An Easy—and Empowering—New Year’s Resolution

By Leah Ralph, Director, Health Policy, ACCC

New Year’s resolutions are the very definition of trope: a common or overused theme. But they don’t have to be. Today I’m asking you to set aside the old standbys of weight loss or more exercise and look at the bigger picture—specifically what you can do to improve the lives of the cancer patients you treat each and every day.

Last year ACCC mobilized members from 23 states and held over 80 meetings with legislators on Capitol Hill about issues of importance to the oncology community. We effected real change. Shortly after our ACCC Hill Day visits, Congress passed a permanent repeal to the Sustainable Growth Rate (SGR) formula, guaranteeing predictable physician payment rates and setting in motion a wave of Medicare reimbursement reforms. Our voices made a difference!

This year, we’re growing our annual Capitol Hill Day program and making some exciting changes: more comprehensive training, more face time with legislators, and, most important a greater focus on helping you tell your community’s story—the one that your legislators most want to hear. What’s going on in your home town? What’s keeping you up at night? What are the stressors that are having a negative impact on your cancer patients?

So whether you’ve attended a previous ACCC Capitol Hill Day or you’re an “advocacy newbie,” here are three solid reasons to make the ACCC 2016 Capitol Hill Day your New Year’s Resolution:

1. More comprehensive training. The ACCC policy team will host webinars and conference calls to prepare for your congressional meetings. We’re planning a comprehensive training and reception for Tuesday, March 1, plus an additional advocacy review on the morning of Hill Day, Wednesday, March 2.
2. More face-time with legislators. Gather for lunch with your ACCC colleagues and congressional members to discuss key issues that impact your program, such as reimbursement for supportive care services, drug costs, staffing shortages, and how excessive data collection and reporting is cutting into the time you can spend on direct patient care.
3. Less focus on specific bill numbers. You don’t need to be a “policy expert” or familiar with specific legislation in 2016. It’s a chance to share YOUR STORY so lawmakers understand how policy impacts oncology care in YOUR COMMUNITY. (Now, if you want bill numbers, we’ll have those too.)

Policymakers rely on healthcare providers—not policy staff—to provide real-world perspectives on policy issues that matter. As the leading national multi-site, multidisciplinary organization, ACCC is uniquely positioned to serve as a resource. This is our value to legislators. The diversity and sophistication of our membership requires a nuanced, balanced approach to policy challenges—and we stand ready to offer insights on how cancer care is delivered today.

As our experts, we invite you to come to Washington, D.C., to do what you do best. Talk about your programs, your processes, and most importantly your patients. Our annual Capitol Hill day is an important and rewarding opportunity to advocate for policy change. Resolve to attend ACCC Capitol Hill Day 2016, and help to put the voice of the cancer care team and cancer patient at the center of policy decisions. Learn more at accc-cancer.org/HillDay.

Transformation ⇒ From Volume to Value

By Leah Ralph, Manager, Provider Economics and Public Policy, ACCC

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.

Ambitious Goals

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!

 

Ringing in the New Year

by Leah Ralph, Manager, Provider Economics and Public Policy, ACCC

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 41^st 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 lralph@accc-cancer.org.

 

 

ACCC on the Hill: Timing is Everything

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 17^th time Congress has acted to prevent scheduled reimbursement cuts due to the SGR since the formula went into effect in 2002.

 

 

 

 

 

 

 

ACCC Hill Day Primer—Issue #4: Eliminate the Prompt Pay Discount

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.

Will you be a cancer care advocate? Learn more about the issues, sign up for Hill Day, and make your voice heard.

ACCC Hill Day Primer—Issue #3: Pass Oral Parity Legislation

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:

1.        Language of the laws varies across the states and only federal legislation will ensure the same protections for all patients; and
2.        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 31^st 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.

Will you be a cancer care advocate? Learn more about the issues, sign up for Hill Day, and make your voice heard.

