EXECUTIVE SUMMARY
NEW YORK STATE MEDICAID RULE
ON PROVIDER DISPENSED PRESCRIPTIONS
New York Department of Health’s (“NY DOH’s”) recent “Policy Clarification for Practitioner Dispensing” 1 seriously and adversely affects the delivery of cancer care to patients on New York Medicaid. The points below summarize the issue and provide an initial framework for resolution.
1. There is a special exception in New York law that lets cancer doctors dispense cancer medications without a pharmacy license. This allows better patient access and medication management through one-stop shopping for care.
2. For many years, Medicaid Managed Care Organizations (“MCOs”) permitted cancer physician practices to enroll in their pharmacy programs and to be paid for cancer drugs like a pharmacy. This helped facilitate access to cancer care in a community, non- hospital setting for vulnerable patients in challenging life circumstances who may struggle with transportation and navigating confusing healthcare bureaucracies.
3. New York Medicaid is switching patients out of MCOs and into the traditional fee for service program for pharmacy benefits effective in the spring of 2023. As part of the switch, the agency is taking the position that cancer doctors will only be paid the acquisition cost of a drug that they dispense to a patient. But because cancer physician practices have overhead costs involved in storing and dispensing medications, this is not sustainable and will force the treating physicians to send their patients to pharmacies, making it harder for patients to access life-saving medicines and for the physicians to educate their patients about how to take the medications and to monitor their patients’ use of the medications.
4. As part of this planned switch, effective October 4, 2022, NY DOH is directing all Medicaid MCOs to end their practice of providing equal reimbursement to physicians and pharmacies for cancer medications and will force the MCOs to cap reimbursement to physicians at the acquisition cost of the drug. This forces cancer physicians to stop dispensing medications to their Medicaid patients (although no one else) and to send them to pharmacies at some other site. This will interfere with patient care and result in barriers to accessing care and medication for Medicaid enrollees with cancer. This policy will also likely clog hospital emergency rooms, where those patients may resort to going to get their medications.
5. Based on available information, NY DOH made these changes without notice and public comment. In other words, NY DOH did not follow the typical practice of first soliciting input from patients, patient advocacy groups, or oncologists. This was a decision made without listening to those on the front lines of caring for vulnerable cancer patients.
ABOUT NEW YORK CANCER & BLOOD SPECIALISTS
New York Cancer & Blood Specialists (“NYCBS”) is a large, integrated oncology practice approaching 200 total physicians by year end. NYCBS is currently the fastest growing oncology practice in the nation. NYCBS has over 50 locations including over 30 medical oncology facilities throughout all five boroughs of New York City and all of Long Island. NYCBS’ practice provides comprehensive services including medical oncology, radiation oncology, surgical oncology and multiple other physician services. Other services include in office infusion services, radiation, imaging, extensive laboratory, pharmacy, social work services, psychological counseling, and nutrition support.
NYCBS’ 50+ locations ensure patients can access high quality care where they live. Same-day walk in visits are available and provide same-day hydration and symptom management services at a fraction of the cost of emergency room visits for the same problem. This is part of NYCBS’ mission to provide high quality, low cost care near patient’s homes in their communities.
In 2021, NYCBS saw over 47,000 new patients, of which 16% were enrolled in Medicaid.
Top among recent growth initiatives, NYCBS is excited to partner with Memorial Sloan Kettering Cancer Center (“MSK”) to explore and build innovative models of care. This includes an announced 40,000 square foot outpatient facility in Brooklyn that will provide medical oncology, radiation oncology, surgical oncology and imaging services to bring high quality, affordable cancer care to an underserved community. All MSK patients admitted to Long Island hospitals are cared for by NYCBS physicians with structured communication and collaboration. As part of the MSK partnership, NYCBS has established an expedited referral process for both patient referrals and second opinion on pathology specimens. NYCBS holds joint bimonthly tumor boards for case review, treatment planning, and education. This unique and growing partnership lets each side do what it does best, fostering the highest quality care while maintaining ubiquitous access at the lowest possible cost. This willingness for a mutually beneficial partnership lies in stark contrast to the demands of non-profit hospitals which exclusively demand complete ownership models and physician employment which raises the total cost of care and diminishes operational efficiency.
i- Available at: https://www.health.ny.gov/health_care/medicaid/program/update/2022/no08_2022-07.htm#dispensing