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ASCO: Proposed Medicare Physician Fee Schedule does not consider cancer care costs
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ASCO has requested CMS reconsider the proposed 2016 Medicare Physician Fee Schedule due to payment policies that may burden oncology practices and lead to reimbursement that does not support optimal care for patients with cancer.
During the public comment period, Julie M. Vose, MD, MBA, FASCO, ASCO president, sent a letter to CMS on behalf of ASCO members that included 23 recommendations on issues such as patient care, physician payment and quality of care.
Julie M. Vose
The proposed changes by CMS could become effective as early as Jan. 1, 2016. However, ASCO expressed concerns over a number of the changes, specifically regarding rules on “incident to” billing, how potential erroneous reimbursement codes are identified, the elimination of the cancer staging measure in the quality reporting system and the changes in the requirements for chronic care management.
“CMS payment policies should support this nation’s transition to a health care system that provides high-quality, high-value cancer care for all patients with cancer,” Vose said in a press release. “We believe that many of the proposed 2016 fee scheduling policies will be foundational to changes for 2019 and beyond. We strongly encourage CMS to implement policies that move us closer to the agency’s own stated goals for transforming the cancer care delivery system — rather than creating barriers.”
ASCO’s concerns
ASCO asked CMS to clarify the “incident to” rules to distinguish that an ordering physician and a supervising physician can be different when it comes to the administration of chemotherapy.
Because of the team-oriented aspect of modern oncology treatment, ASCO noted in the letter that “it would be extremely disruptive, counterproductive and inefficient to require the same physician to both order and supervise ‘incident to’ services such as chemotherapy administration.”
Additionally, ASCO suggested finding alternative methods to identifying misvalued codes other than the “high expenditure by specialty screen.”
That method — introduced by CMS in 2015 to reduce expenditures by reassessing misvalued reimbursement codes — has come under fire because, according to ASCO, it is too inclusive, does not target codes that have a tendency to be misvalued and causes an unnecessary administrative burden.
This method also targets chemotherapy administration codes as potential misvalues. ASCO contended this would leave oncology practices with fewer resources to provide chemotherapy to those patients who need it.
CMS has also proposed to eliminate their Refinement Panel for reviewing and recommending physician work values, something ASCO believes is misguided.
Similarly, ASCO has recommended against the elimination of the cancer staging measure from registry reporting in the Physician Quality Reporting System (PQRS).
Although CMS wants to eliminate the system because it feels the measure does not add clinical value to PQRS, knowing a patient’s initial cancer stage allows for providers to assess the prognosis of the patient and their proper treatment options, according to the ASCO letter.
“The cancer staging measure is… one of only a few oncology-specific measures in the PQRS, which otherwise lacks an adequate number of measures that have meaningful connections to high-quality cancer care and the day-to-day services provided by medical oncologists,” Vose and colleagues wrote.
Chronic care management
ASCO also called for CMS to continue to focus resources on providing beneficiaries access to chronic care management services, which may improve oncology care management and lower expenses. To do this, CMS should eliminate administrative burdens that are counterproductive for providers who are trying to offer chronic care management.
According to the ASCO press release, oncologists have been undermined while implementing chronic care management services because of a heavy, and often confusing, administrative burden. A limitation has permitted only one provider to deliver these chronic care services to a Medicare beneficiary.
ASCO pointed out that the current CMS policy lacks an assurance that the appropriate physician is receiving chronic care management reimbursement and that reimbursement levels are inadequate to support compliance with all of the requirements, such as those that have adequate health information technology, provide 24/7 beneficiary access, provide nursing staff and cover related overhead costs.
The society also asked that CMS develop policies on radiation oncology and biosimilar drug reimbursements.
Support for CMS changes
ASCO offered support for four key CMS proposed changes:
- Reimbursement for advanced care planning: ASCO recommends clearer guidance on a national level to prevent geographic disparities in access to advance care planning.
- Cognitive work: ASCO said there are “critical shortages” in resources in certain specialties where extensive thought is required and does not result from a mere face-to-face meeting with a patient.
- Improving and measuring quality and value by specifically tailoring measures to the day-to-day practices for oncology specialists rather than requiring adherence to measures outside their typical scope of practice.
