Volume 15, Issue 3, December 2004   
The Nurse Practitioner SIG Newsletter is underwritten through a grant from Amgen Inc.
     
Medicare Modernization Act Impacts the Provision of Physician Office-Based Cancer Care

Ilisa M. Halpern, MPP
ONS Health Policy Associate
Washington, DC
ihalpern@gcd.com


Since the enactment of the Medicare Modernization Act (MMA), ONS has been very active in monitoring its implementation because it has numerous provisions related to the provision of cancer care. The MMA—signed into law on December 8, 2003 (Public Law 108-173)—provides seniors and individuals with disabilities with a prescription drug benefit starting in 2006, offers temporary coverage for some oral anticancer drugs in the interim period, and contains significant modifications to the way in which the Medicare program pays for chemotherapy provided to patients in physician office settings. 

In late July, the Centers for Medicare and Medicaid Services (CMS)—the federal agency that oversees the Medicare program—released the proposed 2005 physician fee schedule that contained the agency's projected payments for cancer care drugs and services provided in physician office settings. Early estimates suggest that if the changes are implemented in 2005, cancer care resources will be reduced by more than $500 million. According to that data released by CMS, some physician-administered drugs could be cut by as much as 89%. In the proposed rule, CMS released a table for 32 widely used prescription drugs, illustrating the difference between 2004 and 2005 payment rates and that a majority would be cut from 2%–89%. According to CMS, these cuts would result in net savings in 2005 of $530 million to Medicare; savings to Medicare beneficiaries who pay 20% coinsurance would be $270 million. Last year, the Medicare program paid $10.5 billion for prescription medicines administered in physician offices and clinics, most of which were cancer-related treatments. CMS Administrator Mark McClellan reported that revenues for oncologists and hematologists could decline 2%–8%, but the American Society of Clinical Oncology (ASCO) estimates that the reductions could be greater.

 
The Nurse Practitioner SIG Newsletter is produced by members of the
Nurse Practitioner SIG and ONS staff and is not a peer-reviewed publication.


Special Interest Group Newsletter  December 2004
 
   


Medicare Modernization Act Impacts the Provision of Physician Office-Based Cancer Care

Ilisa M. Halpern, MPP
ONS Health Policy Associate
Washington, DC
ihalpern@gcd.com

Since the enactment of the Medicare Modernization Act (MMA), ONS has been very active in monitoring its implementation because it has numerous provisions related to the provision of cancer care. The MMA—signed into law on December 8, 2003 (Public Law 108-173)—provides seniors and individuals with disabilities with a prescription drug benefit starting in 2006, offers temporary coverage for some oral anticancer drugs in the interim period, and contains significant modifications to the way in which the Medicare program pays for chemotherapy provided to patients in physician office settings. The major MMA changes related to cancer care include

  • Removing an approximately $11.5 billion cut from oncology care over the next 10 years—achieved principally by shifting the 95% of average wholesale price- (AWP-) based reimbursement for drugs to 85% of AWP in 2004 and moving to average sales price + 6% for 2005 and beyond.
  • Paying an additional 32% for practice expenses for essential cancer care services in 2004, but this serves as merely a transitional payment. In 2005, practice expense reimbursement will decrease 29 percentage points to a 3% increase, and no additional funds are provided for 2006 and thereafter.
  • Allowing physicians to obtain chemotherapy prepared by an outside vendor chosen by the federal government via a competitive bidding process. Every year, each physician would elect whether to obtain drugs from a contractor or purchase them on their own and seek reimbursement (as is the current practice).a
  • Providing transitional coverage for some oral anticancer drugs until the comprehensive prescription drug benefits begins in 2006. To view a list of the currently covered drugs, visit www.cms.hhs.gov/researchers/demos/DRUG_list_8302004.pdf
  • Extending Medicare coverage to include some preventive care services, such as a “welcome to Medicare physical” consisting of a comprehensive examination when beneficiaries first enroll in the program (including education, counseling, and referrals to other preventive services).b

In late July, the Centers for Medicare and Medicaid Services (CMS)—the federal agency that oversees the Medicare program—released the proposed 2005 physician fee schedule that contained the agency's projected payments for cancer care drugs and services provided in physician office settings. Early estimates suggest that if the changes are implemented in 2005, cancer care resources will be reduced by more than $500 million. According to that data released by CMS, some physician-administered drugs could be cut by as much as 89%. In the proposed rule, CMS released a table for 32 widely used prescription drugs, illustrating the difference between 2004 and 2005 payment rates and that a majority would be cut from 2%–89%. According to CMS, these cuts would result in net savings in 2005 of $530 million to Medicare; savings to Medicare beneficiaries who pay 20% coinsurance would be $270 million. Last year, the Medicare program paid $10.5 billion for prescription medicines administered in physician offices and clinics, most of which were cancer-related treatments. CMS Administrator Mark McClellan reported that revenues for oncologists and hematologists could decline 2%–8%, but the American Society of Clinical Oncology (ASCO) estimates that the reductions could be greater.

CMS was expected to finalize the payment levels for 2005 by December 1 for January 1, 2005, implementation. Some cancer community advocates have asked Congress to freeze payments at current levels until various agencies conduct and complete studies of the new reimbursement rates. However, Congress unlikely will take such action given the short timeframe left in this Congressional session. One ray of hope is that CMS has suggested that the possibility exists of increasing reimbursement for practice expenses associated with the provision of chemotherapy vis-à-vis new codes. Moreover, because the payment rates will not be finalized until later in the fall, cancer community advocates will have an opportunity to make their case to the agency. As such, ASCO has submitted a series of proposals to the American Medical Association (AMA) Current Procedural Technology (CPT) Drug Infusion Workgroup. The proposals ASCO has developed would establish the following changes to the CPT.

