Tag Archives: SGR reform

SGR Repeal: Are We There Yet?

U.S. Capitol By Leah Ralph, Manager, Provider Economics and Public Policy, ACCC

As ACCC members know, last week brought unprecedented momentum on an issue physicians and Congress have been struggling with for over a decade: repealing the sustainable growth rate (SGR). Just days before the current SGR “patch” expired, the House of Representatives overwhelmingly passed H.R. 2, the Medicare Access and CHIP Reauthorization Act, legislation that would permanently replace the SGR formula with stable Medicare payment updates and encourage physicians to increasingly participate in alternative payment models. The bill builds on last year’s bipartisan, bicameral compromise that ultimately hit roadblocks when legislators struggled to find a way to pay for it.

The Senate was expected to take up the House bill, but on March 27, the chamber recessed for two weeks, leaving a very small window to consider the bill when they return on April 13.

Senate Majority Leader Mitch McConnell has said the bill should move “very quickly” when the chamber comes back into session, and there is “every reason” to believe the bill will pass.

Meanwhile, the current “patch” expired March 31, and CMS has indicated that it will hold claims for two weeks, or 10 business days, through April 14.

We’re in the homestretch; we’re closer to a permanent fix to the SGR than we have ever been before. But are we there yet? Not quite. Now is the time to contact your Senators, and urge them to support passage of H.R. 2, to ensure that physicians have the predictable, appropriate payments they need to continue to provide high-quality cancer care.

Stay tuned. And make your voice heard. Contact your Senators today.

Senate Postpones Decision on SGR

U.S. Capitol By Leah Ralph, Manager, Provider Economics and Public Policy, ACCC

On Thursday, March 26, the U.S. House of Representatives passed H.R. 2, legislation to permanently repeal and replace Medicare’s sustainable growth rate (SGR) formula for physician reimbursement. Read a summary of the legislation here.

Unfortunately, the Senate announced late Thursday evening that they will not consider the SGR repeal bill until they return from recess on April 13, 2015.  CMS has indicated it will hold claims for two weeks, through April 14.

ACCC urges members to contact your Senators in the next two weeks and ask them to support a permanent repeal of the SGR.

SGR Bill Heads to Senate—Contact Your Senators Today!

U.S. Capitol By Leah Ralph, Manager, Provider Economics and Public Policy, ACCC

On March 26, by a vote of 392-37 the U.S. House of Representatives overwhelmingly passed H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015, legislation to permanently repeal and replace Medicare’s sustainable growth rate (SGR) formula for physician reimbursement. Read a summary of the legislation here.

Rep. Michael C. Burgess, MD, (R-Texas), the bill’s primary sponsor, said in a statement, “This is the work of a collaborative body. . . .It is time to end the SGR. Let us never speak of this issue again.”

On March 25, the White House expressed support for the bill.

The Senate is expected to vote on the bill March 27, before Congress recesses for two weeks.

ACCC urges members to contact your Senators and ask them to support a permanent repeal of the SGR. As an expert in cancer care, they need to hear from you!

Call to Action: Support Permanent Repeal of the SGR!

by Leah Ralph, Manager, Provider Economics and Public Policy, ACCC

U.S. Capitol With another SGR deadline looming, leaders in the U.S. Senate and House are coming close to striking a bipartisan, bicameral deal to finally replace the broken Medicare Sustainable Growth Rate (SGR) formula.

On March 24, bipartisan leaders of the House Energy and Commerce and House Ways and Means Committees introduced H.R. 2, the Medicare Access and CHIP Reauthorization Act (MACRA), to permanently replace Medicare’s Sustainable Growth Rate (SGR). The agreement builds upon H.R. 1470, introduced last week.

H.R. 2 would create an improved physician payment system that rewards quality, efficiency, and innovation and put an end to the cycle of annual “doc fix” crises that have created uncertainty for millions of Medicare providers and beneficiaries for over a decade. As you well know, physicians need the assurance of predictable, appropriate payments in order to plan for the future and invest in the personnel and technologies that are essential to providing high-quality cancer care.

This is historic momentum on an issue that has plagued providers—and Congress— for years. This year’s compromise builds on last year’s efforts, and the window to get this bill across the finish line is narrowing. Join us in urging Congress to continue to work together to pass responsible legislation that appropriately reimburses patient care.

Contact your member of Congress to support a permanent repeal of the SGR. As an expert in cancer care, they need to hear from you!

