Ensuring High-Quality Cancer Care in the Medicare Program

With cancer becoming the nation’s leading cause of death, and a majority of new cancer diagnoses occurring among those aged 65 or older (National Cancer Institute, 2007), the Medicare program plays an integral role in the delivery and coverage of cancer care in the United States. A growing population in need, a shrinking cancer care workforce, and an insufficient scope of benefits and services coverage combine to pose a potential cancer care crisis. The U.S. healthcare system will be able to sustain community-based cancer care and continue to deliver comprehensive cancer care to all in need only if Medicare provides coverage and sufficient reimbursement of the full range of cancer-related care, including services provided by oncology nurses (Oncology Nursing Society, 2005, 2007).

• Medicare adequately and appropriately reimburses for and provides access to the full range of benefits and services— including clinical trials—provided in the context of the delivery of multidisciplinary cancer care.
• Medicare ensures timely access to a coordinated team of multidisciplinary oncology specialists when cancer is suspected or diagnosed.
• Medicare provides payment for the provision of nurse-led, individualized, one-hour patient education sessions to patients and their caregivers prior to the initiation of treatment.
• Medicare reimburses oncology practices for the full range of services provided by oncology nurses, such as the necessary care and observation by oncology nurses of patients who are taking oral anticancer therapies and other prescription drugs to ensure compliance and monitoring for side effects.
• Medicare provides adequate reimbursement and maintains other policies that ensure cancer treatment facilities and physician offices can continue to purchase cancer drugs for treatment and employ personnel who are properly trained and equipped to handle, administer, and deliver the full range of cancer treatment and supportive care therapies.
• Medicare ensures that advanced practice nurses are full participants in all pay-for-performance, pilot, and demonstration programs.
• Medicare includes cancer-specific compendia to the mandated reference list used for off-label coverage decisions.
• Medicare permits nurses to bill under therapy codes for the provision of lymphedema care.
• Medicare uses valid and reliable data from comprehensive surveys that capture real costs and real practice patterns to ensure that reimbursement rates are accurate and appropriate.
• Medicare ensures patient safety and well-being and that payment policies for cancer therapies are evidence based and aligned with expert opinion.
• Medicare maintains reasonable and customary coinsurance or co-pay requirements for cancer-related therapies and associated services.
• Medicare prohibits cost-cutting strategies that burden Medicare beneficiaries with responsibilities for purchasing and handling cancer drugs, which often are expensive and temperature- or light-sensitive compounds.
• Medicare ensures that payment policies do not interfere with or have an adverse effect on treatment decisions, access to care, or quality of care.

National Cancer Institute. (2007). Cancer of all sites. Retrieved April 4, 2008, from http://seer.cancer.gov/statfacts/html/all.html

Oncology Nursing Society. (2005). Quality cancer care [Position statement]. Retrieved April 4, 2008, from http://www.ons.org/publications/positions/QualityCancerCare.shtml

Oncology Nursing Society. (2007). Medicare program; proposed revisions to payment policies under the physician fee schedule, and other Part B payment policies for calendar year 2008 [CMS-1385-P]. Retrieved April 4, 2008, from http://www.ons.org/lac/pdf/correspondence/110/530299.pdf

Approved by the ONS Board of Directors 6/03; revised 3/06, 3/08.