26 December 2004

Cuts in Medicare trigger an alert
Some with cancer may face big drug bills, report says

Elderly cancer patients may be saddled with huge drug bills because some oncologists with slashed Medicare reimbursement rates are no longer purchasing drugs on their patients' behalf, a report from a patient advocacy group says.

A report to be released tomorrow by the Medicare Rights Center also cites limited anecdotal evidence that some doctors around the country have already begun requiring patients to purchase their own chemotherapy drugs.

The change is more than an inconvenience. The government's Medicare insurance program reimburses only for drugs administered in the doctor's office if they are purchased by a physician.

As a result, patients get stuck with exorbitant bills for drugs at the highest end of the cost scale. Taxotere, a treatment for breast cancer, for example, costs approximately $300 a dose every three weeks.

''Picture yourself facing a diagnosis of cancer. Add to that, buck-passing between your oncologist, Medicare, and pharmacies about covering the extremely high costs of your medicine," said Robert Hayes, president of the Medicare Rights Center, a New York nonprofit group that produced the report. ''It adds cruelty at the worst time in somebody's life."

Neil Berzak, an architect in Queens, N.Y., withdrew $16,000 from his savings to pay for chemotherapy treatments for his late wife, Joyce Irene Berzak.

A doctor affiliated with a major New York teaching hospital prescribed Camptosar, a chemotherapy drug manufactured by Pfizer Inc., after Joyce Berzak's surgery for a brain tumor.

But instead of paying for the drugs himself and then seeking reimbursement from the government, Neil Berzak said, the doctor ordered the drugs from a specialty pharmacy and told the Berzaks to pay.

''He didn't want to lay the money out," Berzak said of the New York oncologist, whom he declined to identify. The doctor assured the Berzaks they would be reimbursed by Medicare, Berzak said. Eighteen months after his wife's death, his claims have been rejected, and he doubts he'll ever see his $16,000.

Berzak's experience is used an example in the Medicare Rights Center report.

In a second example, a patient suffering from osteoarthritis was prescribed Synvisc, a fluid manufactured by Genzyme Corp. that is injected directly into the knee. The patient was stuck with a bill for $666 after her doctor's billing manager told her to get the prescription filled at a pharmacy, the report said.

The shift potentially affects not only cancer drugs but also other medications that are administered in a doctor's office, such as expensive treatments for multiple sclerosis and rheumatoid arthritis.

The extent of the problem is unknown, Hayes said. But the report said upcoming changes in Medicare reimbursement are likely to make the problem worse.

Beginning Jan. 1, reimbursement for these drugs will be based on the average sale price, eliminating a ''spread" between actual prices that physicians paid and old Medicare reimbursement rate.

The ''spread," often highly profitable for doctors, was the focus of marketing efforts by drug companies as well as numerous fraud investigations in recent years by federal and state governments.

''Changes in drug reimbursement might lead some physicians to believe that Medicare reimbursement is not adequate to cover all of their acquisition costs," the report said.

Gary Karr, a spokesman for the agency that runs Medicare, said federal officials had heard ''rumors" about doctors foisting the responsibility for drug purchases onto their patients. But the agency has no evidence to support the assertions by the Medicare Rights Center, Karr said.

''Medicare is trying to get the payments right, and that will take care of the issue of what's best for the patient," Karr said. A report by the Government Accountability Office on Dec. 1 said the new rates more accurately reflect physicians' purchase price.

Dr. Joseph Bailes, cochairman of the government relations council for the American Society of Clinical Oncology, which represents cancer doctors, said he had not heard of physicians sending their patients to a pharmacy to pay.

''I go to pretty much every oncology center around the country. I have not heard anyone say they intend to send their patients to pay for the drug," Bailes said.

The report recommends that Medicare change its policies, either by requiring that doctors purchase drugs if they submit a bill to Medicare for administering them, or by permitting patients to get direct reimbursement for drugs they bought on their own.

By Christopher Rowland,
Boston Globe Staff

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