On May 19, 2015, following its spring meeting in Washington, DC, members of the ASH Committee on Practice visited more than 40 congressional offices to advocate for legislation to ensure access to safe and effective hematologic drugs, as well as to urge the Centers for Medicare and Medicaid Services (CMS) to take a closer look at outpatient evaluation and management codes for physicians who primarily treat chronically ill patients. For more about these initiatives, see SIDEBAR 1 and SIDEBAR 2.
ASH Committee on Practice members split up into six groups to cover the most ground. ASH Clinical News tagged along with Harriet A. Bering, MD, Chancellor Donald, MD, and Judith Kleinerman, MD, as they met with Senators, Representatives, and staffers to spread the word about insurance parity for oral cancer drugs, evaluation and management (E&M) codes, and other hematology issues that affect patients and providers.
On May 18, the day before hitting the Hill, the Committee members were briefed about the Cancer Drug Coverage Parity Act by Leslie Brady, legislative assistant in the Office of Congressman Brian Higgins (D-NY-26), a co-sponsor of the bill. Ms. Brady shared Congress’ plans to reintroduce oral chemotherapy parity legislation and provided some suggestions on how ASH can urge support for this legislation through its advocacy activities.
May 19, 8:00 a.m.: The day starts with breakfast and a strategy meeting at ASH headquarters, including a review of the schedule and the goals for the day.
9:15 a.m.: The groups depart for Capitol Hill!
9:30 a.m.: Drs. Bering and Kleinerman meet with Melea Atkins, a legislative aide from Senator Elizabeth Warren’s (D-MA) office in the Hart building. Questions are raised about how the Cancer Drug Coverage Parity Act would affect patients with Medicare or Medicaid (rather than private insurance).
In asking for help urging CMS to research E&M codes, Dr. Bering explains that the current codes for determining payment – which were set up in the 1980s – are outdated. Dr. Kleinerman adds: “We need more research because our patients are very complicated, very sick, and all different.”
10:00 a.m.: Drs. Donald, Bering, and Kleinerman meet with Katie Mitchell, a legislative correspondent from Senator David Vitter’s (R-LA) office. Ms. Mitchell believes this is something Sen. Vitter would be interested in supporting!
10:30 a.m.: The doctors meet with Alexander Jones, a legislative correspondent from Senator Ed Markey’s (D-MA) office in the Dirksen building, asking about the co-sponsors of the Cancer Drug Coverage Parity Act. “The work of the hematologist has changed over time,” Dr. Bering explained. “The amount of information-gathering has changed.”
Dr. Kleinerman adds that, while electronic health records give health-care providers more data, they do not accurately reflect the amount of time that is spent with each patient.
11:00 a.m.: Moving over to the Longworth House, Drs. Kleinerman, Bering, and Donald meet with Representative Seth Moulton (D-MA-06) to discuss the importance of the Cancer Drug Coverage Parity Act.
12:45 p.m.: Back on the trail after a lunch stop at the Dirksen Cafeteria, the advocates head to the Senate Office Building to speak with Pranay Udutha, a legislative correspondent from Senator Bill Cassidy’s office (R-LA). Saying that he completely understands the need for the Cancer Drug Coverage Parity Act, he gives the example that “with pills [oral chemotherapy], patients wouldn’t have to drive long distances to receive IV chemotherapy treatment.”
While laws have been passed on the state level in both Massachusetts and Louisiana, Dr. Donald comments that there is still a need to co-sponsor a federal-level law that would help patients living in these states but working elsewhere, as well as patients across the country.
Mr. Udutha also expresses interest in finding out if, beyond this bill, there are any other steps to take to make oral chemotherapy parity a reality.
2:00 p.m.: Back at the House Office Building, the doctors meet with Melissa Gierach, a senior advisor on Health Care and Tax Policy from the office of Representative Charles Boustany Jr., MD (R-LA-03). Ms. Gierach expresses a lot of interest in the bill, asking for more information about the letter request for research on re-examining E&M codes – mentioning how important this is for hematologists and physicians who treat cancer patients because they spend time thinking about treatment plans and providing other support, in addition to their time spent visiting with patients.
3:15 p.m.: A quick meeting is held with Representative Joseph Kennedy III (D-MA-04), where Drs. Kleinerman and Chancellor leave information packets about their requests and their contact information with the Representative’s Chief of Staff.
At the end of the day, the doctors were pleased with how the meetings went – but noted that all these issues will continue to be a part of ASH’s advocacy efforts.
Dr. Kleinerman: “For many years, we were lobbying for the repeal of the SGR [sustainable growth rate], which was finally repealed earlier this year. I think the best thing about this year’s Hill Day – for both sides – was the fact that we did not have to talk about the SGR again!
