PRACTICE RESOURCES > Regulation/AUA Positions, Letters, and Talking Points > AUA Comments to CMS on Revisions to Payment Policies Under the Physician Fee Schedule for Calendar Year 2005


AUA Comments to CMS on Revisions to Payment Policies Under the Physician Fee Schedule for Calendar Year 2005

September 24, 2004

Mark McClellan, MD, PhD
Administrator
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Attention: CMS-1429-P
P.O. Box 8012
Baltimore, MD 21244-8012

Re: CMS-1429-P: Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule for Calendar Year 2005

Dear Dr. McClellan:

On behalf of the American Urological Association (AUA), representing 10,000 practicing urologists in the United States, I am pleased to submit comments on the proposed rule for the 2005 Medicare physician fee schedule. We recognize that CMS staff is under an incredible time crunch to implement multiple provisions from the Medicare Modernization Act (MMA), and realize that many of the proposals in this rule represent extra work from the MMA in addition to the standard fee schedule changes that occur annually.

However, many changes from the MMA will have a great impact on urologists and physicians in general. And, we are concerned about potential negative consequences for patient care if certain proposals are implemented as proposed. We therefore urge CMS to carefully consider our comments and concerns and to work with physicians to implement changes in the best way possible to maintain the current standard of care for urology patients and all Medicare patients.

Because we have many comments about proposals in the rule, I first include a summary of our recommendations to help guide you through the more in-depth discussion that follows. Thank you for considering our comments. If you have any questions or need additional information, please contact Robin Hudson, AUA Manager of Regulatory Affairs, at 410-689-3762 or govaffairs@AUAnet.org.

Sincerely,

President


Summary of AUA Recommendations for 2005 Proposed Fee Schedule Rule

Resource-based practice expense RVUs

Initial Preventive Physical Examination

Payment Reform for Covered Outpatient Drugs and Biologicals

Clinical conditions for coverage of durable medical equipment (DME)

I. Resource-based practice expense relative value units

  1. Practice expense refinement

    The AUA was an active participant in the American Medical Association's (AMA) Practice Expense Advisory Committee (PEAC), which worked since 1999 to review and refine direct cost inputs for CPT® codes. As CMS acknowledges in the proposed rule, the PEAC held its last meeting in March 2004 and subsequently sent its last set of recommendations to CMS. From now on, the AMA's Relative Value Update Committee (RUC) will handle practice expense relative value unit (RVU) issues. Based on our involvement with the PEAC and the RUC, we anticipate that a process will be developed for reviewing existing practice expense RVUs as part of the mandated five-year review for the RVUs. We also anticipate that options will be explored for making practice expense RVUs more stable and for identifying future data sources for updating practice expense RVUs.

    The AUA has much interest in these processes, as certain aspects of the practice expense methodology caused urology practice expense RVUs to shift wildly from year to year during the PEAC process, which was extremely frustrating for physicians who had to deal with new payment changes every year. Based on these issues and for other reasons discussed below in the section on drug payment changes, the AUA has conducted a supplemental practice expense survey. If adopted, we believe that our survey data would assure that resource-based practice expense RVUs for urology procedures reflect the current true costs of running a urology practice and would more closely match the SMS data to the PEAC data.

    Thus, we are interested in how the potential collection of new practice expense data in the future would affect specialty supplemental data that has been adopted by CMS. As CMS explores alternate sources of data and considers how to incorporate new practice expense data into the methodology, we urge you to find a way to incorporate recently-collected specialty supplemental data into any new efforts.

