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2015 Physician Payment Advocacy Highlights

End of the Sustainable Growth Rate
For more than ten years, Medicare physician payment had been threatened with large annual cuts based on a formula tied to the economy and growth in volume of physician services. Throughout that period, Congress passed multiple short term bills to avoid these cuts. In April 2015, Congress finally passed a bill that would eliminate the Sustainable Growth Rate (SGR) formula. The Medicare and CHIP (Children's Health Insurance Program) Reauthorization Act of 2015 (MACRA) replaced the SGR with a fixed annual update of 0.5% per year through 2019, followed by transition to a two path system in which physicians could either be paid under alternative payment models that require some risk bearing or a pay-for-performance system in which fee-for-service payments are adjusted for quality, resource use, use of electronic health records, and participation in practice improvement activities.

The Medicare and CHIP Reauthorization Act of 2015 (MACRA)
The passage of MACRA is a major legislative achievement for ASH and the rest of organized medicine, eliminating a problem that had plagued the profession for well over a decade. ASH members sent numerous letters to Congress and the Committee on Government Affairs advocated for repeal of the SGR formula during its Hill day in March. ASH is now focused on implementation of the major elements of the legislation including the definition of alternative payment models and methods of measuring quality and resource use.

2016 Medicare Physician Payment Rule
In July, the Centers for Medicare and Medicaid Services (CMS) announced annual proposed changes to the Medicare physician fee schedule that would be implemented on January 1, 2016. ASH offered extensive comments on the payment level for infusion services, methods of quality reporting, and the establishment of standards for clinical practice improvement. The final rule was filed on October 30, 2015 (for publication on November 11, 2015) and ASH staff has analyzed the final rule’s impact on hematology services.

Coding, RUC, and Medicare Payment Policies for Hematology-Specific Services
ASH is an active participant in the AMA's Current Procedural Terminology (CPT) Coding and Relative Value Update Committee (RUC). Samuel Silver, MD, PhD, MACP, and Robert Weinstein, MD are ASH's CPT and RUC representatives. The ASH representatives, along with ASH staff have 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.

In addition, the Committee on Practice advocated for the Centers for Medicare & Medicaid Services (CMS) to commission the research necessary to study the outpatient evaluation and management (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.

CAC Meeting
ASH, along with the American Society of Clinical Oncology (ASCO), held the annual meeting of the Medicare Contractor Advisory Committee (CAC) in July 2015. This meeting is 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 discussed at the meeting included molecular diagnostics, chemotherapy, and biosimilar drugs.

Center for Medicare and Medicaid Innovation
ASH continued to work with the Center for Medicare and Medicaid Innovation (CMMI) to refine details of an upcoming Oncology Care Model and discuss opportunities for a care model focused on rare non-malignant diseases such as sickle cell disease.

After many years of delay, the United States converted to the tenth version of the International Classification of Disease (ICD-10) on October 1, 2015. ASH provided resources to guide members through the new more detailed diagnosis codes and continues to monitor the transition for potential issues.