Understanding The Protecting Patient
The Issue
An unintended consequence of the Inflation Reduction Act’s (IRA) Medicare Drug Price Negotiation Program is a significant disruption to physician reimbursement for critical therapies.
Beginning in 2028, Medicare Part B reimbursements for selected oncology and complex therapies are projected to be cut by 40 to 60 percent or more, forcing community oncology practices to absorb substantial financial losses.
Without a statutory fix, these cuts will undermine the viability of community oncology practices, limit access to local care for patients who need it most, and push cancer treatment into higher-cost hospital outpatient settings. Here’s why it matters:
- Community oncology practices treat the majority of Medicare cancer patients, providing high-quality care closer to home.
- Care closer to home reduces travel burdens, supports treatment adherence, and improves outcomes, particularly for seniors, rural patients, and those in underserved communities.
- Unsustainable reimbursement cuts and rising practice costs will force community practices to limit services, stop offering certain therapies, or close entirely, leaving patients with fewer local care options.
- Shifting care to hospital settings increases patient cost-sharing and drives higher Medicare spending.
A Bipartisan Solution
The Protecting Patient Access to Cancer and Complex Therapies Act is a targeted, bipartisan, fiscally responsible fix that protects patients, preserves independent practices, keeps treatment close to home, and prevents higher long-term Medicare costs.
Specifically, the bill:
- Maintains stable physician reimbursement for selected Medicare Part B drugs, ensuring providers can continue to offer critical therapies in community settings.
- Prevents providers from being caught in the transition from Average Sales Price (ASP) to Maximum Fair Price (MFP).
- Requires manufacturers to pay Medicare a rebate equal to the difference between ASP and the lower MFP, allowing the program to achieve the same negotiated savings without shifting costs onto providers.
- Bases patient coinsurance on the lower MFP, directly reducing out-of-pocket costs for Medicare beneficiaries.
- Prevents unnecessary migration of care to higher-cost hospital outpatient departments.
By the Numbers
Avalere Health estimates that physicians could lose at least $25 billion in reimbursement over the first 10 negotiated Part B drugs and an additional $12 billion to $19 billion through 2032.
A Milliman analysis found that under the Protecting Patient Access to Cancer and Complex Therapies Act:
- Physicians avoid $56.3 billion in reimbursement losses that would occur under IRA alone.
- Patients save $93.3 billion in cost-sharing while maintaining access to care.
Medicare saves $71.3 billion overall, including $68.1 billion from IRA negotiation and $3.3 billion generated through the rebate mechanism over 10 years.
- More than 65 Patient Advocacy Organizations and Physician Groups Support H.R. 4299.
The Bottom Line
The Protecting Patient Access to Cancer and Complex Therapies Act is a bipartisan solution that ensures Medicare drug price negotiation delivers on its promise: lowering costs for patients and taxpayers without sacrificing access to life-saving treatments.
Your voice matters! Join patients, providers, and caregivers in telling Congress,
“Protect my access to care and support the Protecting Patient Access to Cancer and Complex Therapies Act.”