Oncology Nursing Society
Pittsburgh, Pennsylvania 15275-1214
October 13, 2002

The Honorable Nancy Johnson
Chair
Health Subcommittee
House Committee on Ways and Means
United States House of Representatives
Washington, DC 20515

Dear Chairwoman Johnson:

On behalf of the Oncology Nursing Society (ONS) - the largest professional oncology group in the United States composed of more than 30,000 nurses and other health professionals dedicated to ensuring access to quality care for people with cancer - we are writing to submit this letter as written testimony to be included in the record of your recent hearing on “Medicare Payments for Currently Covered Prescription Drugs.”  We very much appreciate this opportunity to provide our input and stand ready to work with you, your colleagues, the Centers for Medicare and Medicaid Services (CMS), and others to address Medicare oncology and nursing payment related issues to ensure that Medicare beneficiaries with cancer receive quality care.

ONS shares the concerns of Congress and CMS regarding the ongoing viability of the Medicare program and recognizes the need to take steps now to preserve access to care for all beneficiaries with cancer.  In the attached “principles” document, you will see that ONS - along with seventeen of our partner organizations in the cancer community - has endorsed Representative Jim Greenwood’s principles for Medicare “reform” of the current Average Wholesale Price (AWP) system of payment for Medicare reimbursable prescription drugs.  ONS feels strongly that the Medicare program should neither overpay nor underpay for benefits and services.  Moreover, ONS maintains that the current AWP payment policy unfairly results in larger co-payments for Medicare beneficiaries and distorts the entire cancer care payment system.

To that end, we join you and your colleagues in calling for reform and advocate that Congress develop - and CMS implement - new policies that ensure that the full range of services provided in the provision of cancer care is reimbursed adequately and appropriately.  The attached principles document - along with a joint letter (attached) sent by ONS with the National Patient Advocate Foundation (NPAF) to Senate Finance Committee Chairman Max Baucus - make clear that ONS fully supports reform but maintains that changes to the “AWP system” cannot occur at the expense of patient access to community-based, quality care.  We feel strongly that reductions in drug payments should occur only simultaneously with commensurate increases in reimbursement for chemotherapy administration and associated supportive care services.

As you know, cancer is a complex, multifaceted, and chronic disease, and people with cancer require specialty-nursing and clinical interventions at every step of the cancer experience. To that end, people with cancer are best served by multi-disciplinary teams of health care professionals specialized in oncology care, including nurses certified in that specialty.  Approximately 4 out of 5 cancer care encounters occur in community settings, where oncology nurses play a central role in the provision of quality cancer care as they are principally involved in the administration and monitoring of chemotherapy and the associated side-effects patients may experience.  The shift in the provision of cancer care from inpatient to outpatient, community-based settings has resulted in significant benefits for patients and savings for the health care system as a whole.

However, despite this important change in the provision of cancer care, ONS believes that the current Medicare payment system fails to adequately recognize the reality of the current contributions made by oncology nursing and other clinical staff in this “new” outpatient system of care.  As anyone ever treated for cancer will attest, oncology nurses are intelligent, well-educated, highly skilled, compassionate professionals who provide quality clinical, psychosocial, and supportive care to patients and their families.  In short, they are integral to the cancer care delivery system.  Therefore, it is essential that we assure that Medicare payment policies recognize the full range of health professionals who contribute to the delivery of quality cancer care to beneficiaries in need.

In addition to updating Medicare payment for the administration of chemotherapy and supportive care services provided by oncology nurses and other health professionals, ONS urges Congress and CMS to ensure that the Medicare program does not unintentionally devalue the work of oncology nurses and other non-physician clinical staff.  Specifically, we call upon you to eliminate the use of the term “zero work pool” for those services provided by nurses and other non-physician health professionals.  While we realize that the actual name for services without physician work Relative Value Units (RVUs) is “zero physician work pool,” the vernacular used by agency and Congressional staff and other stakeholders is “zero work pool.”  This nomenclature suggests that the work done by oncology nurses and other clinical staff is without value - that their work is of “zero” value.  We understand that while it is not the intention of Congress or CMS to connote a zero value for oncology nurses’ contributions, the reality is that our organization, our members, and others - such as oncology social workers and radiology technicians - take offense at its use.  Moreover, in a time in which our country is facing a nursing shortage - the nature and scope of which we have never before experienced - we must make positive policy changes that work to elevate the visibility and express the importance of nursing.   One of the causes of the current nursing shortage is low morale within the profession.  Now more than ever is the time to highlight the range of work done by our nation’s nurses, not to diminish it.

Therefore, as you consider changes to the Medicare program, we urge that you and your colleagues take actions to ensure that the Medicare program better acknowledge the essential and unique role of oncology nurses in the provision of quality cancer care.  Through official comments to CMS on the 2003 Physician Fee Schedule, we have asked the agency to rename the “zero physician work pool” in the final rule for the 2003 Physician Fee Schedule.  We are advocating a title that better reflects the significant contributions made by nurses and other non-physician cancer care providers in outpatient settings.  We understand that the “zero work pool” may be eliminated altogether and/or oncology services may be pulled out from it.  However, in the interim, while the methodology is still being used, we propose the following as possible appropriate alternative titles:

• Non-physician clinical staff time;
• Non-physician work components; or
• Non-physician work pool;
• Non-physician health professional pool.

