Category Archives: DC

Fasten Your Seat Belts. . .

By Leah Ralph, Director of Health Policy, ACCC

Overlapping roadways As we head into the New Year, 2016 is rapidly receding in the rear view mirror. Still, it was quite a year. We saw the Obama Administration finalize regulations for sweeping physician payment reform in Medicare, oncology practices nationwide navigate the first year of the Oncology Care Model (OCM), policymakers try – and fail – to push through drug pricing reform with a national mandatory demonstration program, the 21st Century Cures Act signed into law, and the drug pricing debate hit a fever pitch, fueled by public scrutiny of recent spikes in drug spending and prompting a range of policy proposals to reduce spending on pharmaceuticals, raising bigger questions about how to define value in cancer care.

And after nearly eight years of a healthcare system shifting to achieve the aims – and requirements – of President Obama’s signature health reform law, the surprise election of Donald Trump and transition to a Republican administration and Congress who have prioritized repealing the Affordable Care Act (ACA) in early 2017 – combined with unprecedentedly thin policy prescriptions on the campaign trail – mark the beginning of an uncertain, tumultuous, perhaps even bumpy period for health policy. And fasten your seat belts because it may happen fast: the first 18 months of a new presidency and congress is the most active period of policymaking in the U.S.

ACA’s Uncertain Future

With respect to the ACA, while the health reform law encompasses far more than the insurance exchanges, the public debate to date has been focused on the coverage mandate and subsidies in the individual marketplace. It’s important to note that regardless of the election results, the health insurance exchanges are doing worse than expected. The exchange markets are facing sicker-than-expected risk pools and lower enrollment, causing high premium increases and insurer withdrawals. To survive, the exchanges would have needed stabilization under any administration – meaning a Trump Administration could simply leave the exchanges untouched and effectively allow them to wither on the vine, leaving 20 million uninsured.

But President-Elect Trump has signaled that he favors politically popular consumer protections in the ACA, such as banning insurers from discriminating against people with pre-existing conditions and allowing children to remain on their parents’ health plan until age 26. However the path to achieve this without a requirement that individuals either obtain coverage or pay a penalty remains unclear. And while there’s no agreed-upon replacement plan, Congressional Republicans have also supported allowing the sale of health insurance across state lines, expanding the use of health savings accounts (HSAs), replacing the ACA’s health insurance subsidies with tax credits, and establishing high-risk pools. But none of these proposals would meaningfully restore access to insurance coverage for the more than 20 million people who have gained coverage under the ACA, creating a long road ahead to find ways to cover this newly expanded population in any replacement plan.

What will these changes mean for cancer patients and providers? While the scope and details remain unclear, generally, under the proposals put forward to date, cancer providers may see an increased number of patients who are under- or uninsured, and higher uncompensated care costs. For the exchange population, benefits and cost-sharing assistance will likely be less generous, which could pose significant access barriers to quality cancer care.  At the same time it’s important to note that the ACA overpromised and underperformed – while patients without access to subsidies are seeing out-of-pocket costs spike, concurrently providers’ expectations of gaining fully insured patients under the ACA have not necessarily been realized. Patients with exchange coverage have generally been sicker and more expensive to treat and, on top of that, some providers are starting to see their Disproportionate Share Hospital (DSH) payments evaporate, as agreed to under the law. Fixes to the ACA – beyond what Republicans are proposing – are needed to shore up the long-term viability of our healthcare system for both patients and providers.

The Path Ahead

As the New Year rings in the changes in Washington, D.C., there will undoubtedly be significant impact on the direction of federal policy with respect to access and coverage in 2017. Still, we expect that key market trends such as value-based purchasing will continue. While the fate of the Center for Medicare and Medicaid Innovation (CMMI), which was created by the ACA, remains uncertain, we suspect that Medicare’s push towards value-based payment is inherently non-partisan and the movement to test different ways to pay providers based on cost and quality is here to stay. In fact, many experts predict that 2017 will be the year value-based purchasing moves from concept to reality. CMMI has implemented more than 50 demonstration programs. Some of these are becoming mandatory, including bundled payments for cardiac care and joint replacement.  (At the same time, the Republican-controlled Congress may create some guardrails for CMMI, including limiting its ability to implement mandatory demonstrations.)  Just around the corner, Medicare physician payment is shifting from fee-for-service (FFS) to value-based purchasing as required under MACRA . Reporting on MACRA measures begins in 2017 and will determine provider Medicare reimbursement in 2019. And the pharmaceutical industry is also engaged in value-based purchasing, increasingly pursuing outcomes-based contracts with private plans.