  • New codes specific to IV infusion of monoclonal antibodies
  • New codes for complex management of drug therapy for chemotherapy regiments and non-chemotherapy regimens
  • A new code for physician management of complications arising from parenteral drug administration
  • New add-on codes to reflect the infusion of multiple drugs during the same encounter
  • Revisions to the codes for port access and management services

Should AMA accept ASCO's proposal, the next step is presenting the new codes and associated reimbursement rates to CMS for its consideration for inclusion in the final 2005 physician fee schedule. ONS is in close communication with ASCO on this and other MMA-related implementation concerns and will be submitting comments to CMS in support of new practice expense codes and increased reimbursement rates for the services provided by oncology nurses and others on the cancer care team. Although ONS, ASCO, and others in the cancer community have articulated concerns about the impact that MMA will have on access to quality cancer care, the Congressionally mandated studies of access to drugs and services because of inadequate payments are not due out until 2006.

ASCO has reported in its newsletter, MMA Today, that ASCO leaders and their colleagues are considering staff reductions and curtailing ancillary services, including computers and software, as a result of the cuts. Some practices also are considering reducing or eliminating services provided at their rural clinics and diminishing participation in clinical trials. ONS and others in the cancer community are concerned that the reimbursement levels that are to take effect in 2005 and 2006 may result in limited access to quality, comprehensive cancer care, particularly in traditionally underserved communities. As such, ONS has been engaged in a comprehensive effort to ensure that the voice of oncology nursing is heard by our nation's policymakers as these changes take effect and that ONS is doing its part to help ensure that Medicare beneficiaries with cancer continue to receive the quality, comprehensive cancer care they need and deserve.

The following are some highlights of ONS's recent advocacy efforts related to MMA implementation. For more information about these activities and other related health policy issues, please visit the ONS Legislative Action Center.

  • ONS has submitted numerous comments and testified before the CMS regarding the Society's concerns about the MMA cancer reimbursement changes and CMS's proposed rules for Medicare chemotherapy-related reimbursement in 2004 and 2005.
  • ONS has communicated the Society's concerns to members of Congress and key Congressional committees and their staff.
  • ONS leaders met with policy analysts at the Medicare Payment Advisory Commission (MedPAC), which is conducting an MMA-required study of oncology nursing and other practice expenses related to the provision of chemotherapy in physician office settings.
  • ONS has worked with the Department of Health and Human Services, CMS, and the cancer community to help make seniors with cancer aware of—and enroll in–the MMA demonstration program that provides temporary coverage in 2004 and 2005 for some oral anticancer drugs.

In addition, ONS is conducting regular (approximately every six months) surveys of ONS members who work in private practice settings to glean information about their experiences with MMA and its effects and capture any changes in status that occur over time. The first of the surveys was conducted in the spring, and the results were made available over the summer to ONS cancer community partners, members of Congress and their staff, and key policymakers in CMS and other federal agencies involved in MMA implementation and monitoring. The survey was conducted electronically via e-mail using an online survey subscription service called Zoomerang. It was sent to 3,248 ONS members and completed by 487 respondents for a response rate of approximately 15%. The goal of the survey was to get a snapshot of what ONS members were currently experiencing in their work settings. The survey was not highly scientific in its methodology but rather provided a quick means by which anecdotal information could be gleaned. Although respondents had some concern about what the future may hold, thus far, none of the respondents had lost their jobs or closed their practices. Of serious concern is that some nurses reported that the choice of certain therapies for some Medicare patients is being driven by reimbursement rates. Moreover, of similar concern is that some nurses reported that Medicare beneficiaries without supplemental coverage are being referred to other care site settings that may be less convenient or maintain a lesser capacity in the provision of oncology care. Although these reports are anecdotal and anonymous, ONS has concerns that the quality of care for people with cancer—particularly those in the Medicare program—may be threatened because of insufficient Medicare reimbursement for chemotherapy administration, supportive care, and the therapies themselves. Positive pieces of information related to this survey are that results can be interpreted as valid at the +5% level, results indicate that most respondents are familiar with Medicare reimbursement changes, a large number of respondents reported contacting Congress, and many anecdotal comments can be used to gain perspective on the impact of the MMA and guide additional work to explore the issue. Some Web-based resources for MMA implementation include

Centers for Medicare and Medicaid Services MMA Information
ONS MMA Summary
ONS Final Outcome of Medicare Legislation
ONS's Comments to Congress and CMS on MMA implementation

To help ensure that your voice is heard on this and other priority oncology care and practice issues, please join ONStat, ONS's electronic grassroots network. Through ONStat, ONS members receive notification of when advocacy action is needed on a priority ONS issue, the quarterly Capitol Hill Electronic Advocacy Report newsletter, and information about their elected officials so oncology nurses can be effective advocates at home and in Washington. To sign up for ONStat, visit http://onsopcontent.ons.org/interactive/onstat/signup.aspx.

a Under this new outsourcing system, an oncology practice would order the needed therapies from a third-party vendor, which would prepare and deliver the chemotherapy drugs to the practice after they are ordered, a method which in most instances, if not all, precludes same-day delivery. This represents a significant change in the current practice of oncology, whereby practices maintain pharmacies onsite and can deliver the appropriate drugs to patients at the time they are seen by the physicians and nurses on their cancer care reams. ONS has serious concerns about this new system, namely that timely, convenient, and safe administration of treatment to Medicare beneficiaries will be virtually impossible because patients likely will not be able to receive treatment the day it is prescribed and practices will be unable to confirm the manner and circumstances under which the drugs have been prepared and handled.

b Already covered preventive cancer-related services include mammography, screening Pap tests and pelvic examinations, prostate cancer screenings, and fecal-occult blood tests, flexible sigmoidoscopies, barium enema, or colonoscopies to screen for colorectal cancer.