ACCC Hill Day Primer—Issue #2: Exempt Cancer Drugs From Medicare Sequester

by Sydney Abbott, JD, Manager, Provider Economics & Public Policy, ACCC

Just 12 days remain until ACCC’s Capitol Hill Day on March 31. ACCCBuzz is featuring a primer series on the key issues ACCC members will be talking about when they visit their elected officials. In this second of four installments, we’ll look at the sequester and legislation to exempt cancer drugs from the cuts.

As you already know, the sequester was put into effect as a result of failed debt negotiations in Congress in 2011. Initially, the sequester was designed to impact all domestic spending equally for 10 years. However, through the budget deal at the end of 2013, pre-sequester funding was restored to some federal agencies, while being extended for other programs. Medicare was one of those unfortunate programs. Instead of ending in 2021, the 2% across-the-board sequester on Medicare has been extended through 2023.

Considering this extension, ACCC has shifted focus from eliminating the sequester altogether to exempting cancer drugs specifically. There is currently a bill in the House that would leave the sequester intact for all items billed to Medicare except for cancer drugs. Because of the high fixed costs of cancer drugs, the sequester disproportionately impacts oncology. However, HR 1416, with 110 bipartisan cosponsors, would help level the playing field between oncology and other specialties.

ACCC members will ask Congress to pass HR 1416 during the annual Hill Day on March 31. Learn more about the issues and sign up for Hill Day now!

Hill Day Primer—Issue #1: Eliminate the SGR

By Sydney Abbott, JD, Manager, Provider Economics & Public Policy, ACCC

As we count down the days until ACCC’s Capitol Hill Day on March 31, ACCCBuzz will feature a primer series on the key issues ACCC members will be talking about.  In this first of four installments, we’ll look at SGR repeal and replacement.

Due to the flawed sustainable growth rate (SGR) formula that determines Medicare reimbursement, each year physicians face reimbursement uncertainty. Each year, Congress has been forced to step in with a “doc fix” to prevent enormous pay cuts for providers.

We’ve been following the progress on SGR reform in ACCCBuzz.

As you know, there’s been much discussion on how best to fix the SGR. Should there be a time-limited pay freeze vs. annual updates? Which quality metrics should be used? Should the new policy develop over five years or ten?  At last Congress is showing some consensus around the policy discussion, while still grappling with the question of how to pay for a fix. Companion legislation in the House (HR 4015) and Senate (S 2000) is now moving forward and includes the following reforms:

Predictable Payment Updates—Under these bills, a positive 0.5% for fee-for-service update would be implemented for 2014–2018. The 2018 Medicare reimbursement rate would then remain in place through 2023. Starting in 2024, provider reimbursement could increase by 1% for those participating in alternative payment models, while remaining at 0.5% for those not participating.

Reimbursement Tied to Quality—The proposed legislation would consolidate the three Medicare incentive/penalty programs –Physician Quality Reporting System (PQRS), the Value-Based Modifier (VBM), and Meaningful Use of electronic health records (EHR MU)—into one streamlined program, the Merit-Based Incentive Payment System (MIPS).  The MIPS will evaluate providers based on quality, resource utilization, EHR meaningful use, and clinical improvement activities. Although specific measures would be established through CMS rulemaking, positive or negative payment adjustments would be made to providers using a composite score compared to a performance threshold.  Negative adjustments will be capped at 4% in 2018, 5% in 2019, 7% in 2020, and 9% in 2021.

Providers who receive a significant portion of their revenues through alternative payment models (APMs) involving risk of financial loss and with a quality measurement component would receive a 5% bonus each year 2018–2023. Importantly, the legislation encourages CMS to test APMs relevant to specialty professionals, like oncology.

Additionally, at least one new payment code will be created for care management services provided to patients with chronic conditions.

Each year CMS would propose a plan for establishing the quality measures to be used in the MIPS and APM programs.  Annual funding of $15 million would be allocated for the development of such measures, and stakeholders would be able to submit comments to CMS’s proposed plans.

Physician-Specific Data Would be Made Public—Starting  in 2015, CMS would publish utilization and payment data for providers on the Physician Compare website, including information on the most commonly provided services and the submitted charges for those services.  Providers would have the opportunity to review and correct inaccurate data.