    Minor errors and assigning values outside of standard packages
    Outside of the regular practice expense refinement process that is to be established, there should also be a process for fixing minor errors that are identified in between refinement periods. The database of practice expense inputs is huge and the process for assigning inputs is very complex, meaning that mistakes are bound to occur. Currently, errors are required to go back to the PEAC, so that it takes a whole year to fix mistakes in the practice expense data. One other issue that should be considered for refinement is the difficulty of assigning inputs to a code if the inputs fall outside of a PEAC-developed standard input package. Although we understand the interest in uniform policies that can be easily applied across numerous CPT® codes performed by various specialists, there should also be a system to address individual exceptions to standard packages. While we would hope that concerns such as this could be addressed as part of a five-year review, we seek clarification from CMS on whether such concerns can be addressed in between reviews and the proper process to follow.

  2. New in-office practice expense RVUs in the SGR

    According to the RUC, there are 81 CPT® codes that will have in-office practice expense RVUs assigned to them for the first time in 2005. We agree with the RUC that CMS should consider these changes as a change in regulation for the purposes of calculating the SGR. These newly-created non-facility practice expense RVUs will create a shift in site-of-service to the office from the more expensive hospital setting with no requisite shift of dollars to the physician fee schedule. Therefore, due to the regulatory nature of the physician fee schedule, these should be considered as a change in regulation.

  3. PEAC recommendations for practice expense inputs for 2005
    1. CMS has requested price information for the following urology items:
      • Cystoscopy table (used in 52204-24, 52265-75, 52310-17, 52327-32). We are still gathering information on the price of the cystoscopy table and will forward it as soon as possible.
      • Kit, vasotomy, used for CPT® codes 55200 and 55250, should be deleted.

    II. Provisions of the Medicare Modernization Act of 2003

    1. Section 611 - Initial Preventive Physical Examination
      The AUA supports the creation of a "Welcome to Medicare" physical for new beneficiaries. However, we agree with the RUC that it would be more appropriate to use the existing CPT® code, 99387, Initial comprehensive preventive medicine evaluation and management for a patient 65 years and older, and its values rather than to create a new G code. We also agree with the RUC that if CMS does decide to implement a new code rather than utilize the existing CPT® code, CMS should consider a RUC review and recommendation on the valuation of this new code. To realize the complete potential of this new benefit, it must be valued properly.

      Also, because the new preventive physical examination benefit is mandated by law, the change in spending for physicians' services that result from creation of the new benefit will be included in the calculations for future sustainable growth rates (SGR), or targeted rates of growth for physician services. Therefore, any cost increases not accounted for could have a negative effect on physicians by penalizing them for a growth in services that is a direct result of a new coverage law.

      Although we are not sure what assumptions were used for the calculations, table 29 in the proposed rule shows an estimated impact of $65 million next year for this new benefit. The proposed rule also states that new payments for the physicals will be made to physicians and other practitioners who provide these examinations and for any medically necessary follow-up tests, counseling, or treatment that may be required as a result of the coverage of these examinations. Addition of this new benefit will create many more services including referrals to specialists, and we urge CMS to provide more information in the final rule on the assumptions used for the impact calculations and how this will affect the SGR.

    2. Section 303 - Payment Reform for Covered Outpatient Drugs and Biologicals
      Urologists are hugely impacted by the changes to Medicare drug payments, with CMS estimating a 36% reduction in Medicare drug revenue to the specialty as a whole in 2005. And, due to the tight timeframe for implementation, this is a time of great uncertainty and frustration for urologists and their practice managers, who are attempting to plan for the future based on very limited and unstable information. We are concerned that urologists and other physicians are being forced into a situation where they are making rash decisions that could affect patient care because they do not have accurate, timely information.

      The MMA provided an unreasonably short transition time to the new drug payment system, giving physicians only one year to reevaluate and restructure their business and patient care plans in light of practically unknown payment changes. Such a short transition time for drug payment reductions has the potential to greatly disrupt or hinder treatment for patients who currently receive drug therapy in the office. We are receiving countless inquiries from our members asking for guidance on how to handle these payment changes and what to tell their patients.