Where the Rubber Meets the Road

In 2017, ACCC members will need to consider how value-based payments will increasingly shift responsibility for managing cost and quality to providers, and how your cancer program is positioned to engage in a risk-based reimbursement structure. Providers should also prepare for a shift in coverage for patients, and anticipate how to respond to changes in access to care.

Now more than ever is the time for oncology care providers’ voices to be heard – join us in Washington, D.C., March 29-31 for ACCC’s annual policy meeting, Cancerscape, to understand how policy changes will impact your program and patients, engage in policy discussions with your colleagues, and help shape the future of healthcare policy in 2017 and beyond.  So buckle up, check out the Cancerscape agenda, and register today.

ACCC Asked: Congress Listened

By Leah Ralph, Director of Health Policy, ACCC

time for actionToday 242 members of Congress joined in a bipartisan letter to CMS Acting Administrator Andy Slavitt urging the agency to withdraw its proposed Medicare Part B Drug Payment Model.  The effort was spearheaded by House Ways and Means Committee Member and Budget Committee Chairman Tom Price, MD (R-GA), House Energy and Commerce Committee Member John Shimkus (R-IL), and House Ways and Means Committee Charles Boustany Jr., MD (R-LA).

You asked and Congress listened.  Last week, hundreds of ACCC members reached out to their legislators asking that they sign on to the Congressional letter to CMS.  ACCC thanks its membership from 2,000 cancer programs and practices across the country for speaking up and telling their legislators about the detrimental impact this proposed rule would have on their patients and providers.

But the question remains: Will CMS listen?

May 9 is the deadline for comments to CMS on this misguided proposal. ACCC will be submitting comments to the agency and urges its members to send comments as well.

Learn more about ACCC advocacy efforts on this issue here.

Oral Parity: When Modern Medicine Outpaces Policy

By Leah Ralph, Director of Health Policy, ACCC

PillsACCC has been a longtime champion of oral parity, the legislative effort to equalize patient cost sharing for intravenous (IV) and oral chemotherapy drugs.

Oral oncolytics can offer a better quality of life for patients undergoing chemotherapy treatment, including less travel time, fewer work absences, often fewer side effects, and the convenience and comfort of at-home administration. For some cancer patients, an oral anti-cancer medication is the only option for treatment. Yet insurance coverage has not kept pace with medical innovation. Outdated insurance benefit designs continue to cover oral medications under the pharmacy benefit, which often means high, burdensome out-of-pocket costs for patients. (Traditional IV chemotherapy is covered under a plan’s medical benefit, resulting in minimal co-pays or no cost for patients.) This coverage disparity creates financial burdens for patients prescribed an oral anti-cancer medicine, leaving them less likely to adhere to treatment and often unable to fill their prescription. The number one reason a patient does not take his or her medication appropriately is cost. According to a 2011 study published in the Journal of Oncology Practice and the American Journal of Managed Care, 10 percent of cancer patients failed to fill their initial prescriptions for oral anticancer medications due to high out-of-pocket costs.

Progress at the State Level

We’ve come a long way in terms of state law. To date, 40 states plus the District of Columbia have passed oral parity legislation. These laws are not a mandate to cover oral chemotherapy, but rather require that if an insurance plan covers chemotherapy treatment, a patient’s out-of-pocket costs must be the same, regardless of how the therapy is administered. As a member of the State Patients Equal Access Coalition (SPEAC), ACCC has partnered with several state oncology societies—including Virginia, West Virginia, and Arizona in recent years—to pass oral parity laws, and this year we’re focusing our efforts on Tennessee and South Carolina. (If you are a provider in either of these states, and you’d like to be an advocate, email ACCC Director of Health Policy, Leah Ralph. ACCC participated in this new SPEAC video that helps to tell the oral parity story from the patient’s perspective.

Why Federal Legislation is Necessary

And even though a majority of states have now passed state-level oral parity legislation, federal legislation is still needed. A federal law would ensure that new cost-sharing restrictions are implemented consistently across the country, and that plans that fall outside state regulation, such as those covered under the federal ERISA law (usually large, multi-state health plans), must comply with the same equitable coverage requirements. In September, an ACCC member spoke at a Congressional briefing on the Cancer Drug Coverage Parity Act of 2015 (S.1566/H.R.2739), helping gain critical momentum to move the bill forward.

