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Health care reform, consultation codes and off-label drug use all big issues for hem/oncs
HemOnc Today recently convened its well-respected Section Editors to present on ‘hot’ or controversial topics they deemed important to their subspecialty area.
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Presented here is Samuel M. Silver, MD, PhD’s discussion of his hit list of topics that he believed fulfilled this qualification. HemOnc Today will continue to follow and expand coverage of these topics in the ensuing months. Next issue, we will present a report from Laurence Boxer, MD. We hope you find these executive overviews informative.
With the recent passage of the heath care reform bill, many hematologists and oncologists are trying to figure out how this new legislation will affect them. Although I cannot address all of the details of the bill, I think that for hem/oncs, the legislation is a positive.
First, there are more covered lives, so we will have more paying patients. In Michigan, every time I am in clinic, I have a patient who is on active chemotherapy tell me they have lost their job, their wife has lost her job, they have lost their insurance or their COBRA has lapsed. Obviously, now these patients will have insurance and will be able to pay for the items and services that we provide.
Second, the new legislation mandates coverage of the routine care costs throughout clinical trials. What I do not know is exactly how this will work with regard to the Employee Retirement Income Security Act and self-funded employers.
Third, there is funding for participation in voluntary care organizations. These organizations encourage physicians or health systems to get together and incent the flow of information between specialists and generalists.
Next, the new legislation includes incentives for the use of generic drugs. In order to increase the use of generics, especially biologics, they will pay biosimilars at the average sale price plus 6% of the average sale price of the reference biologic, giving doctors incentive to go with generics.
Finally, the reform includes a Centers for Medicare and Medicaid Services Innovation Center. This is $10 billion allocated to test new Medicare payment models. There is also a model specific for oncology, for guideline-based oncology and follow-up care.
Sustainable growth rate
Despite all these positives, health care reform was silent on sustainable growth rate (SGR). SGR is a statutory formula that sets overall targets to hold down spending on Medicare Part B physician services. Payment rates are adjusted every year to reflect differences in actual spending and the target. Every year, it goes down to bottom line with a big pay cut scheduled, and every year, Congress overrides the cut.
Although this information is constantly changing, as of March 27, there was a second extension that delayed the Medicare physician reimbursement pay cut until April 1.
The Senate failed to vote on a temporary SGR extension for April, and because Congress adjourned for Easter recess, the SGR cut took effect on April 1. CMS instructed its contractors to hold claims containing services paid for the first 10 business days of April.
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I was told by the American Medical Association: “In a reply to the standoff that occurred a month ago, this time it was Senator Tom Coburn of Oklahoma who objected to the bill’s consideration, on the basis that it should not be considered emergency spending that would be exempt from budgetary offsets. As a result, Congress will adjourn for its two-week spring recess without taking action to stop these programs from expiring. We are told that the Senate plans to hold a cloture vote after the recess which, if supported by 60 Senators, will allow a vote to occur on the legislation and that could occur as early as April 12.”
There remains a huge potential for major cuts, and the AMA has given out advice to physicians on the process for disenrolling from Medicare.
Consultation codes
As of Jan. 1, the consultation codes for inpatient and outpatient care have been eliminated by Medicare, and many private companies are following suit. Most of the cognitive disciplines, of which hematology/oncology is one, feel that this devalues their work.
Discussions are ongoing in the physician community to partially correct this issue. Among the things being discussed:
lProposed editorial changes to the “prolonged services” CPT codes so that one can potentially have add-ons to higher-level new patient visits to increase the worth of those visit.
lSeeking favorable interpretation from CMS contractors on in-patient face-to-face time. Right now, unless you are actually in that patient’s room, you cannot use these add-on codes if you looking at X-rays, etc. None of that time counts, and that is not how we take care of patients.
lSubmitting a CPT code change proposal that lowers the time threshold for billing prolonged services. Right now, it starts at 30 minutes, but having one that starts at 15 minutes might help.
Private hem/onc practices
There also seems to be an increasing trend toward failing hematology/oncology practices being assumed by hospital systems. For example, in Massachusetts three or four years ago, about 60% of patients were taken care of by private practice oncology; today, it is about 10% because of the assumption of practices by hospitals.
This is happening at an increasing rate throughout the country. Why? Reasons include decreasing drug margins, the consolidation of third-party payers and the increasing dominance of hospital systems in some areas. This increasing dominance by hospitals gives private practices little influence when negotiating contracts with third-party payers, so their payment rates are going down.
If previously well-run practices are going under, and they are assumed by a hospital, will they do any better? In some circumstances, the hospitals have an advantage. Those are the hospitals that are part of 340b drug pricing programs. These hospitals take care of indigent patients and are given tremendous drug discounts. Therefore, all of their employees, even at a different hospital, would have the same drug pricing advantages.
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Off-label drug use
Moving forward, the hem/onc community is also concerned about the use of off-label chemotherapy and the drug compendia. Estimates of the frequency of the use of off-label therapy in medical practice range from 21% to 51%. Although listing in the CMS-approved drug compendia allows payment for off-label chemotherapy drugs, certain contractors have taken the position that compendia listing does not mandate coverage. This is a major day-to-day issue.
Finally, another area of concern among hematologists and oncologists is the FDA’s erythropoiesis-stimulating agents risk evaluation and mitigation strategy (REMS). Since the FDA announced the REMS program — which will require all of us to be educated about the risks of ESAs, how to use them and have certain materials to educate our patients — ASH has heard from several hematologists who raised questions and concerns on how the program will apply to patients with off-label use of ESAs in patients with myelodysplastic syndrome. The myelodysplastic syndrome is becoming the majority use for ESAs these days. These patients require ESAs for prolonged periods of time, not just for the short period of time patients are on chemotherapy. Physicians want to know, if it is off label, how will the REMS work.