 
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Special Interest Group Newsletter  December 2004
 
   


Medicare Coverage Extended to Include Some Oral Anticancer Drugs for Some Patients

Ilisa M. Halpern, MPP
ONS Health Policy Associate
Washington, DC
ihalpern@gcd.com


ONS urges its members to help qualified Medicare beneficiaries access the transitional Medicare coverage for oral anticancer therapies available between now and 2006 when the full Medicare prescription drug benefit becomes available. Under the Medicare Modernization Act (MMA), Congress provided a short-term benefit to provide coverage for certain oral anticancer therapies for some Medicare beneficiaries with cancer. This demonstration is limited to no more than 50,000 enrollees and $500 million in funding for drug costs. However, early responses suggest that the cap may not be met, so qualified patients should apply for the program.

To qualify for this demonstration, a patient must meet the following requirements: have Medicare Part A and Part B (Medicare must pay first for their healthcare services [called the primary payer]); have a signed document from his or her doctor (or nurse practitioner [NP] if the NP is writing the prescription for the demonstration covered drug) stating that he or she needs one of the drugs covered under this program for the specific covered condition; does not have comprehensive outpatient prescription drug coverage from any other insurance (other than a Medicare Advantage plan or Medigap policy), including Medicaid, TRICARE, or an employer or union group health plan or other source of comprehensive coverage for these drugs; and lives in one of the 50 states or the District of Columbia

The initial deadline for applications has passed, but because so many slots are available, Medicare has extended the deadline indefinitely until all slots are filled. To get an application, visit www.cms.hhs.gov/researchers/demos/drugcoveragedemo.asp or call 866-563-5386. TTY users should call 866-563-5387. Customer service representatives are available from 8 am–7:30 pm ET Monday–Friday. Medicare has contracted with TrailBlazer Health Enterprises, which will have trained staff ready to answer your questions and give you information about helping your patients apply for this program.

Applications will be considered under two categories: (a) those seeking coverage for a covered cancer drug and (b) those seeking coverage for any other replacement drug covered under the demonstration. Applicants will be notified in writing of their status regarding participation in the demonstration. If fewer applications are received than the maximum number of enrollees permitted (which seems very likely at this time) or than can be covered within the projected funding limits, then all eligible beneficiaries who have submitted applications by the deadline will be enrolled in the demonstration. To the extent that enrollment slots remain unfilled and Medicare projects available funding for additional participants, additional applications will be considered on a rolling basis after that date.
For more information about this program, visit
www.cms.hhs.gov/researchers/demos/FctSht_Benefic_REVISED_COSTS_070104.pdf or www.cms.hhs.gov/researchers/demos/MMAExternalQsAs_081304.pdf.

The Patient Advocate Foundation Patient Assistance Program offers Medicare beneficiaries assistance with meeting the copayment or coinsurance requirement of participation in this program. For more information, visit http://pap.patientadvocate.org.

 
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Special Interest Group Newsletter  December 2004
 
   


Check Out the Nurse Practitioner SIG Virtual Community

Bridget A. Cahill, ANP, NP-C
Chicago, IL
bcahill@nmff.org

This is just a friendly reminder that the Nurse Practitioner (NP) SIG Web site exists at www.ons.org under “Virtual Communities.” To find the NP SIG Web site, click on Special Interest Group Virtual Community and select Nurse Practitioner. This site provides a lot of valuable information. The Web site contains very important and useful information. NP documents such as job descriptions, standards of oncology for APNs, and billing information are available. Upcoming events are posted on the Web site. General announcements for ONS are posted. NP SIG favorites include ONS bylaws, ONS board members, and a link to www.aanp.org.

Since Congress, we have been trying to launch new programs on the Web site. Some of the programs include case studies for discussion, an NP list serve, and a mentorship program.

The case studies will be presented in the featured discussion area. If you have a concern regarding treatment or need assistance with a particularly difficult case, please feel free to e-mail the concern or comment to nursepractition-discussion@lists.ons.wego.net. To find the responses, select “Discussion” along the top and choose a Web page. Double click and enter the featured discussion area.

We currently are working on the NP list serve and the mentorship program. Details of these new programs will be in the announcement section of the Web site. The mentorship program would consist of volunteers to assist, develop, and nurture novice NPs in oncology.

Joyce P. Griffin-Sobel, RN, PhD, AOCN®, APRN-BC, editor of the Clinical Journal of Oncology Nursing (CJON), is looking for authors and has contacted us regarding topics that NPs would like to see in CJON and any interest in PDA downloadable features. Please feel free to contact her at cjoneditor@jsobel.com.

If you have any questions, ideas, comments, or concerns regarding the Web site, please contact me at bcahill@nmff.org.

 
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Special Interest Group Newsletter  December 2004
 
   


Find Legislative Issues for Oncology Nurse Practitioners on the Internet

Wendy H. Vogel, MSN, FNP, AOCN®
Kingsport, TN
wvogel@charter.net

Do you believe that you should be involved in legislative issues concerning health care but you just don’t know exactly what to do? Have you wanted to express your opinion about a particular issue, but you weren’t sure to whom to address your comments? Have you ever wanted to support a certain bill but didn’t know if it was being presented in the House or Senate, much less the bill number?

If you answered yes to any of these questions, you are not alone! Our governmental process can be overwhelming. So what is a busy oncology nurse practitioner to do? Come along with me for little Web surfing, and I will show you.

Let’s sit down at your computer and log on to the Internet. After you’ve browsed the headlines and looked at the weather, go to www.ons.org. Have you seen the new Web design yet? Very nice! Skim through this home page for the latest happenings, and then click on “Legislative Action Center.” It’s on the left-hand side of the page, under HOME, about four lines down. Are you there? Great!

This is where you can find out just what the issues are that could affect oncology nurses and our practice. If you would like to have these issues delivered to you on a regular basis, sign up for the ONStat Program. To do this, click on “Grassroots Advocacy” (located on the left, under HOME). Then you will see the link to sign up for regular alerts and policy updates. You can also click on the “CHEAR (Capital Hill Electronic Advocacy Report) newsletter” (on the left, under HOME). After you sign up with ONStat, you will receive CHEAR on a quarterly basis, right in your e-mail inbox!

