Reimbursement Policy Leaves Cancer Patients in a Lurch

By Jeffrey VanDeusen, MD, PhD

The conversation usually begins with an apology.  I need a biopsy, I tell my patient, to see how their cancer has changed and to guide the next steps in treatment.  Getting biopsy results back will take some time. I’m sorry, I tell them. I will lean on non-specific treatments to fill the treatment gap while we wait for answers.

Patients tend to be understanding.  But for physicians, this conversation underscores a deep source of frustration.  The lag I describe to my patients stems from a technicality in Medicare hospital reimbursement.  It’s a technicality that delays cancer patients’ access to treatment while they are fighting for their lives.

Here’s the issue.  Say a patient is hospitalized for surgery to obtain a biopsy.  The expense of any lab work, like molecular diagnostic testing on the biopsy, occurring within 14 days of hospitalization gets lumped into the bill for that hospital stay.  Because Medicare pays a flat rate for the visit, the added expense cuts into hospitals’ profit. So hospitals require a two-week waiting period on lab work requests after a biopsy.  

This presents a problem for at least three reasons.

First, time is life if you’re a cancer patient.  Requiring physicians to sit on their hands for two weeks means allowing our patients’ tumors to grow larger and their lives to grow shorter.  It is hardly patient-centered care. I, like my colleagues in oncology and across other fields, am mindful of my oath to “First, do no harm.”

Second, intermediate treatment, the medicine oncologists provide patients while they wait for diagnostics to guide next steps, may not be what’s best for the patient.  Chemotherapy, the likely choice, presents a level of toxicity. If the biopsy testing later reveals that another medication would have been better, we’ve exposed this patient to some unpleasant side effects just to bide our time. 

Third, the genomic sequencing from the patient’s biopsy could indicate whether a targeted cancer medicine might work for this patient.  Think of immuno-oncology drugs like the checkpoint inhibitor that worked for former President Jimmy Carter, for instance. This could be game changing, even lifesaving, for a patient with aggressive cancer.  Every day we spend waiting to submit the biopsy for testing is a day this patient could see tumors shrinking, a day this patient could move closer to remission.

I’m reminded of a patient with breast cancer who wasn’t responding in a traditional way to her therapy.  One area of her cancer continued to grow while the other areas did not. We did a small surgery to remove the atypical area and try to understand what was happening.  It turns out that her cancer had mutated into a different subtype, triple negative cancer.  

The information was a revelation.  I knew that immune therapy sometimes works for those patients and, once she started this medication, she responded remarkably well.  But during the required cool-off period while we both waited, first to send off the biopsy for genomic testing and then for the results, she suffered side effects from her cancer that was not under control.  The cancer grew in her spine, causing pain and impeding mobility. She was stuck taking a medicine that didn’t address the issue and was in no way the best treatment for her.

This patient’s experience is not unique.  The 14-day waiting period stems from Medicare policy, but commercial insurers have followed suit.  That means that most hospitals now require the wait for all cancer patients, regardless of insurance type.

Genetic testing for cancer diagnostics is expensive, I fully understand.  But when we force ill patients to wait for weeks as their cancer grows, we’ve taken fiscal responsibility to an unhealthy extreme.  I urge policymakers to reconsider the unintended consequences of this reimbursement policy.

Jeffrey VanDeusen, MD, PhD, is medical director of The Ohio State University’s James Cancer Center and a member of the Alliance for Patient Access.


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