On Thursday, March 26, the U.S. House of Representatives passed H.R. 2, legislation to permanently repeal and replace Medicare’s sustainable growth rate (SGR) formula for physician reimbursement. Read a summary of the legislation here.
Unfortunately, the Senate announced late Thursday evening that they will not consider the SGR repeal bill until they return from recess on April 13, 2015. CMS has indicated it will hold claims for two weeks, through April 14.
ACCC urges members to contact your Senators in the next two weeks and ask them to support a permanent repeal of the SGR.
On March 26, by a vote of 392-37 the U.S. House of Representatives overwhelmingly passed H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015, legislation to permanently repeal and replace Medicare’s sustainable growth rate (SGR) formula for physician reimbursement. Read a summary of the legislation here.
Rep. Michael C. Burgess, MD, (R-Texas), the bill’s primary sponsor, said in a statement, “This is the work of a collaborative body. . . .It is time to end the SGR. Let us never speak of this issue again.”
On March 25, the White House expressed support for the bill.
The Senate is expected to vote on the bill March 27, before Congress recesses for two weeks.
ACCC urges members to contact your Senators and ask them to support a permanent repeal of the SGR. As an expert in cancer care, they need to hear from you!
by Leah Ralph, Manager, Provider Economics and Public Policy, ACCC
With another SGR deadline looming, leaders in the U.S. Senate and House are coming close to striking a bipartisan, bicameral deal to finally replace the broken Medicare Sustainable Growth Rate (SGR) formula.
On March 24, bipartisan leaders of the House Energy and Commerce and House Ways and Means Committees introduced H.R. 2, the Medicare Access and CHIP Reauthorization Act (MACRA), to permanently replace Medicare’s Sustainable Growth Rate (SGR). The agreement builds upon H.R. 1470, introduced last week.
H.R. 2 would create an improved physician payment system that rewards quality, efficiency, and innovation and put an end to the cycle of annual “doc fix” crises that have created uncertainty for millions of Medicare providers and beneficiaries for over a decade. As you well know, physicians need the assurance of predictable, appropriate payments in order to plan for the future and invest in the personnel and technologies that are essential to providing high-quality cancer care.
This is historic momentum on an issue that has plagued providers—and Congress— for years. This year’s compromise builds on last year’s efforts, and the window to get this bill across the finish line is narrowing. Join us in urging Congress to continue to work together to pass responsible legislation that appropriately reimburses patient care.
Contact your member of Congress to support a permanent repeal of the SGR. As an expert in cancer care, they need to hear from you!
by Amanda Patton, ACCC Communications
March 23 marked the five-year anniversary of President Obama’s signing of the Affordable Care Act into law. Over the last five years, nearly 16.4 million Americans have gained health coverage under the ACA.
Last week, at ACCC’s Annual Meeting, CANCERSCAPE, in Arlington, Va., panelists Steven D’Amato, BSPharm, BCOP, executive director, New England Cancer Specialists; Wendy Andrews, BS, practice manager, Hematology/Oncology at the University of Arizona Cancer Center; and George Dahlman, executive vice president, Federal Affairs & Operations, National Patient Advocate Foundation, explored the impact of the ACA from the patient advocate and provider perspective, sharing the view from the frontlines of care delivery and patient advocacy. The discussion was moderated by ACCC Executive Director Christian Downs, JD, MHA.
One challenge panelists identified is meeting the increased demand for services driven by growing numbers of insured patients.
“In Maine we have an exchange, Maine Community Health Options. It’s been so successful that the challenge is having adequate staff to manage the program,” said Steven D’Amato. “The big challenge will be the workforce challenge as we have more insured patients.”
Wendy Andrews, who is a practice manager, noted that Arizona has expanded Medicaid, which has moved many patients from self-pay to Medicaid. While they are seeing more patients with insurance, these patients all tend to be underinsured.
Another challenge expressed by each of the panelists is the pressing need to help patients understand their insurance coverage and, especially, their out-of-pocket costs.
