by Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC
1) There is now bipartisan, bicameral legislation to reform the sustainable growth rate (SGR) that does not give Congress sticker shock; and
2) The U.S. Department of Health and Human Services (HHS) has declared that that it does not consider health insurance plans and other related federal subsidies that are offered through the new insurance exchanges, to be federal healthcare programs.
The House Energy & Commerce, Ways & Means, and Senate Finance Committees have worked together to introduce policy to repeal the flawed SGR formula with stable payments and quality-based incentive payments moving forward. Energy & Commerce was the first to introduce legislation in September, but the Congressional Budget Office (CBO) estimated the bill would cost $35 billion more over 10 years than the CBO’s most recent scoring for an SGR fix. Now, the Ways & Means and Senate Finance Committees have introduced new legislation more in line with the CBO’s anticipated costs.
This proposed legislation would prevent the 24.4% cut to reimbursement – which is currently set to go into effect on Jan. 1, 2014, unless Congress steps in. Under the new legislation, the SGR formula would be replaced with a pay freeze for the next 10 years. The proposal, which is still in discussion draft form, calls for gradually replacing Medicare’s existing fee-for-service payment system with a “value-based performance system” focused on medical outcomes rather than procedures. This means there will be financial incentives to participate in alternative payment models. Under the draft legislation, it’s possible that reimbursement could be adjusted based on performance as soon as 2017. The bill relies on the Physician Quality Reporting System (PQRS), the value-based modifier, and the EHR Meaningful Use Program – currently penalty-only systems – to create incentive payments for high-quality care. In addition, the proposed legislation would keep the penalty portion of these programs to help fund the incentive payments.
We can all agree that the current SGR formula is fundamentally flawed and that a new reimbursement system is necessary. The CBO has estimated the cost of “freezing” physician Medicare payments for 10 years at $138 billion. While this is a relative bargain in congressional terms, Congress still faces an uphill battle to find the funds to replace the SGR. To date, the draft legislation addresses the policy behind SGR reform only; the battle to identify a ‘pay-for’ has not yet begun.
Exchange Plans Not Federal Programs
With the new insurance exchanges, there has been much confusion concerning whether drug manufacturers would be able to continue certain patient assistance programs because it was unclear whether the new insurance exchanges and their related subsidies were considered federal programs. Generally, drug manufacturers can provide copay assistance to patients who are unable to afford their medication so long as they are not in receipt of assistance through a federal program. Although the insurance plans purchased through the exchanges are private, the fact that they are being offered through a federal marketplace and federal funds are available to offset the cost of premiums led to many unanswered questions. Many drug manufacturers wondered if they would be able to continue to offer patient assistance programs to these needy patients.
Thankfully, in a letter to Congressman Jim McDermott, HHS clarified that qualified health plans and related federal subsidies are not considered federal programs for the sake of manufacturer copay assistance programs. This is great news. The clarification means that drug companies may continue to offer the much needed assistance that many low-income patients have come to rely on.
So forget about the federal government shut down, looming debt ceiling, and other congressional woes for a few minutes. With Thanksgiving approaching, let’s be thankful for a few of the bright spots coming from Washington and, for the moment at least, view the glass as half full.
by Matt Farber, Director, Provider Economics and Public Policy, ACCC
The role of technology in healthcare—and the many headaches that can accompany the adoption of new technology—has been put under the microscope in recent weeks. Missteps and glitches during the roll-out of the new health insurance marketplaces’ online enrollment have some questioning broadly whether technologies designed to improve the healthcare system can actually achieve their goal.
The process may not be easy, but evidence shows that appropriate technology can improve efficiency and coordination in healthcare, whether it’s online insurance enrollment, electronic health records, or—as explored in a new white paper from ACCC—health information exchanges.
ACCC’s new white paper, “Cancer Care in the Age of Electronic Health Information Exchange,” discusses the potential impact of health information exchange on cancer care and the hurdles to adoption. It is the second white paper to come out of ACCC’s Institute for the Future of Oncology, with the first released in October.
Health information exchange describes two related concepts: the electronic sharing of health-related information among organizations, and the entities that provide services to facilitate this electronic information sharing.
“Cancer Care in the Age of Electronic Health Information Exchange” explores the current state of health information exchange adoption, the importance of HIE, and also the potential for improved quality of care and reduced costs that an HIE can provide.
