By Matt Farber, MA, Director of Provider Economics & Public Policy, ACCC
On July 3, 2014, the Centers for Medicare & Medicaid Services (CMS) released the 2015 proposed rules for the Hospital Outpatient Prospective Payment System (OPPS) and the Physician Fee Schedule (PFS), and ACCC is busy poring through the documents in order to get the most pertinent information out to our members as soon as possible. Look for complete summaries of both rules from ACCC shortly, and ACCC members be sure to dial in to our conference call on the proposed rules on Wednesday, July 23rd at 2 pm ET.
At first glance, we can say the 2015 proposed rules do not appear to include as many drastic changes as in previous years.
For example, the proposed 2014 OPPS rule contained proposals to collapse all E&M codes, package drug administration services, and other packaging proposals, which–had they all been implemented—would have meant significant changes for oncology. In the end, while CMS did finalize the proposal to collapse E&M codes, the agency did not finalize all of the packaging proposals. Now, for 2015, the agency is proposing to increase packaging and composite APCs; however, drug administration is not included in that list. That being said, we know that CMS still wants to study drug administration, so we do not believe that changes to that area are necessarily off the table.
Another interesting proposal for 2015 has to do with off-campus departments of hospital outpatient departments (HOPDs). Last year, CMS stated that it wanted to collect data to determine if payments made to “off-campus facilities,” often practices that have recently been purchased by a hospital and converted to a HOPD, are justified at different rates. For 2015, CMS is proposing to require that all services rendered in these off-campus departments be billed with a modifier, so that the agency can study the issue and potentially make changes in the future.
Finally, in the 2015 proposed OPPS rule, drugs are still scheduled to be reimbursed at ASP+6% in the HOPD. So it appears that the ACCC’s years of hard work on this issue have continued to pay off.
On the Physician Fee Schedule side, there is the continuing issue of the sustainable growth rate (SGR)—but this is no surprise. Once again, under this flawed formula, there is a scheduled cut to physician reimbursement of 21%. And once again, this most likely will not go into effect, as Congress will step in later this year or early next year with yet another (hopefully long-term!) “doc fix.” Under the proposed PFS, medical oncology is slated to receive a 1% increase, which is always better than a negative number. On the other hand, radiation oncology would not fare as well, with larger cuts scheduled for radiation oncology and radiology.
While at first look, it may appear that the 2015 proposed rules put forth less onerous issues than in prior years, ACCC will still be submitting comments to CMS with our concerns, and we encourage you to submit comments as well. Once ACCC’s comments are completed, ACCC will post them in the Advocacy section of the website, and members can use these as a template, if desired. CMS is accepting comments on these rules until Sept. 2, 2014.
Meanwhile, ACCC encourages all members to join us with your questions on the July 23 members-only conference call. For more information, please contact Matt Farber at firstname.lastname@example.org.
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.
By Matt Farber, Director of Provider Economics & Public Policy, ACCC
Last week’s Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) low confidence vote for annual low-dose computed tomography (LDCT) screening for patients at high-risk for lung cancer came as quite a surprise. The Medicare national coverage determination panel’s vote is disappointing in light of the evidence of mortality benefit demonstrated in the National Lung Screening Trial (NLST) and the U.S. Preventive Services Task Force (USPSTF) December 2013 grade “B” recommendation.
The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. The recommendation states that screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. While the Affordable Care Act (ACA) requires private payers to cover services rated highly by the USPSTF, including LDCT, beginning Jan. 1, 2015, the ACA does not mandate the same coverage for Medicare. So providers are awaiting a Medicare national coverage determination (NCD).
ACCC member cancer programs have been following the issue of low-dose CT screening for lung cancer closely. Many community cancer programs have developed or are in the process of developing evidence-based lung screening programs in response to the evidence presented in the NLST study and the USPSTF final recommendation.
ACCC recently submitted comments to the Centers for Medicare & Medicaid Services (CMS) urging full coverage of lung screening for individuals at high risk.
According to media reports, among the MEDCAC panel’s main concerns were the high false-positive rate of CT screening, the potential for LDCT screening to expand beyond the intended high-risk population, and quality issues for scans with low radiation dose. The issues raised by the panel highlight some of the real-world challenges encountered when translating research into practice.
It’s important to keep in mind that Medicare does not have to follow the recommendations of the MEDCAC, so the panel’s recommendation is not the end of the story for LDCT screening coverage. In fact, even if Medicare does agree with the MEDCAC, the public will still have the opportunity to comment on the national coverage decision before a final version is released.
So, while this recommendation is certainly disappointing, it is not the end of the advocacy efforts for ACCC and our members. Stay tuned for the proposed NCD later this year, and more from ACCC. The proposed national coverage determination is due in mid-November, and the public will have 30 days to comment.
ACCC will keep its members updated as this policy evolves. If you have questions or concerns, please contact Matt Farber at email@example.com.
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 Sydney Abbott, JD, Manager, Public Policy & Provider Economics, ACCC
For nearly 30 years, researchers, physicians, and cancer patients have relied on clinical trials provided by the National Cancer Institute’s (NCI’s) Community Clinical Oncology Program (CCOP). Now, due to the Congressional budget-reduction mindset, NCI is woefully underfunded, leading to the Institute’s decision to end funding for federally-funded clinical trials through CCOP as of June 1, 2014. The NCI CCOPs bring clinical trials to patients in their local communities across the country and support for these could end until new NCI research grants are awarded in September 2014, at the earliest.
Additionally, NCI’s new National Clinical Trials Network (NCTN) is facing a 40 percent budget reduction, which has led to a reorganization of cancer clinical trials, including fewer investigators and a total reduction in number and size of trials funded.
The primary programs in the NCTN, CCOP, the Minority-based Community Clinical Oncology Program (MB-CCOP), and the NCI Community Cancer Centers Program (NCCCP) will be consolidated into the NCI Community Oncology Research Program (NCORP). As announced by NCI on April 4, “NCORP will be comprised of some of the sites formerly funded through the CCOPs, MB-CCOPs, and NCCCP…” [emphasis added]. Please see the NCI statement here.
ACCC is concerned that a reduction in clinical trials will lead to decreased innovation of cancer therapies, as well as decreased access to the best care for cancer patients. ACCC urges NCI to reinstate funding for the CCOP and to continue support for community-based clinical trials and research.
Editor’s Note: Since this blog was posted, NCI has issued a letter clarifying funding for community clinical trials during the transition to the new NCORP. Read our update blog here.
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.