The Centers for Medicare & Medicaid Services (CMS) is seeking comments on the best methods for assisting physician practices in the move from a fee-for-service reimbursement model to alternative payment models. On March 5, CMS issued a request for information (RFI) on delivery system reform. The agency is asking for input on policy considerations about large scale transformation of clinical practices with the aim of better care and better health at lower costs. CMS may use the information collected from this RFI to test new payment and service delivery models.
The deadline for comments is April 8, 2014.
On March 4 the Obama administration proposed a fiscal year (FY) 2015 budget that includes nearly $1 trillion for federal health programs administered by the Department of Health and Human Services (HHS). Included are legislative proposals for Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) that the administration says will save more than $400 billion through 2024.
However, it is unlikely that the administration’s proposals in their current form will be passed by Congress. Many of the proposals have been included in previous budgets proposed by the administration and have not been acted upon.
The proposed FY 2015 budget includes the following Medicare-specific proposals:
Read the Health and Human Services FY 2015 Budget in Brief here.
The Centers for Medicare & Medicaid Services (CMS) has announced the agency will start the first phase of Sunshine Act data collection on Feb. 18, 2014. During the initial phase, some manufacturers and group purchasing organizations will start submitting data to CMS on payments made to healthcare providers, including gifts, consulting fees, and research activities. Phase two, which will begin in May, will include industry registration in the CMS Open Payments system, submission of detailed 2013 payment data, and legal attestation to the accuracy of the data, Bloomberg BNA reports.
On Feb. 7, the Centers for Medicare & Medicaid Services (CMS) announced a one-month extension—from 11:59 pm on February 28 to 11:59 pm on March 31, 2014—of the deadline for physicians and other eligible professionals (EPs) to meet the requirements of Medicare Meaningful Use program in 2013.
The hospital deadline was Dec. 1, 2013. However, the agency said that hospitals that experienced problems in attesting in 2013 can retroactively submit their attestation data in 2014. Hospitals that want to retroactively submit 2013 data must contact CMS by March 15, 2014.
The one-month deadline extension applies only to the Medicare EHR Incentive Program and not to the Medicaid EHR Incentive Program or the Physician Quality Reporting System EHR Incentive Program, the agency said.
A memorandum from the Department of Health and Human Services (HHS) Office of Medicare Hearings and Appeals (OMHA) states that it is suspending the assignment of new Medicare appeals to administrative law judges for at least two years in order to work through an increasing backlog of appeals, according to Bloomberg BNA Health Care Daily Report (01/16, 2014). However, new beneficiary-initiated appeals will not be suspended.
The memorandum, authored by OMHA’s Chief Administrative Law Judge Nancy J. Griswold, said the suspension was effective as of July 15, 2013, and will affect most Medicare appeals at the ALJ appeal level. Griswold said the suspension applied to “Medicare providers and suppliers, and Medicaid state agencies,” BNA reports.
However, the letter stated that appeals filed directly by Medicare beneficiaries will continue to be assigned and processed “to ensure [beneficiaries’] health and safety is protected.”
OMHA will hold an Medicare Appellant Forum in Washington on February 12 to address the impact of the appeals suspension.
The Centers for Medicare & Medicaid Services (CMS) have granted Kyprolis® (carfilzomib) for Injection a permanent Healthcare Common Procedure Coding System (HCPCS) J-code. The new code, J9047, is defined as “Injection, carfilzomib, 1mg.” This code is effective January 1, 2014.
The Centers for Medicare & Medicaid Services (CMS) have granted KADCYLA® (ado-trastuzumab emtansine) and PERJETA® (pertuzumab) permanent J-codes that go into effect January 1, 2014. The J-code for KADCYLA is J9354 (injection, ado-trastuzumab emtansine, 1 mg) and the J-code for PERJETA is J9306 (injection, pertuzumab, 1 mg).
Please be sure to prepare your systems for the introduction of these 2 new codes. For additional assistance, you can contact one of the dedicated Specialists at Genentech BioOncology™ Access Solutions at 888.249.4918, or visit Genentech‐Access.com/BioOncology for more information.
