By Sydney Abbott, JD, Manager, Provider Economics & Public Policy, ACCC
Implementation of the Affordable Care Act (ACA) is bringing many changes to the healthcare system, including the establishment of health insurance exchanges and new requirements for insurance coverage.
Health insurance exchanges (also known as health insurance marketplaces) provide an option for patients to purchase health insurance outside of employer-based plans and are a step toward the goal of universal coverage. However, because all plans offered through an exchange must meet minimum health benefits and satisfy other insurance reforms, such as a cap on annual benefits and coverage for young adults, individual plan premiums on the exchanges are often more expensive than patients expect. This could lead–and in some cases, has already led–to missed premium payments.
In the event of a lapsed premium payment for individuals enrolled in a federally facilitated exchange (FFE) plan, the ACA gives patients 90 days to become current on any past payments before insurance coverage is terminated. The ACA replaces all existing state laws with the 90 day rule. The rule applies to all consumers, in all states, who purchase subsidized coverage through the FFE health insurance marketplace.
How the 90-Day Rule Works
Here’s how the 90-day grace period works. After the first premium is made, patients have 90 days to pay the next premium. If the patient doesn’t pay the premium for the second month, the insurer can hold all claims. At the end of the third month, if the patient still has not paid, the insurer may terminate the policy.
Unfortunately, there is one wrinkle in the 90-day rule that is concerning for providers. This issue only applies to those individuals who receive tax subsidies to purchase insurance through the FFE insurance marketplace. In this instance, if a consumer still fails to make a payment after 90 days and his or her coverage is dropped, insurers are not required to pay for claims incurred during the last 60 days of the grace period. This means that if coverage for these patients is dropped for nonpayment, physicians must work directly with the patients to collect payments for the balance incurred during days 31-90 of the grace period.
While this issue only applies to individuals who receive tax subsidies to purchase insurance through the federally facilitated insurance exchanges, providers need to know that patients’ insurance cards will not include information on whether or not the patient is receiving subsidies. Claims unpaid the 31st through the 90th day may be pended by the insurer. If the enrollee never pays his or her share, the claim is not payable by the insurer.
During a recent House Energy & Commerce Oversight and Investigations Subcommittee hearing, insurers were asked about health insurance marketplace enrollment and premium payment by enrollees. Representative Michael Burgess (R-TX) and other subcommittee members expressed concern over the 90-day grace period and the chilling effect it may have on provider participation in exchange plans. Insurance company executives testifying at the hearing assured the subcommittee that adequate systems are in place to give physicians the ability to determine patient payment and eligibility status. Industry representatives said call centers, and in some instances online applications, are available for premium payment verification. However, premium status policies vary by company and so providers and their staff are left with a complex process for determining a patient’s status. At the conclusion of the hearing, the Oversight and Investigations Subcommittee remained concerned that this information is not readily available to healthcare providers who might ultimately be left unreimbursed for care already provided.
ACCC agrees with the concerns expressed by House Energy and Commerce Subcommittee members and urges Congress and the Administration to work together to require more easily accessible and real-time patient status data to be available to providers. ACCC has submitted a letter to the Administration about this issue and continues to work with members of Congress to raise the volume. We will keep members posted on any developments on the 90-day grace period.
In April, ACCC held its 40th Annual National Meeting, with a focus on policy, economics, and business. The session on “Strategies for Growth in Cancer Care Delivery,” with Sg2 Vice President Trever Burgon, PhD, was standing room only. ACCCBuzz invited Dr. Burgon to share some key takeaways from his talk. Read on and find out why the term “indispensable” is the way you want patients and payers to describe your cancer program.
Let’s start with a provocative statement: There is no service line more important to your hospital, practice or health system’s future competitive position than cancer services. Here are three areas of evidence to support this claim:
1. Growing demand – An aging population and expanding treatment options will drive strong demand for cancer services. At the recent ACCC 40th Annual National Meeting in Arlington, Va., I shared data from Sg2’s Impact of Change® forecast model, which projects demand for healthcare services over the next decade. Much of this growth will happen in the outpatient setting, in fact, Sg2 forecasts stronger outpatient growth for cancer than for any other service line. Nationally, we anticipate that demand for ambulatory cancer care will increase 15% over the next five years and 31% over the coming decade. Demand growth will be softer on the inpatient side, increasing only 3% over the next decade. There is an important nuance in these inpatient numbers. Many inpatient surgical procedures will see strong growth of +9% over the next 10 years, while non-surgical admissions are expected to fall by 5%. This expected decline will be the result of improved patient management in the ambulatory setting and expanded access to appropriate palliative and end-of-life care which will reduce avoidable hospitalizations. Meeting this demand will require hospitals and health systems to develop and expand strong systems of care that coordinate services across the care continuum, from screening and diagnosis to outpatient and inpatient treatments through survivorship and end-of-life care.
