I 

113TH CONGRESS 

1ST SESSION H. R. 2869 

To amend title XVIII of the Social Security Act to establish payment parity 

under the Medicare program for ambulatory cancer care services furnished in the hospital outpatient department and the physician office 

setting. 

IN THE HOUSE OF REPRESENTATIVES 

JULY 31, 2013 

Mr. ROGERS of Michigan (for himself and Ms. MATSUI) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To amend title XVIII of the Social Security Act to establish 

payment parity under the Medicare program for ambulatory cancer care services furnished in the hospital outpatient department and the physician office setting. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Medicare Patient Ac5 cess to Cancer Treatment Act of 2013’’. 


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1 SEC. 2. FINDINGS; SENSE OF CONGRESS. 

2 (a) FINDINGS.—Congress finds the following: 

3 (1) The National Cancer Institute estimates 

4 that approximately 13.7 million Americans with a 

5 history of cancer were alive on January 1, 2012. 

6 (2) About 8 million of the 13.7 million Ameri7 cans living with cancer are over age 65, and approxi8 mately half of cancer care spending is associated 

9 with Medicare beneficiaries. 

10 (3) National spending on cancer care in 2010 

11 is estimated at $125 billion. 

12 (4) In 2011, the National Cancer Institute re13 leased projections of the cost of cancer care in the 

14 United States, finding the total cost of cancer care 

15 in 2020 is expected to be $206 billion. 

16 (5) In a 2010 study, Milliman reported that in 

17 2007 a cancer patient receiving chemotherapy in18 curred average costs of approximately $111,000, 

19 three times the cost of a coronary artery disease pa20 tient, and six times the cost of a diabetes patient. 

21 (6) Over the last several years, the United 

22 States has been touted as world leader in providing 

23 high-quality cancer care. 

24 (7) United States cancer survival rates are 

25 higher than the average in Europe and Canada for 

26 13 of 16 types of cancer. 


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1 (8) Until recently, over 80 percent of United 

2 States cancer patients received care in the commu3 nity setting. 

4 (9) Over the past several years, the country has 

5 experienced a significant shift of outpatient cancer 

6 care delivery from the physician’s office to the hos7 pital outpatient department. 

8 (10) Reports show that over the past six years, 

9 43 community practices have started referring all of 

10 their patients elsewhere for treatment, 288 oncology 

11 office locations have closed, 131 practices have 

12 merged or were acquired by a corporate entity other 

13 than a hospital, and 469 oncology groups have en14 tered into an employment or professional services 

15 agreement with a hospital. 

16 (11) Over 1,000 clinics or practices have been 

17 impacted over the last 3 years out of a population 

18 of only 6,000 oncologists in community practice in 

19 the United States. 

20 (12) A 2013 study published by The Moran 

21 Company (‘‘Moran study’’) found that, between 

22 2005 and 2011, there was a 150 percent increase in 

23 administered chemotherapy in the hospital out24 patient setting for Medicare fee-for-service bene25 ficiaries (increasing from 13.5 percent in 2005 to 


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1 33.0 percent in 2011) as compared to administration 

2 in physician community cancer clinics. 

3 (13) The Moran study found that, in 2005, al4 most 87 percent of Medicare patients were receiving 

5 their care in the community setting, by 2011 only 67 

6 percent were utilizing the community setting. 

7 (14) The Moran study reports that Medicare 

8 payments for chemotherapy administered in hospital 

9 outpatient settings have more than tripled since 

10 2005 (from $90 million to $300 million) while pay11 ments to physician community cancer clinics have 

12 actually decreased by 14.5 percent. 

13 (15) The Medicare physician fee schedule rate 

14 in 2012 for CPT Code 96413 (Chemo, iv infusion, 

15 1 hr), the most common drug administration code 

16 billed by oncology practices, is $139 but the pay17 ment rate for the same service under the Medicare 

18 hospital outpatient prospective payment system 

19 (HOPPS) fee schedule in 2012 is 50 percent higher 

20 at $208. 

21 (16) Utilization-weighted Medicare payment for 

22 infusion services is approximately 55 percent higher 

23 at the hospital outpatient department than in a phy24 sician’s office. 


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1 (17) Medicare proposed in 2012 to pay hospital 

2 outpatient departments 25 percent more for radi3 ation therapy services than for the same services 

4 performed in physicians’ offices, including a 70 per5 cent differential for intensity modulated radiation 

6 treatment (IMRT) and a 188 percent differential for 

7 stereotactic body radiation therapy delivery (SBRT). 

