February 2, 2004
Medicare has been cracking down on claims for motorized wheelchairs in recent months and may soon refuse to pay for experimental cancer drugs.
In the case of the motorized wheelchairs, officials of the Centers for Medicare and Medicaid Services (CMS) say the crackdown is a response to a growing incidence of abuse and does not represent a new policy.
Providers of the wheelchairs and spokesmen for affected groups disagree. Long-term care providers say that denying the powered wheelchairs means that staff members or family caregivers will have to perform many functions that ill or disabled persons are able to do by themselves if they have the motorized chairs.
"They are going to force people to impoverish themselves in institutional settings. People who have not committed fraud are penalized, and the punishment doesn't fit the crime," said Andrew Imparato, president of the American Association of People with Disabilities.
The crackdown was ordered by Thomas A. Scully, who stepped down as CMS administrator to take a lobbying position last month. At the time Scully said the increased scrutiny was in response to increasing fraud.
Demand for the motorized wheelchairs has nearly tripled in recent years, much of it sparked by shady companies who used high-pressure salespeople to sell the chairs and who took advantage of a relative loose Medicare approval process. More than 60 cases have been filed against alleged such perpetrators.
Besides prosecuting fraudulent wheelchair salespeople, CMS instituted a new ten-point program that includes much tighter screenings of claims and narrows the outline of who is eligible for a power wheelchair.
The cutback in payments for expensive cancer drugs would initially affect only four drugs, used to fight non-Hodgkin's lymphoma and colorectal cancer. But a decision on those four could set a precedent that would apply to many other costly drugs.
The drugs in question include Bexxar and Zevalin, from GlaxoSmithKline and Gioden Idec respectively. They are sometimes used as first-line treatment for non-Hodgkin's lymphoma at a cost of more than $22,000 for a course of treatment. They are approved for use only as third-line treatment, after other drugs have failed.
The other two drugs are Camptosar and Eloxatin, made by Pfizer and Sanofi-Synthelabo, used to treat colorectal cancer.
Medicare administrators face the uneasy task of living within their budget as they prepare to initiate a costly new prescription drug benefit. Excessive spending in one area means spending in other areas must be cut back.
In the case of "off-label" cancer drugs, Medicare would try to cut back on reimbursements for drugs that doctors prescribe to treat one type of cancer that may not be approved by the F.D.A. or recognize by medical texts as being effective. Such off-label use is commonly accepted and is a part of nearly every cancer specialist's arsenal.
If Medicare stopped paying for off-label treatments, the government would save billions of dollars but elderly cancer patients would either have to pay the cost out of their own pockets or their doctors would have to prescribe other drugs that might not work as well.
There might also be intense pressure on the drug companies to reduce the cost of the drugs, or to broaden their compassionate programs, under which expensive drugs are made available at little or no cost to those who cannot afford them.
Currently, Medicare pays only for drugs administrated in a physician's office or hospital. But when the prescription drug plan goes into effect in 2006, Medicare will pay for all drugs. Thus a ban on drugs used for unapproved purposes would have enormous impact.