In the CHEAR newsletter, you will find out about the status of ONS’s federal legislative priorities and associated advocacy activities. There are links that will take you right to the issues. You can read about the issues, learn the bill numbers, who supports this issue and who doesn’t, and much more. Now you are ready to roll.

You don’t have enough time to compose a letter? Not really clear on what exactly to ask for? And how in the world do you address a congressional representative? No problem! Click on “Action Alerts” (again, on the left-hand side). Then, click on the “Issues & Legislation” tab. Click on your issue. Scroll down a bit. Well, lookey here! (That’s what we say in East Tennessee. It means WOW! Look at that!) Here is a prewritten letter to your senator or representative. All you have to do is personalize it and fill in the blanks. Your personal story or experience is extremely valuable, but if you are already three patients behind, just fill in the contact information, click "remember me" (so you won’t have to do it again) and click “send message.” Depending on your congressional representative, you might have to select a topic for the subject line of your e-mail. Some public offices require this because of the amount of e-mail they receive daily. Click “Send Message” again and you are finished!

Now if you want to have your friends and family do the same, you can fill in up to six of your friends and colleagues’ e-mail addresses. An e-mail will send them a link to this Web site and they can send their own message. Wasn’t that easy? You have just been heard.

Two issues right now should be addressed by us as oncology nurse practitioners. One is tobacco, and the other is genetics. Lawmakers have voted to grant the U.S. Food and Drug Administration authority to regulate tobacco products. The House and the Senate bills are different in numerous areas, as you can imagine. So now this legislation will go to a conference committee where the differences will be worked out to develop a single, uniform measure. We need to urge our senators and representatives to support the Senate-passed version of the legislation. You can read all about this in the CHEAR newsletter or at www.tobaccofreekids.org/Script/DisplayPressRelease.php3?Display=776.

Another issue that really needs our help is the Genetic Information Nondiscrimination Act of 2003 (S 1053), which is stalled in the House of Representatives. The Senate has passed this act, and the White House and numerous public health organizations support it. We need to encourage members of the House to expedite this and bring the bill directly to the floor before the end of the 108th Congress. If you live in Texas, Illinois, or Ohio, you have some representatives who are key players. Your voice is especially vital. Regardless of where you live, though, we all need to send an e-mail to our representatives.

Ok, you can do it! Go out there and make a difference. Go surfing, and make a wave happen!

Bibliography
Oncology Nursing Society. (2004, August). Capitol Hill Electronic Advocacy Report. Retrieved August 20, 2004, from http://www.ons.org/lac/chear

Campaign for Tobacco-Free Kids. (2004, July). Public health groups applaud historic Senate vote to regulate tobacco products [Press release]. Retrieved August 20, 2004, from http://www.tobaccofreekids.org/Script/DisplayPressRelease.php3?Display=776


 
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Special Interest Group Newsletter  December 2004
 
   


Drug Update
Bevacizumab Offers Treatment Options for Colorectal Cancer

Diane G. Cope, PhD, ARNP, BC, AOCN®
Fort Myers, FL
ecope@attglobal.net


Introduction
Colorectal cancer is the third most common cancer in men and women, with an estimated 106,370 colon and 40,570 rectal cancer cases expected in 2004 (American Cancer Society [ACS], 2004). Mortality rates have declined over the past 15 years, however; an estimated 56,730 deaths are expected in 2004, accounting for approximately 10% of cancer deaths (ACS). The relative five-year survival rate for early-stage colon cancer is 90% but declines to only 5% for those with distant metastatic disease.

Avastin™ (bevacizumab, Genentech, South San Francisco, CA) is a new monoclonal antibody indicated for first-line treatment of patients with metastatic colon or rectal carcinoma. Avastin binds to and inhibits the biologic activity of human vascular endothelial growth factor (VEGF) with receptors on the surface of the endothelial cell. Normally, the combination of VEGF and these receptors leads to endothelial cell proliferation and new blood vessel formation or angiogenesis. Therefore, inhibition of VEGF reduces microvascular growth and inhibits metastatic disease progression.

Clinical Studies
The safety and efficacy of Avastin was studied in two randomized, controlled clinical trials in combination with IV 5-flourouracil- (5-FU-) based chemotherapy. The first study was a randomized, double-blind, controlled clinical trial evaluating Avastin as first-line treatment of metastatic colon or rectal carcinoma. Patients were randomized to bolus IFL (irinotecan, 5-FU, and leucovorin [LV] given once weekly for four weeks every six weeks) plus placebo (arm 1) (N = 411), bolus IFL plus Avastin every two weeks (arm 2) (N = 402), or 5-FU/LV plus Avastin every two weeks (arm 3). Arm 3 enrollment was discontinued when the toxicity of Avastin with bolus 5-FU/LV was deemed acceptable at 10 mg/kg every two weeks.

The primary endpoints were response rate and progression-free survival. In arm 1, the overall median survival was 15.6 months and progression-free survival was 6.4 months, compared to 20.3 months median survival and 10.6 months progression-free survival in arm 2. Overall response rate was 35% in arm 1 compared to 45% in arm 2 (Genentech Bio-Oncology, 2004; Hurwitz et al., 2004).

The second study was a randomized controlled trial evaluating Avastin in combination with 5-FU/LV as first-line treatment of metastatic colorectal cancer. Patients were randomized to 5-FU/LV weekly for six weeks every eight weeks (arm 1) (N = 36), 5- FU/LV plus Avastin 5 mg/kg every two weeks (arm 2) (N = 35) or 5-FU/LV plus Avastin 10 mg/kg every two weeks (arm 3) (N = 33). The primary endpoints were response rate and progression-free survival, with treatment continuing until disease progression. The overall response rate was 17% for arm 1, 40% for arm 2, and 24% for arm 3. Progression-free survival was significantly better in patients receiving Avastin 5 mg/kg in comparison to those not receiving Avastin (Genentech Bio-Oncology, 2004).

