Cuts to Medicare are driving Utah cancer clinics to turn away patients and refer them instead to hospitals for treatment.

Oncologists say the cuts, ordered April 1 under the recent budget sequester, reduced what Medicare pays them for expensive chemotherapy drugs, making it impossible for them to administer the drugs and stay afloat.

“We’re being pushed off the cliff,” said Richard Frame, a medical oncologist and partner at Utah Cancer Specialists. “Inconvenient is not the right word for it. It’s tragic when you have patients you’ve been treating in your office and now all of a sudden you have to arrange to have them treated elsewhere.”

Utah Cancer has referred 10 Medicare patients to hospitals and has identified 100 more for possible transfer.

It’s the state’s largest oncology group, logging about 7,500 patient visits a month across its eight clinics in Salt Lake, Davis, Tooele and Utah counties. About 40 percent of its patients are on Medicare, the government insurance program for retirees.

Frame says the disruptions could delay care for those who can’t land hospital appointments right away or who will have to drive long distances multiple times a week for their chemo treatments.

“It just takes patients away from their doctors,” Frame said. “It means more phone calls to track and monitor patients, and getting other doctors involved who probably don’t know the patient as well.”

It also may end up costing Medicare more.

Hospital-delivered chemotherapy costs an average of 24 percent more than treatment done in a doctor’s office, according to a survey of claims from 2008 to 2010 by Avalere Health, an industry consultant.

“There’s no question, hospitals are a more expensive model for care,” said John Sweetenham, the new medical director at Huntsman Cancer Institute.

Huntsman has ample room to take on new patients, but capacity could become a problem if community oncology groups fold, said Sweetenham. “Community oncologists do a great deal of the day-to-day, less sophisticated oncology care.”

Utah Cancer, the oncology provider for the state’s largest hospital chain, Intermountain Healthcare, says it treats 65 percent of the state’s chemo patients.

“This is not something that should be happening to our sickest and elderly,” said the group’s business manager Christy McGowan.

Medicare’s share of the sequester’s across-the-board spending cuts was just 2 percent and affects all Medicare providers.

But they hit oncologists especially hard because their payment is tied to the chemo drugs they deliver.

Medicare reimburses a flat amount for drugs, the average sales price plus 6 percent. And because oncologists generally can’t negotiate for the same discounts on drugs that hospitals get, the margins are tight, said McGowan. “We don’t get anywhere near average sales price. Even prior to sequestration, we had some drugs that cost us more than what Medicare pays for, but we made it work. Now we’re under water on about 35 percent of the drugs.”

Wagering Congress will soon broker a better budget deal, Utah Cancer is taking the hit for some patients.

“If we can come within $300 of our costs,” McGowan said, “we’ll consider seeing them.”

But a 2 percent loss on chemo treatments that cost tens of thousands of dollars adds up fast. “These aren’t nickel and dime losses,” she said.

Some doctors in the practice, she added, have said they’d rather go out of business than turn away patients. But if that happens, McGowan wonders, “Where will all these patients go?”

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Dr. Justin Favaro, Oncology Specialists of Charlotte, North Carolina is featured in this news clip:

By Linzi Sheldon

CHARLOTTE, N.C. —

The Affordable Care Act, or Obamacare, as it’s become known, provides health care coverage for millions of Americans who previously did not qualify.

And while supporters point to the coverage as one of the biggest benefits of the plan, some critics, including doctors, are also pointing out negative side effects to the reforms.

Dr. Bryan Young, a heart surgeon and, later, general surgeon for more than 30 years, opposes Obamacare for specific reasons.

He left his job in November to take a position as medical director in a new Physician Assistant Studies program at Gardner-Webb University.

Dr. Young originally planned to retire in January. He said he was tired of the unpredictable schedule and was ready for a change. But he moved up the date because his clinic was converting to all-electronic medical records.

“I took the computer courses and it was very burdensome and very… tedious,” he said.

The move to electronic medical records is not new. In fact, the federal government began offering incentives to convert to electronic medical records as part of stimulus legislation in 2009.

But Obamacare emphasizes the use of electronic medical records, putting in place, according to the federal Healthcare.gov website, “a series of changes to standardize billing and requires health plans to begin adopting and implementing rules for secure, confidential, electronic exchange of health information.”

It builds on electronic records as a way to collect data and measure quality. Many systems are working to go all electronic to prepare and qualify for other federal incentives.

“I think it’ll get better with time, but it will get better without me,” Dr. Young said.

According to The Physicians Foundation’s 2012 Survey of America’s Physicians, surveyed doctors said in the next one to three years, more than 50 percent of them plan to retire; work part-time; switch to concierge medicine, a type of service that doesn’t take insurance; or make other changes that would reduce patient access.

The North Carolina Medical Society said issues like low reimbursements, increasing regulation and administrative requirements, and rising costs are some of the reasons for this trend, which would only add to a current serious doctor shortage across the country.

The Medical Society’s CEO, Bob Seligson, said doctors are telling him Obamacare is just more reason on top of these other issues to leave, cut back, or change how they provide care.

