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A bill authored by Tom Reed would ensure seniors suffering from cancer, heart disease and other illnesses have access to the most up-to-date, state-of-the-art treatments. Under new payment policies adopted by the Centers for Medicare and Medicaid Services (CMS), hospitals are incentivized to use older, cheaper services, even if they are clinically outdated. Reed’s bipartisan Ensuring Equal Access to Treatments Act requires CMS to use fair payment classifications for breakthrough bladder cancer treatments, as well as other clinically necessary services that are being negatively impacted by CMS policies, so that all patients have access to the most effective treatments.

“We heard from patients, doctors and hospitals in the district as well as from across the country that the most up-to-date technology was being reimbursed at such low levels that providers were resorting to using treatments more than 20 years old and less effective,” Reed said. “If patients aren’t receiving the most effective, breakthrough care, that’s a problem we need to find a solution for. Our bill puts patients first and incentivizes quality care outcomes over short-sighted, unfair CMS policies out of Washington.”

The new CMS rule in question redefines Medicare’s “packaged payment” policy, under which a hospital receives a single packaged payment to cover healthcare items and services needed to diagnose and treat patients. Under the new CMS policy, drugs and biologics are incorporated into the single payment the hospital receives from Medicare instead of reimbursing properly for both the procedure and the drug.

For example, this new policy is severely impacting the treatment of bladder cancer where a new cancer detection drug used in conjunction with a blue light scope technology has significantly increased the ability of physicians to detect and remove cancer lesions. Unfortunately because the cancer detection drug, Cysview, is included in the new “packaged payment” for bladder cancer cases, hospitals are not adequately reimbursed and opt for an older, less effective treatment. Since CMS made the policy change, hospitals that were providing the new bladder cancer treatment have ceased doing so and new hospitals have opted not to adopt this new technology due to the lack of proper reimbursement.

Reed initially learned about this issue from Mark Ryckman of Corning. Mark became aware of the problem after being examined at the University of Rochester Medical Center using this new blue light technology to monitor his bladder cancer. Mark reached out to Reed asking for his help to ensure others have access to this advanced technology.

“Four years ago, I was diagnosed with bladder cancer,” Ryckman said. “After two years of treatment and monitoring, a new drug, “Cysview” coupled with a blue light scope, came on the market. This technology increases the ability of urologists to find bladder cancer lesions. Studies have shown this blue light technology is more effective than the old method.  If Medicare's "packaged payment" policy is not fixed, I am worried hospitals will not offer this technique because they aren’t reimbursed for the drug. That means some patients might not have access to the same potentially life-saving care I received.”

Reed’s bill addresses this serious issue by requiring CMS to create two separate payment codes, one for the procedure without the newly packaged drugs and another for the procedure with the newly packaged drugs. Reed says the common sense fix will end up saving CMS money in the long run if it allows the new technology to become available more widespread.

This new policy also impacts the diagnosis of coronary artery disease and other up and coming health care technologies and discoveries. To detect this deadly disease, many seniors require an imaging procedure utilizing a stress test. For high-risk patients unable to safely elevate their heart rate on a treadmill, doctors prescribe a drug that produces the same effect. In the past, hospitals would bill each test separately and receive appropriate reimbursement based on the services provided. Now, Medicare packages all tests together and, as a result, hospitals receive a fixed payment no matter whether the doctor utilized the zero-cost treadmill stress test or the pharmacologic stress test when necessary. Accordingly, CMS is financially incentivizing the use of the cheapest therapy without regard to patient health outcomes.

"We are grateful for Rep. Reed and the co-sponsors for their leadership on this issue. With so few advances in the disease, it is vital that patients have access to new technology. This change in the rule would greatly benefit the bladder cancer community,” said Monica Smith, Executive Director of Bladder Cancer Advocacy Network (BCAN).

The bill continues to build support from the health industry including the Bladder Cancer Action Network, Society of Women’s Health Research (SWHR) and leading university medical centers such as the Mayo Clinic and Montefiore Medical Center in New York.

Original co-sponsors Reps. Roskam, Rogers (MI), McDermott, Schneider and Capps joined Reed to introduce the bill.

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