Virginia can lead on affordability without gambling with access, guest columnist Dr. Richard Ingram writes.
Richard Ingram –
As a full-time practicing medical oncologist in Winchester, I spend my days with Virginians who bravely fight cancer. Sadly, these patients and their families face another battle, one that induces stress and anxiety: the cost of care.
The financial burden can be as overwhelming as the disease itself. Both are hard. Lawmakers in Richmond can help patients by enacting policies that alleviate this financial burden, and I share the goal behind proposals to create a Prescription Drug Affordability Board (PDAB).
Drug prices are unsustainable, and patients are paying the price in real, painful ways.
But before Virginia rushes into this policy experiment, we should slow down and insist on a careful, evidence-driven review. We must look especially closely at one provision that sounds simple and fair but can cause real harm in practice: upper payment limits (UPLs).
Cancer drugs are not like most consumer goods. In community oncology, we often operate on a “buy and bill” model. That means clinics must purchase high-cost medications upfront — sometimes tens of thousands of dollars for a single dose — store them appropriately, prepare them safely, and administer them with trained staff under strict protocols.
We take on the financial risk to ensure the medicine is there the moment the patient needs it. If a UPL is set below what a practice actually pays to acquire a drug, or below what it costs to procure, store, prepare, and administer it, the math becomes brutal and immediate.
Practices simply cannot pay more for a medication than they are reimbursed. When that happens, options for a local clinic shrink fast: stop offering the drug, send patients elsewhere, stop accepting certain insurance, or close the doors entirely. These outcomes are not theoretical. They are the predictable result of a reimbursement cap that does not match the realities of drug acquisition and delivery in the community setting.
When community practices shrink or disappear, patients are pushed into large hospital outpatient settings or university systems. While these institutions offer excellent medical care, they often provide essentially the same therapies that a patient could — and should — receive in their own hometown. The difference isn’t the quality of the medicine; it is the quality of the patient’s life.
A patient treated here in Winchester can receive their chemotherapy and still have the energy to pick up their children from school or put in a few hours at their job. They are surrounded by a team that knows them by name and a support system of local friends and family.
This continuity of care — staying with the same team throughout a long, scary journey — is a clinical asset that cannot be easily replaced. Forcing a patient to travel two or more hours to a large hospital system for the same treatment adds an intolerable travel tax of time, fuel, and physical exhaustion.
Furthermore, this shift can actually raise total spending for taxpayers and consumers, even as a UPL appears to generate savings on paper.
Data consistently shows that cancer care in community-based clinics is often at least 30% or more less expensive than the same care delivered in hospital outpatient settings, which often carry significant and opaque facility fees. It also threatens access, especially in rural and underserved parts of Virginia where a local oncology clinic can be the difference between starting treatment next week versus next month.
We should also be honest about what drives costs today. The drug supply chain is complex and crowded with intermediaries, including pharmacy benefit managers who negotiate hidden rebates that rarely reach patients. A UPL that squeezes the front-line provider, while leaving the middle of the system opaque, risks punishing the wrong link in the chain. We should be enacting policies that protect vital community hubs, not creating reimbursement caps that make their survival impossible.
Many of the drugs under review will be cancer therapies. Real-world expertise matters from those who see patients every day as they undergo their treatment. Virginia can lead on affordability without gambling with access.
If lawmakers move forward with a drug affordability board, they must include rigorous guardrails: modeling scenarios where UPLs might fall below acquisition costs to prevent clinic closures; evaluating likely shifts to higher-cost hospital settings to ensure the policy actually saves money; building robust exception and appeals processes for life-saving therapies; phasing implementation with real-world monitoring to catch access issues early; and including independent community oncologists in the decision-making process to provide real-world expertise.
Patients deserve both affordability and access. Virginia can deliver both — if we get the details right and protect the hometown care that keeps our families whole.