IRA, 340B, Medicaid: The Policy Pressures on Community Oncology

Drug price negotiation, Medicaid coverage changes, insurer utilization management, and 340B reform are stacking financial pressure on community oncology practices, with one panelist estimating reimbursement could fall 30% to 40% without a legislative fix, according to oncology policy leaders during a panel at The American Journal of Managed Care^®’s annual Patient-Centered Oncology Care® conference.

The “Washington Ways Without Means” session was moderated by Nick Ferreyros, managing director of policy, advocacy, and communications at the Community Oncology Alliance. Panelists were Alyssa Schatz, DrPH, MSW, vice president of policy and advocacy at the National Comprehensive Cancer Network (NCCN); Aaron Lyss, MBA, senior director of payment policy and innovation at OneOncology; and Robert “Bobby” Wamble, PharmD, director of pharmacy business at Park Pharmacy, the medically integrated specialty pharmacy associated with Tennessee Oncology.

How IRA Price Negotiation Could Cut Oncology Practice Payments

Lyss said rising cancer care costs and the rising cost of delivering that care are “2 math problems…escalating in conflict with each other.” Without passage of a proposed bill, HR 4299, “Protecting Patient Access to Cancer and Complex Therapies,” he said practice reimbursement would decline approximately 30% to 40%. Such a drop would be unsustainable for practices, driving consolidation and limiting access, Lyss said. If it passes, Inflation Reduction Act (IRA) price reductions would come through manufacturer rebates to CMS rather than lower payments to practices, he explained.

Wamble said the Part D side of the IRA is already complicating planning. Park Pharmacy focuses on oral oncolytics, and he noted that significant agents have Medicare-negotiated prices taking effect in 2027—palbociclib (Ibrance; Pfizer) for breast cancer, enzalutamide (Xtandi; Astellas Pharma and Pfizer) for prostate cancer, pomalidomide (Pomalyst; Bristol Myers Squibb) for multiple myeloma, and acalabrutinib (Calquence; AstraZeneca) for certain leukemias and lymphomas.^1,2

Practices face a problem either way: waiting on manufacturer rebates or seeing a manufacturer lower its wholesale acquisition cost (WAC), the list price, Wamble explained. Practices of any size, from a single clinic to a large group like Texas Oncology, could have significant sums tied up in a "churn of rebate," money that can't go toward supporting providers and patients, he said. The problem will compound each year as more drugs are added to the negotiation list.

“I'm a pharmacist, so I only count by fives,” he joked, adding that money tied up in a constant rebate cycle “sounds like an accounting nightmare to me.”

Medicaid Cuts and Work Requirements Raise Risk for Patients With Cancer

Schatz focused on coverage and explained that NCCN is concerned about Medicaid coverage losses and about growth in catastrophic and other plans with fewer protections, particularly for people not yet diagnosed with cancer. With states now implementing Medicaid cuts and community engagement requirements, she said patients, survivors, and caregivers are at risk.^3,4

“The community engagement requirements are really not structured well to appropriately exempt those people from the requirements,” she said.

The medical frailty exception, Schatz said, will require extensive paperwork and physicians certifying whether patients can work, “which sometimes is a fuzzy area.” She added that the caregiver definition generally covers people caring for someone disabled or a minor, not someone with cancer. NCCN is piloting educational materials with members and authoring an article in the Journal of the National Comprehensive Cancer Network on the exception criteria.

Radiation Oncology Coding Changes Squeeze Practice Revenue

Radiation oncology was in a “very threatened position” a year ago, Lyss said, as CMS moved toward a 2026 fee schedule that included a 2.5% “efficiency adjustment” to work values for many services and a consolidated set of radiation treatment codes.⁵ Medicare's implementation of the coding changes in January mitigated some of the impact,⁶ he said, but the biggest economic threat came from how commercial payers applied them. Intensive work with private payers to restructure reimbursement has since "steadied the ship," he said.

That episode fits a broader pattern, the speakers said. "It does feel like for the last 10 years, policymaking in general has just been responding to crisis after crisis with short-term fix, short-term fix," Schatz said. Lyss added, "The next thing could be the thing that breaks the system, and that's never a position that anyone should put anyone in."

Prior Authorization and Step Therapy Still Burden Practices

Insurer utilization management drew some of the sharpest comments. Ferreyros said insurer pledges with HHS on prior authorization reform⁷ have “not changed things at all for practices.” Wamble’s experience has been that nearly 100% of prior authorizations end up getting approved, even if they were first denied. He further argued that with guidelines in oncology, there’s even less reason for prior authorizations.

