Increasing restrictions on how, with what, and where oncologists will be allowed to care for cancer patients are being imposed by a variety of payer groups. These restrictions threaten cost-effective, quality cancer care by requiring oncologists:

• to acquire cancer care drugs from specific sources not of their own choosing;

• to administer chemotherapy and supportive care drugs that are prepared at outside agencies not of their own choosing; and/or,

• to order the administration of chemotherapy and supportive care drugs by an outside agency not of their own choosing.

The Association of Northern California Oncologists (ANCO) opposes efforts to restrict patient access to and oncologist supervision of cancer care by insurance companies, managed care organizations, and other entities. Restricting oncologists' access to and supervision of cancer care drugs and their administration is ultimately detrimental to the clinical wellbeing of cancer patients and the economic wellbeing of the health care system. Requiring oncologists to acquire cancer care drugs from specific sources or to refer cancer patients to other entities for their administration will not decrease the total cost of cancer care and could adversely affect the quality of cancer care. Oncologists cannot be held responsible for the care of their patients if they do not maintain supervision of who will and what will be used to care for these patients.

Introduction

The hallmarks of state-of-the-art community-based cancer care are:

• Highly-trained and qualified personnel.

• Physician responsibility for and supervision of patient care.

• Cost-effective, efficient, compassionate, and quality patient care.

The most effective and economic cancer care takes place in oncology practices using drugs obtained, prepared, and administered by the practice staff. Increasing restrictions on how, with what, and where oncologists will be allowed to care for cancer patients are being imposed by a variety of payer groups. These restrictions threaten cost-effective, quality cancer care. Therefore, ANCO opposes any and all efforts to restrict patient access to and oncologist supervision of cancer care by insurance companies, managed care organizations, and other entities, including the acquisition, preparation, use, and administration of chemotherapy and supportive care drugs.

On Drugs

There are several fundamental reasons why the outsourcing of pharmaceuticals is unacceptable in the oncology setting—safety, quality, liability, efficiency, and economics. In summary, the outsourcing of pharmaceuticals threatens the safety and quality, efficiency and timeliness, and cost-effectiveness of community-based cancer care.

Oncologists cannot relinquish their responsibility for and the supervision of their sources for cancer care drugs. Doing so threatens the quality of care for cancer patients as well as their safety. Most chemotherapy agents are extremely toxic and capable of causing death or serious injury to patients. Oncologists administering and cancer patients receiving chemotherapy prepared by an outside entity may face several risks related to the drug's age, storage and handling, mixing, identification, labeling, freshness, and sterility. Minimizing these risks in order to protect cancer patients becomes very difficult if not impossible when drugs are supplied by outside sources. Indeed, as recent events demonstrate, not even the purity and dosing of chemotherapy drugs can be guaranteed when they are supplied by outside sources, even pharmacists!

In exchange for accepting the responsibility for and supervision of their sources for cancer care drugs, oncologists accept a large amount of liability should errors or contamination occur. ANCO doubts that any insurance company, managed care organization, or other payer, would indemnify their providers against this liability under an outsourcing model.

Oncologists manage efficient and cost-effective drug procurement systems. Obtaining cancer care drugs from a myriad of specific sources required by each of an oncologist's many payers would add time, cost, difficulty, and confusion to the drug procurement process. The time, cost, difficulties, and confusion would be multiplied as each payer mandates specific drugs and/or sources. Therefore, while ANCO understands that reducing the cost of drugs is an important issue, focusing on the prices of drugs (rather than the total cost of cancer care) results in increasing the cost of cancer care and delaying the care of the patient. The added costs of time, personnel, and organizational inefficiencies must be factored into the equation.

Insurance companies and managed care organizations may be able to obtain and provide cancer care drugs at a lower cost. However, lost revenues from cancer care drugs will undercut many of the other services provided by oncologists—services that are currently subsidized by drug revenues. Taking effective and compassionate care of cancer patients is time consuming and a cognitively intensive endeavor. Oncologists cannot provide an effective level of service without drug revenues (in lieu of restructuring reimbursement for professional services).

The outsourcing of pharmaceuticals is a de facto reduction in reimbursement. Medicare has considered significant reductions in payments for drugs. ANCO, as well as the American Society of Clinical Oncology (ASCO), strongly oppose such cuts on the ground that Medicare payments for drug administration services are inadequate and that continued reimbursement for drugs at current levels is essential to offset these underpayments. CMS (and Congress) agrees that administration payments are too low and has concluded that any reductions in drug payments without balanced increases in practice expense reimbursement could deny Medicare patients access to cancer treatment.

On Administration

Most oncology practices meet and/or exceed specific and comprehensive criteria established and promulgated by the American Society of Clinical Oncology (ASCO) for facilities and personnel administering cancer chemotherapy. Oncologists should not refer patients to outside entities for chemotherapy, such as infusion centers or home care agencies, which do not meet these criteria. Some drugs should be administered only with the physician in attendance.

Furthermore, oncologists should never be required to refer chemotherapy administration to a specific outside entity for several reasons. This requirement reduces the quality of cancer care, is less efficient, and increases cost by delaying care, increasing the risk of medication errors, and involving more personnel and organizational overhead. The skill of individuals administering chemotherapy at outside entities cannot be adequately assessed.

Secondly, this requirement complicates and fragments patient care. It distances the cancer patient from his or her oncologist, decreasing the intimate relationship between physician and patient. It increases the economic and logistical costs of cancer care. Since oncologists and cancer patients understand that cancer care is more than just administering drugs, the quality of and satisfaction with patient care suffers.

Finally, this requirement forces oncologists to relinquish close supervision of patient care while retaining responsibility for the patient. This is unethical and legally questionable. If they are to be held ultimately responsible for patient care, then oncologists must retain their freedom of choice, medical judgment, and clinical discretion in directing the care of cancer patients. Having chemotherapy done away from the office setting makes it more difficult for oncologists to maintain and monitor the quality of their patient care.