On Nov. 27, 2013, the Centers for Medicare & Medicaid Services (CMS) released the calendar year (CY) 2014 Physician Fee Schedule (PFS) final rule. Among the provisions included in the 2014 PFS final rule are the following:
Primary Care and Chronic Care Management. Medicare will begin making a separate payment for chronic care management services beginning in 2015. The rule indicates that CMS intends to establish practice standards necessary to support payment for furnishing care management services through future notice-and-comment rulemaking.
Misvalued Codes. Consistent with amendments made by the Affordable Care Act, CMS has been engaged in a vigorous effort over the past several years to identify and review potentially misvalued codes, and make adjustments where appropriate. The agency is continuing this effort as the values for around 200 codes were finalized and approximately 200 additional codes had their work relative value units changed on an interim basis for 2014.
CMS is not finalizing its proposal to adjust relative values under the PFS to effectively cap the physician practice expense payment for procedures furnished in a non-facility setting at the total payment rate for the service when furnished in an ambulatory surgical center or hospital outpatient setting. Instead, CMS will take additional time to consider issues raised by the public commenters and plans to address this issue in future rulemaking.
Compliance with State Law for “Incident To” Services. CMS is requiring as a condition of Medicare payment that “incident to” services be furnished in compliance with applicable state law. CMS also eliminated redundant regulations for each type of practitioner by consolidating the “incident to” requirements for all practitioners that are permitted to bill Medicare directly for their services, reducing the regulatory burden and making it less difficult for practitioners to determine what is required in order to bill Medicare for “incident to” services.
On Nov. 27, 2013, the Centers for Medicare & Medicaid Services (CMS) released the final calendar year (CY) 2014 Hospital Outpatient Payment System (OPPS) rule. The final rule updates the OPPS market basket by 1.7 percent for CY 2014.
Under the final rule, changes to hospitals OPPS payments and policies include:
Items and Services to be “Packaged” or Included in Payment for a Primary Service. For 2014, CMS finalizes five new categories of supporting items and services rather than the seven proposed. For certain cases, a separate payment would be made if the item or service is furnished on a different date of service as the primary service. The five final categories are:
1) Drugs, biologicals, and radiopharmaceuticals that function as supplies when used in a diagnostic test or procedure;
2) Drugs and biologicals that function as supplies; when used in a surgical procedure, including skin substitutes. Skin substitutes will be classified as either high cost or low cost and will be packaged into the associated surgical procedures with other skin substitutes of the same class;
3) Certain clinical diagnostic laboratory tests;
4) Certain procedures described by add-on codes;
5) Device removal procedures.
In addition to packaging these five categories, CMS finalizes its proposal to create 29 comprehensive APCs to replace 29 existing device-dependent APCs, but with a modification to apply a complexity adjustment for the most complex multiple device claims. CMS is delaying the implementation of these comprehensive APCs until CY 2015.
Collapsing Five Levels of Visits to One. The final rule streamlines the current five levels of outpatient clinic visit codes, replacing them with a single Healthcare Common Procedure Coding System (HCPCS) code describing all clinic visits.
The final rule does not finalize the proposal to replace the current five levels of codes for each type of emergency department visits. CMS intends to consider options to improve the codes for these services in future rulemaking.
Part B Drugs in the Outpatient Department. The rule finalizes the proposal to continue paying at ASP+6 percent for non-pass-through drugs and biologicals that are payable separately under the OPPS.
On Nov. 22, 2013, the U.S. Food and Drug Administration (FDA) expanded the approved uses of Nexavar (sorafenib) to treat late-stage (metastatic) differentiated thyroid cancer. Differentiated thyroid cancer is the most common type of thyroid cancer.
Nexavar works by inhibiting multiple proteins in cancer cells, limiting cancer cell growth and division. The drug’s new use is intended for patients with locally recurrent or metastatic, progressive differentiated thyroid cancer that no longer responds to radioactive iodine treatment.