We would appreciate it if you and your committee colleagues would please contact CMS to voice your support of this change.  We welcome an opportunity to discuss these or other suggested titles with you as well as agency staff as they review and consider modifications for the final rule.  A change such as this would send a strong message to the oncology nursing community that the nation values their work.  Such a step would help boost morale within the nursing community in a time when our nation is facing a nursing shortage of serious proportion.

Again, ONS would like to express its gratitude to you and the Subcommittee for this opportunity to provide comments on these issues of priority for our organization.  We believe that bringing Medicare payments for drugs more in line with actual costs - coupled with increasing and expanding practice expense payments for chemotherapy administration and supportive care and recognizing the contributions of oncology nurses - will help ensure that Medicare beneficiaries will have access to the quality care they need and deserve.

If ONS can be of any assistance to the agency on these or other nursing or oncology matters, please do not hesitate to contact our Health Policy Associate, Ilisa Halpern (202/857-8968, halperni@arentfox.com).

Sincerely,

Judy E. Lundgren, RN, MSN, AOCN
President

Pearl Moore, RN, MN, FAAN
Chief Executive Officer

Attachments

Guiding Principles:[1]

• The system should not adversely affect patient access to quality health care.
• Medicare reimbursement for drugs should be closely linked to the cost of the drugs.
• Reimbursement for services should be based on actual expenses.
• Drug reimbursement should not impact medical decision-making.
• Payments should be equalized to ensure there is no incentive to choose one setting for receiving care over another.

Additional Policy Positions:

• The role of oncology nurses in the provision of cancer care should be reflected explicitly in Medicare legislation, statute, regulation and other policies.
• Nursing specifically should be included - and named in statutes, regulations, and other policies as included participants - in any policy making, policy analysis, and policy review processes in which the Centers for Medicare and Medicaid Services, the General Accounting Office, and other federal agencies engage with regards to Medicare reimbursement for care involving the direct or indirect contribution of nurses.
• Medicare reimbursement for oncology nursing practice expenses should be based on current practice data using a bottom-up methodology.  The Centers for Medicare and Medicaid Services (CMS) should support “work sampling” studies and incorporate the results into its practice expense calculations to ensure that Medicare reimbursement is based on real costs and real practice patterns.
• Changes to Medicare policy and associated reimbursement must be considered in aggregate to ensure that adjustments in one area do not have unintended consequences with regards to patient access to quality care.  The Medicare program should monitor and evaluate - on an ongoing basis - the impact that reimbursement policy changes have on patient migration, access, and outcomes.  Such tracking studies involve the Agency for Healthcare Research and Quality (AHRQ), the Institute of Medicine (IOM), and the Medicare Payment Advisory Commission (MedPAC).
• If the CMS maintains the “zero work pool” alternative methodology, the “zero work pool” should be renamed to reflect more accurately the substantive contributions that nurses and other non-physicians make to the provision of care to Medicare beneficiaries.  The current nomenclature connotes a lack of value of the critical contribution that nurses make and further exacerbates a misconception that the work that nurses do is not quantifiable or significant.
• As nursing specialty organizations typically lack the resources of physician specialty groups, regulatory and statutory requirements relating to public input into policymaking processes should be reasonable, accommodating, and flexible to ensure that nurses are not disenfranchised. 
• With the current and impending shortage of nurses coupled with the expected growth in cancer incidence over the next two decades, all Medicare policy and reimbursement must be crafted with the goal of preserving and strengthening the nation’s system of community-based cancer care. 
• To ensure long-term solvency, Medicare policy should prove fiscally responsible; however, changes to Medicare reimbursement should not result in such financial pressures that patients would lose access to nurses specially trained in oncology.  Oncology nurses are an integral part of a comprehensive cancer care team and studies have shown that patients fare much better when they receive care from health care providers specially trained in oncology.  To ensure the highest quality of cancer care for Medicare beneficiaries, Medicare policy should seek to safeguard the provision of chemotherapy administration and related services by nurses specially trained in oncology.
• The Medicare program should provide adequate reimbursement for the full-range of supportive care services provided to oncology patients.  Such services include: patient counseling/psychosocial support, oncology social work, oncology case management, medical nutrition therapy, and investigating and enrolling patients in cancer clinical trials.