The issues we discussed this year were not as challenging. Many people did not know about or understand the oral parity legislation, but thought that it was a fair topic to address. It is a hard point to argue against – especially because the bill concerns private, not public, insurers.
Explaining the request for research into E&M codes was more of a challenge; the crazy and confusing physician payment system is constantly evolving. No matter what payment system is adopted, it is still impossible to compare the value of the cognitive time that a hematologist spends on patient care and the time that a surgeon may spend on a quick wound check. Not to demean what surgeons do at all, but it’s just not an equitable reflection of the amount of work we put into a patient visit.
We had a team-based strategy: One advocate was assigned to handle the initial presentation of the issue, then the others would contribute their perspective. The people we met with were sympathetic and, on the whole, asked great questions and were engaged. There was no hostility – there rarely is. Even when we were lobbying for SGR repeal, we were met more frequently with eye-rolls than hostility.”
Dr. Bering: “Overall, the staffers and Congressmen and women were receptive and supportive, particularly of the oral parity legislation – or, no one seemed to be opposed to it, at least!
Gauging response to the E&M research request was a little bit more difficult. The reaction to that request seemed to be, “We just repealed the SGR; now what are you asking for?” Once we explained the concerns about awarding cognitive services rather than just procedural services, people were more interested in supporting research. For most people we met with, this was likely not even an issue on their radar, so, in that regard, we were successful in our goals.
These issues are certainly not going anywhere. Even if the oral parity legislation gets passed, there are still questions about high-cost drugs and access to them. The high cost of drugs is very frustrating for physicians. Over the last 10 years or so, it seems that physicians are being targeted to a greater degree than other players in the industry. Physician reimbursement has been cut back, and we are asked to sacrifice to help control health-care costs; meanwhile the drug companies keep raising their prices and insurance company executives are making mega-millions of dollars. It’s a demoralizing situation for the physician community.”
Dr. Donald: “For me, highlights of the day were seeing how the unique character of each office reflected its district, educating congressional staff on issues pertinent to the practice of hematology, and enjoying collegiality with fellow hematologists from around the country.
Although we are all busy with our practices, it is extremely important that we take time to help shape policy that will impact our patients. It is disappointing to see stalemate in politics, but we cannot allow this to deter our willingness to have a loud, singular voice regarding the delivery of care to our patients.
We can only claim success if we are effective in shaping appropriate policy.”
Goal #1: Find co-sponsors for the Cancer Drug Coverage Parity Act
The bipartisan Cancer Treatment Parity Act (H.R. 2739/S. 1566) was introduced in the 113th Congress; in the House, the legislation was sponsored by Representative Brian Higgins (D-NY) and by Senators Al Franken (D-MN) and Mark Kirk (R-IL) in the Senate. The legislation would require any health plan that provides coverage for cancer chemotherapy treatment to provide coverage for orally administered and self-injectable anticancer medications at a cost to the patient no less favorable than the cost of intravenous (IV), port-administered, or injected anticancer medications.
Oral chemotherapy treatments – many of which do not have traditional IV or injected alternatives – have become more prevalent for patients with hematologic malignancies. Unfortunately, insurance coverage has not kept pace with innovation: While IV treatment is typically paid for as part of a health plan’s medical benefit, patient-administered anticancer drugs are often covered under the prescription drug benefit, making patients responsible for extremely high and unmanageable co-pays. This can be a large financial burden on patients and potentially a life-or-death decision.
Though the bills gained a significant number of co-sponsors, neither saw any additional movement through the legislative process. Sponsors of the legislation in both the House and Senate remain committed to the issue, however, and reintroduced the legislation – renamed the Cancer Drug Coverage Parity Act – in early June. This time around, Rep. Brian Higgins (D-NY) was joined by Rep. Leonard Lance (R-NJ) in the House. In the Senate, the bill was once again introduced by Sens. Kirk and Franken.
Goal #2: Encourage Congress to Urge CMS to Study E&M Codes
Medicare and private payers pay physicians according to a series of more than 7,000 different codes describing various services. Services are codified according to Current Procedural Terminology (CPT), a product coordinated by the American Medical Association (AMA). Each of these services is then valued according to the level of physician work required as well as the supplies, equipment, and staff that are needed to complete it.
Physicians who work in the areas of surgery, radiology, and pathology have a large number of procedure codes to describe the work they do. Primary-care physicians and medical specialists, on the other hand, often have a much smaller menu of service codes from which to select.
The current E&M codes do not properly describe the cognitive work performed by physicians who primarily treat chronically ill patients. Committee members asked for congressional support in urging CMS to commission the research necessary to study the E&M codes and determine where they are deficient in describing the work performed by physicians such as hematologists.
ASH Committee on Practice advocates are requesting that CMS study the E&M codes and determine what improvement can be made to the description of work and documentation requirements as well as determine if new codes are needed.