The most common adverse events among all patient were asthenia, pain, abdominal pain, headache, hypertension, diarrhea, nausea, vomiting, anorexia, stomatitis, constipation, upper-respiratory infection, epistaxis, dyspnea, exfoliative dermatitis, and proteinuria. Avastin also can result in the development of gastrointestinal perforation and wound-healing complications.

Hypertension should be monitored at baseline, before infusion, at 15 minutes, at one hour, and at completion of the Avastin infusion. Patients with known hypertension may have a rise in blood pressure during the course of treatment and may require addition hypertension management with standard oral antihypertensives. Patients with hypertension were more likely to develop proteinuria; therefore, urine dipstick analysis is recommended every two to four weeks. Temporary suspension of Avastin is recommended with severe proteinuria or hypertension not controlled by medical management.

Avastin also can result in the development of gastrointestinal perforation and wound-healing complications. Avastin therapy should not be initiated for at least 28 days following major surgical procedures.

Avastin also was associated with an increased risk of arterial thromboembolic events, including cerebrovascular accidents, myocardial infarction, transient ischemic attacks, and angina, with an estimated overall rate of approximately 5%. Avastin therapy should be permanently discontinued if a patient experiences any of these events.

Dosage and Administration
The recommended dose of Avastin is 5 mg/kg given once every 14 days. Avastin should be diluted in a total of 100 ml of 0.9% sodium chloride and should not be administered or mixed with dextrose solutions. The initial dose should be infused over 90 minutes. If the first infusion is well tolerated, the second infusion may be administered over 60 minutes. If well tolerated over 60 minutes, all subsequent infusions may be given over 30 minutes.

In summary, Avastin in combination with standard first-line chemotherapy for metastatic colorectal cancer results in statistically significant improvement in overall response rate, survival, and progression-free survival. At present, ongoing clinical trials are evaluating Avastin in combination with other regimens and as single-agent treatment for colorectal cancer and for other tumor types (Nanda & St Croix, 2004).

References
American Cancer Society. (2004). Cancer facts and figures 2004. Atlanta, GA: American Cancer Society.

Genentech Bio-Onclogy. (2004). Avastin™ (bevacizumab) full prescribing information. South San Francisco, CA: Author.

Hurwitz, H., Fehrenbacher, L., Novotny, W., Cartwright, T., Hainsworth, J., Heim, W., et al. (2004). Bevacizumab plus irinotecan, fluorouracil, and leucovorin for metastatic colorectal cancer. New England Journal of Medicine, 350, 2406–2408.

Nanda, A., & St. Croix, B. (2004). Tumor endothelial markers: New targets for cancer therapy. Current Opinion in Oncology, 16, 44–49.


 
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Special Interest Group Newsletter  December 2004
 
   


Timely Tips for Reimbursement

Wendy H. Vogel, MSN, FNP, AOCN®
Kingsport, TN
wvogel@charter.net

Are you undercoding your E&M (evaluation and management) services? Many nurse practitioners (NPs) will undercode their patient visits because they are afraid of overcoding. Some NPs say that they are afraid of sparking an audit. Others might say that they undercode because they think some of the work might be covered by the chemotherapy administration. Some practices erroneously believe that NPs can’t bill higher-level codes.

Don’t cheat yourself or your practice! Oncology medical decision-making involved in the E&M visit usually is complex, especially when it involves chemotherapy decision making. Often patients have other comorbidities that impact the cancer or cancer treatments. If your documentation merits a high-level code (such as 99214 or 99215), then bill it! The difference between level 3 and level 4 for an established patient visit is about $30. If you undercode by one current procedure technology level, your practice could miss out on about $30 per patient. If you see 15 patients per day, five days a week, 47 weeks per year, your lost revenue could total $105,750 per year!

Practitioners also can bill E&M services based on the amount of time the practitioner spends in face-to-face counseling and/or coordination of care. If more than 50% of the visit was spent in counseling or coordination of care, this may apply. For example, if the patient visit lasts 40 minutes, and you spent more than 50% of that time explaining test results and discussing treatment options, then you may bill a level 5 visit. You must, however, document the time. You can do this even if you are billing incident-to your physician (as long as the incident-to criteria are met). If the physician and the NP both see the patient, you may combine the time, following Medicare’s shared billing rules. (These rules can be found at www.cms.hhs.gov/manuals/14_car/3b15052.asp#_15501_0.)

Although many fears we have about billing are valid, if we consistently undercode our services, we actually are devaluing what we do and the complexity of our services.
 
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Special Interest Group Newsletter  December 2004
 
   


Positron-Emission Tomography Scan Use and Reimbursement

Wendy H. Vogel, MSN, FNP, AOCN®
Kingsport, TN
wvogel@charter.net

Positron-emission tomography (PET) scans use radioactive positrons to detect subtle changes in the body’s metabolism and chemical activities. A 2-FDG (fluorine-18-deoxyglucose) PET scan uses FDG as the radiotracer. A PET scan will show the function of a particular area of the body instead of structure. Generally, a function change will precede structural changes, so a PET scan can detect abnormalities earlier than other tests. PET scans have a greater sensitivity and specificity than many other diagnostic tests. In oncology, malignant tumors use glucose and grow at faster rates than healthy tissues, and these areas will uptake more FDG.

PET scans can determine the best area to biopsy, allow initial tumor staging, show response to treatment, and give possible etiologies of subtle abnormalities (such as necrosis from recurrence).

PET scans, however, are not perfect. They are of limited use in noninvasive bronchioalveolar carcinoma, low-grade sarcomas, and hepatocellular, renal cell, and transitional cell carcinomas. The practitioner must know that some PET scans may be misleading. For example, esophagitis may look like cancer, and lung nodules caused by inflammatory process may look like small cell lung cancer.

In general, the practitioner can prepare patients with the following instructions.

