Community Oncology Bracing for IRA Impact

“The goal of this is not to be your traditional IRA analysis panel,” explained Nic Ferreyros, managing director of the Community Oncology Alliance (COA), as he kicked off the panel discussion, “Preparing for the IRA’s Impact on Community Oncology,” at the recent 2025 Community Oncology Conference. “But more to talk about how practices are thinking and preparing for that.”

Nicolas Ferreyros | Image Credit: Community Oncology Alliance

For a detailed look at how the Inflation Reduction Act (IRA) will reverberate across the community oncology arena, he was joined by Barbara McAneny, MD, FASCO, MACP, medical oncologist and CEO of New Mexico Oncology Hematology Consultants, member of the COA executive committee and board of directors, and former president of the American Medical Association; and Austin Cox, PharmD, senior director of trade relations, Florida Cancer Specialists & Research Institute.

Sounding the Alarm

Many may be familiar with more recent developments concerning the IRA and community oncology:

• The 2023 release and 2026 implementation of the first 10 Medicare Part D drugs selected for price negotiation under the IRA that includes just 1 oncology medication, ibrutinib (Imbruvica; Pharmacyclics/Johnson & Johnson)¹
• January’s announcement of the second phase of Part D drug prices negotiated for 2027,² which expands the list to 15 medications, 4 of which are oncology drugs:
  • Acalabrutinib (Calquence; AstraZeneca)
  • Palbociclib (Ibrance; Pfizer)
  • Pomalidomide (Pomalyst; Bristol Myers Squibb)
  • Enzalutamide (Xtandi; Astellas Pharma/Pfizer)
• For 2028, the third phase of negotiated prices and another list of 15 medications covered under Medicare Part B and D are predicted—10 for Part B and 5 for Part D—to encompass an additional 4 oncology drugs^3-6:
  • Pembrolizumab (Keytruda; Merck)
  • Romiplostim (Nplate; Amgen)
  • Nivolumab (Opdivo; Bristol Myers Squibb)
  • Atezolizumab (Tecentriq; Genentech)

There will be a tremendous impact on practices, Ferreyros noted, emphasizing the massive financial implications and practice-ending shifts that by 2028 could include significant financial losses by way of reductions in Part B reimbursement. Under the IRA’s Maximum Fair Price (MFP) model, studies from Avalere Health predict reductions in Part B add-on reimbursement of 49.5% for medical oncology/hematology providers, 33.8% for rheumatology providers, 49.1% for all physicians, and 47.2% for all providers (physicians and hospitals).⁷ Meanwhile, under the cost-recovery model for Part B add-on reimbursement, the corresponding reductions would be 63.8%, 64.7%, 64.9%, and 62.9%.

Austin Cox, PharmD | Image Credit: Florida Cancer Specialists & Research Institute

The decisions around adopting a prospective reimbursement model vs a retrospective one, therefore, are complex, with contributing factors that include flow volatility, reconciliation, and heightened risk of audits—in addition to predicted delays and inefficiencies. Rollout remains unclear, with providers caught in the middle and not having standardized guidance to consult.

“This is going to be a considerable challenge for all of us,” Cox said. “Regardless of the model, whether it's retrospective or prospective, there's going to be [full-time equivalent] consumption there. There's going to be an enormous amount of education that needs to go in place.”

Community oncology needs to come together to preserve access to care and sustain independent care delivery, with advocacy, cost accounting, and strategic diversification no longer optional—they are essential. | Image Credit: Jo Panuwat D-stock.adobe.com

Another fear is long-term damage to innovation, with the significant reductions in reimbursement leading many to fear disincentives for drug development.

“We had some of our friends from the manufacturer side and pharma talk about how the manufacturers are going to respond when there's less money for them to do clinical trials,” stated McAneny. “There's no point in adding a third and fourth and fifth indication if you're going to run out of your patent in 2 years—and that will have an impact on us.”

Independent practices are in an especially precarious position, with the potential for failure greater when not backed by a hospital system. Collaboration, transparency, and refining of reimbursement pathways are all necessary to avoid irreversible harm.

“My fear, and I have a lot of fear about this, [is] Congress didn't intend for this to happen. They were not after the practices. They were not after the delivery system. They just thought, 'Here's a clever way we can negotiate drug prices lower,'” McAneny continued. “My concern is that as this rolls through—starting next year, we will start to see the decline in the margin that we get from the drugs that both in Part D and eventually B—practices will start to fail.”

Structural Uncertainty

Rural and underserved areas are in an especially precarious position from an unsustainable drug reimbursement model. The disturbing implications are that countless patients can be displaced and costs will increase overall, with care having to be funneled into more and more hospital system—an outcome that contradicts the IRA’s ultimate end point to lower health care spending, the panel concurred.

