An additional recommendation from MedPAC is to establish a single billing code, or payment, for reference biologic drugs and their biosimilar equivalents. Such a policy could cause practices to swing toward use of the cheapest obtainable drug under the single code, while also creating problems for practices whose physicians prescribe drugs that are priced higher than the corresponding payment under the code, Turgon said. Under Price at HHS, such a policy could conceivably come about, she said.
With much uncertainty about the drug pricing policies that will emerge as the Trump tenure unfolds and Price and others, including Seema Verma, newly confirmed head of CMS, begin to exercise their mandate to control spending, it’s incumbent upon practices to protect themselves the best way they can. Turgon said this means adhering to clinical pathways, using evidence-based treatment alternatives, educating prescribing doctors about the costs of drugs, and having cost-of-care discussions with patients. She also recommended reducing wasteful drug use—in particular by choosing infusion bag sizes carefully, and practicing just-in-time delivery by keeping inventory supplies of high-priced drugs as low as possible.
In addition, practices need to develop defensive readiness for what seem to be rising and often arbitrary claims rejections by payers, Turgon said. “What we were seeing at some cancer centers at the turn of the year was 1 in 4 claims were being denied. It takes time, it takes, energy, but making sure that your denial process and your authorization process are fine-tuned would be part and parcel of helping your cancer center run effectively.”