2. Changing economics – Per person, cancer is the most expensive disease to treat in the U.S. For providers and health systems, cancer care represents an important source of revenue that helps subsidize other care delivery services. At the same time, spending on cancer is increasingly coming under the scrutiny of public and private payers looking to control healthcare spending costs. As we heard multiple times at the recent ACCC meeting, various new payment reforms, including robust benefits management, bundled payments, and narrow networks, all have the potential to materially impact cancer services. Successfully navigating these changing economic structures has the potential to impact the entire enterprise.
3. Connecting with patients and families – Cancer occupies a unique and important part of our healthcare landscape. It is a terrifying disease that will impact virtually each one of your patients and prospective patients either through a personal diagnosis or that of a loved one. Meeting the needs of these patients and their families with seamlessly coordinated, patient-focused services that span the care continuum represents a powerful opportunity to engage and care for these consumers over their lifetime. Guiding a patient from initial diagnosis to treatment, providing critical but under-reimbursed psychosocial support services, or ensuring that patients’ end-of-life treatment plans are aligned with their quality of life goals, can be some of the best opportunities to establish your program as the go-to place of care for all of a family’s healthcare needs. If you can provide this level of coordinated, patient-centered care for a complex disease like cancer, you can do it for any disease.
What must cancer programs do to position themselves for success in the face of growing demand, changing economics, and unique opportunities to connect with patients? Build a differentiated program that is indispensable to both patients and payers.
There are many ways to build this type of program and no two cancer programs will establish their indispensability in the same way. One area that will be consistent across all successful programs, however, will be a robust system of care that delivers value by ensuring patients and data flow seamlessly between the many providers and sites that span the cancer care continuum. At ACCC’s Annual National Meeting in April, we discussed a number of clinical opportunities for differentiation, including protocol-driven lung screening, easy-access one-day multidisciplinary clinics, and cancer-program-embedded outpatient palliative care services. In addition, we examined a number of oncology-specific bundled payment and accountable care pilots that progressive organizations are using to differentiate themselves with payers.
There are not enough resources to build every clinical program you would like, and not all of the new payment pilots will be successful and scalable. But these types of investments and innovations will be the key to making your cancer program indispensable in your market. And it will be these indispensable programs that succeed, to the benefit of your hospital, practice, or health system and more importantly, your patients.
by Sydney Abbott, JD, Manager, Provider Economics & Public Policy, ACCC
National Cancer Institute’s (NCI’s) recent announcement that two community-based research networks, the Community Clinical Oncology Program (CCOP) and the NCI Community Cancer Centers Program (NCCCP), would be combined under the NCI Community Oncology Research Program (NCORP), raised concern and confusion about future clinical trial funding for community-based programs. In a blog post last week, ACCC expressed concern about a reduction in clinical trials and a possible gap in funding.
The NCI announcement about the change states that the new NCORP will have fewer investigators and “will be comprised of some of the sites formerly funded through the CCOPs, MB-CCOPs, and NCCCP, as well as new grantee institutions….”
NCI Director Harold Varmus has now released an open letter to the oncology community clarifying how this consolidation will impact clinical trial funding. The newly formed NCORP network will center on treatment and prevention-based clinical trials, as well as population-based studies and other research.
Dr. Varmus responded to concerns about maintenance of funding between the current round of annual CCOP awards (June 2014) and the start of the newly created NCORP (estimated to be August 2014), stating:
“With Fiscal Year 2014 budgets now in place, our grantees can be assured that NCI will fund all CCOPs at their current levels during this period. While this was always our intention, this has not been clearly communicated. Furthermore, currently funded investigators should continue the active, uninterrupted accrual of patients to new or ongoing clinical trials during this interval. As in the past, full funding for all research activities required to carry out approved studies will be provided.”