During the first year of the Marketplace in Arizona, those trying to help consumers with plan selection often had a lack of knowledge [about coverage] and patients were “actually given the wrong information,” Ms. Andrews said. Now, in the Marketplace’s second year, this problem continues.
From the patient advocate’s perspective, George Dahlman finds that the Marketplace experience is exposing consumers’ education gaps. “We have 200 case workers that help patients with insurance problems and copay programs. [This is exposing] the biggest education gaps for consumers. Most people look at the insurance premiums—not what’s included in the benefits program” when purchasing coverage.
Andrews agreed, finding that “ninety percent of all patients really, truly do not understand their insurance benefits.”
Providers and patient advocate organizations alike are challenged to help educate consumers about their coverage. “These are complicated insurance products, and you’re educating two patient populations: previously insured and those who’ve never had insurance before. It’s a brave new world for consumers,” said Dahlman. Patients need information about whether they can keep their current providers when considering insurance options, and what their out-of-pocket costs will be.
“In our practice, it’s essential that patients meet with a financial advocate first,” said D’Amato. Wendy Andrews agreed. “We pre-register all of our patients and verify their benefits.” Her practice requires that patients also verify that they’ve made premium payments. As a result, the front-end administrative burden for providers has increased.
Finally, the panel touched on the impact of narrow networks within marketplace plans. In a rural state, like Maine, “you always worry about access,” said D’Amato. “Creation of narrow networks creates inconvenience for patients.” In Arizona, Andrews said,“the problem we see the most is lack of providers being available in all the plans. What does a patient do when there isn’t a provider in their plan and they have to travel long distances [for care]?”
In summary, the panelists’ described three key challenges post-ACA implementation:
- Access challenges, i.e., having enough providers to meet increased patient demand; narrow networks potentially limiting patient access to providers
- Education challenges, i.e., increased need to help patients, both previously insured and those who are newly insured, understand their coverage and out-of-pocket costs, and
- Front-end administrative burdens, i.e., verifying coverage, understanding patients’ insurance plan coverage, and helping identify resources for underinsured patients.
by Amanda Patton, ACCC Communications
On Tuesday, March 17, at ACCC’s Annual Meeting, Ron Kline, MD, Medical Officer with the Center for Medicare and Medicaid Innovation (CMMI), and Kavita Patel, MD, MS, of the Brookings Institution helped bring a little more clarity to CMMI’s Medicare’s Oncology Care Model (OCM).
The OCM has been developed by CMMI to test new payment and service delivery models, as part of its overarching triple aim of better care, smarter spending, and healthier people. OCM goals center on care coordination; appropriateness of care; and access for beneficiaries going through chemotherapy, Dr. Kline said. Learn more here.
In his overview of the five-year pilot, Dr. Kline pointed to the multi-payer nature of the OCM. “Payers are encouraged to work as part of the model. The point is to leverage the OCM to bring in more and more payers and patients to this model.”
Finally, he stressed the OCM is not intended to be a one-size-fits-all model.
“Part of the point of OCM is that we don’t have all the right answers for all the parts of the country…and the best way to move forward is to learn best practices [through the model].”
CMMI plans to hold webinars, site visits, and meetings at ASCO and elsewhere to share OCM best practices, he said.
So, What’s Everyone Asking?
According to Dr. Patel, the top OCM hot topics are:
# 1 Eligibility. CMMI wants the OCM to “include everyone as much as possible as long as we adhere to the principles of the OCM, attribute, and benchmark appropriately,” said Dr. Kline.
“ACCC is exactly the audience the Oncology Care Model is tailored for—those providing ongoing services for cancer care,” said Dr. Patel.
#2 If you have a practice, can only some providers participate? The short answer is, if you participate, anyone in the practice who is prescribing chemotherapy would be automatically included in the OCM. This includes NPs or PAs who might be prescribing. Simply put: It’s an inclusive model.