The FDA approved Nexavar to treat advanced kidney cancer in 2005. In 2007, the agency expanded the drug’s label to treat liver cancer that cannot be surgically removed.
On November 1, 2013, the U.S. Food and Drug Administration (FDA) approved obinutuzumab (Gazyva™ injection, for intravenous use, previously known as GA101) for use in combination with chlorambucil for the treatment of patients with previously untreated chronic lymphocytic leukemia (CLL).
Obinutuzumab is approved with a BOXED WARNING regarding Hepatitis B virus reactivation and Progressive Multifocal Leukoencephalopathy. Patients should be advised of these risks and assessed for Hepatitis B virus and reactivation risk. Infusion reactions are included in the WARNING and PRECAUTIONS section of the label.
As a condition of payment for hospital inpatient services under Medicare Part A, section 1814(a) of the
Social Security Act requires physician certification of the medical necessity that such services be
provided on an inpatient basis. The order to admit as an inpatient (“practitioner order”) is a critical
element of the physician certification, and is therefore also required for hospital inpatient coverage and
payment under Part A. The physician certification, which includes the practitioner order, is considered
along with other documentation in the medical record as evidence that hospital inpatient service(s)
were reasonable and necessary.
The new guidance applies to all inpatient hospital and critical access hospital (CAH) services unless otherwise specified. To read the certification guidance in full, please click here.
CMS has extended the deadline to register in Administrative Claims from Oct. 15 to Oct. 18.
The ACA requires CMS to apply a Value-Based Modifier (VBM) to all physicians’ Medicare payments by 2017 and to some physicians’ payment beginning in 2015. In response, CMS intends to apply a 1 percent VBM penalty to the Medicare payments of physicians in groups of 100 or more that did not engage in group participation in the Physician Quality Reporting System (PQRS) in 2013. This VBM penalty would be in addition to another 1.5 percent penalty that would apply to all physicians who did not participate in PQRS either as an individual or as part of a group.
To avoid these penalties, physicians in groups of 100 or more should ensure that their group is registered for one of the PQRS group participation options. Physicians who are not subject to VBM and are not yet participating in PQRS can still avoid the 2015 payment cut by registering for the CMS-calculated administrative claims reporting mechanism in 2013.
The PQRS registration system will close on Oct. 18, click here to access: https://portal.cms.gov. Use of the system requires an Individuals Authorized Access to the CMS Computer Services (IACS) number, which can be acquired here. Additional information regarding registration and obtaining or modifying an IACS account is available at the Self Nomination/Registration web page. Please note that due to the government shutdown, CMS is unable to update the October 15 date listed on their website.
Additionally, please note the help desk phone number listed in error messages on the PQRS registration portal is incorrect. Users should call the PV-PQRS Help Desk at 1-888-734-6433 Option 3 for questions about registration. They can also contact CMS’ QualityNet help desk at: 1-866-288-8912 (TTY 1-877-715-6222).
On Sept. 6, 2013, the U.S. Food and Drug Administration expanded the approved uses of Abraxane (paclitaxel protein-bound particles for injectable suspension, albumin-bound) to treat patients with late-stage (metastatic) pancreatic cancer.
Abraxane is a chemotherapy drug that can slow the growth of certain tumors. Abraxane is intended to be used with gemcitabine, another chemotherapy drug, in patients with pancreatic cancer that has spread to other parts of the body.
The FDA reviewed the new use for Abraxane under the agency’s priority review program, which provides for an expedited review of drugs. Abraxane was also granted orphan product designation for pancreatic cancer because it is intended to treat a rare disease or condition.
According to a Congressional Budget Office (CBO) cost estimate issued on Sept. 13, 2013, the House bill (H.R. 2810) to reform the Medicare physician payment system would cost about $175 billion over 10 years.
The House Energy and Commerce Committee unanimously passed the bill in July. However, the Senate Finance Committee, with jurisdiction over the issue in that chamber, has yet to put forward a proposal.
