2016 Medicare Payment Rules Finalized

By Maureen Leddy, JD, Manager, Policy and Strategic Alliances, ACCC

The Centers for Medicare & Medicaid Services (CMS) on Oct. 30, 2015, released the final 2016 Physician Fee Schedule and Outpatient Prospective Payment System rules. With the exception of radiation therapy codes, the final rules align quite a bit with the proposed rules. A preliminary summary is included below. Stay tuned for detailed summaries and analysis on an upcoming ACCC members-only conference call on these 2016 final rules.

Highlights of 2016 PFS Final Rule

Radiation Oncology

In a noteworthy departure from the proposed 2016 PFS rule, CMS did not finalize new radiation therapy treatment payment codes. CMS responded to concerns expressed by ACCC and other stakeholder groups and delayed implementation of new radiation oncology codes, continuing use of current G-codes and values for 2016. However, the agency did finalize its proposal to increase the linear accelerator equipment utilization rate assumption from 50 percent to 70 percent over two years. CMS continues to seek empirical data on costs and usage of capital equipment, including linear accelerators.

Advance Care Planning

For 2016, CMS finalizes its proposal to establish separate payment for advance care planning services, consistent with the recommendations of the American Medical Association and other stakeholders, including ACCC. These new codes compensate providers for shared decision-making conversations at various stages of a patient’s illness.

Biosimilars

For 2016, CMS finalized its proposal to include all biosimilars of a reference biological product within the same billing and payment code. ACCC had commented against this proposal, raising concerns regarding traceability and administrative burdens expected with the use of a single code. While ACCC supports efforts to increase patient access to biologics, ACCC maintains that a system must be in place to track the specific biosimilar product used for each patient.

“Incident To”

CMS finalized its proposal to clarify requirements for billing for “incident to” services. CMS now formally requires that the physician or practitioner billing for “incident to” services must have directly supervised the auxiliary personnel providing these services. Addressing stakeholder concerns about the treating physician’s supervisory role in “incident to” services, the final rule clarifies that the supervising physician need not be the treating physician for billing purposes.

Highlights of 2016 OPPS Final Rule

CMS finalized its proposed cut in hospital outpatient payment rates of – 0.3 percent. Within this calculated –0.3 percent rate update is a –2 percent cut, applied due to the agency’s calculation of excess packaged payment for laboratory services in 2014. As a result of this year’s rate cut due to miscalculations in packaging policies, ACCC urged CMS to proceed cautiously with any additional packaging proposals to ensure future negative adjustments would not be necessary. However, CMS finalized its proposal to expand conditionally packaged services to include three new APCs: level 4 minor procedures, and level 3 and 4 pathology services. CMS notes that packaging of these services is consistent with the agency’s overall packaging policy.

Advance Care Planning

ACCC had also advocated for separate payment under advance care planning codes in the hospital outpatient setting. The 2016 OPPS final rule calls for conditionally packaging payment for these services, permitting separate payment in the hospital outpatient setting in limited circumstances.

Biosimilars

In the 2016 OPPS final rule, CMS finalized its proposals to pay biosimilars based on ASP+ 6% of the reference biologic product, and to allow biosimilars to be eligible for pass-through status. ACCC supported these proposals, noting that providing equivalent payment rates in the physician office and outpatient setting for biosimilars removes incentives to select one setting over another.

Two-Midnight Rule

CMS also finalized proposed changes to its two-midnight rule regarding hospitalization payment status. CMS will now allow certain patients not expected to meet the two-midnight stay requirement for inpatient status to still be classified as inpatient. CMS indicates that qualifying patients are those that require inpatient hospital care, as determined by the admitting physician and supported by the medical record, despite the expectation that their stay will last less than two midnights.

ACCC continues to analyze the 2016 payment rules and will update its members in the coming weeks.

 

ACCC Responds to CMS on Proposed 2016 PFS Rule

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

On September 8th, ACCC submitted comments on CMS’ proposed 2016 Physician Fee Schedule rule. This year, the proposed PFS was released later than usual and contained a number of provisions that ACCC will be watching closely in the coming months.