#3 Data requirements. Participants need the administrative and technological resources to support these.
For those contemplating OCM participation Patel suggests the following steps:
- Evaluate what infrastructure investment you will need to make.
- Perform a serious “gut check” with providers on what OCM participation will mean.
- Consider how you’ll get all those involved in the OCM to understand the model’s total cost of care framework. (This last item is likely the biggest organizational hurdle, Patel said.)
- Finally, consider the staffing requirements for participation.
What components will be needed for OCM success? Dr. Patel identified three:
- Bringing on primary care physicians
- Learning how to do robust data exchange inside the practice, e.g., having an EMR able to deliver clinicians what they need at point of service
- Being able to predict which patients in your population will need more intensive services (risk stratify).
Perhaps it’s not surprising that even during the OCM discussion, the SGR made a cameo appearance. Dr. Patel noted that details of an SGR fix currently being negotiated on Capitol Hill will likely include some provisions that will force doctors to enter into alternative payment models in the next five years.
ACCC’s 41st Annual Meeting, CANCERSCAPE, kicked off on March 16 with Capitol Hill Day. ACCC members from across the country fanned out across the Capitol for more than 70 scheduled meetings with legislators and key staff members from both the House and Senate.
With the current Sustainable Growth Rate (SGR) patch set to expire March 31, the timing was ripe for these advocates to speak up for a permanent fix to the SGR.
First time ACCC Hill Day participant Linda Gascoyne, patient advocate for medical oncology, East Maine Medical Center in Brewer, Maine, spent the day with the Maine delegation that met with Senator Susan Collins on Monday, afternoon. “I found her [Senator Collins] to be very empathetic as she listened and learned about what we were asking [from Congress],” Ms. Gascoyne said. In addition to the SGR, the Maine delegation talked with Senator Collins about the need for federal oral parity legislation and elimination of the prompt pay discount from the ASP calculation.
Donna Sulsenti, practice manager, South Shore Hematology Oncology and president of HOMNY was part of the New York delegation that had visits with four congressional offices. “It was extremely interesting speaking about issues with our legislators and getting something accomplished,” she said. She also finds it “satisfying to know that ACCC is working for us.”
Another first time ACCC Hill Day participant Monica Cfarku, nurse manager, Oregon Health & Science University, Knight Cancer Institute, said she “learned a lot” from her meetings with hill staff. In turn, she found staff engaged on the issues and interested in learning from her. “I felt like I offered them a different perspective as someone on the frontline of care delivery.” In fact, staff from a congressional office invited her to return later in the week to share more of her perspective.
Stay tuned for more from ACCC’s Annual Meeting, Cancerscape underway in Arlington, Va. Follow us on Twitter at #cancerscape15.
By Leah Ralph, Manager, Provider Economics and Public Policy, ACCC
As ACCC members are well aware, on February 12, the CMS Innovation Center (CMMI) released its much-anticipated Oncology Care Model (OCM) as part of the broader effort to lower healthcare costs and tie reimbursement to quality and value. ACCC has been conducting an in-depth analysis, and, overall, the OCM generally resembles the discussion draft we saw in August; while the model contains many positive elements, other areas still need clarification.
At its core, the OCM looks similar to a patient-centered oncology medical home or accountable care organization (ACO), with a target expenditure and shared savings component that encompasses the total cost of patient care during a particular period of treatment. The model is a voluntary, five-year program slated to begin in spring 2016. Physician group practices, hospital-based practices (except for PPS-exempt hospitals), and solo practitioners that furnish cancer chemotherapy are eligible to participate. Payments will be based on a six-month episode of chemotherapy treatment that is triggered by the administration of a pre-set list of chemotherapy drugs, and will take into account all Part A, Part B, and some Part D expenditures for that patient during the episode. In addition to a FFS payment, providers will receive a care coordination payment to improve quality of care ($160 per patient, per month during the episode) and a performance-based payment to incentivize lower costs that will be based on the difference between a risk-adjusted target price and actual expenditures during the episode. The payment arrangement is one-sided risk, with the option of converting to two-sided risk in the third year.
