2017 Physician Payment Advocacy Highlights

The Medicare and CHIP Reauthorization Act of 2015 (MACRA)

ASH provided comments to the Centers for Medicare and Medicaid Services (CMS) in April on the episode-based cost measure development for the Quality Payment Program (QPP), the new pathway for how Medicare will pay physicians, created through the Medicare and CHIP Reauthorization Act (MACRA). The episode-based cost measures will be used to determine physician reimbursement under the Cost Performance Category, one of four performance categories in the QPP. In May, ASH launched a new webpage devoted to keeping members up-to-date on the QPP. The website features information on ASH’s partnership with Healthmonix, a 2017 Qualified MIPS Registry. ASH members can now sign up to report data for the 2017 performance year for the Merit-based Incentive Payment System (MIPS) through Healthmonix’s MIPSPRO. ASH and Healthmonix hosted a joint webinar on November 13, 2017 to provide guidance on how to use the MIPSPRO registry.

In August, ASH submitted comments on the proposed rule for Year 2 of Medicare’s Quality Payment Program (QPP). ASH thanked CMS for the adjustments made to accommodate small practices, the efforts to reduce administrative burden, and continuing to allow the use of 2014 Edition Certified Electronic Health Record Technology (CEHRT). ASH supported the proposal to maintain the weight of zero for the cost performance category for the second year of the program, emphasizing that CMS must finalize the required risk adjustment, attribution methodologies, and ensure that there are adequate episode measures for all specialties before this category counts towards a clinician’s final score. The final rule was released in November. An oral report regarding the rule’s impact on hematologists will be provided to the Committee on Practice during its December meeting. In addition, the full analysis of the rule will be posted on ASH’s website soon.

2018 Medicare Inpatient Hospital Rule

ASH offered comments on the 2018 proposed rule for the Inpatient Prospective Payment System (IPPS). The rule determines payment levels and related provisions for Medicare patients who are admitted to the hospital. ASH supported increased reimbursement for hematopoietic cell transplantation (HCT), reassignment of autologous and allogenic transfusion codes, and two new add-on payments for VYXEOS and Kite’s axicabtagene ciloleucel. ASH also provided extensive comments on evaluation and management document requirements, as it relates to reducing administrative burden. The final IPPS rule was issued in August. Although the final rule did not address the reimbursement for HCT, it did finalize that the autologous and allogenic transfusion codes would maintain their original assignment, which ASH supported. Additionally, Kite’s application for a new add-on payment was pulled prior to the issuance of the final rule and VYXEOS was considered ineligible because the product had not met the July 1 deadline for approval by the US Food and Drug Administration.

2018 Medicare Physician Payment Rule and Hospital Outpatient Prospective Payment System Rule

In July, the Centers for Medicare and Medicaid Services (CMS) released their annual proposed changes to the Medicare Physician Fee Schedule (PFS) that would be implemented on January 1, 2018. The rule updates payment policies and payment rates for services provided in the physician office. ASH commented on a number of proposed valuations of specific CPT codes, including codes for therapeutic apheresis, bone marrow aspiration, chemotherapy aspiration, and hydration. Additionally, the Society commented on proposed payment rates for non-excepted items and services furnished by non-excepted off-campus provider-based departments of a hospital and on CMS’s proposal to review and revise the Evaluation & Management (E/M) documentation requirements.

The Hospital Outpatient Prospective Payment System (HOPPS) proposed rule was also released in July. This rule outlines changes in payment policies for services rendered in hospital outpatient settings. ASH commented on CMS’s proposal to drastically reduce payments to the 340B program and on coding related to bone marrow transplants and hematopoietic cell harvesting. Additionally, ASH opposed the proposal to package low cost drug administration services and on the payment for hematopoietic stem cell transplantation.

The final rules for the PFS and HOPPS were published in November and an oral report regarding the rules’ impact on hematology services will be provided to the Committee on Practice during its December meeting. In addition, the full analysis of the rules will be posted on ASH’s website soon.

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

ASH was officially voted back into the American Medical Association (AMA) House of Delegates (HOD) at the AMA HOD meeting in June. Dr. Gamini Soori and Dr. Chancellor Donald, both members of ASH’s Committee on Practice, serve as delegate and alternate delegate to the AMA HOD and represented ASH at this meeting and the AMA Interim Meeting in November. Beginning in 2018, ASH will also have a delegate for the Resident and Fellow Section (RFS) of the AMA HOD. Dr. Amar Kelkar, soon to be a hematology oncology fellow, will serve as an extra voice in supporting issues relevant to and important to ASH. Dr. Samuel Silver continues to serve as the ASH representative for the AMA CPT Advisory Committee and the AMA RUC Advisory Committee. Dr. Silver, along with ASH staff, attends the CPT and RUC meetings to ensure that hematology services continue to be properly coded and appropriately paid. ASH also started working closely with ASBMT on issues related to coding and reimbursement for CAR-T therapy after the FDA approved the first two CAR-T therapies in August and October of 2017.

ASH continues to be actively involved in 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, including hematologists, who primarily treat chronically ill patients. 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

In July, ASH, in conjunction with the American Society of Clinical Oncology, held the annual meeting of the hematology / oncology carrier advisory committee (CAC) network. This annual event brings together the hematologists and oncologists who serve as representatives to regional Medicare Contractors, Medicare Contractor Medical Directors, leaders from hematology and oncology state societies, and members of ASH and ASCO practice committees. The meeting is intended to provide attendees with a better understanding of the CAC process; discuss issues of common concern and develop solutions; and improve the overall CAC process throughout the year. Topics at this year’s meeting included reimbursement for next generation sequencing, allogeneic SCT and CAR-T therapies for lymphoma, MACRA, coverage of off label medications, and use of chronic red cell exchange (apheresis) in the management of adults with sickle cell disease.

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 Oncology Care Model (OCM) and also arranged for CMMI staff to meet with ASH members who are participating in this new payment model during the ASH Annual Meeting. ASH also met with CMMI staff to discuss ideas for a delivery and payment model for patients with sickle cell disease.

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 provide dedicated funding for sickle cell disease surveillance, outreach, and education programs to the Centers for Disease Control and Prevention’s (CDC) Blood Disorders Division in the fiscal year 2018 Labor, HHS, Education Appropriations bill. The group also asked members of Congress to support legislation (the Cancer Drug Parity Act, H.R. 1409), which would require insurance companies to cover oral chemotherapy at the same rate as intravenous chemotherapy. 

ASH Palliative Care Working Group

ASH launched a Palliative Care Working Group, comprised of members of the Committee on Practice, the Committee on Government Affairs, and the Committee on Quality. The group will examine what ASH can do to promote further understanding of palliative care as it relates to the practice of hematology. The group will recommend and explore actions that ASH can take related to palliative care in the following areas: education of ASH members, guidelines and evidence-based practice, payment and reimbursement, and policy and legislation. The group chose to focus their efforts on coverage for palliative blood transfusions in hospice care.