Read on for a quick roundup of major provisions and ACCC recommendations to CMS:

Radiation Oncology Cuts

CMS proposes several significant changes to payment for radiation oncology procedures that would collectively result in drastic cuts for radiation oncology providers – an estimated 3% for radiation oncology and 9% for freestanding radiation therapy centers. CMS is proposing payment rates for new CPT codes that would effectively reduce Medicare reimbursement for IMRT and other radiation treatment delivery services. The agency also proposes to remove several essential direct practice expense inputs from the new radiation treatment delivery codes, including the on-boarding imaging equipment that is essential to providing safe and accurate radiation treatment. Finally, CMS proposes to adjust the equipment utilization rate assumption for the linear accelerator used in image guidance from 50% of available time to 70% of available time over two years, reducing reimbursement for services that make use of that equipment.

In our comments, ACCC expressed significant concern to CMS that these deep, simultaneous cuts in radiation oncology reimbursement will have the effect of forcing some cancer care providers, particularly those operating in rural and underserved areas, to close their doors. ACCC urges CMS to take the necessary steps to mitigate this threat, for example, by not implementing the proposed increase in the equipment utilization rate. ACCC will be monitoring this closely and stands ready to work with CMS to find ways to implement any appropriate changes over a period sufficient to allow providers to absorb the changes while not compromising access to critical radiation oncology services.

 Biosimilar Reimbursement

CMS proposes a payment methodology for biosimilar products in which all biosimilars with the same reference product would be assigned a single HCPCS code and reimbursed based on the volume-weighted average sales price (ASP) for all products under the code plus 6% of the reference product’s ASP.

ACCC asks CMS not to finalize this proposal. We expressed concern that assigning multiple biosimilar products a single HCPCS code would create new and unnecessary administrative burdens for physicians and other providers when treating patients with biosimilar products, as they would not only need to enter the HCPCS code into the medical record, as they do now, but also the specific biosimilar therapy used for the patient. Additionally, this approach could significantly impede effective tracking of safety information and other information about the patient experience with specific biosimilar products—after these enter the market. We urge CMS to promote effective tracing of safety information and to minimize administrative burdens on providers who prescribe biosimilars.

 Advance Care Planning

CMS proposes to establish payment rates for the two CPT codes adopted by the AMA CPT Editorial Panel to describe advance care planning services. ACCC strongly supports this proposal and asks that the payment rates for these services adequately reflect the cost to physicians of providing advance care planning.

As ACCC believes advance care planning services are equally important in the hospital outpatient setting, where they also take substantial time and resources and contribute significantly to the quality of patient care. In our comments to the proposed 2016 Outpatient Prospective Payment System rule, we urged CMS to pay separately for these two CPT codes in the outpatient setting as well.

Chronic Care Management

CMS recognizes that Medicare’s payment rates for the CPT codes for transitional care management (TCM) and chronic care management (CCM) do not fully account for the cognitive work that primary care physicians and other practitioners perform in managing and delivering care, particularly to chronically ill beneficiaries. CMS identifies add-on codes as one potential means of establishing payment rates that appropriately value the additional time and intensity of physicians’ cognitive work often involved in delivering care management services. ACCC encourages CMS to develop such codes, and to work with ACCC and other provider organizations to ensure that any new add-on codes are structured and valued appropriately.

ACCC also has concerns related to CMS’ proposal for chronic care management in the 2016 OPPS proposed rule. On the hospital outpatient side, CMS is proposing to permit only one hospital to bill for CCM services during a calendar month. ACCC points out to CMS that because cancer care is highly multidisciplinary, it can be difficult to agree upon who should be the designated CCM physician, and we are concerned that CMS’ rules for these services already make it very difficult for hospitals to seek payment for them. We urge CMS to continue to consult with hospitals and physicians on the best way to determine which entities should bill for these services.

“Incident To” Services

CMS proposes to require that the physician or other provider who bills for an “incident to” service must also be the physician or other provider who directly supervises the auxiliary personnel in providing that service. If CMS were to finalize this proposal, ACCC urges the agency to provide education to physicians and other providers on the revised requirement to ensure providers do not experience unwarranted disruption in billing for appropriate “incident to” services.