ACCC on Capitol Hill

DSC_0545by Amanda Patton, ACCC Communications

ACCC’s 41st Annual Meeting, CANCERSCAPE, kicked off on March 16 with Capitol Hill Day. ACCC members from across the country fanned out across the Capitol for more than 70 scheduled meetings with legislators and key staff members from both the House and Senate.

With the current Sustainable Growth Rate (SGR) patch set to expire March 31, the timing was ripe for these advocates to speak up for a permanent fix to the SGR.

First time ACCC Hill Day participant Linda Gascoyne, patient advocate for medical oncology, East Maine Medical Center in Brewer, Maine, spent the day with the Maine delegation that met with Senator Susan Collins on Monday, afternoon. “I found her [Senator Collins] to be very empathetic as she listened and learned about what we were asking [from Congress],” Ms. Gascoyne said. In addition to the SGR, the Maine delegation talked with Senator Collins about the need for federal oral parity legislation and elimination of the prompt pay discount from the ASP calculation.

Donna Sulsenti, practice manager, South Shore Hematology Oncology and president of HOMNY was part of the New York delegation that had visits with four congressional offices. “It was extremely interesting speaking about issues with our legislators and getting something accomplished,” she said. She also finds it “satisfying to know that ACCC is working for us.”

Another first time ACCC Hill Day participant Monica Cfarku, nurse manager, Oregon Health & Science University, Knight Cancer Institute, said she “learned a lot” from her meetings with hill staff. In turn, she found staff engaged on the issues and interested in learning from her. “I felt like I offered them a different perspective as someone on the frontline of care delivery.” In fact, staff from a congressional office invited her to return later in the week to share more of her perspective.

Stay tuned for more from ACCC’s Annual Meeting, Cancerscape underway in Arlington, Va. Follow us on Twitter at #cancerscape15.

Ringing in the New Year

US Capitolby Leah Ralph, Manager, Provider Economics and Public Policy, ACCC

The last few months have brought big changes to Washington, D.C. We will ring in the New Year with both chambers of Congress under GOP control, which means the parties are reorganizing and, importantly, the legislative agenda is shifting. While it’s still anyone’s guess whether new leadership will mean less political infighting in 2015, issues like trade, energy, and tax reform are early contenders for potential areas of compromise next year.

The ACA (Affordable Care Act) will also make the top of the political agenda: starting in January, you can count on Republicans to look for every opportunity to take the legs out from under President Obama’s signature achievement. Although full repeal is unlikely, as it would face an all-but-guaranteed presidential veto, expect the new majority to focus their efforts on introducing a series of stand-alone bills targeting the most unpopular provisions of the law.

Predicting the fate of non-ACA healthcare legislation is a tougher call. On the one hand, healthcare fatigue still looms large among legislators, making issues like a long-term fix to the Sustainable Growth Rate (SGR), oral parity, and sequestration more of an uphill climb. On the other hand, new leadership, a renewed vow to work across the aisle, and public dissatisfaction with the status quo are bringing new energy to Congress.

Will 2015 Bring a Permanent SGR Fix?

In 2014 we saw what was arguably the best opportunity in years to finally fix the fundamentally flawed SGR formula. Congress came to agreement on a bipartisan bill that had a relatively low price tag, but in the end could not reach consensus on how to pay for the fix. As a result, the bill never came to a vote and will need to be reintroduced in the new Congress. Still the fact that Congress achieved consensus on policy is a promising sign for 2015. We have now weathered seventeen (17!) “doc fix” patches that, if added together, cost far more than the comprehensive approach lawmakers are considering today. This year’s ACCC Capitol Hill Day is scheduled for March 16, so we will be visiting with our legislators just weeks before the current “doc fix” expires on March 31.

Will We See Federal Oral Parity Legislation?

Passing a national oral parity law continues to be a top priority for ACCC membership. On the state level, oral parity efforts are gaining momentum. To date, 34 states and D.C. have enacted oral parity laws, and several other states are ramping up their grassroots efforts for 2015. Given that an estimated 25 to 35 percent of all oncology therapies in the pipeline will available only in pill form, the need for comprehensive, federal oral parity legislation is increasingly critical to patient access. While state-level legislation remains important, lawmakers need to understand that federal legislation would ensure consistency in oral parity laws across the country and would include plans that fall outside the purview of state regulation.

Will We See Any Relief from the Sequester?

Last year, legislation to exempt cancer drugs from the Medicare sequester gained more than 100 cosponsors. ACCC will be advocating for this legislation to be reintroduced in 2015.

As you can see, 2015 is the year to make your voice heard! Join us for Capitol Hill Day on March 16, and stay for the ACCC 41st Annual Meeting, CANCERSCAPE, which will follow March 17–18 in Crystal City, Va. Read our agenda and register today!

