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New Medicare rules could hurt Oregonians

Researchers at Oregon State University recently discovered a new way to fight cancer. Utilizing nanotechnology, an inactive drug (or “prodrug”) is introduced into the body. Once the drug is metabolized, it can penetrate sections of tumors that traditional chemotherapies can't reach.

Unfortunately, Oregon patients may never have a chance to benefit from such innovations — all because of one federal organization's desire to change Medicare, the federal program that provides medical care to 57 million Americans. Under the Trump administration, the Center for Medicare and Medicaid Innovation (CMMI) could restrict 750,000 Oregonians' access to vital medicines.

CMMI's mandate is to test new reimbursement formulas to see if they lower costs and improve care. CMMI officials have often ignored that mandate, however. They've focused solely on slashing spending, patients be damned.

Consider one of CMMI's recent suggestions.

Last year, it proposed reforms to Medicare Part B, which covers the cost of drugs administered to patients in doctor's offices and outpatient clinics. Under Part B, doctors pay for drugs up front. Then, Medicare reimburses them for the average sales price of the drug plus an additional fee for overhead costs.

CMMI proposed slashing this additional fee by more than half.

The changes would have devastated small clinics and independent doctors’ practices and would have made it much more difficult for patients to receive treatment. A previous cut to the Part B reimbursement rate in 2013, for instance, led to a 20 percent increase in clinic closures.

Faced with this scenario, the medical community and patient groups condemned the proposal to cut reimbursement rates further, fearing that clinics wouldn't be able to administer many medications or treatments for patients. In addition, they feared that the cuts would force doctors to opt for less-advanced drugs – even if those drugs didn't meet the needs of their patients.

Recognizing these problems, the Obama administration abandoned the reform. But similar proposals easily could wreak havoc on patients.

If CMMI were to change Medicare so it stopped covering certain medications, patient out-of-pocket costs could skyrocket.

Consider the drug oxybutynin, which is commonly used to treat overactive bladders. Ninety-nine percent of Part D plans cover this drug – and beneficiaries pay as little as $1 for 60 five-milligram tablets. Without coverage, the same dosage can cost more than $200.

Or consider the consequences of tests like CMMI's Comprehensive Care for Joint Replacement (CJR) Model. CMMI boasted these restrictions would reduce expenses by reimbursing hospitals a flat amount for hip and knee replacements, rather than reimbursing them on a case-by-case basis. If hospitals spend more than the flat payment, they effectively pay a fine to Medicare. Hospitals are then forced to pass these costs on to non-Medicare patients or turn away Medicare beneficiaries who are more likely to require additional care.

CMMI wanted this flat joint replacement coverage to be mandatory, meaning patients across America would have been affected by the change. Fortunately, in August, the Center for Medicare and Medicaid Services (CMS), which oversees CMMI, proposed making the change optional rather than mandatory. This is a good first step toward blunting these harmful changes.

CMS also recently instituted a series of changes that would protect beneficiaries, including limiting tests to a small number of providers. This is another great step.

But more safeguards are needed to prevent these sweeping, harmful changes under future administrations.

For instance, CMMI currently implements tests to Medicare without Congressional approval. The people's elected representatives should have the power to approve or reject major changes to Medicare.

Hundreds of thousands of Oregonians rely on Medicare. Allowing CMMI to implement mandatory, large-scale changes without direct congressional oversight could create significant financial hardship for Medicare recipients, and essential care may become unaffordable. We must ensure the current administration continues closely watch CMMI activity.

— Rob Skinner, M.D., is a urologist in the Portland area and president of the Oregon Urological Society.