When the Medicare Modernization Act of 2003 was passed by Congress and signed by President George W. Bush, there were still several concerns that it would have a substantially negative effect on chemotherapy patients because of the stipulated reductions in reimbursements to physicians for drugs given during outpatient chemotherapy care. However, a new study published in the July 9 issue of JAMA finds that since 2003, there has not been a large change in travel distances nor patient wait times for Medicare patients who receive chemotherapy.

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) created an outpatient prescription drug benefit for Medicare beneficiaries and altered physician reimbursement for drugs and administrative services related to chemotherapy. Since physicians were able to receive major discounts on chemotherapy-related drugs, Medicare payments to physicians for these drugs were frequently higher than the cost of the drug to the physician. The MMA sought to address this imbalance by reducing payment for chemotherapy drugs, arguing that it better-aligned reimbursement with market prices.

Alisa M. Shea, M.P.H. (Duke University School of Medicine, Durham, N.C.) and colleagues, authors of the JAMA study, indicate that, "There was concern that the reduction in physician reimbursement would lead to closures of some private oncology practices, requiring the 80 percent of cancer patients who receive treatment in community settings to travel farther from their homes to local hospitals for treatment. Moreover, without sufficient opportunity to plan and expand their services and without financial incentive to do so, hospital-based clinics might not have adequate resources to support the anticipated rapid influx of patients seeking chemotherapy, thereby further delaying provision of care."

To test these hypotheses, Shea and colleagues studied wait times and travel distance for patients who received chemotherapy before and after the enactment of the MMA. The researchers used a nationally representative sample that included 5% of claims from the Centers for Medicare & Medicaid Services submitted from 2003 through 2006. The sample consisted of Medicare beneficiaries with new cases of breast cancer, colorectal cancer, leukemia, lung cancer, or lymphoma who received chemotherapy in inpatient hospital, institutional outpatient, or physician office settings. The patients presented 5,082 new cases of the aforementioned cancers in 2003; 5,379 cases in 2004; 5,116 cases in 2005; and 5,288 cases in 2006.

Notable findings from the study include:
Each year, 70% of patients received their first chemotherapy treatment in a physician's office, while about 10% received it as inpatients in a hospital. There was a small significant difference in the distribution of treatment settings between 2003 and 2006, and no difference between 2003 and 2004. 10.2% received chemotherapy in as inpatients in 2003 compared to 8.8% in 2006. 21.1% received therapy in institutional outpatient settings in 2003 compared to 22.5% in 2006. 68.7% of patients received therapy in physician offices, and this remained stable from 2003 to 2006. To go from diagnosis to first chemotherapy visit, patients waited 28 days in 2003, 27 days in 2004, 29 days in 2005, and 28 days in 2006, on average. In 2005, the average wait time for chemotherapy was 1.96 days longer than in 2003, but the difference was not found to be significantly different comparing 2003 to 2006 (only a 0.88-day difference). In 2003, patients traveled about 7 miles to therapy, while the distance slightly increased to 8 miles in 2004 through 2006.
The authors conclude: "As measured by travel distance and time to chemotherapy, our findings do not support anecdotal reports that the enactment of the MMA has changed access to chemotherapy in a meaningful way. Given the slow transition to full implementation of the reimbursement changes mandated by the MMA and the limited amount of follow-up data available at present, it may be premature to observe a relationship between these changes and delivery of care. With the aging of the U.S. population, the number of elderly individuals with cancer is expected to increase proportionally, with incidence doubling in less than 30 years. As the burden increases, researchers should continue to monitor the effects of major policy changes on Medicare beneficiaries' access to care."

Association Between the Medicare Modernization Act of 2003 and Patient Wait Times and Travel Distance for Chemotherapy
Alisa M. Shea; Lesley H. Curtis; Bradley G. Hammill; Lisa D. DiMartino; Amy P. Abernethy; Kevin A. Schulman
JAMA (2008). 300[2]: pp. 189 - 196.
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: Peter M Crosta