      In the face of such uncertainty, urologists are preparing for the worst and are considering making drastic changes in their practices when payments are based on ASP in 2005. These changes include closing satellite offices, sending patients to the hospital for drug administration, laying off employees, sending patients to the pharmacist with a prescription for their drugs, reducing or stopping drug administration services for all or new Medicare patients and collecting copays up front from Medicare beneficiaries with no MediGap policies. With a 6% markup, physicians can not afford to order, stock and cover the bad debt associated with it for patients that do not have supplemental Medicare coverage. In this time of uncertainty, physicians are worried that they may not be able to maintain enough inventory, or may not be able to afford to purchase the drug at ASP, and patients may suffer access problems.

      List of drug payments

      We understand that CMS is working under an extremely tight time schedule to implement the Medicare drug payment system changes that were mandated in the MMA. And, we appreciate that CMS provided an estimated 2005 payment for the drugs that constitute the vast majority of urologists' Medicare drug revenue. However, urologists administer many drugs to their patients other than the drugs listed in the proposed rule, for diseases such as bladder cancer and interstitial cystitis. The lack of information for many of these drugs in the proposed rule is disappointing, considering that the ASP payment system is supposed to go into effect in 3 months.

      Even before the transition began this year to the new drug payment system, many urologists were reporting break-even or negative profit margins on certain bladder cancer drugs. Many of them are concerned that they will not be able to provide the best therapy for these patients, which is a combination of BCG and interferon for patients who have failed BCG therapy. We have alerted CMS about problems with bladder cancer drugs in previous comments (see attachment 1) and have continually asked that a complete list of drugs be provided as soon as possible so that physicians can make informed decisions for next year. We once again urge CMS to release a complete list of drug payments as soon as possible.

      There are also doubts about the accuracy of the drug payments that are listed in the rule as well as the accuracy of the drug payment changes impact analysis for urology due to CMS's assumption that all Carriers apply least costly alternative pricing for Lupron and Zoladex. We are not certain what effect this assumption and the listing of the wrong price for Lupron had on the impact estimates, but request that CMS take this into account when preparing the impact analysis for urology in the fee schedule final rule and assure that the impact analysis is as accurate as possible.

      Drug payment survey to urologists

      Based on baseline data we have collected as part of an online survey conducted with the American Medical Association, we urge CMS to carefully monitor patient access and to establish a mechanism to address questions and problems that arise during the transition phase to the ASP payment system for drugs in 2005 and the hybrid ASP/competitive acquisition payment system in 2006. An online survey conducted this summer by the American Medical Association and the American Urological Association queried urologists on their awareness of the Medicare drug payment changes, practice and patient care changes made in 2004, and anticipated changes for 2005 and beyond.

      A total of 5,230 urologists were sent an email notifying them of the survey with a link to the survey so they could complete it online. Three reminder emails were also sent out. A total of 628 urologists responded to the survey, with 473 completing the survey in its entirety, 1,007 emails were undeliverable, and 39 urologists were not eligible to participate in the survey because they did not provide 20 hours or more of direct patient care or they did not administer drugs to Medicare patients in their office in 2003.

      The majority of urologists said they were familiar with the Medicare drug payment changes that took effect on January 1, 2004 (86%) and the additional changes that are scheduled to take effect in 2005 and 2006 (73%).

      Urologists said they had made the following changes since January 1, 2004:

      • 16% of urologists indicated the percentage of Medicare patients who needed physician-administered drugs and that received this treatment in their office decreased from 2003, with 81% stating the decrease was reimbursement related. On average, urologists reported a 5% drop from 87% in 2003 in the number of their Medicare patients who needed physician-administered drugs and have received treatment in their office.
      • 19% of urologists state that there are certain services and/or drugs that they provide to private patients, but not to Medicare patients. The most frequently mentioned drugs were testosterone (J1080), mitomycin (J9290 and J9291), and interferon (J9214).
      • 23% of urologists report there has been a change in the number or type of support services offered to patients receiving physician-administered drugs in their practice and/or locality. The main change in support services mentioned is decreased patient education.
      • 38% of urologists state that changes in Medicare reimbursement has affected access to physician-administered drugs for the patient population in the locality/localities served by their practice.
      • 56% of urologists think the Medicare reimbursement changes have decreased the quality of care provided to patients receiving physician-administered drugs in their practice and/or their locality.
      • 36% of urologists believe Medicare beneficiaries' out-of-pocket costs have increased.