In addition, the letter states that programs not selected to receive funding under the new NCORP will receive assistance to ensure the smooth closeout of operations.
ACCC continues to monitor developments and will keep members updated as additional information is released.
by Amanda Patton, Manager, Communications, ACCC
The language delaying implementation of ICD-10 that was piggy-backed on last week’s SGR “patch” legislation caught many off guard. With months—if not years—of preparation and planning for implementing the new code set—it seems we’re back to uncertainty. ACCCBuzz asked Cindy Parman, CPC, CPC-H, RCC, to share her thoughts on the delay and next steps for cancer programs. Parman is a principal at Coding Strategies, Inc., and authors the “Compliance” column for ACCC’s journal, Oncology Issues.
ACCCBuzz: What are your thoughts on this latest delay by Congress?
Parman: First, it isn’t over until it’s over. The Centers for Medicare & Medicaid Services (CMS) has not weighed in yet [at the time this post was written] on what the inclusion of ICD-10 delay language in the SGR fix legislation really means. At present, several news sources have suggested that the agency’s silence on the never-ending drama—termed by one publication as “ICD-10 Held Hostage”—could mean:
- There will be an official implementation delay until October 1, 2015, or
- CMS will establish a different mandatory/voluntary implementation scheme, or
- CMS will decide to allow those providers who want to voluntarily implement ICD-10 on October 1, 2014, to do so, or
- CMS will decide that the legislation is not valid, since there was no Federal Register announcement, no comment period, etc., and
- Other payers may decide to “go live” on October 1, 2014, regardless of the SGR patch legislation that affects only the Department of Health & Human Services (HHS).
ACCCBuzz: Assuming that ICD-10 implementation is delayed, what does that mean for hospitals and physician groups who have already invested in computer system upgrades, clinical documentation improvement, and coding education?
Parman: According to the American Health Information Management Association (AHIMA) in a March 31, 2014, email to its membership:
Effects of a one year delay include an estimated likely cost of $1 billion to $6.6 billion to the healthcare industry and lost opportunity costs for failing to move to a more effective code set. A cloud will also be cast over the employment prospects of more than 25,000 students who have learned to code exclusively in ICD-10 in HIM associate and baccalaureate educational programs.
ACCCBuzz: So what should oncology providers do now with respect to the ICD-10 transition?
Parman: It’s important to stay the course. Shelving the work completed so far and losing the financial investment is simply not an option! Here are some tips to help:
- Keep working on clinical documentation improvement (CDI). This is not just a project that affects ICD-10; it affects quality reporting, value-based modifiers, responses to audits and investigations, patient portals, and almost every other aspect of healthcare. Practices and facilities who have not implemented a CDI program should get the ball rolling as soon as possible. (Find out more about why you need a CDI program here.)
- Know the ICD-9-CM Official Guidelines for Coding and Reporting! The ICD-10-CM Official Guidelines include some changes to sequencing, mandatory assignment of additional diagnosis codes for tobacco and alcohol use, etc., but they are built on the same format and structure. As a compliance consultant that performs both radiation oncology and infusion center chart audits, I rarely see correct and complete ICD-9-CM diagnosis coding. If a facility or practice is completely documenting all primary, secondary, and tertiary medical conditions with ICD-9, the transition to ICD-10 will be so much easier.
- For those providers who have initiated or completed training on the ICD-10 code set, it is use it or lose it. Make certain that coding staff continues to use the ICD-10-CM code set, by dual-coding a subset of medical records, performing peer review of records coded with ICD-10, etc. Do something creative, like a weekly Lunch-and-Learn to discuss unique ICD-10 coding situations.
- For those providers who have not initiated or completed training on the ICD-10 code set, don’t wait – just do it. The whole point of any transition delay is to maximize the remaining time to complete the task. This is a larger coding classification than ICD-9-CM with variances in the verbiage and specificity of available codes. Don’t underestimate the extent of education required, and don’t wait until the last minute and assume that there will be training programs available.
- Continue to perform end-to-end testing with those payers who are ready for this. Test often with any payer that is available for testing, and set up a process for denial management. There is a potential for an increased number of denials with the implementation of ICD-10, so make sure your denial management process is efficient and accurate. Of course, the best way to manage denials is not to have any, so use this gift of time to also improve front-end processes to minimize rejections and denials.
