ORIENT: Sequestration pain for cancer patients

Drug-payment cuts could jeopardize survival

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White House tours may be the focus of attention, but the most brutal effect of sequestration may fall on cancer patients. The administration isn’t mentioning this one.

As of April 1, the allowable charge for cancer chemotherapy drugs will be cut by 1.7 percent, so independent oncologists will not be able to charge enough to cover the cost of administering many expensive but lifesaving drugs. Hundreds of thousands of vulnerable patients could have their treatment disrupted.

This is happening under President Obama, who promised Americans that “if you like your doctor, you can keep your doctor.” It’s happening at the same time that advocates of the Obamacare Medicaid expansion are trotting out hard-luck stories of cancer patients who lose their insurance in the midst of treatment. Medicare patients, of course, aren’t losing their insurance — just their ability to get the care they need from the doctor they trust.

Sequestration does not have to do this. The last time sequestration went into effect, 20 years ago under the Gramm-Rudman-Hollings Balanced Budget Act, the Medicare reimbursement was cut, but not the allowable charge. This meant that patients could still get their treatment, but had to come up with an additional 2 percent of the charge. Supplemental insurance may have taken care of it. Or if the patient couldn’t afford it, doctors might have been able to waive the charge in some cases and still stay in business.Sequestration might not save any money in this instance, as all chemotherapy may simply be driven into hospitals. Large institutions might be able to negotiate lower prices for drugs, but overall, care is far more expensive in hospitals, up to 10 times as much as in outpatient facilities. Third parties, including Medicare and Medicaid, often pay hospitals much more than independent physicians for exactly the same service.Does this make sense? Looking at the numbers, it probably doesn’t — not yet. It does, however, help achieve the stated agenda of many “reformers” — getting rid of independent, fee-for-service physicians. Big institutions are much easier to control. Physicians who care about their individual patients are much less likely to go along with the agenda of hastening death instead of giving the patient every chance. Legislation being proposed in Texas makes this agenda perfectly clear: Hospitals want the right to impose denial-of-care directives, with immunity.Patients may love the idea of not having to worry about paying the bill for treatment. Do they, however, want the one sure way of eliminating the bill — eliminating the treatment? A little-known, ugly fact about Medicare, Medicaid, and indeed most managed-care plans is that they cut off the patients’ options. If the insurer doesn’t pay, or pays so little that no one will offer treatment, nobody is allowed to pay. No point in appealing to a rich uncle, taking out a loan, having a family member get another job, or holding a bake sale. If a Medicare-enrolled oncologist accepts an extra 1.7 percent, he could go to prison. If a managed-care provider accepts private payment from a plan enrollee for a “covered service” that the plan has ruled “inappropriate” in a particular patient’s case, he is violating his provider contract, and his career could be ruined. It is not sequestration itself that could have a death-panel-like effect. It just triggers other mechanisms that do or will. These will increasingly have a dronelike impact on persons identified as risks to the public Treasury or optimum population health. The administration need not claim responsibility — as long as there are still doctors.

Dr. Jane M. Orient practices internal medicine in Tucson, Ariz., and is executive director of the Association of American Physicians and Surgeons.

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