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Tuesday, June 10, 2003
A prominent hospital in Washington State is:
Performing clinical economic correlative studies on Procrit, Aranesp, Neulasta, and Neupagen to determine which drugs are now affordable to provide.
The hospital is not able to initiate Zevulen, the radioactive anti-lymphoma antibody because of the poor reimbursement.
A large university hospital in Pennsylvania is:
Starting to cut many supportive care services such as psychology services, educational services, pain services and complementary medicine services.
They have started a running re-evaluation whether to continue to operating hospital outpatient oncology clinics (which is their preference) or to convert these locations to physician practice locations.
They are very seriously considering attempting to join the exempt cancer center group because they do not believe they can maintain outpatient oncology operations under the current system.
They are now distinguishing between Medicare and private pay patients, making sure that only the latter get the new cutting edge treatments while no C-code is in place. So Medicare patients continue to get the older therapeutic equivalent drugs until there is a C-code. This institution is finding a 9-12 month lag for Medicare patients to get the same drugs.
A hospital in Hawaii has for years maintained an outpatient chemotherapy clinic which has served the needs of patients residing in central Oahu. Earlier in May, this hospital:
Terminated all chemotherapy services due to poor reimbursement and an inability to continue sustaining financial losses.
Patients suffering from advanced cancer in central Oahu are now forced to commute to downtown Honolulu in order to receive treatment at other hospital facilities (none of which are eager to accept the added patient volume and added financial liability); or, alternatively, to receive chemotherapy in their physicians' private office which is also a one hour drive, each way.
Another hospital in Hawaii on the North Shore has already closed its outpatient chemo infusion center. They tell us that others are likewise considering this option.
One hospital located between the North Shore hospital and downtown Honolulu is verbally discouraging physicians from referring these patients as they realize they are already taking losses on their chemotherapy and don't want to incur further losses on another hospital's patients.
Of note, there is no physician office-based chemo infusion alternative for patients on rural Oahu. However, physicians are considering opening an office to provide their patients access to chemotherapy for which they might otherwise have to travel to downtown Honolulu.
A hospital in southern Florida with a 70% Medicare mix expects to lose $700,000 this year because of the reimbursement cuts.
One of their oncology nurses left and they have decided not to replace her for now, thus increasing the nurse to patient ratio for their patients.
They no longer allow their doctors to order or administer new drugs without a C code or they require patients to pay cash or come up with a payment plan up front for the drugs.
They are also devising a plan to remove the chemo infusions from the hospital setting.
In Montana:
One of the only large hospitals in the state of has stopped giving drugs without a C code.
They are also looking into moving chemo infusions out of the hospital.
They estimate a loss of $400-500,000 this year based on the mix of drugs they gave in the first half of last year.
They are now running the same analysis with the mix of drugs they gave in the latter half of the year. They expect the loss to be greater than originally projected, since some new expensive drugs have come out.
A large tertiary care hospital in Wisconsin has been monitoring reimbursement for chemotherapy for some time.
They have seen a 5-6% margin on chemo as a whole (not just Medicare) in the past. But for Jan and Feb '03, they have experienced a minus 8% margin. For them, this equates into a loss of $245,000 in these two months alone.
They are waiting for March and April numbers broken down by payer before deciding next steps. They have started discussions however about sending patients to the physician office setting instead.
They note that the problem is exacerbated by the need to give the newer drugs more and more often, which are the more expensive drugs.
A prominent hospital in Colorado notes that they have been in discussions with physicians, pharmacy leadership, and nursing managers in the hospital on next steps:
They are starting a focused review with drug cost and reimbursement information being provided to physicians with the intent for them to at least have the economic impact of their selection of drug treatment available as they choose chemo agents.
They are also going through a detailed analysis to determine if they should turn patients over to a physician office for the sake of better economics/reimbursement differential for chemo drugs.
Finally, although they are a regional referral center for cancer patients, in at least a few cases so far, they have advised potential referring physicians not to send their patients to their facility for care, based on the low reimbursement for their type of treatment, citing their need to protect their mission to treat the patients from their state first with limited funds to underwrite contractual adjustment losses on high cost drug therapies.
A hospital in Oklahoma with almost 50% Medicare patients has been monitoring reimbursement the last several months.
They are seriously reviewing how much longer they can do brachytherapy or administer Zevelin.
Using volume and procedures data from 2002, they project losses of almost 20% under the 2003 reimbursement rates.
Two more hospitals in Oklahoma located in communities with a lot of retirees, hence a lot of Medicare beneficiaries, have closed their centers.
Both have dropped their chemotherapy infusion centers and sent patients to their nearest physician offices.
In some cases, this has resulted in patients having to get their chemotherapy in the physician's office in the morning and then traveling to the hospital for their lab services or radiation in the afternoon. The hospital staff noted how fragile some of these patients are after their chemo and expressed concern about the travel.
One of these hospitals was treating lung cancer patients with investigational protocols and they too have to travel for care now. These patients are particularly weak and likely to face complications.
In more than one case, patients not reacting well to treatment in the physician office setting have had to be transferred by ambulance and admitted into the hospital for further care. This could have been avoided if the hospital's infusion center had evaluated the patient before that day's treatment or, at the very least, avoided the expensive transport services and the transfer of frail patients.
In indigent care hospital in Missouri can't close its doors because cancer patients will have nowhere else to go.
Almost 30% of their patients are Medicare beneficiaries. The majority of their patients don't pay at all for the care they receive.
Hospital closures nearby have driven even more patients to their doors.
The hospital is communicating the financial impact of their drug purchases to their nurses and physicians as they see patients. Especially concerning are the anti nausea, supportive care drugs that aren't reimbursed at all as of January 1st, suggesting that patients be given older drugs or lower doses of drugs.
Pharmacists are working with physicians to calculate appropriate dosages for patients based on vial sizes, to help ensure that less drug is used since the reimbursement is insufficient.
A hospital in Kansas with a case mix of about 60% Medicare patients is especially concerned.
They have started reviewing each contract as it comes due to decide if they can continue giving those drugs. They are especially aware of their supportive care drug contracts, as they decide which ones they can continue to provide cost effectively. These are the drugs with zero reimbursement since January 2003.
They are already cost shifting, increasing charges to non-Medicare patients. They are concerned that their "working poor" patients � those who are working but uninsured � are especially hard hit under this shift. And private insurance companies are pushing back, refusing to make up the difference for the loss on Medicare patients.
This hospital supports a program they recently set up for indigent care, where they often write off the costs of care. This program is now under serious review.
They are also reviewing and reworking their dosing guidelines on certain drugs where the reimbursement is particularly low.
The next nearest hospital is 30 miles away. They are concerned about whether patients should have to drive that distance after chemotherapy infusions.
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