Feds should attack disease, not patients

Mirta Avila Santos and Delfin Santos

Fifty million Americans are under attack — from their own bodies. Their immune systems assault healthy cells instead of infections.

Managing these “autoimmune” diseases, which often cause painful swelling, rashes, and immobility, is a trial-and-error process that requires regular doctor visits and a range of medications. Getting the treatment regimen just right is difficult under the best circumstances. And it’s about to get a lot more challenging.

The Obama Administration plans to slash payments to physicians for drugs covered by Medicare. Reimbursements would be inadequate to cover the costs of treating many patients. That would force many healthcare providers to switch patients to cheaper medicines, turn them away, or close up shop entirely. The consequences could be dire for autoimmune disease sufferers.

Medicare Part B covers medicines, including immunosuppressive drugs and advanced medicines for rheumatoid arthritis, that must be administered at a medical facility.

For years, physicians who provided these therapies were reimbursed by Medicare for the average price of the drug plus an additional 6 percent. This add-on helps cover physicians’ labor costs, since administering sophisticated medications by injection or IV can take hours. In 2013, budget cuts reduced that additional payment to 4.3 percent.

Beginning this year, Medicare could reduce Part B drug reimbursements to the average drug price plus 2.5 percent, while adding a flat fee of $16.80.

The new reimbursement rate won’t cover the cost of treating many patients. Federal officials know this—they’re trying to influence doctors to prescribe cheaper, less-advanced drugs instead of state-of-the-art treatments. The flat fee means these less expensive treatments have a larger margin than costlier options.

When it comes to treating autoimmune patients, there’s no place for such federal meddling.

Consider individuals suffering from Behcet’s Disease, a rare condition that commonly results in painful oral and genital ulcers.

There is no single test for Behcet’s, so identifying the condition can be a lengthy, frustrating ordeal. Once diagnosed, patients require a combination of treatments administered by a range of specialists in order to manage their symptoms.

Every step of this process relies on physicians’ ability to follow their intuitions, test different therapies, and adjust treatment plans to suit each individual patient. The proposed Part B changes would make such a doctor-patient relationship nearly impossible to maintain in many cases.

Rheumatologists and ophthalmologists—physicians that are often critical to managing illnesses like Behcet’s — will see some of the most severe reimbursement cuts, according to healthcare consultancy Avalere. Many of these doctors will face a choice between providing subpar care and taking a financial loss. Confronted with this decision, more and more clinics will turn away Part B patients, while others will go out of business.

This trend is already evident among clinics that provide chemotherapy to Part B patients. Faced with declining reimbursements, over 300 of these facilities have closed since 2008. Almost 400 are dealing with financial difficulties.

Clinics that treat autoimmune diseases will meet a similar fate under the administration’s Medicare plan. Countless patients will lose access to the physicians that have overseen their health for years. Some will be forced to forgo the only medication that successfully controls their illness.

For autoimmune patients, unavoidable health problems are a fact of life. Thankfully, the complications created by reforming Part B are easily prevented. It’s up to leaders in Washington to cancel this wrongheaded policy before any damage is done.

Mirta Avila Santos, MD is executive director of the American Behcet’s Disease Association. Her husband, Delfin Santos, is a rheumatologist.