Reimbursement Cuts Threaten Access to Cancer Care

Oncology providers and advocates discussed future implications of declining reimbursements and the urgent need to collaborate with both payers and policymakers—and with each other—to improve patient access and practice viability.¹

The 2025 Patient-Centered Oncology Care^â (PCOC) Conference panel discussion, “In a Wave of Change: Advocacy Is Everyone’s Job,” on September 25, enlisted panelists to break down the current state of oncology reimbursement amid declining Medicare and Medicaid budgets. Cuts to Medicaid will impact individuals who are financially dependent on government aid for health care services, as well as rural health systems that treat a significant percentage of underserved populations.^2,3 Furthermore, panelists explained the current barriers they face as providers trying to treat their patients with projected cuts to Medicaid and Medicare.

Moderator David Eagle, MD, a hematologist-oncologist and chair of legislative affairs and patient advocacy for New York Cancer and Blood Specialists, began the discussion by asking fellow panelists how the current reimbursement climate affects their ability to efficiently treat patients.

The Current State of Payer Reimbursements

Ben Jones, vice president of government relations and public policy at The US Oncology Network, described significant reimbursement disparities over the past 20 years. Payments have doubled in hospital settings but have plateaued in community practices, likely influenced by the lack of Medicare site neutrality.^1,4 Jones advised moving away from short-term fixes to reimbursement disparities and encouraged a provider reimbursement plan that accounts for current inflation rates.

“It makes no sense that, from a provider’s perspective, every cost that they incur goes up 20%, but reimbursement stays flat, or we’re fighting to save just a couple percent off,” Jones said.

Jones then continued to describe the financial implications of Medicare site neutrality. Traditionally, Medicare’s payment structure reimburses hospital systems more for the same services than independent physician offices. Thus, leading hospitals and community care centers to buy out physician practices, pushing patients toward more profitable health care provider sites.⁴

Another panelist, Sucharu “Chris” Prakash, MD, director of quality services for Texas Oncology and medical director for its office in Paris, Texas, emphasized the monopoly that hospital systems have become. Not only is there horizontal integration of health systems buying physician practices, but there is also vertical integration among insurers, pharmacy benefit managers (PBMs), pharmacies, and physicians, all owned by a single entity.

“Why is that a problem? Because that will drive care away from the community, especially in the rural settings, over to the hospital setting,” Prakash said. “And that’s bad because the hospital care we know is more expensive. It wastes time, but there’s no choice. Patients have to do whatever they’re told and go wherever they’re told.”

Panelist James Lee, MSHLS, director of state regulation and policy for the Community Oncology Alliance, offered advice on approaching policymakers, emphasizing the need to destigmatize the perception of these leaders as “celebrities” and see them as regular people. He said it would help drive actionable conversations about the necessary services physicians provide and how investing in relationships with policymakers needs to be consistent to see change.

“You introduce your business, and you talk about the value you bring to your community,” Lee said.

Critical Issues in Reimbursement Disparities

Medicaid expansion, although a nationwide issue, will affect individual states differently. For example, Prakash practices in Texas, where Medicaid was not expanded, but he said the cuts will still have a significant impact on rural and disadvantaged populations.¹

“Rural communities—this population that’s socioeconomically disadvantaged—depend on some kind of assistance,” Prakash said. “[Whether that be] government health care, prescriptions, or transportation, [they’re looking at] 2 hours away from the center, sometimes each way. They could use a lot of help. If we’re going to have a Medicaid cut, that’s going to pose a huge issue.”

Similarly, places such as Eagle’s New York practice and those that accept all forms of insurance, including Medicaid, will also struggle. Eagle explained that in his practice, as the only major oncology provider in the New York City/Long Island area, Medicaid reimbursement constitutes almost one-third of his practice’s income.⁵

Furthermore, Lee pointed out that PBM reform could potentially combat the monopolization of health care systems and related entities. The Rutledge v Pharmaceutical Care Management Association ruling from the Supreme Court of the United States requires that PBMs reimburse pharmacies for the full cost of prescription drugs. This ruling was only the beginning of regulating PBMs, panelists said. At the time of the PCOC meeting, Arkansas had passed a law to prohibit PBMs from owning or operating a pharmacy within the state; however, a federal judge had put the law on hold.⁶

“I think we’re going to see more and more conversation about states’ ability to continue to act on PBM reform,” Lee said. “As states have introduced more and more measures to regulate PBMs, they keep trying new ways to get across or to sidestep the new policy and new reforms that states are implementing.”