The price tag for the House bill is more costly than a freeze to avoid a pay cut under the sustainable growth rate (SGR) payment methodology, as reported in BNA Health Care Daily Report. The CBO had estimated that freezing physician reimbursement and stopping SGR-related cuts for 10 years would cost $139 billion.
On Sept. 13, 2013, the Centers for Medicare & Medicaid Services (CMS) released the final rule implementing funding reductions required by the Affordable Care Act (ACA) for the disproportionate share hospital (DSH) program. The rule is slated for publication in the Federal Register on Sept. 18, 2013. The rule will go into effect on Nov. 12, 2013.
The final rule includes a reduction methodology only for FY 2014 and FY 2015. CMS will revisit the methodology and promulgate new rules for DSH reductions in FYs 2016 and beyond, the agency said.
The rule is available here.
On Sept. 10, 2013, the Institute of Medicine released a new report, Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. The report concludes that the U.S. cancer care delivery system is in crisis due to a growing demand for cancer care, increasing complexity of treatment, a shrinking workforce, and rising costs. While calling for "changes across the board" to improve the quality of cancer care, the report proposes a conceptual framework for improving the quality of cancer care comprising six interconnected components:
On June 13, 2013, the U. S. Food and Drug Administration (FDA) approved denosumab (Xgeva injection, for subcutaneous use, Amgen Inc.) for the treatment of adults and skeletally mature adolescents with giant cell tumor of bone (GCTB) that is unresectable or where surgical resection is likely to result in severe morbidity. Xgeva was approved following a priority review by the FDA.
On June 5, 2013, the U. S. Food and Drug Administration (FDA) approved lenalidomide capsules (REVLIMID, Celgene Corporation), for the treatment of patients with mantle cell lymphoma (MCL) whose disease has relapsed or progressed after two prior therapies, one of which included bortezomib.
The approval was based a single-arm, multicenter clinical trial enrolling 134 patients with mantle cell lymphoma who have relapsed after or were refractory to bortezomib or a bortezomib-containing regimen. All 134 patients received prior treatment with bortezomib and 60% were documented to have disease refractory to bortezomib therapy. Patients received a median of 4 prior therapies for MCL. The median age was 67 years, 81% were male, 96% were Caucasian, and 61% had MCL for at least 3 years.
The Centers for Medicare & Medicaid Services on May 29, 2013, issued a final Decision Memo for Aprepitant for Chemotherapy-Induced Emesis (CAG-00248R) expanding coverage of anti-nausea and vomiting therapy for beneficiaries undergoing chemotherapy.
The decision memo states: "The three-drug regimen of oral aprepitant, an oral 5HT3 antagonist and oral dexamethasone is reasonable and necessary for beneficiaries receiving moderately emetogenic chemotherapy (MEC) immediately before and within 48 hours after the administration of the anticancer treatment."
The decision memo states that this all-oral regimen is covered when it is administered in that time frame with any of the following chemotherapeutic agents, administered either singularly or in combination: alemtuzumab, azacitidine, bendamustine, carboplatin, carmustine, cisplatin, clofarabine, cyclophosphamide, cytarabine, dacarbazine, daunorubicin, doxorubicin, epirubicin, idarubicin, ifosfamide, irinotecan, lomustine, mechlorethamine, oxaliplatin, and streptozocin.
Medicare Administrative Contractors (MACs) may determine coverage for other all-oral three-drug antiemesis regimens of aprepitant or any other FDA approved oral NK-1 antagonist in combination with an oral 5HT3 antagonist and oral dexamethasone with the chemotherapeutic agents listed above, or any other anticancer chemotherapeutic agents that are FDA approved and are defined as highly or moderately emetogenic.
CMS is defining highly emetogenic chemotherapy and moderately emetogenic chemotherapy as those anticancer agents so designated in at least two of three guidelines published by the National Comprehensive Cancer Network (NCCN), American Society of Clinical Oncology (ASCO), and European Society of Medical Oncology (ESMO)/Multinational Association of Supportive Care in Cancer (MASCC).
