OPINION

Protect Patient Access to Medications Administered in Physician Offices

As an independent gastroenterologist, I treat thousands of patients in the Washington, D.C., metropolitan area who have gastrointestinal issues. Some of the most challenging cases my colleagues and I confront are for patients who live with Crohn’s disease or ulcerative colitis, which are painful, medically incurable diseases that attack the digestive system.

Unfortunately, the Senate is considering a proposal that would make it harder for my patients to afford much-needed medications that improve their quality of life. 

I share the Senate Finance Committee’s goal of ensuring the sustainability of the Medicare program and appreciate the committee’s leadership in working to lower drug prices. In considering these goals, I am generally supportive of the Prescription Drug Pricing Reduction Act and its focus on price transparency, access and affordability.

However, Section 102 of the bill seeks to include the value of coupons and other patient assistance programs that pharmaceutical manufacturers provide to patients in the calculation of Medicare’s average sales price reimbursement formula. This proposal, if it becomes law, could be devastating for people who are living with conditions that require intensive medical management, such as cancer, rheumatoid arthritis and macular degeneration, among other diseases and chronic conditions.

For GI physicians, our patients with Crohn’s disease and ulcerative colitis will be hit hardest. Crohn’s and colitis are major categories of inflammatory bowel disease affecting 1.6 million Americans.

Treatments for these conditions help people who are suffering from abdominal pain, persistent diarrhea, rectal bleeding, fever, weight loss and worse. The treatments are enormously complex, and the medications are expensive.

As you can imagine, the coupon programs have become increasingly important in helping many patients continue with expensive treatments. According to a 2018 study in Health Affairs, the price reduction can be significant, saving patients between $50 and $100 a month. While the goal seems to be lowering Medicare expense through a change in ASP pricing, the bill could instead lead pharmaceutical companies to eliminate the coupons and patient assistance programs because of the overall effect on their margins.

With no change in the ASP pricing, Medicare won’t save money, but the patients who need financial help the most will experience even higher costs. This could lead our patients to forsake needed treatments and experience more complications, which would thereby increase the cost of care in the long term.

If the policy does cause the ASP price to fall, it could make it harder for some practices to provide certain medications in the convenience of our offices. Physician practices are already confronting reduced reimbursement as a result of the budget sequestration of 2013. If the Medicare reimbursement rate falls because the value of coupons are included in calculating the ASP, the actual costs for some treatments may not be covered, which could cause physicians to stop providing those treatments.

If physician practices can no longer afford to administer these drugs, it will likely force patients to seek care in the more expensive hospital setting, where Medicare and patients pay dramatically more for drug administration – the exact opposite of what Congress is trying to achieve.

The Digestive Health Physicians Association has joined many other physician and patient advocacy groups in voicing opposition to section 102 of the PDPRA. We’re hopeful that we’ll be able to work with Congress to find policy solutions that will reduce costs for patients with Crohn’s disease, ulcerative colitis, and other diseases and chronic conditions without weakening access to medications that improve the quality of life for thousands of patients.

 

Dr. Michael Weinstein is president and CEO of Capital Digestive Care and serves as president and board chair of the Digestive Health Physicians Association, and he has also served on the American Gastroenterological Association Board of Trustees and as the American Society for Gastrointestinal Endoscopy representative to the American Medical Association’s CPT Advisory Panel.

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