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 practices to absorb substantial financial losses.
Without a statutory fix, these cuts will undermine the viability of community practices, including oncology clinics, 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.”