- Facilities who have completed the computer system updates, clinical documentation improvement, and most or all of the coding education can consider “backtrack” diagnosis coding. This means that the medical coding staff reports ICD-10-CM diagnosis codes, but the software backtracks and bills the ICD-9-CM code. This is a much easier conversion process (to go from one detailed code back to a more general diagnosis code) and can be accomplished by many existing billing software engines. If this process is initiated during calendar year 2014, the actual transition to ICD-10, when it finally occurs, may be smooth and straight-forward.
ACCCBuzz: What about those who say, “Why not just wait for ICD-11?”
Parman: Have you seen ICD-11? It is built on ICD-10, so be careful what you wish for! Attempting to transition from the ICD-9 classification directly to ICD-11, and bypassing ICD-10, will create additional stress (economic, financial, and mental), especially for intermediate and small physician practices.
The World Health Organization (WHO) plans to release the ICD-11 classification somewhere between 2015 and 2017 (depending on which WHO document you read). Not only will ICD-11 incorporate all the functionality of ICD-10, it will be digital only (no paper manuals) and will link with terminologies such as SNOMED CT (Systematized Nomenclature of Medicine – Clinical Terms) and support electronic health records and information systems. Remember that a WHO “release” as early as 2015 still means that various agencies and committees will have to meet and develop the Clinical Modification (CM) that will be used in the U.S.
ACCCBuzz: Any parting advice?
Parman: Use any implementation time resulting from a delay in ICD-10 transition to improve operations, documentation integrity, and coding skills. Never waste the gift of time!
Editor’s Note: ICD-11 release date in this post was updated 4/14/14 to reflect ambiguity in the current WHO timeline.
By Amanda Patton, Manager, Communications, ACCC
By the time ACCC’s Annual National meeting wrapped up this week, attendees had heard plenty of numbers. Here is just a small sampling:
7.1 million Estimated number of enrollees under the ACA’s health insurance marketplaces
70% Percent of plans on insurance exchange that are considered “narrow networks”
30 Number of states that have now passed oral parity legislation
13.7 million Current number of cancer survivors in the U.S.
1.5 million Number of new cancer cases diagnosed annually
18% Percent of U.S. population that will be Medicare eligible by 2020
17 Number of times Congress has passed a “doc fix” to the SGR
All these figures and more added up to some overarching themes from this year’s meeting sessions:
Strength in numbers is needed to make the voice of community cancer care heard on Capitol Hill. “At the end of the day, I think we need more clinical voices in the policy setting,” said keynote speaker Kavita Patel, MD, of the Brookings Institution. “You don’t want Medicare or Congress thinking about cancer care without [your voices being heard].”
Patient-centered care requires open communication. In Tuesday’s panel on “What Are the Costs and Where Is the Value in Cancer Care?” panelists agreed that discussion about value in cancer care is complex but must be patient-centered. “For patients, value has a number of different meanings,” said panelist Nancy Davenport-Ennis of the Patient Advocate Foundation. “Patients want to have open dialogue with physicians about what the options are and how they are going to pay for this [treatment].”
The need for good communication with patients was also part of an earlier panel discussion on Multidisciplinary Care in Oncology. Smaller hospitals and cancer programs trying to create multidisciplinary programs should first look to the relationship that needs to exist between patients and the team, said panelist Tom Kean, MPH, of C-Change. It’s important to ask: “What does the patient value?”
The future oncology care delivery structure & workforce will look different. Given the perfect storm brewing of escalating costs, a growing demand for oncology services, and a projected future shortage of oncologists, the way we deliver cancer care will have to change. Several presenters circled around the medical home (possibly in combination with some type of pay-for-performance) as potentially a good fit for oncology—in part because many cancer centers are already providing the services encompassed by this model. And several sessions touched on how the cancer care workforce will have to change to meet the projected demand. This new “care force” will not only include more non-physician providers, but also is likely to have non-clinical care providers and make increased use of community resources.