If you have additional questions, or would like to get involved with ACCC advocacy, please contact me at lralph@accc-cancer.org.



Alternative Payment Models, Risk-Sharing Ahead, Says ACCC Keynoter

meetings-AM2014-Patel(1)by Amanda Patton, Manager, Communications, ACCC

With polarization on Capitol Hill impeding the legislative process, ACCC 40th Annual National Meeting keynote speaker Kavita Patel, MD, of the Brookings Institution told attendees: “If you are looking for change, I would point you to your own selves in the mirror, not to Washington, D.C.”

With the Senate having passed the SGR reform patch the night before, Patel noted that despite the fact that SGR reform was one of the few things with bi-cameral support in Congress, ultimately, we once again have a one-year “doc fix.” This is the 17th time Congress has enacted an SGR patch since the formula went into effect in 2002.

Still, Patel believes there is potential for Congress to act on long-term reform next year.

The current “SGR fix” legislation reflects Congress’s focus on “value” and value-based alternative payment models, she noted.

“At some point, it will be important for your community to think about what that would look like at your programs.” She believes medical oncology may be well suited to what Congress is thinking about with alternative payment models.

While cancer care has evolved so greatly over the past several decades, our reimbursement policies to pay for that care have not evolved.

Among the alternative payment models, Patel believes the medical home model may be suited to oncology, while bundling is a poor fit.

“If people think there’s going to be bundling in oncology, they are wrong,” she said.

So is fee for service gone forever? “No,” says Patel. “The answer is there is always going to be room for fee for service in certain settings.”

But, some form of risk-sharing is definitely in the cards. “In 10 to 15 years, the majority of people in this room will have some sort of risk-based contract…that will become the norm in the next several decades.”

However, she warned that if you turn to Congress for a solution, they are likely to turn it around and ask you to show them viable solutions—and this is a good thing.

At the end of the day, I think we need more clinical voices in the policy setting arena, “ she said. “You don’t want Medicare or Congress thinking about cancer care without [our] voices.”

ACCC on the Hill: Timing is Everything

by Amanda Patton, Manager, Communications, ACCC

photoMore than 50 ACCC members from 27 states were walking the halls of Congress on March 31 for ACCC’s Capitol Hill Day. With the Senate poised to vote on the SGR patch legislation, the timing was perfect for talking with elected officials about the need for a permanent fix to the sustainable growth rate.

Participants were scheduled for more than 100 visits with House and Senate offices throughout the day.

From first-time meeting attendees to veteran hill day participants, the consensus was that the time spent meeting with elected officials was well worth the effort.

The day was “extremely educational,” said new ACCC member Cindy Krasnecky, director of the cancer center at Harrington Memorial Hospital in Southbridge, Massachusetts. “I was impressed by the level of knowledge and experience of the [Hill] staffers.”

ACCC members focused on four main concerns in their conversations with Hill staff:

  • Finding a permanent solution to the flawed SGR formula
  • Passing oral parity legislation
  • Removing anti-cancer drugs from the Medicare sequester
  • Eliminating the prompt pay discount.

“It felt empowering to have your voice actually heard by someone setting policy,” said Angela Tambini of the Lahey Clinic in Massachusetts.

Anecdotally, we heard frustration in many congressional offices over the status of SGR reform and disappointment with an inability to effect more sweeping change.

At the end of the day on Monday, the Senate passed a bill to extend Medicare physician pay rates through March 15, 2015. The legislation will also delay ICD-10 implementation until 2015.

According to BNA Bloomberg this marks the 17th time Congress has acted to prevent scheduled reimbursement cuts due to the SGR since the formula went into effect in 2002.








Hill Day Primer—Issue #1: Eliminate the SGR

By Sydney Abbott, JD, Manager, Provider Economics & Public Policy, ACCC

Capitol-HillAs we count down the days until ACCC’s Capitol Hill Day on March 31, ACCCBuzz will feature a primer series on the key issues ACCC members will be talking about.  In this first of four installments, we’ll look at SGR repeal and replacement.

Due to the flawed sustainable growth rate (SGR) formula that determines Medicare reimbursement, each year physicians face reimbursement uncertainty. Each year, Congress has been forced to step in with a “doc fix” to prevent enormous pay cuts for providers.

We’ve been following the progress on SGR reform in ACCCBuzz.