  • Nothing by mouth four hours before, except a little water with medication.
  • Glucose intolerant and diabetics may require adjustments in medications or diets (blood glucose < 150).
  • Wear loose-fitting, comfortable clothes, no jewelry or items with metal, like belts.
  • The PET scan generally takes two to three hours. The actual scanning time is 15-120 minutes.
  • The FDG tracer is specially ordered and flown in, so patiets should not be a no-show and be on time!
  • An IV is used to inject FDG. Then there is a wait of 30-60 minutes.
  • A pelvic scan may require urinary catheter. An abdominal scan may require preparation.
  • The cost is about $1,500–$4,500
  • PET still may be considered experimental by many third-party payers.

You must ensure that patients' insurance will cover PET scans. Here are some oncologic diagnoses for which Medicare will pay for a PET scan.

  • Evaluation of a solitary pulmonary nodule (793.1)
  • Evaluation of recurrent colorectal with a rising carcinoembryonic antigen (153-154.8)
  • Staging of lymphoma if PET substitutes for Gallium test (200-200.88)
  • Detection of recurrent melanoma (172-172.9)
  • Diagnosis, initial staging, and restaging of non-small cell lung cancer, melanoma, and colorectal and esophageal cancer
  • Initial staging and restaging of Hodgkin and non-Hodgkin lymphoma (201.9)
  • Diagnosis of head and neck cancer (except thyroid and CNS) (195)
  • Breast cancer staging on inpatients with distant metastases, restaging with locoregional recurrence or metastases, or monitoring a tumor when considering a change in treatment (174.9). Will not cover diagnosis of breast cancer.
  • Recurrent or residual thyroid when another scan doesn't work (237.4)
  • Tumor of unknown origin covered on case-by-case basis; generally Medicare does not pay.
  • Medicare will not cover routine monitoring of therapy.
  • For the above diagnoses, Medicare usually will cover restaging when treatment is complete.
Bibliography
Freedland, S. (2004). PET coverage. Part B News, 18(26), 5-6.

Medicare coverage issues manual. (2002). Retrieved December 8, 2004, from http://www.partbnews.com/htm/MCIM156.htm

Medicare coverage issues manual. (2003). Retrieved December 8, 2004, from http://www.partbnews.com/htm/MCIM171.htm

 
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Special Interest Group Newsletter  December 2004
 
   


Coordinator’s Corner
NP SIG Sees Changes in Leadership Positions

Diane G. Cope, PhD, ARNP, BC, AOCN®
Fort Meyers, FL
ecope@attglobal.net


Hello to all. I hope that you had a wonderful, relaxing, fun-filled summer. My summer went so fast, as I am sure that all of yours did; however, my summer, as did most of the state of Florida, ended with quite a bang with hurricanes Charley, Frances, and Ivan. It is an experience that is beyond description. We are all trying to recover and get back to normal, whatever that is or was. We had to keep a watchful eye on the tropics, and my most-watched TV station for a while was the Weather Channel!

I wanted to highlight several updates with the Nurse Practitioner (NP) SIG. First, we have had a change of newsletter editorship. Christie Hancock, APN, MSN, RN, CS, OCN®, and Janet VanCleave, MSN, ACNP-CS, AOCN®, have stepped down from their responsibilities as editors of the Nurse Practitioner (NP) SIG Newsletter. We now have three new coeditors that I hope you will all welcome and support. The first is Debbie Heim, ARNP, MSN, BC, AOCN® (e-mail heimcats@yahoo.com), who is responsible for this issue of the newsletter. The second is Barbara Biedrzycki, MSN, AOCN®, CRNP (e-mail NPBiedrzycki@aol.com), who responsible for the January NP SIG Newsletter. Barb also works on the SIG archives. The third co-editor is Virginia Rudd, RN, MS, NP-C, AOCN® (e-mail vrudd@rcn.com), who will be responsible for the July newsletter. I have included each person’s e-mail for a reason! Please, please, support our newsletter and these volunteers who have so willingly agreed to coedit the newsletter and make it a possibility for our SIG. Write an article—It is fun and easy to do!

On a sadder note, both of the leaders of the mentorship program have stepped down. Christy Dolbey-Erikson, RN, OCN®, AOCN®, MSN, NP, did an outstanding job with the creation and development of our mentorship program. Thank you, Christy. Much thanks as well to Marianne Davies, OCN®, ACNP, APRN, CNS, who was an integral part of and worker in the mentorship program. Both of these individuals did an incredible job that was unique to our SIG. If anyone would like to take over the leadership position of the mentorship program, please contact me. I will help you with the transition and obtain the necessary work resources. Please think this over and strongly consider volunteering. This was an excellent program that is currently on hold. We are the only SIG group to have such an outstanding program, and I am sure that none of you would like to see this deleted for our members.

I also would like to highlight several of the articles in this issue. Ilisa Halpern, MPP, ONS health policy advocate, and Wendy Vogel, MSN, FNP, AOCN®, NP SIG coordinator-elect, have provided excellent information concerning legislative and reimbursement issues that impact us. I hope that your will find this information useful in your practice. Please also note the article by Bridget A. Cahill, MS, APN, NPC, our Web site administrator, who has highlighted all the changes on the site that were suggested at the NP SIG meeting in Anaheim, CA, during the 2004 Congress.

Once again, please consider volunteering. Our SIG needs you!
 