Importantly, the OCM is a multi-payer model in which commercial payers and state Medicaid agencies are encouraged to participate. Aligning financial incentives by engaging multiple payers will leverage the opportunity to transform oncology care across a broader population. During the selection process, CMMI will favor practices that participate with other payers in addition to Medicare. In addition, practices will have to meet certain quality metrics and undergo practice transformation requirements, including: effective use of electronic health records; 24-hour access to practitioners who can consult the patient’s medical record in real time; comprehensive patient care plans; patient navigators; and continuous quality improvement.
While we were pleased to see much of ACCC’s feedback incorporated in the final version, our dialogue with CMS is ongoing. Our members continue to have questions about the benchmarking methodology, specifics on the quality metrics and practice transformation requirements, eligibility to participate in the model, and more. ACCC will continue to seek answers to these questions, and will offer CMS feedback based on member input.
If your practice is interested in participating, or considering participation, we encourage you to submit a non-binding letter of intent to CMS by the deadline of April 23, 2015. We anticipate CMS will continue to provide additional guidance until the application deadline, which is June 18, 2015.
Join us at ACCC’s Annual Meeting CANCERSCAPE on March 17 and hear directly from Ron Kline, MD, Medical Officer with the Center for Medicare and Medicaid Innovation—an author of the Oncology Care Model, as he shares an insider’s perspective on New Payment and Delivery Models in Medicare.
This week the CMS Innovation Center announced the launch of the Oncology Care Model—the agency’s newest payment and service delivery model, described as a multi-payer, oncology practitioner-focused model designed to improve the quality of cancer care while lowering cost.
According to the CMS announcement, key facets of the model include:
- Episode-based payment that targets chemotherapy and related care during a six-month period following the start of chemotherapy treatment.
- Multi-payer design with Medicare fee-for-service and other payers working in tandem to promote care redesign for oncology patients.
- Requiring physician practices to engage in practice transformation to improve quality and coordination of care.
This is the latest signal that the shift from volume-based reimbursement to payment for value and quality is gaining momentum. The interest in moving healthcare payment away from a system that incentivizes quantity has been reflected in every major healthcare law in recent years—from the Medicare Modernization Act (MMA) in 2003 to the Affordable Care Act (ACA) in 2010.
In fact, the ACA created the $10 billion Center for Medicare and Medicaid Innovation (CMMI) with the sole aim of developing and testing innovative ways to pay providers. And on Feb. 12 the Innovation Center provided its first model for oncology care.
The launch of this model is not unexpected given that in January 2015, for the first time in Medicare’s history, the Department of Health and Human Services (HHS) announced explicit goals for tying Medicare payments to alternative payment models and value-based payments. According to the HHS timeline, 30 percent of all fee-for-service (FFS) Medicare payments will be tied to alternative payment models by 2016—including, but not limited to, Accountable Care Organizations (ACOs), medical homes, and bundled payments for episodes of care. By 2018, 50 percent of payments will be tied to these models. CMS also set a goal of tying 85 percent of traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through such programs as the Hospital Value Based Purchasing or Hospital Readmissions Reduction programs.
The initial benchmark of 2016 sets a laudable, but ambitious, goal. Certainly the announcement signals the Obama Administration is making this issue a priority, and we can expect to see an accelerated push to transition Medicare payments and, in turn, private payers.
This shift is a huge undertaking that will not only affect payments, but fundamentally change incentives for how providers deliver care. Implementation will take time, and will require the right balance of forward momentum and important safeguards to ensure that patients continue to receive the most appropriate, quality care. As HHS moves full steam ahead, the provider community must speak up and urge policymakers to:
- continue to work to find consensus on appropriate quality measures,
- establish a sound, fair methodology for calculating financial benchmarks and risk adjustment, and
- allow providers the time, resources, and flexibility they need to implement these new payment models.