“If you're a payer, you're spending time, money, resources to implement this prior authorization process,” he said. “As a practice, we're spending time, money, resources. You're not really blocking anything. You're not really creating any savings. What's the gain?”

Schatz said she worries more about a rise in step therapy. While prior authorization can delay care and be administratively burdensome and costly, appeals are ultimately successful, and the treatment decision doesn’t change, she said.

“With step therapy, the insurance company is saying, ‘We disagree. We think that you should use this [treatment] instead,’ including in some cases where [the treatments] are not interchangeable,” Schatz said. “That actually leaves me more concerned.”

CMS 340B Payment Proposal Puts Spotlight on Program Reform

Ferreyros said a CMS proposal would pay for 340B-acquired drugs at average sales price minus 33.4% next year, down from ASP plus 6%, after the administration's earlier attempt was struck down by the Supreme Court because CMS hadn't surveyed acquisition costs.^8,9 Lyss said the proposal levels the playing field, particularly for entities that used the 340B Drug Pricing Program to drive consolidation of cancer care into health systems, but that lasting reform would have to tie eligibility and economic benefits “to the patients that should benefit from them.”

“Washington loves its blunt instruments of reform,” Ferreyros said, noting about half a dozen bills addressing 340B remain pending in Congress.

Wamble questioned what comes next for health systems reliant on 340B revenue. “Is that going to drive more consolidation? Are they going to get way more aggressive in going out and trying to acquire more independent practitioner groups?” he asked.

Panelists Urge Congress to Support Community Oncology

In closing remarks, Schatz urged Congress to reduce unnecessary utilization management and ensure comprehensive coverage, noting that “the health of that system is the health of the whole system.” Wamble said keeping community oncology payment site-neutral compared with hospital outpatient departments offers Congress savings, calling it “a math problem.” Lyss cautioned against fixes that hinder lower-cost community delivery and urged empowering community practices to participate more in drug development.

Ferreyros said the system needs Washington's support and fair payment. “We also need to pay equitably and fairly for the care that is delivered and not shortchange the physicians and the community oncology practices along the way,” he said.

References

1. Bonavitacola J. Next round of Medicare drug price negotiations to include semaglutide. AJMC^®. January 17, 2025. Accessed September 29, 2026. https://www.ajmc.com/view/next-round-of-medicare-drug-price-negotiations-to-include-semaglutide

2. Shaw ML. Community oncology bracing for IRA impact. AJMC. May 31, 2025. Accessed September 29, 2026. https://www.ajmc.com/view/community-oncology-bracing-for-ira-impact

3. Steinzor P, Brueggeman D. How MCOs should be preparing for the OBBBA's Medicaid cuts: David Brueggeman, MBA. AJMC. June 18, 2026. Accessed September 29, 2026. https://www.ajmc.com/view/how-mcos-should-be-preparing-for-the-obbba-s-medicaid-cuts-david-brueggeman-mba

4. McCrear S. CMS Medicaid work requirements may reshape coverage for millions by 2027. AJMC. June 2, 2026. Accessed September 29, 2026. https://www.ajmc.com/view/cms-medicaid-work-requirements-may-reshape-coverage-for-millions-by-2027

5. CMS Modernizes Payment Accuracy and Significantly Cuts Spending Waste. News release. CMS. October 31, 2025. Accessed September 29, 2026. https://www.cms.gov/newsroom/press-releases/cms-modernizes-payment-accuracy-significantly-cuts-spending-waste

6. Beatley E. Major radiation oncology code changes in 2026. ASTROnews. Winter 2026. Accessed September 29, 2026. https://www.astro.org/news-and-publications/astronews/2026/winter-astronews/society-news/major-radiation-oncology-code-changes-in-2026

7. HHS Secretary Kennedy, CMS Administrator Oz secure industry pledge to fix broken prior authorization system. News release. HHS. June 23, 2025. Accessed September 29, 2026. https://www.hhs.gov/press-room/kennedy-oz-cms-secure-healthcare-industry-pledge-to-fix-prior-authorization-system.html

8. Hohmann E. 340B drug payment cuts headline CMS proposal to lower Medicare costs. AJMC. July 7, 2026. Accessed September 29, 2026. https://www.ajmc.com/view/340b-drug-payment-cuts-headline-cms-proposal-to-lower-medicare-costs

9. Joszt L. Supreme Court unanimously rules in favor of hospitals in 340B decision. AJMC. June 14, 2022. Accessed September 29, 2026. https://www.ajmc.com/view/supreme-court-unanimously-rules-in-favor-of-hospitals-in-340b-decision