One shift that is already underway in some cancer programs is careful assessment of skill sets. Multidisciplinary Care in Oncology panelist Marie Garcia, RN, OCN, said, for example, her practice took a close look at the skill set needed to provide survivorship services. For their survivorship program was a nurse practitioner needed? Could the position be filled by a nurse? Or a patient navigator? “In a value-based world, you need everyone on the team performing at the top of their licenses,” said co-panelist Mark Soberman, MD, MBA, FACS.
We must be the change. Across sessions the recurrent message was that cancer providers need to be proactive. It’s fine to start small, but start now, assess ways to demonstrate value, explore new payment models, and work more collaboratively with payers, providers, and community resources.
With polarization on Capitol Hill impeding the legislative process, ACCC 40th Annual National Meeting keynote speaker Kavita Patel, MD, of the Brookings Institution told attendees: “If you are looking for change, I would point you to your own selves in the mirror, not to Washington, D.C.”
With the Senate having passed the SGR reform patch the night before, Patel noted that despite the fact that SGR reform was one of the few things with bi-cameral support in Congress, ultimately, we once again have a one-year “doc fix.” This is the 17th time Congress has enacted an SGR patch since the formula went into effect in 2002.
Still, Patel believes there is potential for Congress to act on long-term reform next year.
The current “SGR fix” legislation reflects Congress’s focus on “value” and value-based alternative payment models, she noted.
“At some point, it will be important for your community to think about what that would look like at your programs.” She believes medical oncology may be well suited to what Congress is thinking about with alternative payment models.
While cancer care has evolved so greatly over the past several decades, our reimbursement policies to pay for that care have not evolved.
Among the alternative payment models, Patel believes the medical home model may be suited to oncology, while bundling is a poor fit.
“If people think there’s going to be bundling in oncology, they are wrong,” she said.
So is fee for service gone forever? “No,” says Patel. “The answer is there is always going to be room for fee for service in certain settings.”
But, some form of risk-sharing is definitely in the cards. “In 10 to 15 years, the majority of people in this room will have some sort of risk-based contract…that will become the norm in the next several decades.”
However, she warned that if you turn to Congress for a solution, they are likely to turn it around and ask you to show them viable solutions—and this is a good thing.
At the end of the day, I think we need more clinical voices in the policy setting arena, “ she said. “You don’t want Medicare or Congress thinking about cancer care without [our] voices.”
by Amanda Patton, Manager, Communications, ACCC
More than 50 ACCC members from 27 states were walking the halls of Congress on March 31 for ACCC’s Capitol Hill Day. With the Senate poised to vote on the SGR patch legislation, the timing was perfect for talking with elected officials about the need for a permanent fix to the sustainable growth rate.
Participants were scheduled for more than 100 visits with House and Senate offices throughout the day.
From first-time meeting attendees to veteran hill day participants, the consensus was that the time spent meeting with elected officials was well worth the effort.
The day was “extremely educational,” said new ACCC member Cindy Krasnecky, director of the cancer center at Harrington Memorial Hospital in Southbridge, Massachusetts. “I was impressed by the level of knowledge and experience of the [Hill] staffers.”
ACCC members focused on four main concerns in their conversations with Hill staff:
- Finding a permanent solution to the flawed SGR formula
- Passing oral parity legislation
- Removing anti-cancer drugs from the Medicare sequester
- Eliminating the prompt pay discount.
“It felt empowering to have your voice actually heard by someone setting policy,” said Angela Tambini of the Lahey Clinic in Massachusetts.
Anecdotally, we heard frustration in many congressional offices over the status of SGR reform and disappointment with an inability to effect more sweeping change.
At the end of the day on Monday, the Senate passed a bill to extend Medicare physician pay rates through March 15, 2015. The legislation will also delay ICD-10 implementation until 2015.
According to BNA Bloomberg this marks the 17th time Congress has acted to prevent scheduled reimbursement cuts due to the SGR since the formula went into effect in 2002.
By Sydney Abbott, JD, Manager, Provider Economics & Public Policy, ACCC
ACCC’s Capitol Hill Day on March 31 is just around the corner. ACCCBuzz is featuring a primer series on the key issues ACCC members will be talking about on Capitol Hill. In this final of four installments, we’ll look at the need to pass legislation to fix the prompt pay discount.
