2021 Year End Physician Payment and Coverage Advocacy Highlights

Medicare Inpatient Hospital Rule

ASH offered comments in June on the fiscal year 2022 proposed rule for the Centers for Medicare and Medicaid Services (CMS) Inpatient Prospective Payment System (IPPS). The rule determines payment levels and related provisions for Medicare patients who are admitted to the hospital. ASH’s comments included continued support for the methodology CMS uses to determine the weight for the chimeric antigen receptor (CAR) T-cell therapy Medicare Severity-Diagnosis Related Group (MS-DRG). Additionally, ASH supported policy proposals related to payments to hospitals for direct and indirect graduate medical education (GME) costs. In the final rule released on August 2, CMS finalized a new name for MS-DRG 018, Chimeric Antigen Receptor (CAR) T-cell and Other Immunotherapies, in order to reflect reporting of non-CAR T-cell therapies and other immunotherapies. CMS, however, did not address the GME policies citing that this was due to the number and nature of the responses on this topic and indicated that this will be addressed in future rulemaking.

Medicare Physician Fee Schedule

On November 2, CMS released the Medicare Physician Fee Schedule (PFS) final rule outlining changes to be implemented on January 1, 2022. The rule updates payment policies and payment rates for services provided in the physician office. ASH submitted comments on the proposed rule in September. In the final rule, the most significant policies impacting hematology/oncology are the cuts to Medicare payments - physicians face a 9.75% reduction in reimbursement beginning in January, 2022. Fortunately, Congress took action and passed legislation which stops the majority of the Medicare physician payment cuts – the total cut to the conversion factor is now approximately 0.85%. The final rule also included a number of provisions related to telehealth. CMS will not be extending much of the telehealth flexibilities allowed for under the COVID-19 pandemic, including waiving the geographic restrictions and site of care requirements and allowing coverage and payment for audio-only CPT codes – Congressional action is required to make these flexibilities permanent as CMS does not have the authority under current law.

Coverage for Stem Cell Transplant for Individuals with Myelodysplastic Syndrome

ASH joined the American Society for Transplantation and Cellular Therapy, the National Marrow Donor Program, and the Center for International Blood and Marrow Transplant Research, in writing CMS to formally request reconsideration of the National Coverage Determination for Stem Cell Transplantation (110.23). Specifically, the organizations asked for full coverage of allogeneic hematopoietic stem cell transplantation (HSCT) for individuals with myelodysplastic syndromes (MDS) and the removal of the Coverage with Evidence Development requirement currently tied to coverage for HSCT for Medicare beneficiaries with MDS. CMS accepted the request but due to internal capacity restraints has postponed all action on the request.

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

ASH members attended the virtual American Medical Association (AMA) House of Delegate (HOD) meetings in June and November of 2021. ASH has two delegates, Dr. Chancellor Donald and Dr. Leonard Heffner, two alternate delegates, Dr. Lawrence Solberg and Dr. Kelsey Martin, as well as a delegate for the Resident and Fellow Section (RFS), Dr. Amar Kelkar. Two delegates, in addition to the RFS delegate, can attend each meeting, and vote on resolutions, which help to shape AMA policy positions. ASH also has representation in the AMA Women Physicians Section (WPS) by Dr. Margaret Ragni and Dr. Ariella Marshall.

ASH also remains active in the AMA Current Procedural Terminology (CPT) meetings and the AMA RVS Update Committee (RUC) meetings. Dr. Sam Silver represents ASH for both the CPT and RUC with Dr. Chancellor Donald serving as an alternate for the CPT and Dr. Jamile Shammo serving as an alternate for the RUC.

Medicare Contractor Advisory Committee Meeting

This year ASH hosted a virtual Carrier Advisory Committee (CAC) Network Meeting in June as well as a webinar in November. The June meeting focused on the effort outlined above – ASH's work with peer organizations to have the Coverage with Evidence Development requirement for Myelodysplastic Syndromes (MDS) removed from the National Coverage Determination on Stem Cell Transplant and replaced with full coverage for hemopoietic stem cell transplant for individuals with MDS – and provided an update on ASH’s efforts to secure coverage for stem cell transplant for individuals living with lymphoma. The November webinar covered genomic testing and the role it plays in clinical decision making.

Sickle Cell Disease

ASH continues to work on a number of advocacy issues related to payment for and coverage of therapies and treatments used for sickle cell disease (SCD), including the Society’s work with Congressional champions to introduce legislation which would direct CMS to create a demonstration program to improve access to comprehensive, high quality outpatient care for individuals living with SCD who are enrolled in Medicaid.