Medicare to Lymphoma Patients: Drop Dead!

Beginning Jan. 1, Medicare will reimburse only $16,000 of the $30,000 total cost for hospitals to acquire and administer each treatment of radioimmunotherapy drugs. Currently, only two drugs -- Bexxar and Zevalin -- fall under this class of therapy.

What on earth is going on here? Why would our government reimburse cancer care providers for less than the actual cost of a new lymphoma treatment, not to mention the cost of the physicians, nurses, equipment and space needed in order to give the treatment at the correct dose, in the correct manner, flawlessly, without any adverse outcomes, with no goof-ups that might attract the attention of malpractice-feeding lawyers. Go ahead...we're waiting for your answer.

The Food and Drug Administration first approved Bexxar in 2003, after about 13 years of ongoing clinical trials, to prove the safety and efficacy of the drug. Dr. Mark Kaminski, who helped develop Bexxar, said he hoped the drug's success in clinical trials would have encouraged the Centers for Medicare and Medicaid Services (CMS) not to cut reimbursement for the treatment.

While the class of drugs [i.e., radioimmunotherapy, monoclonal antibodies connected to a radioactive isotope which destroys adjacent cells when the antibodies attach to a lymphoma cell] is small and underutilized, many doctors, patient advocacy groups and drugmakers insist this sharp cut in reimbursement for the drugs will force hospitals to stop offering radioimmunotherapy as a treatment option altogether, and put a chill on further research in this area.

You still haven't answered my question.

According to Don Thompson, acting deputy director of the Hospital and Ambulatory Police Group for CMS, the claims data submitted by hospitals in the past revealed "widely varying reimbursement rates" for radioimmunotherapies.

"Reimbursement rates" is misleading - this refers to the amount of money received from CMS [Centers for Medicare and Medicaid Services] as payment for the treatment. What about the actual cost of giving the radioimmunotherapy?

It turns out that CMS looked at the hospitals' reports of what they paid for the drug, then created an "average" price and announced that this sum is what they are paying for every treatment given in America, regardless of geography. CMS actually accuses hospitals of underreporting the actual cost. Why they would do this I haven't the faintest idea.

"What we realized is that somewhere along the line, the methodology that [CMS] was using is way below what the acquisition price [of Bexxar] is," said Dave Moules, vice president of the oncology unit of GlaxoSmithKline. Instead of basing the amount of reimbursement for Bexxar on the average cost of the drug provided by GSK -- which Moules said is $26,780 -- CMS based the reimbursement rate on the cost reports provided by hospitals.

So if some hospitals are not as skilled as others at what I call "playing the game" of modern American healthcare, and are unfortunately giving CMS inaccurate data on how much a product like Bexxar actually is costing them, then our government's answer is to punish every cancer care provider across this great nation. What a country...

Well, at least CMS can always fall back on the defense of "the treatments are not used much anyway, so they are likely to be of minimal value." Oh, excuse, me - here's another headline from today's news:

New Study Offers Hope For Patients With Advanced Follicular Lymphoma

New data presented at the Congress of the American Society of Hematology (ASH) on the First-line Indolent Trial (FIT) study shows nearly a 2 year improvement in progression free survival (PFS) in patients with advanced follicular lymphoma receiving Zevalin® ([90Y]-ibritumomab tiuxetan) vs, induction chemotherapy alone.

I couldn't make this stuff up if I wanted to. The irony in these two stories is enough to make a doc quit his practice and get a job advising people on why they are better off dead, and with the new attitude of CMS about the war on cancer I'll bet there will be plenty of openings in this peculiar department.


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Thank you!

I think we must be aware of a cynical perspective now circulating among our representatives and address it:

"They are suspicious that patients are being whipped into a frenzy by drug companies predicting doom and gloom if they don't get their price and they get a lot of form correspondence that's prepared by the companies themselves to heighten their suspicions."

That patients are being manipulated by a drug company is always possible, but mostly it seems that this occurs when sponsors try to get patients to put pressure on FDA to approve a therapy for which the data does not support approval ... or is highly questionable.

In this case, our group, Patients Against Lymphoma did its own *independent analysis* of the CMS ruling and data, and it's finding were consistent with ASH, ASCO and all experts that commented on the ruling in the proposal phase.

Our analysis:
ASH commentary: (copied from the public record)

Patients Against Lymphoma is independent of health industry funding .... has never accepted any monies from the industry and therefore has no conflict of interest. In this case, we have participated (but not independently - with the help of other non-profit groups) in driving patient concerns about this ruling affecting a proven drug (an invaluable drug), and therefore the charge that patients have been manipulated in this case is false.

Patient anger in this case is appropriate and rational, because the risk of losing RIT has been cited by experts in the field, such as Dr. Oliver Press who wrote:

"I fear that these products will simply not be available for treatment of non-Hodgkin lymphoma after the new year since the providers will lose money with every administration of the drugs and companies making them will cease production. The payment structure proposed for 2008 w ill not produce savings to the Medicare program in the long run, and it will certainly not ensure access to quality healthcare."

~ Dr. Oliver Press, Letter to Senator Cantwell

Thank you so much for posting this!!!

I hate to be a harpy, but the cost is even more widespread than physician, nurses, equipment, and room. What about the nuclear medicine technologists who deliver the treatment, or the radiation safety / health physicists who monitor the treatment to determine releasbility and to insure the welfare of the general public?

This is sickening. Worse than that, it is disappointing.