      Uncertain future

      Many urologists have indicated that they will take drastic measures in response to an estimated 36% cut in Medicare drug revenue in 2005. Though there are many unknowns at this point in the process, the table below shows urologists' anticipated actions if 2005 drug administration payment reductions go forward as planned, dropping from a 32% transitional increase this year to a 3% transitional increase in 2005.

      Table I. Urologists' changes in treating Medicare patients and practice changes: 2004 and beyond

       

      2004

      planned for 2005 absent any relief

      Reduce office drug administration for all Medicare patients

      11%

      44%

      Stop office drug administration for all Medicare patients

      1%

      28%

      Reduce office drug administration for new Medicare patients

      8%

      36%

      Reduced or stopped office drug administration for Medicare patients without supplemental coverage

      10%

      42%

      Modify drug purchasing practices

      15%

      37%

      Send patients to outpatient department for drug administration

      4%

      40%

      Lay off staff

      4%

      21%

      Close satellite offices

      3%

      10%


      Drug purchasing groups

      In the proposed rule, CMS says it is their understanding that many physicians obtain discounts on drugs because they are members of purchasing groups. CMS also encourages physicians to consider participating in such groups in order to achieve advantageous prices. Based on our survey, about half of urologists receive volume discounts on the purchase price of prostate cancer drugs administered in the office. However, 48% of urologists are in group practice, and these are probably the ones negotiating a discount. Currently, about 48% of urologists are solo practitioners, and they have little or no negotiating leverage with drug manufacturers.

      Many urologists participate in buying groups because the combined volume purchased through the group make it possible to obtain deeper discounts on the unit price of the drug. Sometimes, participation in a buying group deal is predicated on the fact that a urologist will agree to purchase a set number of doses per year. The total of all these commitments determines the buying group's level of discount. Many times, a small urologist in a rural area cannot commit to a large enough volume to participate. In other situations, the sales representative may not introduce the buying group option to a urologist unless and until another drug company will sell a drug at a cheaper price. However, the ASP formula now reflects these discounts, so those urologists who have not been afforded the opportunity to participate in buying groups are immediately placed at a disadvantage and therefore their patients may suffer access problems or be forced to travel long distances to receive the care they could have received in their own community.

      Also, the ability to negotiate a discount does not assure that the drug can be purchased at 106% of ASP, and discounts continue to drive down the ASP reported each quarter by drug manufacturers. And, very few urologists are receiving discounts on bladder cancer drugs, which are the drugs that are currently most as risk for costing more than the Medicare payment. These low volume drugs like Interferon and Mitomycin do not fit into the buying group concept, and urologists are currently losing money on the purchase compared to the reimbursement rate.

      CMS should phase-in or delay drug payment cuts

      Congress required CMS to begin collecting ASP data after the first quarter of 2004, giving CMS and drug manufacturers two "dry-runs" to iron out problems and questions about ASP reporting before submission of third quarter data, which will be used to calculate the January 1, 2005 ASPs. However, we urge CMS to seriously consider whether the payment system based on ASP will truly be ready for implementation on January 1, 2005 and to delay implementing the new payment system if necessary to avoid patient access problems and confusion. CMS should at least phase in the more dramatic cuts by establishing a floor over the next few years. Most major changes to the Medicare fee schedule have been phased in to mitigate impacts on physicians, 95% of which are small business owners according to CMS.