CMS is expected to finalize the 2016 Physician Fee Schedule rule in late October. Stay tuned, as ACCC will keep members updated as CMS revises and finalizes these important proposals.

Proposed 2016 Medicare Rules

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

The Centers for Medicare & Medicaid Services (CMS) 2016 proposed rules are out, and, not surprisingly, we continue to see the agency push outpatient payments toward more bundled services and move full steam ahead to tie Medicare payments at large to quality and value in the coming year.

2016 HOPPS Proposed Rule

Generally speaking, the proposed Hospital Outpatient Prospective Payment System (OPPS) rule includes few surprises, most notably CMS is proposing a -2% across-the-board reduction to compensate for “excessive” packaged payments for laboratory services in CY14. The rule also includes nine new comprehensive ambulatory payment classifications (C-APCs) to add to the 25 introduced last year and proposes consolidation and restructuring of nine APC clinical families. Importantly, CMS will continue to reimburse drugs at ASP+6% in the hospital outpatient department. The agency also provides some flexibility on the “two-midnight” rule. Currently the rule requires that a beneficiary to remain in the hospital for longer than two midnights in order for the stay to be reimbursed as an inpatient stay. Under the proposed rule, CMS would recognize some shorter stays as inpatient, and would evaluate on a “case-by-case” basis.

 2016 PFS Proposed Rule

The proposed Physician Fee Schedule (PFS) rule was released later than expected this year, perhaps due to slightly more contentious provisions. The good news – perhaps – is that, as proposed, the 2016 PFS would have no (0%) impact on Medicare payments in hematology/oncology. However, on the radiation oncology side the news is not so good. If all of the proposals in the rule are finalized, radiation oncology will face an estimated -3% cut and freestanding radiation therapy centers will see a -9% cut due to a combination of new code values and a change in assumption involving the overall use of linear accelerators. CMS also indicates how it will treat biosimilars for the purposes of Part B reimbursement, proposing to assign the same HCPCS code to all biosimilars that reference the same innovator drug. These would be paid based on their volume-weighted ASP+6% of the reference product’s ASP. If no ASP data is available, biosimilars would be reimbursed at 100% of their wholesale acquisition cost.

Under the PFS, CMS also proposes to create two new CPT codes for advanced care planning services, one to start the conversation with a patient and the other for continued discussion. The rule also begins the phasing out of the PQRS (the 2018 payment adjustment will be the last); adjustments for quality reporting will now be made under the new Merit-Based Incentive Program (MIPS), created by the legislation that repealed the Medicare Sustainable Growth Rate (SGR). CMS seeks comments on MIPS on issues like the definition of clinical practice improvement activities, how to define a physician-focused payment model, and more.

ACCC will be submitting comments on both rules, due August 31 and September 8, respectively. On Tuesday, July 21, 4:00-5:00 PM EST, ACCC is hosting a members-only conference call with a full rundown of both proposed rules. Stayed tuned.

 

CANCERSCAPE Session on OCM Brings Insights

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.

Bringing the Oncology Care Model into Focus

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.

Discussing Lung Cancer Screening at #ACCC2014

The recent ACCC 31^st National Oncology Conference featured 45-minute “Think Tanks,” supported by a grant from Genentech. The discussions focused on four hot topics in oncology: Lung Cancer Screening; the Healthcare Marketplace; Personalized Medicine; and Molecular Tumor Boards. This is the first in a four-part ACCCBuzz blog series recapping these discussions from Think Tank facilitator, Joseph Kim, MD, MPH, of MCM Education.

By Joseph Kim, MD, MPH, guest blogger

A small group Think Tank convened at the 2014 ACCC National Oncology Conference focused on key questions around lung cancer screening and how cancer programs are developing lung cancer screening programs. A question on everyone’s mind: Will low-dose CT (LDCT) scans for lung cancer screening be covered by Medicare?

The U.S. Preventive Services Task Force (USPSTF) lung cancer screening guidelines target asymptomatic adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit smoking within the past 15 years. The USPSTF is basing its recommendations on multiple studies including the NLST (National Lung Screening Trial) where 90% of the population was younger than 70 years, while MEDCAC (Medicare Evidence Development & Coverage Advisory Committee) is focusing on patients over the age of 65. The oncology community awaits MEDCAC’s final recommendation coming soon.