The push for adoption and integration of electronic health records (EHRs) has been a first step toward realizing the capabilities and benefits of electronic health information exchange. Adoption of and engagement in HIEs, the organizations that enable electronic sharing of patient data across providers and healthcare organizations, is the next step—and in many areas of the country, this step is still out of reach.
The white paper reflects discussion and perspectives from participants in the Institute’s inaugural forum, which was held in late June 2013. Here is a snapshot of the white paper’s findings:
- HIE adoption is uneven.
- There is a lack of awareness around HIEs.
- HIE initiatives must focus on information standardization.
- HIEs can help benchmark interventions within patient populations.
- Providers must have input on the information released via patient portals.
The potential of HIEs to improve benchmarking, efficiency, and ultimately quality of care in oncology was universally agreed by participants at the Institute. However, the consensus was that many hurdles remain before the potential becomes reality.
ACCC’s Institute for the Future of Oncology addresses key topics impacting oncology now and in the future. If you would like to get involved in upcoming forums of the Institute for the Future of Oncology, please contact Matt Farber at email@example.com.
By Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC
The federal government is back in business. On Wednesday evening of this week, the House and Senate passed a continuing resolution to fund the government through January 15, 2014, and raise the debt ceiling until February 7, 2014. So, the shutdown is over, but Congress essentially just kicked the can down the road—and not very far.
The good news? Funding for new clinical trials will be restored and the Centers for Medicare & Medicaid Services (CMS) will get back to writing the final rules for the 2014 Physician Fee Schedule (PFS) and Hospital Outpatient Prospective Payment System (OPPS). However, funding has been restored at post-sequestration levels, and the conversation continues about how this is impacting community cancer care. It’s also possible that the three-week government shutdown may cause a delay in CMS’s release of the final rules, which would mean less time for implementation of the new policies that go into effect on January 1, 2014.
What about hopes for SGR reform? With less than two months remaining in 2013 and Congress focused on little besides the budget and debt ceiling, hopes of passing reform this year are slipping away. This means we are looking at the probability of yet another last-minute “Doc Fix” to stave off the anticipated 25% cut to Medicare reimbursement created by the flawed SGR formula. This year, many in the advocacy community believed that the timing was ripe to finally do away with the SGR given the CBO’s low budget score and the fact that the House Energy & Commerce, Ways and Means, and Senate Finance Committees all drafted legislation. While there is an outside chance that SGR repeal could get looped into a larger budget deal, the current SGR repeal legislation is expected to cost $175 billion over 10 years and no offsets have yet been identified, so Congress will likely wait another day to take on that fight.
Déjà vu all over again? Come January we may see ourselves in the same situation from which we just emerged: partisanship and political gridlock threatening another shutdown. While the conversation on the Hill continues to be budget-driven, ACCC will continue to work with members of Congress to preserve provider reimbursement and access to care for patients. We will be participating in a Hill day next week with other members of the cancer advocacy community to request adequate funding for cancer research and other programs. Please stay tuned for updates.
By Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC
As you undoubtedly already know, we are in the third week of the government shutdown due to Congress’s inability to agree on a continuing resolution (CR) to fund discretionary spending. This means that discretionary spending has stopped, but mandatory spending for things that protect life, property, and entitlements continues on an automatic basis. What does this mean for cancer care providers?
1) At least in the short term, Medicare reimbursement will continue as usual (at post-sequestration levels).
2) The National Institutes of Health (NIH) will continue with clinical trials currently in progress, but will not begin any new trials until funding is restored.
3) The U.S. Food and Drug Administration (FDA) has furloughed a number of workers, which could slow the approval of new drugs if there is a prolonged shutdown.
The federal government is expected to hit the debt ceiling—the point at which the country cannot borrow new money—on October 17. Speaker Boehner has committed to not reaching the debt limit, even though the House and Senate are still unable to reach a deal that pleases everyone. Some members of the House Tea Party remain committed to only voting in favor of funding if implementation of the Affordable Care Act (ACA) is delayed. Current negotiations would fund the government through the middle of January, and raise the debt ceiling through the middle of February; barely enough time to catch a breath before the threat of shutdown is upon us again.