“I think the experience level, when you take that out of the system, it hurts the system… and ultimately it means that the care may not be as good,” Seligson said.

He said patients should ask their doctors how the Affordable Care Act will affect their care and whether their doctors are changing or leaving their practices.

Seligson said doctors are also closing private practices and joining larger health systems, like Novant Health, Carolinas HealthCare System, or CaroMont.

These aren’t the only side effects from Obamacare that critics are citing.

Dr. Justin Favaro, who treats cancer patients at Oncology Specialists of Charlotte, said some insurance companies are increasing, and in some cases, doubling what patients used to pay.

“Their co-pay may be $20 or so for a primary care doctor, and upwards of $70 when it comes to seeing a specialist,” he said.

But Dr. Andrew Mueller with Novant Health, which runs Presbyterian Hospital, said higher insurance costs will make patients choosier. And that, he said, will force doctors to compete and provide better quality care.

“They’re going to be looking for value in the care they receive,” Dr. Mueller said.

Dr. Mueller practices family medicine at Blakeney Family Physicians and is also senior vice president of Physician Services for Novant Health.

“Does that mean that doctors have to step up their practice?” Eyewitness News asked.

“They do. That’s exactly what it means,” he said.

Dr. Mueller said all of Presbyterian will be on electronic records by October, which he said will give doctors immediate access to a patient’s history. And Novant is expanding a program, MyChart, that lets patients email their doctors and access their personal medical information online.

Earlier in February, Novant announced more than 100,000 patients were using it.

Dr. Young agrees patients will eventually benefit from parts of Obamacare. But he believes they’ll experience some growing pains to get there.

“For quite a while, I think health care’s going to be more expensive, it’s going to be longer waits,” he said. “I think the American people are going to have a hard time waking up to that.”

Bureaucratic Red Tape is Harming Patients

As a doctor, I used to order medication in the hospital chart, the pharmacy would fill it, and the patient would get it. This is no longer happening. I need to explain a circumstance, which I fear is going to be happening all too often. This instance describes the overwhelming amount of bureaucratic red tape necessary to get helpful medicines to patients.

A patient, Mr. WP, was diagnosed with a bone marrow disorder called light chain disease. This is a condition that is oftentimes difficult to diagnose because small proteins are manufactured in excess quantities. These proteins are so small that they require a specialized test to identify the so called Bence-Jones proteins.

When present in increased amounts, the proteins cause deposition in myelin sheaths causing neuropathy, and in kidneys causing renal insufficiency. Mr. WP was diagnosed with this plasma cell dyscrasia called light chain disease. He was treated with standard treatment of dexamethasone, and arrangements were attempted to get him a very helpful medicine in this condition called Revlimid. The attempts to get Revlimid turned into an unfortunate comedy of frustrations for all.

Mr. WP was seen in an outpatient setting. His diagnosis was confirmed by bone marrow, but he required admission to the hospital. He was then transferred to a rehabilitation service and transferred back to the hospital when his condition deteriorated. This pathway of going back and forth between institutions did not help with trying to get his medication, Revlimid. The acquisition of Revlimid for any patient is difficult to begin with. It becomes even more complicated when revlimid is requested at one place but the patient is located at another.

The Revlimid is acquired through a STEPS program provided by the manufacturer. The program requires that different forms be completed.  The patient is able to get the medicine at different costs, depending on which institution he is located. The process of getting Revlimid was extremely difficult for this patient. Insurance forms were filled out 4 times.  This is our job.  We do this often for our patients.  There were multiple hours put in by clinic staff and by the hospital pharmacy staff in trying to acquire this medicine. Despite our best efforts, the patient was unable to get the medicine until late in his course. This took greater than 2-3 weeks to finally get the medicine, at great cost to the patient.

The patient’s family also went through the emotional roller coaster of not having this medicine available and then finding out that they had to pay over $8000 to acquire it.

The patient’s condition continued to deteriorate. He developed congestive heart failure and other complications. Nevertheless, the patient’s family felt obligated to pursue getting this medicine and paid for it out of pocket. The patient was in the donut hole of his Medicare reimbursement.

The patient’s family was able to get the medicine. They had to pay $8000 or more out of pocket. Two days later, the patient died. The patient died from complications of light chain disease and was unable to get treated with Revlimid in a timely fashion.

To add insult to injury, the patient’s family cannot even give this unused medicine back to the pharmacy for use with other patients. This is $8000 worth of a valuable drug that is going to be disposed of and unused by the patient.

This comedy of errors and bureaucratic red tape is overwhelming. I fear that this is just the start of more complications from a medical system gone awry. The reimbursement for drugs is part of the issue, but the bureaucratic red tape is overwhelming and killing patients.

We can all be in Mr. WP’s position before too long. People need to know that federal regulation is getting in the way of providing timely treatments to patients.  The Medicare donut hole prevents prompt delivery of medication that can be of exorbitant cost to patients.

Enough of my rant. Do you have one about the challenges of giving cancer care?  We would love to hear from you.

Richard Frame, MD

Oncologist, Salt Lake City, UT

Medical Chair, Community Oncology Alliance patient Advocate Network (CPAN)