Think Tank participants acknowledged that an effective lung cancer screening program can be very cost effective. After all, lung cancer is the leading cause of cancer-related mortality in the U.S., with 159,000 deaths annually. Today, most patients are diagnosed with advanced disease, but effective screening would allow patients to get diagnosed and treated earlier in their disease. When LDCT was used for lung cancer screening, 55% to 85% of detected cancers were found at stage I.

Ensuring Appropriate Follow-Up

Are cancer programs in the community ready to handle the volume of new lung cancer patients? According to expert estimates, almost 9 million adults would be eligible for lung cancer screening. Although many hospitals may be prepared to handle the volume of performing LDCT scans and having radiologists interpret those studies, they are not adequately prepared to run and maintain a lung nodule clinic that will provide ongoing follow-up to patients who have a non-negative screening test. Some programs are implementing interdisciplinary teams, comprised of pulmonologists, surgeons, radiologists, oncologists, and nurses, who are working collectively to develop effective follow-up programs for patients who have a lung nodule. To ensure appropriate follow-up, these lung nodule clinics will need to maintain a strong level of communication with the patient’s primary care provider (PCP), but this may be especially challenging when patients who undergo a screening LDCT scan do not have an established PCP.

Smoking Cessation Remains Key

Think Tank participants also noted that some patients who undergo LDCT or who get diagnosed with lung cancer may not want to quit smoking. Therefore, cancer programs are making every effort to integrate robust smoking cessation interventions into the lung screening program so that every patient who is a smoker receives thorough counseling about the importance of smoking cessation.

Lung Cancer Navigators

To prepare for the increase of new lung cancer patients, many cancer programs in the community are investing in training or hiring new lung cancer navigators who can provide appropriate follow-up and care for patients.

Conclusion

Regardless of CMS’ coverage decision on LDCT for lung cancer screening, cancer programs in the community are developing and launching lung cancer screening programs because they believe that the evidence supports the value of having such programs in place. Think Tank participants agree that community hospitals recognize the key challenges they will face and are proactively planning ways of navigating around those barriers and obstacles. The Lung Cancer Alliance offers a wealth of resources and information about lung cancer screening.

Stay tuned for Think Tank #2 Discussing Healthcare Reform at #ACCC2014.

 

The Sun is Shining. . . .Now What?

By Matt Farber, MA, Director, Provider Economics & Public Policy, ACCC

On Sept. 30, the Centers for Medicare & Medicaid Services (CMS) released the first round of Open Payments data to the public. The Open Payments program, which was mandated by a section of the Affordable Care Act (ACA) known as the Sunshine Act, requires drug and device manufacturers to report any payments or transfers of value – such as money for research activities, speaking fees, meals and travel – to physicians and teaching hospitals.

The recently released data is based on five months of payment reports, collected from August through December 2013. CMS continues to collect payment information this year and reporting on all 2014 expenditures is expected sometime next summer.

CMS provided a relatively short window (45 days) during which physicians could register and log in to the Open Payments system, check the accuracy of data reports and, if necessary, dispute any reports that they did not believe to be accurate.  Unfortunately, most physicians did not review the reports before public release of the data. In fact, technical glitches with the Open Payments system—approximately one-third of the payment reports had “intermingled data”—caused  CMS to shut the system down for several days during the physician data review window.  In the face of these technical difficulties, both the American Medical Association and PhRMA urged CMS to delay the public release of the Open Payments data but, as we’ve seen, CMS held firm on the Sept. 30 release date.

What Does This Mean for Providers?

First, ACCC recommends that all physicians log in to the Open Payments system, and ensure that all data reports are accurate. CMS is reporting that 4.4 million payments were made during the second half of 2013, totaling $3.5 billion attributable to 546,000 individual practitioners and 1,360 teaching hospitals. Of the 546,000 individuals, only 26,000 (less than 5 percent) registered in the system, the first necessary step to verifying data reports. In addition, CMS suppressed 40 percent of the Open Payments records released because the agency could not reconcile differences in provider names and numbers reported by industry. CMS expects these data to be corrected in time for the next reporting period.