      Least costly alternative policy for Lupron and Zoladex

      The AUA believes that the intent of Congress is to reduce the overall costs of prescription drugs paid for by Medicare Part B in a physician's office by allowing market forces and competition to keep the average sales price at acceptable rates. Under the new scheme, the manufacturer reports the sales price including all volume discounts, rebates, etc. The 2005 reimbursement for each drug will be set at this computed Average Sales Price (ASP) plus 6%. These rates are to be changed quarterly to maximize advantage gained under price reductions due to competitive pressure. The effects of market and competitive forces will be distorted in areas where the carrier has implemented a Least Costly Alternative (LCA) policy, because the only drug that is actually reimbursed at ASP plus 6% is the least costly one. All other drugs covered under a LCA policy are paid at something less than the amount that would result from the Congressional formula. We believe this contradicts Congress's intent.

      The concept used to justify LCA in the AWP mode of payment was that there were two prostate cancer drugs that provided the same measure of efficacy and therefore the cost to the Medicare program should be the same. The patient's preferences and the physician's professional judgment in selecting the drug that would be most effective based on a particular patient's needs are denigrated by these policies.

      In the new paradigm of ASP, the effects of volume discounts and rebates to reduce unit costs and thereby increase the market share of one of these drugs over the other will eventually affect the Average Sales Price of the drugs, so there is no longer any reason to maintain LCA policies at the carrier level. Therefore, we urge CMS to require all Medicare carriers to discontinue least costly alternative policies for Lupron and Zoladex.

      Questions

      To convey the current state of confusion and frustration, below are some unanswered questions that urologists have been asking. We urge CMS to provide guidance on these questions through any means possible, including a question and answer document on its website, a Medlearn article or other appropriate avenues.

      1. Can I write a prescription and have my patient bring the drug to the office? Writing a prescription for a drug given in the office, commonly called "brown-bagging," is particularly disconcerting because there is no way to assure that patients will properly store the drugs until they bring them into the office. Also, there are questions and conflicting information about whether the current Medicare rules allow physicians to write a prescription for drugs that they administer in the office, but we have heard from some of our members that certain Medicare carriers have implemented policies requiring this.

        It is unclear how creation of Medicare Part D will affect a physician's ability to write a prescription for drugs that were already covered by Medicare under the existing Part B drug payment system. It is also unclear what affect such policies will have on the intended policy objectives of switching to the ASP payment system. We urge CMS to clarify this issue in the final rule or before publication of the final rule if possible and to work with the AUA and other physician organizations to assure that physicians understand the rules.

      2. What should I tell my patients if my practice decides that it can not afford to purchase a drug? Where can I send my patients?
      3. Can I send my patient to the hospital for medications? Can a hospital (at which I am on the staff) refuse to give the drug even if I have called in the order to the hospital?
      4. What effect will reduced drug payment by Medicare have on my non-Medicare patients who have traditional insurance?
      5. Will oncology practices be able to give urology drugs and can I refer my patients to an oncologist for prostate cancer drugs?
      6. Will university hospital medical centers want to give drugs to my patients?
      7. How will the new 2005 drug payments affect me if I purchased the drug in 2004? Should my practice consider reducing its inventory of drugs purchased in 2004 to "zero" by the end of December?

      Offsets from drug administration codes don't help urologists

      The MMA required a prompt evaluation of existing drug administration codes for physicians' services to ensure accurate reporting and billing for those services, taking into account levels of complexity of the administration and resource consumption. The law also mandated that any changes in expenditures in 2005 or 2006 resulting from this review are exempt from Medicare budget neutrality requirements. As required by the law, existing processes through the AMA's CPT® Editorial Panel and Relative Value Update Committee are being used for the consideration of coding changes and the establishment of relative value units.

      As an affected specialty, the AUA has participated in the CPT® Workgroup. However, the results of the CPT® workgroup are not likely to provide any offsets to decreasing drug payments for urologists, and may in fact cause payment to decrease for drug administration codes used by urologists. Urologists mainly bill only two codes within the injections and chemotherapy administration sections of CPT®:

      CPT® code 90782 - Therapeutic, prophylactic or diagnostic injection (specify material injected); subcutaneous or intramuscular.