While Congress continues to negotiate the government’s budget and borrowing limit, other important legislation waits on the sidelines. The status of the sequester remains of specific interest to the oncology community. ACCC continues to support HR 1416, legislation that would exempt cancer drugs from the Medicare sequester. This legislation is becoming increasingly important not only because of its 108 bipartisan cosponsors, but because of the current political climate. Congress is in a deficit-reduction mindset. While they understand that the sequester is a blunt budgetary tool which impacts oncology providers in a particularly unfair manner, they are reluctant to eliminate the sequester because it is saving the government money. In other words, Congress views the sequester as the new normal and proved this by only introducing budget bills with post-sequestration spending levels.
Cancer care providers, please complete ACCC’s follow-up sequester impact survey so we can show how the two percent Medicare sequester is impacting you and your ability to care for patients. As always, ACCC will keep members up to date on this important matter.
by Amanda Patton, Manager, ACCC Communications
An expert panel—representing the payer, private practice, hospital-based cancer program, academic medicine, and the patient advocacy perspectives—discussed Innovation: Value, Quality, and Technology on Thursday, Oct. 3, at the ACCC National Oncology Conference in Boston, Mass. Echoing keynote speaker Whitney Johnson’s theme of disruption and innovation, panelists identified major disruptors to the status quo and multiple constraints challenging oncology care delivery.
Disruption is not limited to oncology. “It’s our entire medical system,” said panelist Roy Beveridge, MD, Senior Vice President and Chief Medical Officer, Humana, Inc. “It’s a brave new world and the next five years will be very exciting.”
Specific disruptions cited by panelists included changing relationships between primary care providers and specialists, hospitals and payers, and providers and payers. Added to this are overarching uncertainties about reimbursement, how (or if) the sustainable growth rate (SGR) fix will be achieved, and the impact of the newly created health insurance exchanges on oncology providers and the patients they serve.
Panelist Al Benson, MD, FACP, Professor of Medicine, Northwestern University’s Feinberg School of Medicine, sees constraints ahead in three main areas: patients having to deal with fragmentation of services, workforces shortages, and technology-driven challenges. “Technology is really overwhelming, and I wonder how a general medical oncologist is going to adjust to these massive changes. With more diagnostic tools, it’s not only how we’re going to afford them, but how to integrate the technology into healthcare structures so patients can move through the system more efficiently.”
Nancy Davenport-Ennis, CEO of the Patient Advocate Foundation (PAF), shared the patient advocate perspective. “Disruption for patients begins the day their name and cancer is said in the same sentence,” she said. For her organization, a major challenge has been the accelerated growth of uninsured patients over the past year. Thirty-eight percent of patients served by PAF in 2012 were uninsured, she said.
Panelists also discussed the evolving provider-payer relationship. Quality care does not have to be expensive care, panelists agreed.
Partnering with a payer, a provider can demonstrate quality metrics and use of pathways, commented panelist Kim Woofter, RN, OCN, Chief Operating Officer, Michiana Hematology Oncology. Through participation in Health Information Exchanges (HIEs) practices can integrate with other providers to streamline patient enrollment in clinical trials, as well as partner with hospitals to reduce hospital re-admission.
Panel moderator Cliff Goodman, PhD, the Lewin Group, asked panelists to share innovations they’ve developed in response to these challenges.
Given the fragmentation of the current delivery system, Norma Ferdinand, Senior Vice President, Lancaster General Health, said her heath system is responding by supporting a culture of innovation and learning. The health system recently opened a new cancer center to centralize services with a patient-centered, rather than physician-centered design. The system is also participating an accountable care organization, among other initiatives.
Kim Woofter said her practice has taken ownership of care coordination in the period immediately after hospital discharge. A large triage staff handles the 48 hours post-discharge, following up with patients to ensure they have needed medications and resources. “We can affect return admission by interacting with that patient within the first 48 hours after discharge,” she said. Participation in a Health Information Exchange (HIE) is also facilitating the practice’s ability to demonstrate quality to payers.
Davenport-Ennis described a range of services PAF is providing including 24/7 patient portals, online easy-to-use tools for consumers, and more.
A key takeawy from the discussion: Innovation at the nexus of value, quality, and technology requires a patient-centered, data-driven, learning organization.
by Amanda Patton, Manager, Communications, ACCC
Johnson’s talk, “Dare to Disrupt: Innovate from the Inside,” focused on channeling the energy from “disruption” into positive growth—both for individuals and in the workplace.
In a week that has seen both the shutdown of the federal government and the launch of health insurance exchange marketplaces—disruption could not be a more timely focus for discussion.