A yet-to-be resolved issue is what will happen with these data. First, it is important to note, as CMS has, that these payments do not necessarily signal wrongdoing; physicians have relationships with industry for a host of reasons, some of which are critical to advancements in innovative medical therapies and patient care. This glimpse into payments is just that: a limited window into billions of dollars in industry spending. ACCC has also long stated that we do not believe that the Open Payments data will greatly impact patients’ choice of providers.  There will certainly be outliers, physicians who have a high dollar figure associated with them (not counting those with research money attributed to them) who may draw the attention of the media. This may be especially true if the same physicians appear with a high Medicare payment figure from CMS’ earlier release of data on Medicare payments to physicians. But for a majority of providers, we predict little impact.

Moreover, ACCC hopes that Open Payments data reporting will not have unintended consequences, such as a chilling effect on participation in clinical research. For example, if providers do not want their name to appear in the data reports, they may no longer participate in industry-sponsored trials, nor will they accept certain publications from industry, important activities to advancements in clinical research and cancer care. In addition, if CMS finalizes its proposed rule on the 2015 Medicare Physician Fee Schedule that included elimination of the exemption for payments made to speakers at CME events, the sunshine reporting may have a negative impact on participation in certain CME programming.

If you are a physician or if you work with physicians who have not yet registered in the system, we highly encourage registering today to ensure the accuracy of the reporting. For more information, click here.

ICD-10: Ready or Not?

by Amanda Patton, Manager, Communications, ACCC

While the granular detail offered by ICD-10 may seem daunting and even excessive—as highlighted recently in the Washington Post’s Wonkblog,  “When Squirrels Attack! There’s a Medical Code for That”—the move has been a long time coming. (Implementation was originally scheduled for 2008 and has been postponed twice.)

All signs suggest that this time, the Centers for Medicare & Medicaid Services (CMS) is not going to blink. The agency says ICD-10 implementation is on course for Oct. 1, 2014.

Last week, CMS Administrator Marilyn Tavenner, addressing the American Medical Association’s National Advocacy Conference, urged physician practices to volunteer for “end-to-end” testing.

In its MLN Matters series, the agency said it will offer some testing services in May and full end-to-end testing to a small sample group of providers in late July.

With Oct. 1 just a little more than six months away, ACCCBuzz talked to Oncology Issues’s Compliance columnist Cindy Parman, CPC, CPC-H, RCC, about what cancer centers  should already have crossed off their “To Do” list and what still remains to be done.

What should be done by March 2014?

Parman: At this point, cancer centers should have:

• Completed awareness training (the “ready or not, here it comes” session) and selected a cross-functional implementation team. Ideally, you have a “champion” or “champions” who will lead the transition to ICD-10:

-A physician champion taking the lead on documentation improvement

-An  IT champion for software issues

-A medical coder champion to be an onsite expert, etc.

• Finished the gap analysis and workflow review, and established a plan to make changes where necessary. (You may have needed to re-think how diagnosis codes are currently assigned and which personnel should be performing the medical coding.)

• Identified all systems that will be impacted and prioritized these for software and/or hardware upgrades.

• Reviewed physician documentation and scheduled education for documentation improvement. Ideally this education has already started or even been completed—you don’t have to wait until ICD-10 is fully implemented!

• Set up an initial budget to include all transitional costs and established a training plan.

What do cancer centers needs to focus on between March and October 1, 2014?

Parman: Centers need to:

• Continue to pay attention to complete and accurate medical record documentation.

• Keep up ongoing communication with internal and external vendors to ensure that end-to-end testing is completed and any issues detected during testing are addressed immediately.

• Revisit and revise the budget for system upgrades, coding education, etc., as needed to account for any unexpected costs.

• Implement your previously established training plan to ensure that the cancer center has enough trained medical coders or other personnel who can accurately assign ICD-10-CM codes following the guidelines for this code set. Some facilities are performing “dual coding” (both ICD-9-CM and ICD-10-CM) to determine if there will be a need for temporary staff to help out during the months immediately following the transition.

