A Roadmap to Meaningful Health System Reform

J Clin Pathways. 2025;11(3):28-30.

The US health care system is failing far too many patients with cancer. Despite unprecedented medical advance­ments, access to affordable, high-quality care is being systemati­cally undermined by rising costs, hospital consolidation, insur­er-driven barriers, and bureaucratic red tape. Patients and their families are ultimately bearing the brunt—forced to navigate a system that too often prioritizes profit over patient well-being.

But it doesn’t have to be this way. That’s why the Com­munity Oncology Alliance (COA) developed the COA Pre­scription for Health Care Reform.¹ This is a comprehensive, five-part plan outlining specific, achievable solutions that poli­cymakers can implement today to fix what is broken and en­sure every patient can access the care they deserve.

For more than two decades, unchecked system consolidation has eroded competition, driven up costs, and reduced patient access—especially in cancer care. Independent oncology prac­tices, which historically provided affordable, high-quality cancer treatment in local communities, have been decimated by a system that favors hospital-owned providers. The result? Higher costs, fewer choices, and worse outcomes.

Hospitals have leveraged site-of-service payment dispari­ties, 340B Drug Pricing Program loopholes, and aggressive market consolidation to force patients into higher-cost care settings. This is particularly devastating in rural and under­served areas, where independent clinics have been forced to close or sell out to hospitals, further limiting access and driv­ing up costs.

Congress must enact the following meaningful reforms:

• Implement site-neutral payment policies to ensure fair reimbursement across care settings so hospitals are not paid significantly more for the same services provided in independent practices.
• Modify the 340B Drug Pricing Program to stop large, well-funded hospital systems from exploiting discounts without passing savings on to patients.
• Strengthen antitrust enforcement to curb anti-compet­itive mergers that eliminate independent providers and limit patient choice.

Without these changes, consolidation will continue unchecked, which will reduce competition, drive costs even higher, and ul­timately leave patients with fewer and more expensive options for care.

Today, it is well known that insurers and pharmacy benefit managers (PBMs) have manipulated the health care system for financial gain, contributing to inflated drug prices and restrict­ed prescription access, and forcing patients into costlier, insur­er-owned pharmacy networks. These middlemen control 80% of the prescription drug market, often dictating which medi­cations are covered based on profit-maximizing rebates rather than medical necessity. Cancer patients—who don’t have time for delays—are being forced through unnecessary prior autho­rization hoops and steered toward PBM-affiliated pharmacies rather than receiving medication from their providers.

To fix this, Congress must enact the following insurer and PBM reforms:

• Mandate transparency in pricing, rebates, and reim­bursement practices.
• Eliminate anti-competitive PBM practices that force patients into affiliated mail-order pharmacies or deny coverage for medications based on financial incentives rather than clinical evidence.
• Prevent insurers and PBMs from using step therapy and prior authorization to delay or deny timely access to critical cancer treatments.

If policymakers fail to act, PBMs and insurers—not doctors—will continue dictating treatment decisions while patients suffer unnecessary delays, financial hardship, and worse outcomes.

The Medicare Physician Fee Schedule (PFS) has failed inde­pendent oncology practices by steadily cutting reimbursement while driving up practice costs. Medicare payments have not kept pace with inflation, making it harder for independent providers to sustain operations, recruit talent, and remain fi­nancially viable.

Meanwhile, hospitals receive higher reimbursement rates for the same services, fueling consolidation and driving up Medicare costs for both taxpayers and patients. If this mis­aligned reimbursement system continues, independent prac­tices will continue disappearing and cancer patients will be left with fewer, more expensive care options.

Congress must take the following action to stabilize the Medicare system for independent practices:

• Reverse and prevent further cuts to Medicare PFS, ensuring independent oncology practices remain sustainable.
• Tie reimbursement rates to inflation so physician payments reflect real-world costs.
• Eliminate the Medicare sequester for independent practices to relieve financial strain.

Without urgent changes, independent providers will be forced out of the system, and patients will bear the consequences of reduced access and skyrocketing costs.

The carboplatin and cisplatin shortages of 2023 were a wake-up call. Essential generic sterile injectable (GSI) drugs, which form the backbone of cancer treatment, have become alarm­ingly scarce due to fragile supply chains, unsustainable pricing models, and a lack of domestic manufacturing capacity.

To prevent future shortages and protect patient access, Congress must:

• Incentivize domestic production of GSIs through tax credits and market stability measures.
• Ensure reimbursement models encourage continued manufacturing of low-cost but essential cancer drugs.

The introduction of drug price negotiation and other reforms in the Inflation Reduction Act (IRA) offer major patient ben­efits but pose a ticking existential time bomb for independent oncology practices. By placing providers in the middle of nego­tiations with manufacturers, the government is threatening the financial viability of cancer treatment in independent settings.

The problem lies in how the IRA’s mandated lower drug prices will slash Medicare and commercial Part B drug reim­bursement, leaving practices unable to cover the essential costs of drug procurement, storage, and administration. An Avalere analysis commissioned by COA found that these reimburse­ment cuts will reduce practice revenue by double-digit per­centages—an unsustainable hit for independent providers.² If not corrected before the law is fully implemented in 2028, the IRA will accelerate the closure or consolidation of independent practices, shifting more care into hospitals where treatment is more expensive for both patients and Medicare.

Medicare’s outdated payment structure and bureaucratic hurdles have fueled consolidation, reduced competition, and increased costs for both patients and providers. The Center for Medicare and Medicaid Innovation (CMMI) was supposed to foster value-based models, but instead its onerous requirements have made participation burdensome and financially risky—pushing inde­pendent oncology practices out of reform efforts entirely.

Additionally, Medicare’s failure to enforce Part D regula­tions has enabled PBMs to dictate drug pricing and reimburse­ment, hurting independent pharmacies and creating pharmacy deserts in rural areas. The US Centers of Medicare & Medicaid Services (CMS) must actively enforce fair reimbursement for independent pharmacies and prevent PBMs from using preda­tory pricing tactics that threaten access to essential medications. Without real oversight, PBMs will continue exploiting Medi­care Part D to maximize profits at the expense of patient access.

To modernize Medicare and reduce administrative burdens, Congress must:

• Overhaul Center for Medicare and Medicaid Innovation (CMMI) models to make value-based care workable for independent practices.
• Fix Medicare Part D oversight to ensure fair PBM reim­bursement and prevent independent pharmacy closures.
• Allow direct contracting with self-insured employers to support innovative care models.

Without these reforms, outdated Medicare policy will contin­ue pushing independent providers out, leaving patients with fewer, costlier options for care.

The COA Prescription for Health Care Reform provides a clear, actionable framework to address the most pressing issues in cancer care. The problems—consolidation, insurer/PBM abuses, broken reimbursement models, drug shortages, and outdated Medicare policies—are all fixable with strong lead­ership and action from policymakers.

Congress must act now before more independent practices disappear, costs skyrocket, and patients lose access to life-saving care. The solutions COA has provided are clear, evidence-based, and ready to be implemented. This is not a partisan is­sue—it is a patient issue. The time for action is now.