Riding the wave of disruption can be akin to surfing, Johnson said. She offered seven basic rules for learning how to surf the disruption wave to achieve innovation.
1) take the right risks—don’t knock on the door that’s closed, build your own door
2) play to your distinctive strengths—get the skills you need to do your job and then focus on what you do best
3) embrace constraints—recognize that constraints can provide rapid feedback and force greater creativity
4) battle entitlement—create an environment that fosters different opinions and perspectives
5) step back or step sideways—taking a move backwards or a side step can help slingshot you to a new position
6) put failure in its place—daring to disrupt may lead to failure, but lessons learned from failure propel innovation
7) be discovery driven–to become an expert, you may need to go back to a beginner’s mentality
8) find the right metrics to measure your progress–and sometimes, how often you ‘show up’ is the right metric.
We’re living in an era of accelerated disruption, especially in healthcare, said Johnson, so dare to embrace and even seek out disruption. “Ultimately innovation begins on the inside.”
The new state-based Health Insurance Marketplaces are set to open next week, on Oct. 1. These Marketplaces—also known as insurance exchanges—have been created under the Affordable Care Act (ACA), with a goal of providing a simplified process to compare individual market health insurance plans and shop for health insurance coverage.
According to a Department of Health and Human Services (HHS) report released earlier this week, in states where HHS will run or partially run the Marketplace, individuals will have an average of 53 qualified health plan choices.
For those whose lives have been touched with cancer, understanding the coverage for cancer-related health services is crucial for making educated decisions based on their healthcare needs and budgets.
A new tool, launched this week by the Cancer Support Community in partnership with the Association of Community Cancer Centers and 17 other cancer and patient advocacy organizations, is designed to help people with cancer, a history of cancer, or a risk for cancer choose insurance plans in the Marketplaces. The Cancer Insurance Checklist is designed to be used while evaluating insurance plans and also when discussing them with a navigator or healthcare provider, and includes a worksheet to help the consumer detail the costs associated with each plan.
People with cancer concerns or healthcare professionals assisting patients with the Marketplaces can download and print the Cancer Insurance Checklist free of charge by visiting CancerInsuranceChecklist.org, where they’ll also find a comprehensive list of additional resources and glossary of terms related to insurance coverage decisions.
By Matt Farber, MA, Director Provider Economics and Public Policy, ACCC
On Friday, September 6, ACCC formally submitted comments to the Centers for Medicare & Medicaid Services (CMS) on the 2014 Physician Fee Schedule and the Hospital Outpatient Prospective Payment System proposed rules. ACCC has numerous concerns about proposals included in each of the rules, and the public comment period is an important opportunity to voice those concerns. If CMS does not hear from organizations such as ACCC, the agency may believe that its proposals will not adversely impact community oncology. Some of the key issues we focused on in our comments are outlined below.
Physician Fee Schedule. In its comments, ACCC asked that CMS:
- Work with Congress to develop a long-term fix to the Sustainable Growth Rate (SGR) formula and avert a 24.4 percent reduction to the conversion factor in 2014;
- Work with ACCC to study the issue of payment for services rendered in off-campus hospital-based departments;
- Apply adjustments to the work relative value units (RVUs) instead of the conversion factor to reflect changes in the Medicare Economic Index (MEI);
- Exercise caution when reviewing codes it identifies as potentially misvalued;
- Implement the proposal to create a new G-code for complex chronic care management services that meet certain standards; and
- Not implement the proposed cap on PFS non-facility payments using facility rates calculated under the Hospital Outpatient Prospective Payment System (OPPS) or Ambulatory Surgical Center (ASC) payment systems.
ACCC has great concern about the proposal to cap the PFS payments using rates from the hospital outpatient department or ambulatory surgical center settings. Our concern is that, for some codes, CMS is reducing payments based on procedures that are rarely given in certain sites of service. CMS also proposes to apply the cap when as little as five percent of the total volume of services are furnished in the hospital outpatient setting. Analysis of the proposed rates indicates that CMS often set the cap using ASC rates, even though the volume of services in that setting was far below five percent. This extremely low threshold does not help ensure that the capped rates accurately reflect typical costs for providing the service in either the physician office or facility setting. Further, when the Medicare Payment Advisory Commission (MedPAC) recommended that CMS cap certain hospital outpatient payments at the rates applicable in physician offices or ASCs, it recommended a threshold of 50 percent of claims in the setting used to establish the cap to ensure that payment rates are sufficient to protect access to care. ACCC believes that CMS’s proposal is unnecessary, and we are asking the agency to provide justification for its choice of site of service for setting payments.
