COA Policy Update: No Time to Savor Wins Amid More Financial Threats

After years of work, in February the Community Oncology Alliance (COA) celebrated reforms to pharmacy benefit management (PBM) practices contained in the Consolidated Appropriations Act of 2026. But there was little time to savor the victory, because Washington being Washington, there’s always a new threat to the financial health of community oncology practices.

And so it went Tuesday during the annual legislative session at the COA Community Oncology Conference, moderated by COA Executive Director Ted Okon, MBA, and featuring policy experts from across oncology, who addressed PBM reform, the evolving landscape in 340B and site neutrality, and the sudden threat to radiation oncology reimbursement.

Taking part in the discussion were: Ben Jones, senior vice president, Marketing & Government Relations for McKesson's oncology business and The US Oncology Network; Jerrica Mathis, MSED, vice president, Federal Government Relations, Cardinal Health; Shelly Mui-Lipnik, JD, LLM, head of Federal Government Relations, Cencora; Meagan O’Neill, MS, executive director, Association of Cancer Care Centers; and Allison Pearson, JD, MPH, Association for Clinical Oncology, which represents the American Society of Clinical Oncology (ASCO).

PBM Reform: A Genuine Trifecta

Okon framed recent developments as "a trifecta of anti-PBM legislation,” including Congress’ steps on transparency and reform in the appropriations process, a Federal Trade Commission settlement with Express Scripts (with CVS reaching a proposed deal) on insulin pricing, and a Department of Labor proposal requiring transparency to employers. The breadth of these achievements has amazed some of the Washington veterans on the panel, with Mui-Lipnik, a Labor Department alumna, expressing particular surprise that her former agency acted in this matter.

Jones described how COA built the momentum around PBM reform from scratch. “Ten years ago, there was reluctance to even go in,” to a lawmaker’s office with the issue, because “Nobody even really knew what was happening.” They’d just heard all of the horror stories about denials and delayed care.

He credited COA's years of patient story compilation as "absolutely critical to getting this reform across the finish line," and emphasized that the congressional package makes it clear that PBMs should not repeat what they did with Direct and Indirect Remuneration (DIR) fees. In that saga, outlawed fees simply reappeared under a different name, a move that backfired as lawmakers learned of the tactics.

“That's a feat in and of itself, is to get something through Congress. But it passed through Congress in a way that had teeth, and it made it clear that they better hold up to the spirit of the law here,” Jones said.

Mathis said that while the package represented significant progress, banning spread pricing in Medicaid remains unfinished business. She predicted continued bipartisan oversight regardless of midterm outcomes. O'Neill called this "early innings” and stressed that "comprehensive reform" has not yet reached employer-sponsored health plans. Pearson highlighted the landmark 100% pass-through provisions in the consolidated appropriations act, which ensure that “patients are actually benefiting.” Okon pointed to activity in the states and noted a new Tennessee law mirroring one in Arkansas, which bars entities from operating as both a PBM and a pharmacy. CVS has already threatened to sue.

An immediate threat to community oncology comes from a provision of the Inflation Reduction Act (IRA), which failed to account for the fact that physician reimbursement is tied to drug pricing. Mathis said that Cardinal Health supports HR 4299, the Protecting Patient Access to Cancer and Complex Therapies Act, which she said is gaining bipartisan support to ensure fair reimbursement to providers.

340B and Site Neutrality: Reform Is Coming

When it comes to 340B and site neutrality, “The reality is there is movement,” O’Neill said. “It’s not a matter of if anymore, it's really when and to what extent.”

Jones noted that HHS Secretary Robert F. Kennedy Jr. had recently engaged in discourse before Congress about 340B, the portion of the tax code that was created to allow certain safety hospitals to purchase drugs at discounts. Community oncologists have complained for years that the program has been exploited beyond its intent and created unfair competition, a hospital systems’ application of 340B discounts to sites beyond the original safety net locations subsidizes competitors to community oncology, putting many practices out of business.

Kennedy, according to Jones, has also engaged CMS to collect hospital acquisition cost data at an unprecedented level; this is significant, because it was this missing data that caused the Supreme Court to strike down a 2017 reimbursement reduction attempt.

"All of the pieces are starting to form for fundamental reform," Jones said, while acknowledging that the coming midterm elections could delay action.

O'Neill emphasized that her members—spanning community practices and hospital-based providers—are "not operationally ready" for rapid changes, warning of "unintended consequences for patient care" if multiple reforms hit simultaneously. Pearson said ASCO has responded to multiple congressional requests for information on 340B reform, supporting oversight while insisting access must be protected. On site neutrality, Jones pointed to incremental victories: neutrality applied to E&M codes since 2015–2017, and now—effective January 1—to drug administration codes as well, describing it as evidence that "the path is there."

Radiation Oncology: A Sudden and Serious Threat

Okon asked if panelists were surprised by sudden, severe cuts to radiation oncology reimbursement that came after January 1, 2026; despite analyses that showed updated billing codes would bring a net loss of 1% revenue, COA has heard from practices facing cuts ranging from 6% to 20%. Okon called this an existential for facilities with the specialized, capital-intensive equipment radiation requires.

Jones said he was "surprised and disappointed," noting that CMS made "such glaring omissions in their utilization assumptions" when rolling out codes that had been frozen since 2015. He identified Intensity-Modulated Radiation Therapy (IMRT) for prostate cancer as the hardest-hit area but noted a deeper concern. "It's the commercial impact that has truly" caught everyone off guard—payers were not ready to adapt, and neither was CMS. O'Neill described the change as “blunt” and “unsustainable,” noting that radiation oncology has been “a loser in budget neutrality for some time.” Mathis urged the field to watch incoming proposed payment rules this spring closely, asking whether CMS will walk back some of the cuts given a year of damaging implementation, “or do they continue to double down?”

What More Can COA Be Doing?

Okon closed the discussion by asking panelists what advocates for community oncology, including COA, should be fighting for beyond the topics already covered. Jones raised the growing threat of Most Favored Nation pricing models advancing at the state level—states are "pressing the easy button" by using Most Favored Nation or Maximum Fair Price benchmarks as automatic upper payment limits, which Jones flagged as a sleeper issue requiring urgent attention.

O'Neill pointed to prior authorization reform, Medicaid coverage losses, and the downstream effects of the IRA's drug negotiation provisions on infusion as underappreciated threats, particularly for vulnerable and underinsured populations.

Mathis stressed keeping community oncology practices viable so physicians can "focus on clinical decisions and not be bogged down with reimbursement issues." Mui-Lipnik argued that the value of management service organizations in driving innovation and access—especially for rural and underserved populations through clinical trial access—is poorly understood and deserves more advocacy attention.

Okon closed with a direct challenge to every oncologist and practice administrator in the room: "I can't think of how you can tell a patient to fight their disease, fight their side effects, if you're not fighting and advocating for them."