- Alternative payment models, such as ASCO’s Patient-Centered Oncology Payment Model.
“CMS should facilitate participation by oncologists in alternative payment models by implementing and evaluating the Patient-Centered Oncology Payment (PCOP) model as soon as possible through the Center for Medicare and Medicaid Intervention,” Vose and colleagues wrote. “Testing PCOP through the Innovation Center will promote the principles of care coordination and management while removing barriers that exist under the current reimbursement system to the delivery of high-quality, affordable oncology care.” – by Anthony SanFilippo
Reference:
ASCO. Re: CMS-1631-P. Medicare Program: Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2016. Available at: www.asco.org/sites/www.asco.org/files/cms_payment_policies_9.8.15.pdf?et_cid=36647465&et_rid=759925369&linkid=comment+letter. Accessed Sept. 15, 2015.
Perspective
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Samuel M. Silver, MD, PhD, MACP
Many of our professional societies have sent comments to CMS regarding the Proposed Rule for the Medicare Physician Fee Schedule (MPFS).
Many of these comments reference concerns and recommendations regarding reimbursement for transitional and chronic care management, add-on codes for evaluation and management services, advanced care planning, cognitive work and alternate payment models. Comments from ASH, ASCO and the American College of Physicians (ACP) note that transitional care management codes require burdensome documentation requirements for modest payment and limit payment to only a single provider.
The current reimbursement levels are inadequate to support compliance with CMS regulations. The restrictions and complexities of these codes have resulted in underutilization and, therefore, these societies have requested elimination of burdensome restriction and revaluation of these important codes.
In addition, ASH asks CMS to reexamine the decision not to pay for complex management codes (99487 and 99489) that appropriately describe the type of services required by patients treated by hematologists and better account for the associated level of work.
Both ASCO and ASH support codes paying for interprofessional collaboration amongst physicians without the need to perform face-to-face services. There are four CMS unreimbursed interprofessional telephone/internet consultative codes (99446, 99447, 99448 and 99449) that describe varying lengths of such services.
According to the ASH comment letter, “Increasing numbers of hematologists work in consultative roles with internists, general pediatricians and surgeons … to avoid complications relating to bleeding or other symptoms. … In today’s system that hematologist must either provide the service without compensation, or the patient must unnecessarily [have a face–face visit] in order for Medicare to pay the service.” CMS should support incentives for increased coordination and communication to support the delivery of high-value care by supporting payment for these codes.
In addition to the Societies’ comments noted above, a coalition of societies — that includes ASH — submitted a comment letter that discusses improved payment for the work-of-care management services. This coalition, led by John Goodson, MD, a general internist at Massachusetts General Hospital, recommended that the new add-on codes not be restricted to specific specialties.
However, the comment letter goes into detail about the need for more research required to understand the current use of the most frequently used codes in medicine — the evaluation and management codes (E/M codes). To quote from the comment letter:
“While we appreciate CMS’ proposal to compensate physicians for this currently uncompensated work [referring to the add-on codes] and view this proposal as an important first step, it does not go far enough. New payment models being studied and implemented by CMS continue to rely on the resource-based relative value scale when determining physician compensation. Yet, the existing E/M codes continue to be improperly defined and valued. The inequities faced by physicians whose work consists of providing these services in the fee-for-service model will persist in new payment models until CMS addresses these service codes.
Specifically, there continues to be considerable variability in the work completed by different specialties within the existing E/M service codes, and there continues to be a wide range of post-service work completed as a result of the encounter by different specialties. Some are relatively overpaid and some are relatively underpaid. There are just too few basic choices … We previously proposed that CMS improve the accuracy in the Physician Fee Schedule (PFS) by creating new E/M codes that would be developed from a knowledge-base that reflects the current levels of physician work based on nationally representative samples and electronically accessible data. If successful, this research-based model could then be used to address the deficiencies in the other E/M code families.
We urge CMS to commit to doing this research and to hire a contractor to work with stakeholders to develop a comprehensive understanding of what physicians and their clinical staff do on a daily basis.”
This call to evaluate the current use of E/M codes is critical to the correct payment of the work performed by “cognitive” specialties. We will see how CMS responds.
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