Tag Archives: SGR

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.

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!

2015 Proposed Rules: Not So Bad?

By Matt Farber, MA, Director of Provider Economics & Public Policy, ACCC

Centers_for_Medicare_and_Medicaid_Services_logoOn July 3, 2014, the Centers for Medicare & Medicaid Services (CMS) released the 2015 proposed rules for the Hospital Outpatient Prospective Payment System (OPPS)  and the Physician Fee Schedule (PFS), and ACCC is busy poring through the documents in order to get the most pertinent information out to our members as soon as possible.  Look for complete summaries of both rules from ACCC shortly, and ACCC members be sure to dial in to our conference call on the proposed rules on Wednesday, July 23rd at 2 pm ET.

At first glance, we can say the 2015 proposed rules do not appear to include as many drastic changes as in previous years.

For example, the proposed 2014 OPPS rule contained proposals to collapse all E&M codes, package drug administration services, and other packaging proposals, which–had they all been implemented—would have meant significant changes for oncology. In the end, while CMS did finalize the proposal to collapse E&M codes, the agency did not finalize all of the packaging proposals. Now, for 2015, the agency is proposing to increase packaging and composite APCs; however, drug administration is not included in that list. That being said, we know that CMS still wants to study drug administration, so we do not believe that changes to that area are necessarily off the table.

Another interesting proposal for 2015 has to do with off-campus departments of hospital outpatient departments (HOPDs).  Last year, CMS stated that it wanted to collect data to determine if payments made to “off-campus facilities,” often practices that have recently been purchased by a hospital and converted to a HOPD, are justified at different rates.  For 2015, CMS is proposing to require that all services rendered in these off-campus departments be billed with a modifier, so that the agency can study the issue and potentially make changes in the future.

Finally, in the 2015 proposed OPPS rule, drugs are still scheduled to be reimbursed at ASP+6% in the HOPD. So it appears that the ACCC’s years of hard work on this issue have continued to pay off.

On the Physician Fee Schedule side, there is the continuing issue of the sustainable growth rate (SGR)—but this is no surprise. Once again, under this flawed formula, there is a scheduled cut to physician reimbursement of 21%. And once again, this most likely will not go into effect, as Congress will step in later this year or early next year with yet another (hopefully long-term!) “doc fix.” Under the proposed PFS, medical oncology is slated to receive a 1% increase, which is always better than a negative number.  On the other hand, radiation oncology would not fare as well, with larger cuts scheduled for radiation oncology and radiology.

While at first look, it may appear that the 2015 proposed rules put forth less onerous issues than in prior years, ACCC will still be submitting comments to CMS with our concerns, and we encourage you to submit comments as well.  Once ACCC’s comments are completed, ACCC will post them in the Advocacy section of the website, and members can use these as a template, if desired. CMS is accepting comments on these rules until Sept. 2, 2014.

Meanwhile, ACCC encourages all members to join us with your questions on the July 23 members-only conference call.  For more information, please contact Matt Farber at mfarber@accc-cancer.org.

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!