Jack Hoadley

Elizabeth Eaton

Georgetown University

Leigh Ann White

Alana Ketchel

Alma Kuby

Zein Malas

NORC at the 

University of Chicago

MedPAC

601 New Jersey Avenue, NW

Suite 9000

Washington, DC 20001

(202) 220-3700

Fax: (202) 220-3759

www.medpac.gov

• 

• 

The views expressed in this report 

are those of the authors. 

No endorsement by MedPAC 

is intended or should be inferred. 

Access to Chemotherapy

Services for Medicare

Beneficiaries: Summary

of Focus Groups

with Beneficiaries

A study conducted by staff from Georgetown University

and from NORC at the University of Chicago

for the Medicare Payment Advisory Commission

March 2006 • No. 06–1
This study was conducted by staff from Georgetown University 

 and from NORC at the University of Chicago 

Georgetown University: 

Jack Hoadley 

Elizabeth Eaton 

NORC at the University of Chicago: 

Leigh Ann White 

Alana Ketchel 

Alma Kuby 

Zein Malas 

Under contract with the 

Medicare Payment Advisory Commission 

Joan Sokolovsky, Project Officer 

November 14, 2005 

The views expressed in this report are those of the authors. 

No endorsement by MedPAC is intended or should be inferred. 
The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 made 

major changes to the way Medicare pays for chemotherapy drugs and their administration. The 

law also directed the Medicare Payment Advisory Commission (MedPAC) to assess potential 

effects of these payment changes on quality of care and satisfaction of patients, adequacy of 

payment, and access to chemotherapy and chemotherapy-related services. As part of its response 

to this mandate, MedPAC contracted with the Health Policy Institute at Georgetown University 

and NORC at the University of Chicago to conduct in-depth site visits in five markets on medical 

oncology payment and practices in relation to Medicare payment rules. Interviews were 

conducted with oncologists, practice managers, pharmacists, hospital administrators, and other 

stakeholders in the field of medical oncology. In addition, focus groups were conducted in two 

locations with Medicare beneficiaries who had recently received chemotherapy services. 

The objective of the focus groups was to examine whether payment changes have affected the 

experience of Medicare beneficiaries undergoing chemotherapy. Focus group participants were 

asked about any additional insurance coverage they had; where they received treatment; their 

observations about these treatment locations; the treatment they have received; and their 

awareness of Medicare payment changes. 

Overall findings 

 Some focus group participants were aware of changes in Medicare’s payments to 

physicians for chemotherapy treatment, because their doctors had spoken with them 

about the changes. 

 Only one participant reported being referred to a hospital-based infusion center for 

chemotherapy because of a physician who would not provide chemotherapy for Medicare 

beneficiaries without supplemental coverage. 

 Patients believe they receive quality care in both physician offices and hospital-based 

infusion centers, but most prefer to receive treatment in an office setting because of the 

personal attention they receive. 

 According to focus group participants, doctors may sometimes inform them that they 

have selected a treatment based on payment reasons, but most treatment decisions are 

based on clinical needs and convenience for the patient. 

 The type of support services offered to patients varies according to the treatment setting, 

but respondents did not indicate seeing any of these services cut back. 

Focus group characteristics 

Four focus groups were conducted in September and October 2005. Two focus groups were 

conducted in Atlanta, Georgia, where recruitment was conducted by oncology nurses and 

oncology practice managers. The other two focus groups were conducted in Bethesda, Maryland, 

where recruitment was conducted by a focus group research facility. 

All focus group participants were Medicare beneficiaries who had received chemotherapy in the 

previous 12 months. One of these participants was covered only by Medicare, and one was 

covered by Medicaid in addition to Medicare, while 17 participants had some form of 

supplemental insurance—either private Medigap or an employer plan (Table 1). Of the 
participants, 13 received their chemotherapy treatments in a community-based physician 

practice, three received chemotherapy in a hospital-based outpatient infusion center, and three 

patients had received chemotherapy in both kinds of settings (Table 2). In the Bethesda groups, 

at least two participants did not have Medicare Part B coverage because they had federal 

employee retiree coverage. 