The issue: Many drug manufacturers offer a 2% incentive for distributors who pay promptly. However, this 2% discount is not generally passed on to providers. Medicare includes this discount in its calculation of average sales price (ASP), a key component in the Medicare reimbursement formula. Although Congress intends for Medicare Part B to reimburse providers at ASP +6%, the prompt pay discount artificially reduces payments to ASP+ 4%. When you take into account the additional reduction on all drugs and services billed to Medicare due to the sequester, providers are actually seeing reimbursement closer to ASP +2.3%. That’s a long way from the congressionally intended ASP+6%.
Legislation introduced by Congressman Ed Whitfield (HR 800) would change how ASP is calculated by eliminating the prompt pay discount from the Medicare Part B reimbursement formula. Those of you coming to Washington, D.C., on March 31st for ACCC’s Hill Day will have a chance to explain why this legislation matters in person.
ACCC members who cannot make the trip to D.C. next week can still express support for the elimination of the prompt pay discount and ask Congress to pass HR 800. Visit ACCC’s Legislation Action Center to find out how.
by Sydney Abbott, JD, Manager, Provider Economics & Public Policy, ACCC
ACCC’s Capitol Hill Day on March 31 is less than one week away. ACCCBuzz is featuring a primer series on the key issues ACCC members will be talking about on Capitol Hill. In this third of four installments, we’ll look at the need to pass federal oral parity legislation.
By now you know the issue: oral parity legislation is needed to ensure that patients can afford their oral anti-cancer medications. And you have probably already heard that 29 states have passed oral parity laws requiring insurance companies to cover oral chemotherapies at the same rate they already cover IV-infused medications. Considering that more than half of the states have passed oral parity laws, and that number continues to grow, why is oral parity an advocacy issue for ACCC’s federal Hill Day?
Even though state laws are currently being passed, federal legislation is still required for two important reasons:
- Language of the laws varies across the states and only federal legislation will ensure the same protections for all patients; and
- State laws only impact state-regulated plans. Federal legislation is needed to cover self-insured plans (ERISA).
Currently, there are bills in both chambers of Congress, just waiting for ACCC advocates to push them forward. HR 1801 in the House has 71 cosponsors, while the newer S 1879 in the Senate only has one cosponsor. ACCC members, please speak up for this important legislation.
Those of you coming to Washington, D.C., on March 31st for ACCC’s Hill Day will have a chance to explain why this legislation matters in person.
ACCC members who cannot make the trip to D.C. next week can still express support for federal oral parity legislation and ask Congress to pass HR 1801 and S 1879. Visit ACCC’s Legislation Action Center to find out how.
by Amy O’Connor, Guest Blogger
In the last century, the scientific community has made enormous progress in the treatment and prevention of over 200 forms of cancer. Innovative treatments and medicines have led to truly meaningful headway for those with cancer, their loved ones, healthcare providers, and many others who have a stake in the fight.
To build on this progress, Lilly Oncology created PACE, which stands for Patient Access to Cancer Care Excellence. PACE gathers together a global network of advocacy groups, businesses, and individuals to support the healthcare decisions that will lead to new cancer cures and treatments. We encourage public policies that speed the development of new medicines, assure that cancer treatments respond to the needs and qualities of individual patients, and improve patient access to the most effective cancer medicines.
The cancer community faces the challenge of how best to make treatments affordable and accessible to patients, while ensuring that scientific innovation continues. Even with consensus on the need for high-quality, patient-centered care, viewpoints on what makes a cancer treatment valuable vary broadly among stakeholders.
With that in mind, we’re delighted to work with ACCC to bring the dialogue about value and quality in cancer care to center stage at ACCC’s upcoming National Conference. On April 1st, PACE member Jackie Doorhy will join representatives from the National Patient Advocate Foundation, Priority Health, and the Greater Baltimore Medical Center to discuss the value of cancer care and how to ensure high-quality care for people with cancer. But we don’t want to limit the conversation to the stage: we want you to get involved! From 11 am – 12 pm on April 1st, PACE will livestream the panel on our website. Join us by registering today!
By working together—through science, education, and advocacy—we can build the momentum that leads to new treatments and cures for cancer, today and in the future. We encourage you to become a part of the conversation on April 1st by registering for the livestream today and tweeting your questions to the panelists with @PACENetworkUSA and @ACCCBuzz.
Editor’s note: View previous ACCC Town Hall discussions here.