On May 15, 2013, the U. S. Food and Drug Administration (FDA) approved radium Ra 223 dichloride (Xofigo Injection, Bayer HealthCare Pharmaceuticals Inc.) for the treatment of patients with castration-resistant prostate cancer, symptomatic bone metastases and no known visceral metastatic disease. Xofigo is an alpha-particle emitting radiotherapeutic drug which mimics calcium and forms complexes with hydroxyapatite at areas of increased bone turnover, such as bone metastases.
Learn more here.
On May 13, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule on Medicaid payment reductions for safety-net hospitals required under the Affordable Care Act. The proposed rule will be published in May 15 Federal Register. Comments on the proposed rule are due July 12.
Read a CMS fact sheet on the proposed rule here.
Read the proposed rule here.
CMS had posted two updated FAQs related to the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. FAQs include information on how EHR incentive payments will be affected by sequestration, as well as guidance on how to successfully attest following an EHR vendor transition.
Question 1: Will incentive payments earned in the Medicare and Medicaid Electronic Health Records Incentive programs be affected by sequestration?
Answer: Incentive payments made through the Medicare EHR Incentive Program are subject to the mandatory reductions in federal spending known as sequestration, required by the Budget Control Act of 2011. The American Taxpayer Relief Act of 2012 postponed sequestration for 2 months. As required by law, President Obama issued a sequestration order on March 1, 2013... Read the full answer here.
Question 2: For the Medicare and Medicaid EHR Incentive Programs, how should an EP, eligible hospital, or critical access hospital (CAH) attest if the certified EHR vendor being used is switched to another certified EHR vendor in the middle of the program year?
Answer: If an EP, eligible hospital or CAH switches from one certified EHR vendor to another during the program year, the data collected for the selected menu objectives and quality measures should be combined from both of the EHR systems for attestation. The count of unique patients does not need to be reconciled when combining from the two EHR systems... Read the full answer here.
For more information about the EHR Incentive Programs, visit the Medicare and Medicaid EHR Incentive Programs website for the latest news on the EHR Incentive Programs.
On April 9, 2013, Congresswoman Renee Ellmers (R-NC) introduced a bill that would eliminate the sequester on chemotherapy drugs that must be administered in the physician office setting (HR 1416). It would also direct Medicare to repay providers for any reduced payment since the cuts began on April 1.
To send a letter to your Congressional representatives in support of HR 1416, the "Cancer Patient Protection Act", enter your zip code to access the HR 1416 support letter template. There is also a petition to the President urging him to exempt cancer drugs from the sequester. In addition to sending a letter, you can also sign the petition.
Starting on April 1, all Medicare payments will be reduced by 2%. This reduction applies to all services that are billed to Medicare, including E&M codes, chemotherapy administration, hydration, and drugs and their overhead costs. The reduction to drug reimbursement will be felt even more, as the impact of sequestration will reduce reimbursement to ASP+4.3% from ASP+6%.
Why is drug reimbursement being reduced by this amount?
For example, consider a drug with an average sales price (ASP) of $100.
At ASP+6%, reimbursement = $106. The beneficiary pays 20% = $21.20 and Medicare normally pays 80% = $84.80.
After sequestration, Medicare will pay $83.10 (98% of $84.80). Medicare’s share plus the beneficiary’s share after sequestration = $83.10 + $21.20 = $104.30, or ASP+4.3%.
With this change going into effect on April 1, practices and hospitals will begin to see these reductions by mid-April, when they start to get payments for services provided at the beginning of the month (CMS claims can often take 10 days to process). Cancer programs and practices need to be prepared for these reductions.
The March 1, Centers for Medicare & Medicaid Services (CMS) Transmittal 2664, April 2013 Update of the Hospital Outpatient Prospective Payment System (OPPS), lists the updated payments for stereotactic radiosurgery (SRS) under the Outpatient Prospective Payments Systems (OPPS) as mandated by the American Taxpayer Relief Act (ATRA) of 2012. These changes are effective April 1, 2013.