The just-announced Oncology Care Model (OCM) will test the bundling of payments for chemotherapy administration. But with other models, such as the Medicare Shared Savings Program (Medicare ACOs) that are primary care focused, it’s still unclear how oncologists will be included or even participate. Caring for cancer patients is complex and often expensive, leaving inherent challenges in how to account for cancer care in alternative models. How will high-cost drugs and innovative therapies be treated in the construct of an ACO? Will high-cost cancer patients be included in the financial benchmark? What is oncology’s role in shared risk and savings? ACCC and other organizations are continuing to work with CMS to answer these questions.
Call to Action
ACCC encourages the provider community to remain informed and active participants in the policy-making dialogue to ensure that we do, in fact, achieve meaningful, realistic payment reform. One of the best ways to get engaged is meeting with your legislators at ACCC’s upcoming Capitol Hill Day on March 16. The next day, at ACCC’s Annual Meeting, CANCERSCAPE on March 17, we’ll be hearing from Ron Kline, MD, Medical Officer with the Center for Medicare and Medicaid Innovation – an author of the Oncology Care Model. Now is the time to come to Washington D.C. – get your questions answered and voices heard at a pivotal moment for oncology care. Join us!
The last few months have brought big changes to Washington, D.C. We will ring in the New Year with both chambers of Congress under GOP control, which means the parties are reorganizing and, importantly, the legislative agenda is shifting. While it’s still anyone’s guess whether new leadership will mean less political infighting in 2015, issues like trade, energy, and tax reform are early contenders for potential areas of compromise next year.
The ACA (Affordable Care Act) will also make the top of the political agenda: starting in January, you can count on Republicans to look for every opportunity to take the legs out from under President Obama’s signature achievement. Although full repeal is unlikely, as it would face an all-but-guaranteed presidential veto, expect the new majority to focus their efforts on introducing a series of stand-alone bills targeting the most unpopular provisions of the law.
Predicting the fate of non-ACA healthcare legislation is a tougher call. On the one hand, healthcare fatigue still looms large among legislators, making issues like a long-term fix to the Sustainable Growth Rate (SGR), oral parity, and sequestration more of an uphill climb. On the other hand, new leadership, a renewed vow to work across the aisle, and public dissatisfaction with the status quo are bringing new energy to Congress.
Will 2015 Bring a Permanent SGR Fix?
In 2014 we saw what was arguably the best opportunity in years to finally fix the fundamentally flawed SGR formula. Congress came to agreement on a bipartisan bill that had a relatively low price tag, but in the end could not reach consensus on how to pay for the fix. As a result, the bill never came to a vote and will need to be reintroduced in the new Congress. Still the fact that Congress achieved consensus on policy is a promising sign for 2015. We have now weathered seventeen (17!) “doc fix” patches that, if added together, cost far more than the comprehensive approach lawmakers are considering today. This year’s ACCC Capitol Hill Day is scheduled for March 16, so we will be visiting with our legislators just weeks before the current “doc fix” expires on March 31.
Will We See Federal Oral Parity Legislation?
Passing a national oral parity law continues to be a top priority for ACCC membership. On the state level, oral parity efforts are gaining momentum. To date, 34 states and D.C. have enacted oral parity laws, and several other states are ramping up their grassroots efforts for 2015. Given that an estimated 25 to 35 percent of all oncology therapies in the pipeline will available only in pill form, the need for comprehensive, federal oral parity legislation is increasingly critical to patient access. While state-level legislation remains important, lawmakers need to understand that federal legislation would ensure consistency in oral parity laws across the country and would include plans that fall outside the purview of state regulation.
Will We See Any Relief from the Sequester?
Last year, legislation to exempt cancer drugs from the Medicare sequester gained more than 100 cosponsors. ACCC will be advocating for this legislation to be reintroduced in 2015.