Endorsing Organizations:

Alliance for Lung Cancer Advocacy, Support, and Education
Association of Community Cancer Centers
Cancer Care, Inc.
Cancer Research Foundation of America
Candlelighters Childhood Cancer Foundation
Colorectal Cancer Network
International Myeloma Foundation
Kidney Cancer Association
Leukemia & Lymphoma Society
Men’s Health Network
National Association of Pediatric Oncology Nurses
National Association of Social Workers
National Patient Advocate Foundation
North American Brain Tumor Coalition
Oncology Nursing Society
Ovarian Cancer National Alliance
Pancreatic Cancer Action Network, Inc.
US Oncology

National Patient Advocate Foundation, and
Oncology Nursing Society
September 30, 2002

The Honorable Max Baucus
Chairman
Committee on Finance
United States Senate
219 Dirksen Senate Office Building
Washington, DC  20510

Dear Mr. Chairman:

On behalf of our organizations committed to ensuring access to the full-range of quality cancer care for all individuals in need, we are writing to voice our concerns about linking the reform of the Average Wholesale Price (AWP) for drugs with the provision of coverage for oral anti-cancer therapies under Medicare.  While we support both reform of the current AWP system and the expansion of Medicare coverage to include all oral anti-cancer drugs, we have serious concerns about the possibility of a proposal to do so without the necessary and appropriate adjustments to Medicare practice expenses for the actual provision of oncology care.  Unless Medicare provides adequate reimbursement for the full-range of oncology care associated with chemotherapy, such a dramatic change in the Medicare program could have devastating effects on beneficiary access to the care they need and deserve.

Due to the tremendous progress that has been achieved in biomedical research, significant advances have been made in the development of new cancer therapeutics that are having a dramatic impact on the quality of cancer care in America.  However, as you know, many of the newest anti-cancer drugs are not covered under Medicare because they are available only in oral form and there is no injectable equivalent.  To address this inequity, Senator Olympia Snowe has introduced S. 913, the “Access to Cancer Therapies Act,” which will provide Medicare coverage for these life-saving oral anti-cancer therapies.  More than half of your colleagues in the United States Senate have co-sponsored this legislation.  While we strongly support a comprehensive Medicare prescription drug benefit, we believe Medicare coverage for oral anti-cancer drugs would serve as an important first step.  We advocate passage of S. 913 either as a free-standing bill or as part of other Medicare legislation enacted this year.

We are concerned, however, that some are considering that an expansion of Medicare coverage to include oral anti-cancer drugs should be funded by an overall reduction in payments for chemotherapy.  As you know, the issue of reforming the payment methodology for chemotherapy and related practice expenses has been discussed for many years.  Our organizations have participated in numerous meetings with your colleagues and your staff to highlight the concerns of cancer patients and their families surrounding this issue.  We strongly support balanced reform of the current Medicare reimbursement system for cancer care.  However, we are extremely concerned that access to quality cancer care will be endangered if balanced reform is not achieved.

The key to balanced reform is ensuring that the providers of cancer care to our nation’s seniors have the resources necessary to ensure that Medicare beneficiaries with cancer can receive high quality care in their own communities.  Currently, the Medicare system wrongly and grossly overpays for drugs while simultaneously dramatically underpays for chemotherapy administration and the practice expenses associated with cancer treatment and supportive care.  This distorted reimbursement system must be remedied by decreasing drug payments to a level more aligned with actual cost while at the same time increasing practice expense payments so they more accurately cover real expenditures.

Using the “savings” from AWP reform to fund coverage of oral anti-cancer drugs without a commensurate increase in the oncology nursing and related practice expenses is a short-sighted and flawed approach.  First, it fails to ensure that community-based cancer providers will have the overall resources necessary to continue to provide quality cancer care.  Second, the use of oral anti-cancer therapies necessitates the active involvement of a multi-disciplinary cancer care team involved in patient and therapy management.  Many erroneously believe that Medicare beneficiaries will just get a prescription filled and disappear from the cancer care system.  Those individuals taking oral therapies will need to be trained and educated as to how to take their therapy regimen, monitored by their cancer care team to ensure compliance and manage side-effects, and counseled regarding other prescription drugs they may be taking as the average Medicare beneficiary takes four prescriptions a day and fills 18 a year.  Providing oral-drug coverage without also allocating the resources necessary to oncology practices so they can provide their patients with the supportive care they need is irresponsible and not to the benefit of our nation’s seniors.

We believe, however, that balanced reform can be achieved and we have worked with our colleagues in the cancer community to develop the attached comprehensive reform proposal for your consideration.  We welcome the opportunity to speak with you and your staff about our proposal and believe we can strike a much-needed balance in proving fiscally responsible while ensuring access to quality cancer care that Medicare beneficiaries need and deserve.

We strongly encourage you to resist efforts to provide Medicare coverage for oral anti-cancer drugs by reducing payments to physicians for chemotherapy and related practice expenses.  One is not a replacement for the other.  Coverage for traditional chemotherapy and the full range of oral anti-cancer drugs coupled with adequate reimbursement for care provided by a multi-disciplinary oncology care team are essential if Medicare beneficiaries with cancer are to continue to have access to quality cancer care in their communities.

Thank you for your consideration of our viewpoint on this important issue.  Should you have any questions on this or other cancer-related matters, please do not hesitate to contact any of our organizations.

Sincerely,

Nancy Davenport-Ennis
President & CEO

Pearl Moore, RN, MN, FAAN
Chief Executive Officer

(Similar correspondence was sent to Senate Finance Committee Ranking Member Charles Grassley.)

[1]These principles are the same as outlined earlier this year by House Energy and Commerce Oversight and Investigations Subcommittee Chairman Jim Greenwood.