2016 Physician Payment Advocacy Highlights

The Medicare and CHIP Reauthorization Act of 2015 (MACRA)

ASH released a summary of the October 14th Medicare Access and CHIP Reauthorization Act (MACRA) Final Rule. This rule outlines how Medicare will pay physicians moving forward and replaces the flawed sustainable growth rate (SGR) with two reimbursement tracks: a new quality reporting program called the Merit-Based Incentive Payment System (MIPS) and alternative payment models (APMs). ASH also hosted a webinar on November 15, 2016 to provide an overview of the final rule, its impact on hematology, and the compliance implications for clinical practice members. ASH will continue to monitor the implementation of the rule, and in particular, the methods of measuring quality and resource use, use of electronic health records, and participation in practice improvement activities, to ensure that the regulations do not place undue burden on the practice of hematology.

2017 Medicare Physician Payment Rule and Hospital Outpatient Prospective Payment System Rule

In July, the Centers for Medicare and Medicaid Services (CMS) announced annual proposed changes to the Medicare physician fee schedule (MPFS) that would be implemented on January 1, 2017. The rule updates payment policies and payment rates for services provided in the physician office. The Hospital Outpatient Prospective Payment System (HOPPS) proposed rule was also released, which outlines changes in payment policies for services rendered in hospital outpatient settings.

Under both proposals, ASH anticipates there will be an increase in reimbursement for hematologists. CMS estimates that under the proposed policies in the MPFS, reimbursement for hematology and oncology services will increase by 2 percent. The policy changes under the HOPPS, including estimated spending for pass-through payments, are estimated to result in a 1.6 percent increase for hospitals. CMS also proposes several policies that will improve payment for cognitive services in the MPFS. If finalized, CMS will pay separately for non-face-to-face prolonged evaluation and management (E&M) services.

The final rule was filed in early November and ASH staff is analyzing the final rule’s impact on hematology services.

2017 Medicare Inpatient Hospital Rule

ASH offered comments on the 2017 Proposed Medicare Inpatient Hospital Rule, which contains provisions that took effect on October 1, 2016. This rule determines payment levels and related provisions for Medicare patients who are admitted to the hospital. ASH supported the continuation of additional payments for the use of the new drug blinatumomab, a new add-on payment for the drug defibrotide, and opposed the establishment of a new performance measure that would be used for cancer hospitals. 

Medicare Part B Plan to Change Payment for Physician-Administered Drugs

ASH submitted detailed comments on the proposed Medicare Part B Drug Payment Model, which would change the formula for physician-administered drugs in much of the country, reducing payments for expensive drugs, including cancer treatments, and allowing for the use of innovative drug payment models in certain portions of the country. ASH’s comments expressed concern about the size and scope of proposed payment cuts and encouraged a transparent process in the implementation of the program. ASH is still awaiting the final rule and will analyze the impact on hematology therapies that are covered under Medicare Part B. 

AMA, CPT Coding, RUC, and Medicare Payment Policies for Hematology-Specific Services

Although ASH lost its seat in the American Medical Association's (AMA) House of Delegates in 2016 and therefore lost its formal representation in the AMA Current Procedural Terminology (CPT) Coding and Relative Value Update (RUC) Committees, ASH continued to be involved as a public participant in these activities. ASH’s representatives, Samuel Silver, MD, PhD, MACP, and Robert Weinstein, MD, along with ASH staff and consultants attended CPT and RUC meetings and monitored activities to ensure that hematology services continue to be properly coded and appropriately paid. This includes the continued development of codes for chronic care management and changes in infusion and other services. As part of this effort, ASH, in collaboration with multiple specialty societies, participated in two RUC surveys in the fall of 2016 to gather data that will assist in determining fair and accurate valuation for hematology related services under Medicare. ASH members were surveyed on infusion, subcutaneous, intramuscular and intravenous injection codes, as well as therapeutic apheresis codes.

The Society submitted its membership list of practicing members to the AMA in August and based on the numbers, qualified for readmission into the AMA House of Delegates (HOD). Recently, the Rules Committee of the AMA Specialty and Service Society reviewed and approved the Committee Report which recommended to the AMA Board of Trustees that ASH be readmitted into the HOD. The Board of Trustees will consider this recommendation at its June 2017 meeting. Readmission into the HOD will allow ASH to regain its official representation in both the CPT and RUC.

Finally, ASH joined the Cognitive Care Alliance which was established to ensure that evaluation and management (E&M) service code definitions and valuations accurately reflect the intensity of the cognitive work performed. ASH staff participated in meetings on Capitol Hill to ask key policy makers to contact the Centers for Medicare & Medicaid Services (CMS) and urge them to conduct the research necessary to study the outpatient E&M codes. The existing E&M codes do not properly describe the work performed by physicians who primarily treat chronically ill patients, including hematologists. ASH is hopeful that a CMS-commissioned study will determine what improvements could be made to the description of work and documentation requirements so that new codes could be added that better describe the services provided by hematologists.

Medicare Contractor Advisory Committee Meeting

ASH, along with the American Society of Clinical Oncology (ASCO), held the annual meeting of the Medicare Contractor Advisory Committee (CAC) in July 2016. This meeting was intended to allow all hematologists/oncologists who serve on regional CACs to learn about issues of importance and improve the regional CAC process. Attendees at the meeting also included Medicare local medical directors and practice leaders from ASH and ASCO. Topics included the proposed Medicare Part B Oncology Demonstration Model, the proposed Medicare Access and CHIP Reauthorization Act (MACRA) regulations, palliative care, and Medicare policy related to coverage with evidence development.

Center for Medicare and Medicaid Innovation

ASH participated in a meeting at the Center for Medicare and Medicaid Innovation (CMMI) to provide feedback on the recently implemented Oncology Care Model and also arranged for CMMI staff to meet with ASH members who are participating in this new payment model during the ASH Annual Meeting. In addition, ASH wrote a letter to Patrick Conway, MD, Deputy Administrator for Innovation and Quality & CMS Chief Medical Officer to consider developing a payment model focused on rare non-malignant diseases such as sickle cell disease. ASH continues to discuss such opportunities with CMMI staff.

ASH REMS Resource Webpage

ASH launched a new webpage focused on hematologic Risk Evaluation and Mitigation Strategies (REMS). REMS are safety programs to manage the serious risks that can arise from certain drugs or biological products. If a drug or biological product has a high risk, REMS are established by the U.S. Food and Drug Administration (FDA) to ensure that the benefits of the drug will outweigh the risks. This page will track hematologic therapies that require REMS and provide links to programs and additional information. To learn more, please visit our new REMS website.

ASH Toolkit for Transition from Pediatric to Adult Hematologic Care

ASH released a transitional toolkit for hematologists to ease the transitions between pediatric to adult care. These tools, for hemophilia, sickle cell disease, and general hematologic conditions, provide readiness assessment and clinical summary forms to start the conversation between providers and their patients and to ensure that the transition for patients is as smooth as possible. To download the forms, please visit the new ASH Transitions webpage.

ASH Committee on Practice Capitol Hill Day

Members of the ASH Committee on Practice visited more than forty congressional offices to advocate for issues related to sickle cell disease and drug access. The ASH advocates encouraged congressional offices to urge the Center for Medicare & Medicaid Innovation (CMMI) to develop a demonstration program focused on improving care for individuals with sickle cell disease. The group also asked members of Congress to support legislation (the Patient’s Access to Treatments Act, H.R. 1600), that establishes patient cost-sharing limits for high cost drugs in health plans that cover prescription drugs.