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As gastroenterologists, we treat patients in Portland, Ore., and Des Moines, Iowa, with challenging disorders like Crohn’s disease and ulcerative colitis who sometimes need infusions of medications. Legislation before Congress could make it difficult — and potentially impossible — for us to provide this important care in our medical practices.

That could force our patients to go to hospitals or large medical centers for their infusions, which is less convenient for them and more expensive for the health care system.

We are both fortunate to be represented by U.S. senators who are taking leadership roles in working to lower pharmaceutical costs for all Americans, especially seniors. We support many of the key policies in the Senate Finance Committee’s drug pricing bill aimed at lowering prescription drug costs. Unfortunately, one provision in this legislation could drive up costs and threaten patient access to certain medications administered in physicians’ offices for treating severe gastrointestinal disorders, rheumatoid arthritis, macular degeneration, cancer, and other chronic conditions.


The specific provision we are concerned about would include the value of coupons that pharmaceutical companies provide to patients in determining how Medicare calculates a drug’s average sales price, which is used to determine how much physicians are reimbursed for administering the drug.

Many commercially insured patients incur substantial out-of-pocket costs for physician-administered medications. To help cover these costs, many pharmaceutical manufacturers have coupon assistance programs, which reduce those out-of-pocket liabilities. Many patients rely on coupon programs to afford and stay on their course of treatment. Coupon assistance programs from pharmaceutical companies typically save patients between $50 and $100 a month, according to a 2018 study in Health Affairs.


The Senate Finance bill would include these coupons — which are provided to patients — as if they were part of the negotiated price between the insurer and the pharmaceutical company. Doing this would reduce Medicare’s reimbursement to physician practices like ours by lowering the average sales price payment calculation. But our costs for acquiring those products would not change, making it difficult for physician practices like ours to provide these important drugs.

In other words, physicians would pay more to acquire infusion drugs than Medicare would reimburse them. As a result, many practices could end up sending Medicare patients to more costly, less convenient, and less familiar hospital settings to get their infusions. This makes no sense for our patients or the Medicare program, because drug administration is almost twice as expensive in the hospital setting as in physicians’ offices, according to the Magellan Medical Pharmacy Trend Report.

More troubling, this policy could result in some manufacturers scaling back or eliminating the patient assistance programs that commercially insured patients have come to rely on to defray their out-of-pocket costs. The disappearance of coupons could lead some patients to forsake treatments, causing them to experience more complications and, over the long term, increase the cost of their care.

Our gastroenterology practices are members of the Digestive Health Physicians Association, which has joined many other physician and patient advocacy groups in asking Congress to drop this provision before finalizing any drug pricing legislation. Congress should reject policies that could have the unintended effect of jeopardizing access to important drug treatments, shifting care into the more expensive hospital setting, and increasing costs to patients and the Medicare program.

Rajalakshmi Iyer, M.D., is a gastroenterologist at the Iowa Digestive Disease Center in Des Moines, Iowa. James Regan, M.D., is a gastroenterologist at The Oregon Clinic in Portland.

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