      CPT® code 96400 - Chemotherapy administration, subcutaneous or intramuscular, with or without local anesthesia.

      Because of the small number of drug administration codes billed by urologists, any offsets from increases in payment of these codes will be rather insignificant compared to oncologists (who bill a more diverse and larger number of drug administration codes). In the proposed rule, CMS provides a range of potential physician fee schedule impacts for 2005 by showing impacts of the changes required by the MMA if no further changes to the payment or codes for drug administration services are made and also showing the amount the physician fee schedule payments would have to increase to make the net reduction across all Medicare revenues for these specialties equal to 2%.

      According to table 26 in the proposed rule, if no further changes are made to drug administration, physician fee schedule revenues would be unchanged for urology, but urology's physician fee schedule revenue would have to increase by 19% to make the net reduction (from fee schedule payments and drug payments) for urology to equal 2%. Although CMS gives no basis for choosing 2%, we are concerned that CMS created an expectation among urologists that their losses might be held to 2% in 2005. Based on our experience with the CPT® workgroup, we can't fathom how urologist's fee schedule revenue could possibly increase by 19%, or about $323 million.

      Also, urologists were not paid properly for CPT® code 96400 since the switch to resource-based practice expense RVUs because the code was in the nonphysician work pool, which was created to deal with a glitch in the methodology. However, because we shared the code with oncologists, even though urologists bill it the vast majority of the time, CMS at first denied our request to remove the code from the nonphysician work pool. As CMS says in the proposed rule, the code was finally removed from the nonphysician work pool in 2003.

      Then, for 2004, CMS added 0.17 work RVUs to many drug administration services, including CPT® code 96400. Because the codes now had work RVUs, CMS also removed them from the nonphysician work pool, and these changes were exempt from budget neutrality. However, because the AUA had requested that CPT® code 96400 be removed from the nonphysician work pool a year before this, this change did not receive a budget neutrality exception which would have provided further offsets to drug payment changes, while all other codes that CMS removed from the nonphysician work pool in 2004 benefitted from this change and provided offsets. Therefore, because of timing issues and the fact that they bill mainly one or two drug administration codes, urologists have not been able to take full advantage of changes that were intended to offset drug payment losses, and we urge CMS to take this into account and consider ways to provide further offsets to urologists.

      Supplemental practice expense data

      Because 40% or more of urologists payments for Part B services were attributable to the administration of drugs in 2002, the MMA provides an exemption from the budget neutrality requirements in 2005 or 2006 for further increases in practice expense RVUs for drug administration services that may result from using urology supplemental practice expense data. If urology survey data is adopted with a higher practice expense per hour than the current urology practice expense per hour, that will cause the PE RVUs to increase for all codes in the urology pool, including drug administration services. Therefore, we assume that CMS would apply the budget neutrality exemption to additional expenditures that result from the increases in drug administration practice expense RVUs resulting from use of a urology survey that is submitted timely and otherwise meets the established criteria.

      We seek clarification on this from CMS in the final rule, as such survey data will most likely provide more offsets to drug administration codes for urologists than the current CPT® workgroup process. We look forward to working with CMS to assure that urologists can benefit as much as possible from new survey data, not only by applying the MMA-mandated budget neutrality exemption, but also by not blending the new data with previous urology SMS data. Because urologists have not benefitted much from other intended offsets, we hope that CMS will take these points into consideration.

    3. Section 302 - Clinical conditions for coverage of durable medical equipment (DME)

      Section 302(a)(2) of the MMA requires the establishment of standards for clinical conditions for payment for covered DME items, and requires that the standards include the specification of types or classes of covered items that require a face-to-face examination and a prescription. The law requires that standards be established first for those covered items for which CMS determines there has been a proliferation of use, consistent findings of charges for covered items that are not delivered or consistent findings of falsification of documentation to provide for payment of such covered items. The law also requires a face-to-face examination before a power wheelchair can be prescribed.