In a few weeks, at ACCC 2016 Capitol Hill Day on March 2, ACCC members will be walking the halls of Congress to talk with legislators about the importance of this bill to cancer patients and the providers who care for them.

ACCC encourages members to join our efforts, and continue to monitor opportunities to weigh in with your state and federal legislators. For more on this issue, look for an upcoming article to be published in the March/April Oncology Issues, “Exploring the Issue of Cancer Drug Parity.”

 

 

Getting Engaged

One in an occasional blog series on topics from Oncology Issues, the journal of the Association of Community Cancer Centers.

by Susan van der Sommen, MHA, CMPE, FACHE, ACCC Editorial Committee Chair

ThinkstockPhotos-484468581When first hearing of a cancer diagnosis, I imagine a patient’s mind spinning with a cyclone-like ferocity … Am I going to die? How will I tell my family? What about all of my plans? It’s cancer … of course I am going to die … but how soon? Suddenly, life spins out of control.

Engaging patients in their care can dramatically reduce anxiety by giving back some control. Of course they can’t control the diagnosis, but they can control how they face it – on their terms, with their beliefs, wishes, and desires at the forefront of every decision.

In a recent Oncology Issues article, “Talk to Me: Improve Patient Engagement; Improve Your Cancer Program,” author Chad Schaeffer, MS, FACHE, lays the foundation for developing strategies to connect patients and the decision-making process relating to their care. Improved patient engagement can alleviate some of patients’ burden in feeling as if they are hapless victims of heinous misfortune and allow them to regain some semblance of control over their future. Schaeffer is executive director at the Edwards Comprehensive Cancer Center at Cabell Huntington Hospital, Huntington, WV.

Defining patient engagement in simple, broad terms as “the ongoing and mutually beneficial interaction between patient and providers,” he notes that putting the patients’ needs and aspirations first will improve engagement and, ultimately, satisfaction for all.

What are the goals?

Patients’ treatment goals vary and are individualistic. Some desire to extend life at any cost; others prefer quality over quantity. Many want as little disruption to their daily lives as possible. As Schaeffer points out, evening and weekend hours, though not always pleasing to cancer center staff and physicians, will allow some patients and caregivers the flexibility to carry on with their routine (work, childcare, etc.) while receiving treatment and care at a time that is convenient.

Are we meeting your needs?

Cancer center physicians often struggle with the difficult conversations regarding the “end of life,” resulting, as Schaeffer points out, in decisions that may not coincide with a patient’s wishes. According to an end-of-life study at Stanford University, family members whose loved one died in an “institutional setting” reported poor symptom management, lack of physician communication and patient engagement, and a dearth of emotional support for loved ones and caregivers. Conversely, those who passed with home hospice services reported a considerably higher degree of satisfaction with regard to unmet needs and physician engagement.

Is there something you aren’t telling me?

In addition to reviewing Press Ganey and CGCAHPS surveys, the leaders at the Bassett Cancer Institute in upstate New York have instituted a process where they can – in real time – monitor patient satisfaction. Throughout the course of their treatment, patients are offered a tablet on which they answer a few questions about their care. Questions are flagged so that when a patient expresses dissatisfaction, a member of the leadership team can address the patient’s concern during his or her visit. It gives both the patient and staff an opportunity to more effectively understand what drives patient satisfaction while giving patients an active voice in their care.

Engaging patients from the outset of their diagnosis and throughout their care is critical to their satisfaction and ultimately, as Schaeffer points out, a more effective, patient-centered cancer treatment center.

Patient–centered care is a key focus of the upcoming ACCC Annual Meeting, CANCERSCAPE, March 2-4, in Washington, D.C. Learn more here.

Read the current edition of Oncology Issues here.

ACCC member Susan van der Sommen, MHA, CMPE, FACHE, is Executive Director, DSRIP, Bassett Healthcare Network. She currently serves as chair of the ACCC Editorial Committee.

An Easy—and Empowering—New Year’s Resolution

By Leah Ralph, Director, Health Policy, ACCC

Working-Federal-Government-FeaturedNew Year’s resolutions are the very definition of trope: a common or overused theme. But they don’t have to be. Today I’m asking you to set aside the old standbys of weight loss or more exercise and look at the bigger picture—specifically what you can do to improve the lives of the cancer patients you treat each and every day.