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Special Interest Group Newsletter  December 2004
 
   


News From the ONS National Office


Certification News

  • Take a free certification practice test. ONCC now offers online practice tests, including free OCN® and CPON® practice tests. Practice tests for advanced certification will be available soon, as will additional practice tests that can be purchased for a nominal fee. Visit www.oncc.org.
  • 2005 Certification Bulletins are available. The 2005 Oncology Nursing Certification Bulletin is available now at www.oncc.org. Copies of the bulletin will be mailed to certified nurses who are due to renew their credential in 2005 and to noncertified members of ONS and other organizations. Visit the ONCC Web site at www.oncc.org or call 877-769-ONCC (toll free).
  • Save $100 on Advanced Oncology Certified Nurse Practitioner (AOCNP) and Advanced Oncology Certified Clinical Nurse Specialist (AOCNS) tests. ONCC will offer a $100 discount on computer-based AOCNP and AOCNS tests offered in January and April 2005. Learn more at www.oncc.org.
  • 2005 test dates listed on ONCC Web site. ONCC will offer quarterly computer-based test dates in January, April, July, and October 2005. The test dates are posted on the ONCC Web site at www.oncc.org. Applications will be published in the 2005 Oncology Nursing Certification Bulletin.
  • Promote your review course. ONCC publishes a list of certification review courses on its Web site at www.oncc.org. To locate a course, or to submit your review course, e-mail oncc@ons.org.
New Books and Resources From ONS
The updated and expanded Standards of Oncology Nursing Practice are available now! Reflecting the dynamic, evolutionary changes in oncology nursing practice, the Statement on the Scope and Standards of Oncology Nursing Practice focuses on your role as a professional oncology nurse.

Telephone Triage for Oncology Nurses has the symptom-focused telephone protocols and guidelines you need to develop your telephone triage skills. Perfect for oncology nurses just learning the telephone nursing role as well as veterans who wish to develop a formalized system of practice.

Lung cancer represents one of the most challenging health threats in the United States and around the world. If you are involved in the care of patients with this deadly disease, you'll want to add Lung Cancer, the first volume in the Site-Specific Cancer series, to your oncology nursing library.

When you need definitive information on today's concepts and practices in oncology nursing, rely on the Core Curriculum for Oncology Nursing (3rd edition), now available through ONS! Leading experts cover information you need to know in a concise, easy-to-follow outline format. The text follows the organization of the Oncology Nursing Certification test blueprint, and presents coverage on a wide variety of topics important to you. Order now and start preparing for your examination.

The Study Guide for the Core Curriculum for Oncology Nursing (3rd edition) is the ideal companion to the Core Curriculum for Oncology Nursing, and will strengthen your knowledge and help you prepare for certification. This study guide contains hundreds of practice questions that test your mastery of knowledge you need to know.

Designed as a resource for the clinical nurse preparing for the role of clinical educator on patient care units, Unit-Based Staff Development for Clinical Nurses will guide you and your colleagues in understanding the roles and responsibilities of nursing staff development. This book offers hands-on advice for assisting staff in developing as professionals and provides you with a blueprint for creating orientation and educational programs on your clinical unit.

These publications may be purchased through the ONS Web site at www.ons.org or call 866-257-4667 (toll free).

ONS Ethnic Minority Mentoring Program Has Launched
Interested in improving your delivery of culturally competent care to patients? The ONS Ethnic Minority Mentoring Program may be just what the nurse ordered. Those of ethnically diverse backgrounds and/or those who serve or have an interest in serving ethnically diverse populations are ideal candidates to participate in this program.

Please click on “Participate in ONS” in the Membership area of the ONS Web site for more information and to sign up.

Mentor a Nursing Student
Make a difference in the life of a future oncology nurse by signing up to be a mentor. You also can sign up to be mentored by a fellow member. This benefit is offered in conjunction with the Students Virtual Community accessed through “Participate in ONS” in the Membership area of ONS Web site. Students Virtual Community can also be reached directly at http://students.ons.wego.net.

Visit the “Mentoring Opportunities” section of Students Virtual Community for more information on the program and to download assessment forms.

New From OES! Four Free Continuing Education Opportunities

We're Looking for New Writers and Expert Mentors!

Do you know of an oncology topic that needs to be addressed from your perspective as a direct caregiver, but the thought of developing a manuscript overwhelms you?

Are you an experienced author with expertise in writing for publication and a willingness to mentor?

If so, the Clinical Journal of Oncology Nursing (CJON) Mentor/Fellow Writing Program is for you. We are seeking direct caregivers who have a desire to write for publication and experienced authors who are willing to offer them guidance and support. Eight direct caregivers will be selected to participate. Each selected applicant will be paired with a mentor, who will guide the novice writer through the manuscript preparation process. Six months will be allotted to complete and submit the manuscripts to the CJON editor. All manuscripts will undergo the standard CJON peer-review process. Accepted manuscripts will be published in an issue of CJON. Each mentor/fellow pair will be allotted a budget to cover telephone and postage expenses. Each mentor will receive an honorarium when the completed manuscript is submitted and be given second authorship on the manuscript.

For more information or to obtain an application, visit the Publications area of the ONS Web site (www.ons.org) or contact Laura Schnable, ONS Publishing Division administrative assistant, at 412-859-6271 (pubCJON@ons.org). Applications are due February 15.

 
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Special Interest Group Newsletter  December 2004
 
   

Membership Information


SIG Membership Benefits

  • Network with colleagues in an identified subspecialty area around the country.
  • Contribute articles for your SIG’s newsletter.
  • Participate in discussions with other SIG members.
  • Contribute to the future path of the SIG.
  • Share your expertise.
  • Support and/or mentor a colleague.
  • Receive information about the latest advancements in treatments, clinical trials, etc.
  • Participate in ONS leadership by running for SIG coordinator-elect or join SIG work groups.
  • Acquire information with a click of a mouse at http://sig.ons.wego.net.
    • Educational opportunities for your subspecialty
    • Education material on practice
    • Calls to action
    • News impacting or affecting your specific SIG
    • Newsletters
    • Communiqués
    • Meeting minutes
Join a Virtual Community

A great way to stay connected to your SIG is to join its Virtual Community. It’s easy to do so. All you will need to do is
  • Log on to the ONS Web site (www.ons.org).
  • Select "Membership" from the tabs above.
  • Then, click on "ONS Chapters and Special Interest Groups."
  • Scroll down to "Visit the ONS Special Interest Groups (SIG) Virtual Community" and click.
  • Now, select "Find a SIG."
  • Locate and click on the name of your SIG from the list of all ONS SIGs displayed.
  • Once the front page of your SIG's Virtual Community appears on screen, select "New User" from the top left. (This allows you to create log-in credentials.)
  • Type in required information into the text fields as prompted.
  • Click "Join Group" (at the bottom right of the text fields) when done.


