US Oncologists Favor Establishment of NICE-Like Body to Determine Medicare Reimbursement

Oncology Practice Management - June 2015, Vol 5, No 5 - Reimbursement
Rosemary Frei, MSc

According to a recent study, 63.6% of oncologists surveyed favor the establishment of an independent panel of health experts to decide which treatments Medicare will pay for based on a cost-benefit analysis (Gogineni K, et al. J Clin Oncol. 2015;33:846-853). Less than 50% of patients and members of the general public think this is a good idea. The United Kingdom’s National Institute for Health and Care Excellence (NICE) is one model for such a panel.

Despite oncologists’ support, “I think the culture in the US is such that the fear of fewer choices (even if we can safely say that more choices does not necessarily mean better care) will make it very difficult to institute a body like NICE,” lead investigator Keerthi Gogineni, MD, MSHP, Assistant Professor of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, told Value-Based Cancer Care.

“I would hope that one way around this would be to require new drug/technology applications to include an incremental cost-effectiveness analysis as part of the approval process, so that at least we begin generating the data we need to be able to delineate what has value,” she said. In addition, “having clinical guidelines that have to be met, especially in oncology, in order to get reimbursed would be one way to ensure that high-quality care is being delivered,” Dr Gogineni added.

Study Details

A total of 326 patients with cancer with appointments at the University of Pennsylvania’s Abramson Cancer Center, as well as 250 oncologists and hematologists and 891 members of the general public completed the survey.

The majority of the respondents said they feel Medicare spending is a moderate or “big” problem facing the United States, and that cuts can be made without denying healthcare to anyone who really needs it. Furthermore, in response to a menu of 6 potential factors that increase Medicare spending, drug company pricing and insurance company profits were rated as the top 2 contributors to the problem.

Physicians and hospitals also share the blame, however, according to survey respondents—70.3% of oncologists thought unnecessary tests and treatments add a moderate or a large amount to Medicare costs, as did 69.1% of patients with cancer and 80.9% of the general public respondents.

In addition, 66.9% of patients with cancer and 79.4% of the public responded in the affirmative that hospitals or doctors committing “fraud by submitting bills for services not provided” contributes significantly to high Medicare costs.

Only 19.2% of oncologists thought this to be true. The multivariable analysis revealed that African Americans, Hispanic Americans, and Americans aged ≥55 years were most likely to believe that provider fraud contributes to high Medicare costs.

Oncologists Concern with High Cost of Patient Care

The researchers suggested that these results indicate that “health care providers are no longer impervious to criticism as a major contributor of high costs.” This corroborates “physicians’ apprehension about Centers for Medicare and Medicaid Services’ disclosure of provider utilization and payment data,” they wrote.

The survey also included 4 proposed solutions to high Medicare costs.

In response to the first solution, “Refuse to pay when a less expensive test or treatment has been shown to work just as well”—more than 75% of patients, oncologists, and the public supported that proposal.

Means testing, in which patients with more financial resources pay a larger portion of their costs, was supported by small majorities of the 3 groups. Means testing was most highly favored by members of the public who were male or Democrats.

Creating an annual ceiling for the amount that Medicare would spend on any 1 person was far less popular, garnering only 12.9% of patients’ support, 16.8% of oncologists’, and 28.3% of the general public’s.

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Last modified: June 25, 2015
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