Attachment A, Table 2 OPPS APC and Payment Rate for 77371 and G0173 states:
CPT/HCPCS Code 77371—Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based
April 2013 Payment Rate for rural hospitals and other excepted hospitals = $7,911
April 2013 Payment Rate for all other hospitals = $3,301
CPT/HCPCS Code G0173—Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session
April 2013 Payment Rate: $3,301
Read the CMS transmittal here.
On March 13, the Centers for Medicare & Medicaid Services (CMS) proposed ending the Coverage with Evidence Development (CED) requirement for FDG PET scans for oncologic indication.
In its proposed decision memo, the agency proposed coverage of one FDG PET to guide subsequent physician management of anti-tumor treatment strategy after completion of initial anti-cancer therapy. Local Medicare Administrative Contractors (MACs) would decide coverage of any additional FDG PET scans.
However, CMS said FDG PET for subsequent anti-tumor treatment for beneficiaries with prostate cancer is not reasonable and necessary and therefore is not covered by Medicare, Bloomberg BNA reported.
The proposed coverage expansion would remove the current requirement for prospective data collection by the National Oncologic PET Registry (NOPR), the agency said.
Read the proposed decision memo here.
On March 15, the Medicare Payment Advisory Commission (MedPAC) released its annual report to Congress. The Report to Congress: Medicare Payment Policy includes the Commission’s analyses of payment adequacy in fee-for-service (FFS) Medicare; Medicare Advantage (MA), including MA special needs plans; and Part D.
For 2014 MedPAC recommends no update for five fee-for-service payment systems and a 1 percent update for the hospital inpatient and outpatient payment systems.
For two sectors, skilled nursing facilities and home health agencies, it reiterates previous recommendations calling for an array of reforms including rebasing (lowering the base rate), creating incentives to improve quality, and increasing program integrity.
For the physician and other health professional payment system it calls for making the system fairer and for repeal of the sustainable growth rate system (SGR), which governs physician fee schedule payments.
Read the full report here.
Read a fact sheet on the report here.
The Centers for Medicare & Medicaid Services (CMS) says it will allow Medicare Administrative Contractors (MACs) decide coverage for PET imaging scans for oncology.
In a final decision, issued on March 7, CMS changes the national coverage determination so that new PET radiopharmaceuticals will be decided by local contractors, rather than automatically not covered, Bloomberg BNA reports.
Read the decision memo here.
The U.S. FDA has approved Synribo (omacetaxine mepesuccinate) for Injection, for subcutaneous use, for the treatment of adult patients with chronic or acclerated phase chronic myeloid leukemia (CML) with resistance and/or intolerance to two or more tyrosine kinase inhibitors (TKIs).
On Feb. 25, 2013, the U.S. Food and Drug Administration (FDA) expanded the approved use of Stivarga (regorafenib) to treat patients with advanced gastrointestinal stromal tumors (GIST) that cannot be surgically removed and no longer respond to other FDA-approved treatments for this disease.
GIST is a tumor in which cancerous cells form in the tissues of the gastrointestinal tract, part of the body’s digestive system. According to the National Cancer Institute, an estimated 3,300 to 6,000 new cases of GIST occur yearly in the United States, most often in older adults.
Read Bayer HealthCare/ONYX Pharmaceuticals press release.
Read highlights of Stivarga Prescribing Information.
On Feb. 8, the U.S. Food and Drug Administration (FDA) approved Pomalyst (pomalidomide) to treat patients with multiple myeloma whose disease progressed after being treated with other cancer drugs.
Pomalyst is a pill that modulates the body’s immune system to destroy cancerous cells and inhibit their growth. It is intended for patients who have received at least two prior therapies, including lenalidomide and bortezomib, and whose disease did not respond to treatment and progressed within 60 days of the last treatment (relapsed and refractory).
Click on the link below for the fourth quarter 2012 NCCN Flash UpdatesTM report. For ease of reading, this report includes all NCCN Flash Updates released between October 1, 2012, and December 31, 2012, beginning with the most recent updates first.