  • Special Notices
    • If you already have log-in credentials generated from the ONS Web site, use this information instead of attempting to generate new information.
    • If you created log-in credentials for the ONS Web site and wish to have different log-in information, you will not be able to use the same e-mail address to generate your new credentials. Instead, use an alternate e-mail address.
Subscribe to Your SIG’s Virtual Community Discussion Forum

All members are encouraged to participate in their SIG’s discussion forum. This area affords the opportunity for exchange of information between members and nonmembers on topics specific to all oncology subspecialties. Once you have your log in credentials, you are ready to subscribe to your SIG’s Virtual Community discussion forum. To do so
  • Select “Log In,” located next to “New User” and enter your information.
  • Next, click on the “Discussion” tab on the top right of the title bar.
  • Now, select “Featured Discussion” from the left drop-down menu.
  • Locate and select “Subscribe to Discussion” inside the “Featured Discussion” section.
  • Go to “Subscription Options” and select “Options.”
  • When you have selected and entered all required criteria, you will receive a confirmation message.
  • Click “Finish.”
  • You are now ready to begin participating in your SIG’s discussion forum.
Participate in Your SIG’s Virtual Community Discussion Forum
  • First, log in. (This allows others to identify you and enables you to receive notification [via e-mail] each time a response or new topic is posted.)
  • Click on "Discussion" from the top title bar.
  • Select "Featured Discussion" from the left drop-down menu.
  • Click on any posted topic to view contents and post responses.
Sign Up To Receive Your SIG’s Virtual Community Announcements

As an added feature, members also are able to register to receive their SIG’s announcements by e-mail!
  • From your SIG’s Virtual Community page, locate the “Sign Up Here to Receive Your SIG’s Announcements” section. This appears above the posted announcements section.
  • Select the “Click Here” feature, which will take you to a link to subscribe.
  • Once the “For Announcement Subscription Only” page appears on screen, select how you wish to receive your announcements.
    • As individual e-mails each time a new announcement is posted
    • One e-mail per day comprised of all new daily announcements posted
    • Opt-out, indicating that you will frequently browse your SIG’s Virtual Community page for new postings
  • Enter your e-mail address.
  • Click on "Next Page."
  • Because you have already joined your SIG’s Virtual Community, you will receive a security prompt with your registered user name already listed. Enter your password at this prompt and click "Finish."
  • This will bring up a listing of your SIG’s posted announcements. Click on "My SIG’s Page" to view all postings in their entirety or to conclude the registration process and begin browsing.
 
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Special Interest Group Newsletter  December 2004
 
   


Nurse Practitioner Name SIG Officers

Coordinator (2003-2005)
Diane Cope, PhD, ARNP-BC, AOCN®
605 Astarias Circle
Fort Myers, FL 33919-3247
239-437-3571 (H)
239-437-4444 (O)
ecope@attglobal.net

Coordinator-Elect (2004-2005)
Wendy Vogel, RN, MSN, FNP, AOCN®
405 Pettyjohn Rd.
Kingsport, TN 37664-4716
423-323-0715 (H)
423-968-2311 (O)
wvogel@charter.net

Web Site Administrator
Bridget A. Cahill, RN, MS, APN, NPC
5145 N. Meade Ave.
Chicago, IL 60630-1826
773-775-9575 (H)
312-695-0316 (O)
312-695-6189 (Fax)
bcahill@nmff.org (e-mail)

Coeditor
Barbara Biedrzycki, RN, MSN, AOCN®
709 W. Baker Ave.
Abingdon, MD 21009-1457
410-538-7946 (H)
410-614-6894 (O)
NPBiedrzycki@aol.com

 

Coeditor
Deborah Heim, RN, MSN, ARNP, AOCN®
5150 Harborage Dr.
Fort Myers, FL 33908-4542
239-466-4990 (H)
239-275-6400 (O)
heimcats@yahoo.com

Coeditor
Virginia Rudd, RN, MS, NP-C, AOCN®
166 W. 75th St., Apt. 216
New York, NY 10023-1900
212-595-6879 (H)
212-263-7411 b2436 (O)
vrudd@rcn.com

ONS Publishing Division Staff
Elisa Becze, BA
Copy Editor
412-859-6317
ebeceze@ons.org

 

Know someone who would like to receive a print copy of this newsletter?
To print a copy of this newsletter from your home or office computer, click here or on the printer icon located on the SIG Newsletter front page. Print copies of each online SIG newsletter also are available through the ONS National Office. To have a copy mailed to you or another SIG member, contact Membership/Leadership Administrative Assistant Carol DeMarco at cdemarco@ons.org or 866-257-4ONS, ext. 6230.

ONS Membership/Leadership Team Contact Information
Angie Stengel, Director of Membership/Leadership
astengel@ons.org
412-859-6244

Diane Scheuring, Manager of Member Services
dscheuring@ons.org
412-859-6256

Carol DeMarco, Membership/Leadership Administrative Assistant
cdemarco@ons.org
412-859-6230

To view past newsletters click here.

The Oncology Nursing Society (ONS) does not assume responsibility for the opinions expressed and information provided by authors or by Special Interest Groups (SIGs). Acceptance of advertising or corporate support does not indicate or imply endorsement of the company or its products by ONS or the SIG. Web sites listed in the SIG newsletters are provided for information only. Hosts are responsible for their own content and availability.

Oncology Nursing Society
125 Enterprise Dr.
Pittsburgh, PA 15275-1214
866-257-4ONS
412-859-6100
www.ons.org

 
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