers are prevalent and Medicare is the largest health insurer.
And if care centers cut services or close altogether, it will make life that much more challenging for cancer patients. For many, the logistics of getting to and from chemotherapy will get harder and more expensive. Some will forgo treatment altogether.
Shockingly, that is exactly what the Center for Medicare and Medicaid Services seems to expect. In the rule, the agency observes that some of the savings it hopes to achieve will be “attributable to beneficiaries not accessing their drugs through the Medicare benefit.”
As professionals who work with cancer patients every day, we find this unconscionable. We support payment reform that makes quality cancer care more attainable and equitable for all. The MFN rule, however, does not help but harms the ability of cancer centers to provide this care for patients.
Krista Nelson, a licensed clinical social worker and practicing oncology social worker, works at Providence Health and Services in Portland, Oregon. Barbara Jensen, a registered nurse, works as the regional director of Oncology and Palliative Care at Skagit Valley Hospital in Mount Vernon, Washington. Both serve on the board of trustees for the Association of Community Cancer Centers.