Potentially Misvalued Codes—As ACCC has noted previously, identification of potentially misvalued codes remains in the SGR repeal legislation. The current goal is 0.5% of fee schedule expenditures to be slated for identification of misvalued services each year in 2015–2018.

Although the current legislation reflects much consolidation on SGR reform, much work remains in identifying $126 billion in offsets to pay for this fix.  The current “doc fix” runs out at the end of March.  On Capitol Hill Day ACCC members will be walking the halls of Congress, urging members from the  House and Senate to work together to pass this reform and permanently replace the SGR with responsible policy that emphasizes value over volume.

Join us for ACCC’s Capitol Hill Day and help educate your representatives about the importance of SGR reform.

Stay tuned to the rest of this blog series for a deep dive into the issues ACCC members will be talking about  on Capitol Hill: Exempt cancer drugs from the 2% Medicare sequester, create equity in out-of-pocket expenses for oral and IV-infused therapies, and eliminate of the prompt pay discount. See you on the Hill!

Protecting Patient Access: Taking It to the Hill

By Sydney Abbott, JD, Manager, Provider Economics and Public Policy, ACCC

We’re on the countdown to ACCC’s Capitol Hill Day on March 31. ACCC members who join us will be visiting with congressional staff to speak out on major concerns affecting oncology care. Those on the front lines of cancer care can deliver a powerful, clear message on issues affecting cancer patients and providers. Patient access to care—in particular to anti-cancer medications—is a cross-cutting concern.

Where Things Stand in Congress—Two Bills

Many health insurance plans cover IV chemotherapy, injected anti-cancer medications, and oral anti-cancer drugs differently, causing patients to pay far more out-of-pocket for oral drugs than for IV chemotherapy or injected medications. With the ever rising cost of healthcare, insurers employ various methods to keep costs down, including increasingly shifting the cost of prescription drugs to patients. To help patients afford the life-saving medications they need, Congress has introduced two complementary—if not somewhat confusing—pieces  of legislation: HR 1801 and companion bill S 1879 to lower the cost of prescription oral chemotherapy drugs, and HR 460, to limit cost-sharing requirements for prescription drugs on specialty tiers. Both bills aim to protect cancer patients in different ways.

Here’s a quick side-by-side comparison of the legislation. For ACCC members joining us for Capitol Hill Day, this snapshot can help you prepare for conversations with congressional staff.

Oral Parity (HR  1801/S 1879)

• Legislation would require insurers to provide coverage for orally administered anti-cancer medication under terms no less favorable than for medication administered intravenously. Insurers may not create parity by raising rates for IV infusions.
• Focus is on cost-sharing across prescription drug coverage and office visit coverage for anti-cancer medications only.
• Requirements: A physician must deem the treatment to be medically necessary for treating cancer, and the treatment must be clinically appropriate in terms of type, frequency, and duration.
• Types of insurance affected: Group  and individual private plans and self-insured group plans regulated by ERISA that cover oral and IV-infused anti-cancer medications.

Specialty Tier (HR  460)

• Legislation would limit cost-sharing requirements applicable to prescription drugs in a specialty tier to the dollar amount of such requirements applicable to prescription drugs in a non-preferred tier.
• Focus is on cost-sharing in prescription drug coverage plans and formularies for any specialty-tier drug covered by the plan.
• Requirements: A health plan that provides coverage for prescription drugs using a cost-sharing structure shall not impose cost-sharing requirements applicable to prescription drugs in a specialty drug tier that exceed the dollar amount of cost sharing for drugs in a non-preferred brand tier.
• Types of insurance affected: Group and individual private plans that cover prescription drugs and use a formulary or other tiered cost-sharing structure. Bill language is unclear as to whether ERISA plans are affected.

Both bills help protect patient access to affordable prescription drugs. However, because oral parity legislation already has 67 co-sponsors in the House and a companion bill in the Senate, this will most likely move through Congress first. Therefore, ACCC will be advocating for oral parity (HR 1801/S 1879) in both chambers on Hill Day. In addition, we will be talking to our representatives about SGR reform, elimination of cancer drugs from the 2% Medicare sequester, and elimination of the prompt pay discount. Learn more about Hill Day 2014 and register today.