As you can see, 2015 is the year to make your voice heard! Join us for Capitol Hill Day on March 16, and stay for the ACCC 41st Annual Meeting, CANCERSCAPE, which will follow March 17–18 in Crystal City, Va. Read our agenda and register today!
If you have additional questions, or would like to get involved with ACCC advocacy, please contact me at email@example.com.
With election results still rolling in, one thing is clear: the 2014 midterm elections dealt an unequivocal win to Republicans, helping them pick up more than the six seats needed to gain the majority in the Senate, bringing both chambers of Congress under GOP control. While this will mean big changes in leadership and the legislative agenda for the remainder of President Obama’s term, it may have fewer implications for healthcare than many anticipated. Here’s why.
The Affordable Care Act (ACA)
One of President Obama’s signature achievements, the ACA faces little chance of repeal in the remainder of the President’s term. Depending on the election results in Louisiana – the last undecided Senate race – in early December, Senate Republicans will hold 53 or 54 seats, falling well short of the 60 vote super-majority needed to get most things passed in today’s Senate. Even more important, Senate Republicans do not have the two-thirds majority to overcome a presidential veto. This means that even if incoming Senate Majority Leader Mitch McConnell rounds up the votes needed to pass repeal, he will not have enough votes to overcome the President’s all-but-guaranteed veto. In the end, even if Republicans control Congress, we can expect that the ACA will remain largely intact.
So does this mean the entire law is safe? Not exactly. Republicans are already outlining a different strategy, in which they will target individual ACA provisions for repeal or significant modifications. The list includes the 2.3% medical device tax; the employer mandate to provide qualified, affordable coverage; and the ACA definition of a full-time employee as 30 hour/week. We can expect the Senate to take votes to roll back these provisions in the next Congress.
The real fate of the ACA may lie with the Supreme Court. Earlier this year, conflicting rulings came from the Appeals Courts on the legality of providing subsidies to those accessing coverage through the federally-run health insurance exchanges, as the law appears to stipulate that subsidies may only be provided to those in state-based exchanges. The Supreme Court recently announced it would take up the case, and is expected to issue a ruling in June 2015. With the federal marketplace serving 34 states and expected to enroll nearly 11.8 million people in 2016 – an estimated 7.3 million of whom would receive federal subsidies – the Court’s decision could have enormous implications for the success of the law.
Sustainable Growth Rate (SGR)
Last year we saw the best opportunity to permanently repeal the SGR. A bipartisan bill had broad support, and the price tag was (comparatively) low at $138 billion – but Congress could not come together to determine how to pay for it. Instead, Congress passed another short-term patch that will expire in March 2015, which prevented roughly a 24% cut in Medicare physician reimbursement rates for 12 months. In keeping with previous fixes, Congress cut healthcare expenditures to pay for the extension. The Congressional Budget Office (CBO), Congress’ official budgetary scorekeeper, recently re-estimated the cost of the bipartisan legislation at $144 billion over 10 years. This is still considered a bargain by most policymakers, and although we can be hopeful the new Congress will consider the legislation, do not be surprised if another short-term patch is what we’re stuck with; despite an “on sale” SGR fix, offsets continue to be a critical stumbling block.
For more than 18 months providers have faced sequester-mandated cuts to Medicare payments, and more than 10 years remain of the 2% Medicare claims reduction. This year, H.R. 1416, a bill that halts the cuts on reimbursement for cancer drugs, garnered some support, but not enough to pass in either chamber of Congress. Many advocacy organizations will push to have the bill reintroduced next year, but H.R. 1416 will remain difficult to pass as part of any stand-alone healthcare bill. The best chance for a solution will be to attach some kind of fix to a larger bill, such as SGR reform.
A number of other issues may come up in the 114th Congress, including oral parity and prompt pay discounts, but would likely be included in larger healthcare-related vehicles. Stay tuned.
The Association of Community Cancer Centers will host a Capitol Hill day for its members on March 16, 2015. We encourage all of our members to attend this annual event and educate elected officials on these important issues. For more information, please click here.