8 (18) One third of hospitals in the United States 

9 purchase chemotherapy drugs through the section 

10 340B program at a discount of up to 50 percent, re11 sulting in a net cost to such hospitals that typically 

12 is at least 30 percent below reimbursement rate 

13 (which is based on 106 percent of the average sales 

14 price) for community oncologists for such drugs. 

15 (19) Medicare reimburses 70 percent of hospital 

16 bad debt (uncollectable coinsurance). 

17 (20) According to an October 2011 Milliman 

18 study, the cost of treating cancer patients is signifi19 cantly lower for both Medicare patients (10 percent 

20 lower in copayment amounts, more than $650 sav21 ings a year) and the Medicare program (14.2 per22 cent less, a savings of $6,500 a year per patient) 

23 when provided in community-based cancer settings 

24 as compared to the same treatment in hospital out25 patient departments. 


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1 (21) The April 1, 2013, sequestration cuts to 

2 Medicare allowed for a 28 percent cut to the services 

3 reimbursement in Medicare part B drugs to commu4 nity oncologists. 

5 (22) A recent Community Oncology Alliance 

6 survey showed that 69 percent of practices surveyed 

7 reported that patient treatment or operational 

8 changes already have been made due to the seques9 ter cut to cancer drugs, with 49 percent of practices 

10 forced to send Medicare patients elsewhere for treat11 ment, and 62 percent of practices reported that they 

12 will be forced to send Medicare patients elsewhere 

13 for treatment if the sequestration cuts stay in place 

14 through July 31, 2013. 

15 (23) The June 2013 report of the Medicare 

16 Payment Advisory Commission highlighted the large 

17 disparities in payment in outpatient settings and 

18 noted that the payment variations across settings 

19 should be addressed quickly due to the fact that cur20 rent disparities have created incentives for hospitals 

21 to buy physician practices, driving up costs for the 

22 Medicare program and for beneficiaries. 

23 (b) SENSE OF CONGRESS.—It is the sense of Con24 gress that, to ensure the future of community cancer care, 

25 Medicare reimbursement should be equal for the same 


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1 service provided to a cancer patient regardless of whether 

2 the service is delivered in the hospital outpatient depart3 ment or physician’s office. 

4 SEC. 3. EQUALIZING MEDICARE REIMBURSEMENT IN HOS5 PITAL OUTPATIENT DEPARTMENTS AND PHY6 SICIANS’ OFFICES FOR CANCER CARE SERV7 ICES. 

8 (a) IN GENERAL.—Section 1833(t) of the Social Se9 curity Act (42 U.S.C. 1395l(t)) is amended— 

10 (1) in paragraph (2)— 

11 (A) in subparagraph (G), by striking 

12 ‘‘and’’ at the end; 

13 (B) in subparagraph (H), by striking the 

14 period at the end and inserting ‘‘; and’’; and 

15 (C) by inserting after subparagraph (H) 

16 the following new subparagraph: 

17 ‘‘(I) payment for covered OPD services 

18 that are cancer care services (as defined in sub19 paragraph (B) of paragraph (18)) shall be 

20 made consistent with subparagraph (A) of such 

21 paragraph.’’; and 

22 (2) by adding at the end the following new 

23 paragraph: 

24 ‘‘(18) SPECIAL PAYMENT RULE FOR CANCER

25 CARE SERVICES.— 


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1 ‘‘(A) IN GENERAL.—In the case of cancer 

2 care services that are furnished on or after Jan3 uary 1, 2014, the payment amount for such 

4 services under this subsection and under section 

5 1848 shall be a budget neutral combination (as 

6 determined by the Secretary) of— 

7 ‘‘(i) the amount otherwise payable 

8 under this subsection for such services; 

9 and 

10 ‘‘(ii) the amount otherwise payable 

11 under section 1848 for such services. 

12 ‘‘(B) CANCER CARE SERVICES DEFINED.— 

13 For purposes of this subsection, the term ‘can14 cer care services’ means covered OPD services 

15 or physicians’ services for which payment is 

16 made under section 1848 that are furnished in 

17 conjunction with the diagnosis or treatment of 

18 cancer.’’. 

19 (b) CONFORMING AMENDMENT.—Section 1848(a) of 

20 Social Security Act (42 U.S.C. 1395w–4(a)) is amended 

21 by adding at the end the following new paragraph: 

22 ‘‘(9) APPLICATION OF SPECIAL RULE FOR CAN23 CER CARE SERVICES.—In the case of physicians’ 

24 services that are cancer care services (as defined in 

25 subparagraph (B) of section 1833(t)(18)) that are 


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1 furnished on or after January 1, 2014, the payment 

2 amount for such services under this section shall be 

3 the payment amount for such services determined 

4 under subparagraph (A) of such section.’’. 

Æ 


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