• Review Medicare Local Coverage Determinations (LCDs) and other payer policies to determine any updates in medical necessity criteria, payer requirements for diagnosis codes, etc.

Then, you can sit back and know your center is prepared for the biggest change to the diagnosis coding classification in decades!

Resources for ICD-10 implementation are available on the American Health Information Management Association (AHIMA) website here.

CMS Says It Will Not Finalize Part D “Protected Classes” Proposal

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

In a recent blog, we raised concerns about the slippery slope of CMS’s proposed sweeping changes to the Medicare Part D Program, including a proposal to eliminate at least two of the six protected classes of drugs.  ACCC submitted comments, coalesced with 371 organizations to send a letter urging withdrawal of the proposal, and supported the Senate Finance Committee’s request to avoid changes to this already successful program.

ACCC is proud to announce that, thanks to the voices of our members and the work of related organizations, CMS Administrator Marilyn Tavenner has announced that the agency will not be moving forward with four of the proposed changes to the Part D Program, including the proposal related to the “protected classes” definition of three drug classes.

On behalf of Medicare beneficiaries, we thank Administrator Tavenner for this sound decision.

Slippery Slope—CMS Proposal Would Erode Part D Protected Drug Classes

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

The Centers for Medicare & Medicaid Services (CMS) recently proposed a rule that would bring significant changes to the Medicare Advantage and Part D prescription drug benefit programs.  Of the sweeping changes proposed, ACCC is particularly concerned about the agency’s proposal to eliminate at least two of the six protected classes of drugs in 2015, with the possibility of eliminating a third in 2016. And we are not alone.  On Feb. 5, the bipartisan membership of the Senate Finance Committee sent a letter to CMS Administrator Marilyn Tavenner asking the agency to drop its proposed limitations on the Part D program; on Feb. 18, more than 200 groups joined in a letter urging CMS to eliminate the proposed change in protected classes; and on Feb. 19, three congressional Republican committee leaders with jurisdiction over Medicare sent a letter to Tavenner asking that CMS withdraw the proposed rule.

Protection for Vulnerable Populations

At the start of the Part D program, CMS recognized the importance of protecting vulnerable patients who might have lost access to their drugs when transitioning into the Part D program and, in response, created the protected classes policy. The regulations require insurance companies to cover all, or substantially all, of the drugs in the six classes of clinical concern (“protected classes”):

• immunosuppressants
• anticonvulsants
• antineoplastics
• antidepressants
• antipsychotics
• antiretrovirals.

Now, in an about-face, CMS is proposing to remove two classes—antidepressants and immunosuppressants—from the protected class status in 2015, with discussion of eliminating the antipsychotic class in 2016.

Flawed Rationale 

In its proposal CMS says that the policy has driven up the cost of Medicare Part D, and cites patient protection concerns due to the potential for overutilization.  The agency estimates that this proposal, if finalized, will save $1.3 billion between 2015 and 2019.

On the one hand, it’s true that if plans are no longer required to cover all or substantially all of the drugs in a protected class, savings will be realized through Part D.  On the other hand, a potential consequence of this change is that costs will rise across the healthcare system as decreased access to drugs will most likely result in increased hospitalizations and emergency room visits—and,  ultimately, lead to poorer health outcomes.  Certainly this is counter to the aim of providing more patient-centered care.

For the cancer community, CMS’s proposed change represents  a dangerous slippery slope. While Part D plans must still cover all or substantially all antineoplastic drugs and oncology providers and their patients are not facing an immediate threat, CMS’s proposal is creating apprehension about the future of the protected classes policy.  For those battling cancer, it is imperative that all drugs be available, since each patient reacts differently to each of the medications, and changes in treatment regimens may be required as patients experience side effects or as their condition advances.

CMS should to listen to the outcry of the public and Congress and not erode the protected classes coverage requirements.  At the start of the Part D program, CMS created the protected classes requirement in an effort to protect access to needed medications for certain vulnerable populations.  Erosion of this policy now will likely have a chilling effect on Medicare Part D enrollment and CMS should not implement this policy.

ACCC will be submitting comments on the proposed rule and will make them available to members on its website.  We will keep members updated on this issue.