As you know, there’s been much discussion on how best to fix the SGR. Should there be a time-limited pay freeze vs. annual updates? Which quality metrics should be used? Should the new policy develop over five years or ten?  At last Congress is showing some consensus around the policy discussion, while still grappling with the question of how to pay for a fix. Companion legislation in the House (HR 4015) and Senate (S 2000) is now moving forward and includes the following reforms:

Predictable Payment UpdatesUnder these bills, a positive 0.5% for fee-for-service update would be implemented for 2014–2018. The 2018 Medicare reimbursement rate would then remain in place through 2023. Starting in 2024, provider reimbursement could increase by 1% for those participating in alternative payment models, while remaining at 0.5% for those not participating.

Reimbursement Tied to Quality—The proposed legislation would consolidate the three Medicare incentive/penalty programs –Physician Quality Reporting System (PQRS), the Value-Based Modifier (VBM), and Meaningful Use of electronic health records (EHR MU)—into one streamlined program, the Merit-Based Incentive Payment System (MIPS).  The MIPS will evaluate providers based on quality, resource utilization, EHR meaningful use, and clinical improvement activities. Although specific measures would be established through CMS rulemaking, positive or negative payment adjustments would be made to providers using a composite score compared to a performance threshold.  Negative adjustments will be capped at 4% in 2018, 5% in 2019, 7% in 2020, and 9% in 2021.

Providers who receive a significant portion of their revenues through alternative payment models (APMs) involving risk of financial loss and with a quality measurement component would receive a 5% bonus each year 2018–2023. Importantly, the legislation encourages CMS to test APMs relevant to specialty professionals, like oncology.

Additionally, at least one new payment code will be created for care management services provided to patients with chronic conditions.

Each year CMS would propose a plan for establishing the quality measures to be used in the MIPS and APM programs.  Annual funding of $15 million would be allocated for the development of such measures, and stakeholders would be able to submit comments to CMS’s proposed plans.

Physician-Specific Data Would be Made Public—Starting  in 2015, CMS would publish utilization and payment data for providers on the Physician Compare website, including information on the most commonly provided services and the submitted charges for those services.  Providers would have the opportunity to review and correct inaccurate data.

Potentially Misvalued Codes—As ACCC has noted previously, identification of potentially misvalued codes remains in the SGR repeal legislation. The current goal is 0.5% of fee schedule expenditures to be slated for identification of misvalued services each year in 2015–2018.

Although the current legislation reflects much consolidation on SGR reform, much work remains in identifying $126 billion in offsets to pay for this fix.  The current “doc fix” runs out at the end of March.  On Capitol Hill Day ACCC members will be walking the halls of Congress, urging members from the  House and Senate to work together to pass this reform and permanently replace the SGR with responsible policy that emphasizes value over volume.

Join us for ACCC’s Capitol Hill Day and help educate your representatives about the importance of SGR reform.

Stay tuned to the rest of this blog series for a deep dive into the issues ACCC members will be talking about  on Capitol Hill: Exempt cancer drugs from the 2% Medicare sequester, create equity in out-of-pocket expenses for oral and IV-infused therapies, and eliminate of the prompt pay discount. See you on the Hill!

New SGR Fix Proposed—Are We There Yet?

capitol_building_washington_dc_wallpaper_2-normalBy Matt Farber, MA, Director, Provider Economics and Public Policy, ACCC

As most of you know, we are currently in the midst of a short-term, three-month Sustainable Growth Rate (SGR) patch that was passed by Congress  to avert a roughly 24% physician pay cut, which would have gone into effect on Jan. 1, 2014. This short-term fix was passed in order to give Congress more time to work out the differences between three proposed plans to permanently fix the SGR formula. On Thursday, February 6, Congress unveiled a  bipartisan, bicameral bill in the hopes of achieving passage before the current  “patch” expires. Here are some of the pertinent details:

  • 0.5% increase in payments each year for a 5-year span
  • Consolidation of current quality reporting mechanisms (PQRS, VBM, Meaningful Use) into one program that will reward physicians who meet certain performance standards
  • Rewards of up to a 5% bonus payment to physicians who receive a certain portion of revenue from alternative payment models (such as medical homes, ACOs, etc.)
  • Quality and utilization data to be posted to the Physician Compare website.

This newest effort is certainly a step in the right direction.  While ACCC would like to see larger annual increases, we are pleased that positive updates were included in the final bill. The biggest hurdle to passage remains the price tag—which is now estimated to be roughly $120 to $140 billion over 10 years. And, legislators have yet to spell out how Congress will pay for this fix.

ACCC will closely monitor this effort, and also work with elected officials as offsets begin to be discussed.  If you have any questions, please contact mfarber@accc-cancer.org or sabbott@accc-cancer.org.