Eagle and the other panelists compounded on Lee’s point, emphasizing the unnecessary challenge PBMs pose. Eagle even described them as “just insurance companies that own pharmacies.” The panelists also agreed that policy reform regulating PBMs is difficult as PBMs continue to misconstrue the levels to which they can be regulated, claiming regulations should be conducted at the federal level or at the state level, or claiming their acts are protected by the Employee Retirement Income Security Act of 1974.^1,6

Texas is another state that made significant progress in overcoming prior authorizations (PAs) and breaking down some of the barriers PBMs created. The state recently passed a law that will make chimeric antigen receptor T-cell therapy more accessible to patients in rural areas. Previously, oncology therapy centers in the state of Texas required a costly and complex accreditation from the Foundation for the Accreditation of Cellular Therapy.⁷

“Pretty much any center that’s equipped to do this therapy does not need to go through the process of accreditation and certification to say, ‘We’re a center of excellence,’” Prakash said. “I think that’s going to open up this therapy to a lot more patients. And again, like we were saying earlier, I think advocacy can make a change.”

Jones and Eagle also emphasized the burden PAs pose, especially in Medicare Advantage, which were rarely required previously.⁸ A blanket PA for CMS began in February 2016 to protect against fraud in Medicare home health agencies. Similar to private insurers, Medicare PAs have led to unnecessary delays and denials of necessary care for beneficiaries.⁸

“This is not the direction that we want to go in Medicare; in traditional Medicare, even if they start small,” Jones said.

Eagle also attested to the challenges that his patients face due to the Medicare PAs.

“When we intentionally throw sand into the gears of health care, that just absolutely makes me crazy because my patients, particularly my complex [patients with] cancer, have to interact with the health care system so often, and it exhausts them,” Eagle said. “It’s senseless…and I think it’s just an awful thing.”

Change Through Advocacy as a Practitioner

Practitioners are responsible for treating their patients but should also be responsible for enacting changes to benefit the health and well-being of their patients, Lee said. Conversations with policymakers, engaging in community meetings, and inviting policymakers into your practice are a few ways Lee encouraged physicians to demonstrate the value of their work to those with the power to make decisions that would improve the lives of patients.

Jones also mentioned advocacy websites for physicians that provide all the information they need to advocate on behalf of their patients to representatives of Congress.

“They need to understand all of the costs the practices incur that aren’t reimbursed anywhere else,” Jones said. “That’s the critical piece that needs to be understood by the policymakers, because that’s what they don’t get.”

The session concluded on that note of encouraging ways to engage in advocacy as a physician. It’s important to be diligent and start early.¹

“It’s really about that relationship building to help them understand and help this individual ultimately decide the future of what’s impacting your practices and what’s impacting your patients,” Lee said.

References

1. Eagle D, Jones B, Lee J, Prakash S. In a wave of change: advocacy is everyone’s job. Presented at: 2025 Patient-Centered Oncology Care Conference; September 25-26, 2025; Nashville, TN.

2. McNaughton J. IEHP CEO weighs in: who pays the price when millions lose Medicaid coverage? AJMC. October 23, 2025. Accessed October 27, 2025. https://www.ajmc.com/view/who-pays-the-price-when-millions-lose-medicaid-coverage-

3. McCrear S, Escudier S. Financial barriers to accessing oncology care with Susan Escudier, MD. AJMC. October 21, 2025. Accessed October 27, 2025. https://www.ajmc.com/view/financial-barriers-to-accessing-oncology-care-with-susan-escudier-md

4. Choi J. Leveling the playing field with site-neutral Medicare payments. Medicare Rights Center. September 3, 2025. Accessed October 27, 2025. https://www.medicarerights.org/medicare-watch/2025/09/03/leveling-the-playing-field-with-site-neutral-medicare-payments

5. Brown ECF, McCuskey EY. The implications of Rutledge v PCMA for state health care cost regulation. Health Affairs. December 17, 2020. Accessed October 27, 2025. https://www.healthaffairs.org/do/10.1377/forefront.20201216.909942/#:~:text= In Rutledge v., drug benefits for health plans

6. Arkansas General Assembly. Act 624 (HB 1150), 95th General Assembly, Regular Session (2025). Accessed Oct 25, 2025. https://arkleg.state.ar.us/Home/FTPDocument?path=%2FACTS%2F2025R%2FPublic%2FACT624.pdf

7. New Texas law aims to expand access to cutting-edge cancer treatment in rural areas. Texas Oncology. June 26, 2025. Accessed October 27, 2025. https://www.texasoncology.com/news-and-resources/2025/New-Texas-law-aims-to-expand-access-to-cutting-edge-cancer-treatment-in-rural-areas

8. Medicare prior authorization. Center for Medicare Advocacy. Accessed October 28, 2025. https://medicareadvocacy.org/prior-authorization/