      CMS has taken an overly broad interpretation of the law in the proposed rule by proposing to make a face-to-face exam by the physician an explicit requirement for all initial orders of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) and at the time of prescription renewal for all DMEPOS continued-need items. Although most urology practices do not supply DME, this proposal would be very onerous and overly burdensome for urologists, who often will renew orders for patients who are known to have longstanding needs for catheters and ostomy supplies. Also, this is a burden for the patient. For example, it is burdensome for a quadriplegic who is a known patient to have to arrange to come to the physician's office to get a renewal for catheters or ostomy supplies. CMS should not apply this requirement to the DMEPOS fee schedule category of Ostomy, Tracheostomy & Urological Items (OS). Also, items such as commodes, walkers, mattresses and beds should not have this onerous requirement.

      In fact, we urge CMS to remove the requirement for face-to-face evaluation of all items of DMEPOS and to instead establish criteria that could be used to determine which specific classes or types of DMEPOS should be subject to additional clinical coverage conditions and face-to-face prescription requirements.

      Attachment 1

      Problems with payment for bladder cancer drugs
      (Excerpt from 03/08/04 AUA comments on 2004 physician fee schedule, CMS-1372-FC)

      We are hearing some alarming accounts from urologists that the payments for bladder cancer treatment drugs have been reduced below the purchase price of the drugs. In some cases, the gap between the cost of the drug and the payment now received from Medicare is substantial. In some instances the payment rate is slightly higher than cost but there is a significant amount of maintenance required to keep these drugs viable for usage. For example, thiotepa and bacillus Calmette-Guérin (BCG) have to be refrigerated, and BCG is a live attenuated mycobacteria that requires a closed system (hood and ventilator) when a liquid is added to the BCG inside of vials to reconstitute. Also, below we will discuss the administration payments for these drugs.

      We are unsure whether the manufacturers of these drugs have requested an April 1, 2004 change in payment for this drug, and have been unable to obtain from CMS a list of manufacturers that have requested an exception. We urge CMS to investigate this problem with payments for bladder cancer drugs and adjust the payments accordingly.

      HCPCS Code

      Drug Name

      Purchase Price

      January 2004 Payment

      J9340

      Thiotepa, 15mg(Bedford)

      $63.00

      $83.73

      J9280

      Mitomycin 5 MG inj (Bristol Meyers)

      $115.00

      $57.12

      J9280

      Mitomycin 20 MG inj

      $389.24

      $185.64

      J9291

      Mitomycin 40 MG inj

      $787.00

      $255.00

      J9031

      BCG (Organon)

      $150.14

      $143.28


      Overall, bladder cancer is the sixth most common cancer in the United States (the fourth most common for men). About 53,200 Americans are diagnosed with bladder cancer each year and 12,200 die annually of the disease. In recent decades there has been a steady increase in the incidence of bladder cancer, which is linked to smoking and environmental factors. Urologists have been making progress in treatment and survival rates are improving. However, payment reductions may change that abruptly. Several urologists have indicated that they will refer any new bladder cancer cases to academic or outpatient settings, which will increase cost to the Medicare system and create frustration for cancer patients.

      Additionally, one physician relayed that the oncology clinic in his area is now demanding that the few bladder cancer patients they are treating get the drugs needed to treat their cancer from a urologist and bring it with them. In other words, the oncology clinic wants to provide the care and receive the payments for the visits it performs but they want urologists to pay the cost of the drugs. Urologists are telling the AUA that shifting patients and/or delayed treatments is going to lead to a increase in the number of bladder cancers that are not treated in a timely or appropriate fashion, which in turn means that care and treatment will wait until the cancer and its symptoms are much more aggressive and costly to treat.

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