“We have this entire untested system,” Ferreyros said, “…and here you are in the real world with a patient in front of you trying to figure out how you’re going to stay open.”

The panel is calling for a unified strategy. One that sees lawmakers being educated on the implications to community practices of these drug pricing changes, the value-based care arms of payers being engaged in fruitful conversation, and manufacturers and group purchasing organizations—whose goal is to help member health care systems save money and realize savings and efficiency by leveraging collective purchasing power to negotiate discounts.⁸

Barbara McAneny, MD, FASCO, MACP | Image Credit: New Mexico Oncology Hematology Consultants

“The next step is to say, ‘[Congressperson], in your district, there will be X number of cancer patients who are not going to be able to get what they need,’ because they do care about them,” McAneny said. “We're going to have to band together to look at this.”

Practices are also being urged to educate themselves—if they haven’t already—on the true cost of care delivery, which will help them when it comes time to negotiate contracts. Tied into this is the misconception that all physicians only want to prescribe expensive drugs and treatments to make a profit and that, as a result, policy from Washington, DC, is misguided to compensate for those missteps. Data are key to backing up these arguments and combatting the narrative that removes patients at the center, replacing them with dollar signs and percentages and legislation that puts them at a care disadvantage, while pharmacy benefits managers (PBMs), insurers, and payers are being left alone, Ferreyros explained.

Sustainability

The panelists sent out the call that drug margins are vanishing and that without new payment models, practices will struggle to survive. Revenue needs to shift from drugs to transparent payments for services—infusion, imaging, and specialty care, to name a few.

They also made sure to note that the threat extends beyond Medicare to the possibility that commercial payers may embed MFP clauses into contracts, thereby accelerating revenue loss, the so-called “average sales price death spiral,” according to Ferreyros.

Cox concurred, explaining, “I thought that this was just going to be a part B problem, but we're starting to hear rumblings that even the commercial payer agreements that are coming out have MFP language in them on the D side. I’m also concerned that we could see that in the prescription benefit space as well.”

Practices are attempting to diversify in order to adapt to these changes—integrating neurology, rheumatology, imaging, and new therapies—to stabilize revenue. But as McAneny explains above, engagement with lawmakers also is necessary and is urged as part of overall advocacy efforts. PBMs were singled out as ripe for reform, with allegations of siphoning profits without adding value.

The speakers stress urgency in preparing now, advocating relentlessly, and always being ready for further disruption—whether from the IRA or future federal reforms. Community oncology needs to come together to preserve access to care and sustain independent care delivery, they emphasized. Advocacy, cost accounting, and strategic diversification are no longer optional. They are essential.

References

1. Mattina C. CMS releases list of 10 drugs subject to price negotiation under IRA. AJMC^®. August 29, 2023. Accessed May 28, 2025. https://www.ajmc.com/view/cms-releases-list-of-10-drugs-subject-to-price-negotiation-under-ira

2. Bonavitacola J. Next round of Medicare drug price negotiations to include semaglutide. AJMC. January 17, 2025. Accessed May 28, 2025. https://www.ajmc.com/view/next-round-of-medicare-drug-price-negotiations-to-include-semaglutide

3. Dickson S, Hernandez I. Drugs likely subject to Medicare negotiation, 2026-2028. J Manag Care Spec Pharm. 2023;29(3):229-235. doi:10.18553/jmcp.2023.29.3.229

4. Fact sheet: Medicare drug price negotiation program draft guidance for initial price applicability year 2028 and manufacturer effectuation of the maximum fair price in 2026, 2027, and 2028. CMS. May 2025. Accessed May 28, 2025. https://www.cms.gov/files/document/ipay-2028-draft-guidance-fact-sheet.pdf

5. Cubanski J. FAQs about the Inflation Reduction Act’s Medicare drug price negotiation program. KFF. January 23, 2025. Accessed May 28, 2025. https://www.kff.org/medicare/issue-brief/faqs-about-the-inflation-reduction-acts-medicare-drug-price-negotiation-program/

6. Preparing for the IRA’s impact on community oncology. Presented at: Community Oncology Conference; April 29-30, 2025; Orlando, FL.

7. Sullivan M, Tripp A, Isaiah E, Diskey R. IRA Medicare Part B negotiation shifts financial risk to physicians. Avalere Health. November 29, 2022. Accessed May 30, 2025. https://advisory.avalerehealth.com/insights/ira-medicare-part-b-negotiation-shifts-financial-risk-to-physicians

8. What is a GPO? Healthcare Supply Chain Organization. Accessed May 30, 2025. https://supplychainassociation.org/about-us/what-is-gpo/