Table 1. Participant characteristics: Insurance status 

Medicare only Medicare + Medicaid 

Medicare + 

supplemental Total 

Atlanta 1 0 7 8 

Bethesda 0 1 10 11 

Total 1 1 17 19 

Table 2. Participant characteristics: Treatment setting 

Communitybased practice Hospital-based 

infusion center 

Communityand Hospitalbased settings 

Integrated 

health system Total 

Atlanta 6 0 2 0 8 

Bethesda 5 3 1 2 11 

Total 11 3 3 2 19 

Awareness of Medicare payment changes 

Participants in Atlanta were more aware of Medicare payment changes than participants in 

Bethesda. In Atlanta, several participants’ physicians had sent their Medicare patients letters 

explaining some of the changes and stating that the new payment policies would necessitate 

referring Medicare patients without supplemental insurance to a hospital outpatient setting. 

These physicians had also requested that their patients write letters to their representatives in 

Congress to protest the changes. 

Treatment location 

Participants who had received chemotherapy treatment in physicians’ offices spoke positively 

about their experience. In addition to enjoying the convenience of receiving their treatment in the 

same location as their oncologists’ office, participants appreciated the personal attention they 

received during their treatments. Most of these patients saw the same nurse at each visit, which 

made them feel that their care was more personalized, and they were able to communicate easily 

with their care providers about any problems or side effects they were experiencing. Several 

participants also noted that they see many of the same patients in the infusion room at each 

treatment and have formed supportive relationships with one another. 

Participants who had received chemotherapy treatment in most hospital outpatient settings 

reported that they were satisfied with the medical care they had received, but most stated that the 

environment was not as friendly as a physician practice, describing the setting as “sterile” and 
“like a manufacturing facility.” These patients did not see the same nurse each time they received 

treatment, and reported experiencing long waits in between when they had their blood work done 

and when the nurses were able to begin their treatment. Focus group participants who had 

received treatments in both settings emphasized that it took much longer to receive their 

treatments in the hospital than it took when they were treated in a physician office. The 

exceptions to these observations were patients who had received treatment at an academic 

medical center. Patients in this treatment location, which has the appearance of a hospital setting 

but receives payment from Medicare under the physician fee schedule, reported more positive 

treatment experiences than those who had. 

Although several of the focus group participants in Atlanta had been told by their oncologists 

that changes in Medicare payments would force them to treat patients without supplemental 

insurance in a hospital outpatient setting, only one participant reported that her doctor had 

referred her chemotherapy to a hospital infusion center for reasons related to payment. The 

patient had supplemental insurance previously, but could no longer afford it; after this change in 

insurance coverage her oncologist transferred her treatment to a hospital outpatient infusion 

center. The participant stated that she felt comfortable with the quality of care at the hospital, but 

preferred to see the same nurse at every visit and hoped to return to receiving treatment in her 

doctor’s office in the future. None of the participants in the Bethesda focus groups believed that 

any changes in treatment setting were due to changes in Medicare payment of chemotherapy 

drugs. 

Treatment decisions 

Although several patients reported that their chemotherapy regimens had been changed at some 

point, most of these changes were made for clinical reasons (i.e., the patient’s response to a 

particular drug) or for reasons of convenience (i.e., a treatment given every three weeks instead 

of every week). 

 

One focus group participant in Atlanta reported that doctors had made changes in a regimen for 

reasons other than clinical judgment or convenience. The participant, who received treatment in 

a physician office, had been switched from leucovorin and oxaliplatin to zoledronic acid, and the 

physician explained that this regimen change was due to the relative cost of the regimen (i.e., 

relative extent of physician reimbursement under Medicare). 

Availability of ancillary services 

The range of ancillary support services available to the focus group participants varied widely. 

Most patients who were treated in their oncologist’s offices were offered some type of nutritional 

and financial counseling, and some were offered referrals to support groups in the area. Patients 

receiving treatment in a hospital-based infusion center or at a physician practice located within a 

teaching institution had a broader range of services available. None of the focus group 

participants reported seeing any of these support services cut back in the past year. 
Conclusions 

Although some beneficiaries who are undergoing chemotherapy are aware that there have been 

changes in how Medicare reimburses oncologists for chemotherapy drugs and their 

administration, most of the beneficiaries participating in these focus groups are not experiencing 

any modifications in their cancer treatment as a result of the changes. Only one participant 

reported a change in treatment that was related to physician reimbursement. Another reported 

being transferred from a physician office to a hospital-based infusion center for treatment due to 

the participant’s lack of a supplemental insurance policy. Most patients preferred to receive 

treatment in an office-based setting because of the personal attention they receive, but do not 

believe that there is a difference in the quality of care in physician offices and hospital infusion 

centers.