OPPS Proposed Rule. ACCC asks that CMS:
- Implement the proposal to reimburse hospitals for the acquisition cost of separately payable drugs at ASP+ 6%;
- Make separate payment for all drugs with HCPCS codes, or, at a minimum, not increase the packaging threshold for drugs;
- Not implement the proposal to change the calculation for payment rates of computed tomography (CT) scans and magnetic resonance imaging (MRI);
- Not implement the proposal to consolidate clinic and emergency department evaluation and management (E&M) codes from five levels to one level; and
- Not implement the proposal to expand packaging for additional items and services until the agency corrects the significant errors and inconsistencies in the proposed rates, provides opportunity to comment on the corrections and clarifications, and reviews those comments.
In the 2014 proposed OPPS rule, CMS made some drastic moves to increase the amount of bundling in the hospital outpatient department. ACCC believes that the proposals will adversely impact cancer care. Of particular concern are proposals for the consolidation of E&M codes, changes to the calculation for payment rates of CT and MRI, and additional packaging of drug administration services. Added to these concerns is the fact that ACCC and other organizations believe there are significant errors in the proposed rates. We fear that these errors would further decrease reimbursement to critical areas of oncology care. Included with ACCC’s comments are memos from numerous experts that echo the same concerns about the validity of the data. The Hospital Payment Advisory Panel (HOP) agreed with ACCC and other stakeholders at its meeting last month, and recommended that CMS delay its proposals until the agency could verify these data. At a minimum, ACCC asks that CMS delay these proposals. Ultimately, however, it is our hope that CMS will listen to the stakeholders’ concerns and opt not to implement many of the packaging proposals.
We are reminded, once again, of the importance of public comments to these proposed rules. Unless ACCC and other organizations submit comments to CMS, these issues might never have come to light. If you are interested in learning more, or possibly submitting comments in the future, please contact me at firstname.lastname@example.org
By Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC
It is a truth universally acknowledged that the sustainable growth rate (SGR) formula, which the Centers for Medicare & Medicaid Services (CMS) uses to determine annual physician reimbursement rates for services provided, is fundamentally flawed. Because the formula is designed to ensure that the annual increase in the expense per Medicare beneficiary does not exceed the growth in GDP, providers are facing a 25% reduction to reimbursement for 2014, unless Congress takes action. Historically, Congress has stepped in at the last minute each year to avoid such enormous cuts.
This year, however, there are signs that the SGR may be on the way out—permanently.
In February the Congressional Budget Office (CBO), in its annual report on the federal budget and economy, drastically reduced the cost estimate to repeal the SGR formula—down from $245 billion to less than $140 billion over 10 years, a relative bargain in congressional terms. During the intervening months, Congress has been wrestling with legislation to replace the SGR formula. On July 31 the House Energy and Commerce Committee voted unanimously in favor of a bill that would do just that.
The Medicare Patient Access and Quality Improvement Act of 2013 (HR 2810), eliminates the current SGR formula and replaces it with a two-phase approach to physician reimbursement. Phase one stabilizes reimbursement with a 0.5% update to the Medicare fee schedule conversion factor annually for five years. Starting in 2019, phase two begins with 0.5% updates to the conversion factor. In phase two, these updates could be positive or negative—depending on the ability of an individual provider or group of providers to reach pre-determined quality measures or clinical improvement activities.
While ACCC applauds the bill’s aim to replace the flawed SGR formula with stable payments and incentive updates, we are concerned that HR 2810 does not replenish the pool of available funds with savings realized annually by CMS. HR 2810 requires CMS to identify services it overpays and reduce those payments by 1% each year from 2016 to 2018 (RVU reductions). However, the bill contains no language calling for CMS to redirect that money back into services it designates as undervalued. Without this direction, it could mean that the total payment pool would be smaller and planned reimbursement increases might never materialize.
HR 2810 currently awaits a full floor vote with 40 bi-partisan co-sponsors. ACCC will continue to work with legislators to help ensure that legislation passed will appropriately reimburse physician services. ACCC will keep members up to date on any developments.