Last year ACCC mobilized members from 23 states and held over 80 meetings with legislators on Capitol Hill about issues of importance to the oncology community. We effected real change. Shortly after our ACCC Hill Day visits, Congress passed a permanent repeal to the Sustainable Growth Rate (SGR) formula, guaranteeing predictable physician payment rates and setting in motion a wave of Medicare reimbursement reforms. Our voices made a difference!

This year, we’re growing our annual Capitol Hill Day program and making some exciting changes: more comprehensive training, more face time with legislators, and, most important a greater focus on helping you tell your community’s story—the one that your legislators most want to hear. What’s going on in your home town? What’s keeping you up at night? What are the stressors that are having a negative impact on your cancer patients?

So whether you’ve attended a previous ACCC Capitol Hill Day or you’re an “advocacy newbie,” here are three solid reasons to make the ACCC 2016 Capitol Hill Day your New Year’s Resolution:

  1. More comprehensive training. The ACCC policy team will host webinars and conference calls to prepare for your congressional meetings. We’re planning a comprehensive training and reception for Tuesday, March 1, plus an additional advocacy review on the morning of Hill Day, Wednesday, March 2.
  2. More face-time with legislators. Gather for lunch with your ACCC colleagues and congressional members to discuss key issues that impact your program, such as reimbursement for supportive care services, drug costs, staffing shortages, and how excessive data collection and reporting is cutting into the time you can spend on direct patient care.
  3. Less focus on specific bill numbers. You don’t need to be a “policy expert” or familiar with specific legislation in 2016. It’s a chance to share YOUR STORY so lawmakers understand how policy impacts oncology care in YOUR COMMUNITY. (Now, if you want bill numbers, we’ll have those too.)

Policymakers rely on healthcare providers—not policy staff—to provide real-world perspectives on policy issues that matter. As the leading national multi-site, multidisciplinary organization, ACCC is uniquely positioned to serve as a resource. This is our value to legislators. The diversity and sophistication of our membership requires a nuanced, balanced approach to policy challenges—and we stand ready to offer insights on how cancer care is delivered today.

As our experts, we invite you to come to Washington, D.C., to do what you do best. Talk about your programs, your processes, and most importantly your patients. Our annual Capitol Hill day is an important and rewarding opportunity to advocate for policy change. Resolve to attend ACCC Capitol Hill Day 2016, and help to put the voice of the cancer care team and cancer patient at the center of policy decisions. Learn more at accc-cancer.org/HillDay.

2016 Medicare Payment Rules Finalized

Centers_for_Medicare_and_Medicaid_Services_logoBy Maureen Leddy, JD, Manager, Policy and Strategic Alliances, ACCC

The Centers for Medicare & Medicaid Services (CMS) on Oct. 30, 2015, released the final 2016 Physician Fee Schedule and Outpatient Prospective Payment System rules. With the exception of radiation therapy codes, the final rules align quite a bit with the proposed rules. A preliminary summary is included below. Stay tuned for detailed summaries and analysis on an upcoming ACCC members-only conference call on these 2016 final rules.

Highlights of 2016 PFS Final Rule

Radiation Oncology

In a noteworthy departure from the proposed 2016 PFS rule, CMS did not finalize new radiation therapy treatment payment codes. CMS responded to concerns expressed by ACCC and other stakeholder groups and delayed implementation of new radiation oncology codes, continuing use of current G-codes and values for 2016. However, the agency did finalize its proposal to increase the linear accelerator equipment utilization rate assumption from 50 percent to 70 percent over two years. CMS continues to seek empirical data on costs and usage of capital equipment, including linear accelerators.

Advance Care Planning

For 2016, CMS finalizes its proposal to establish separate payment for advance care planning services, consistent with the recommendations of the American Medical Association and other stakeholders, including ACCC. These new codes compensate providers for shared decision-making conversations at various stages of a patient’s illness.

Biosimilars

For 2016, CMS finalized its proposal to include all biosimilars of a reference biological product within the same billing and payment code. ACCC had commented against this proposal, raising concerns regarding traceability and administrative burdens expected with the use of a single code. While ACCC supports efforts to increase patient access to biologics, ACCC maintains that a system must be in place to track the specific biosimilar product used for each patient.

“Incident To”

CMS finalized its proposal to clarify requirements for billing for “incident to” services. CMS now formally requires that the physician or practitioner billing for “incident to” services must have directly supervised the auxiliary personnel providing these services. Addressing stakeholder concerns about the treating physician’s supervisory role in “incident to” services, the final rule clarifies that the supervising physician need not be the treating physician for billing purposes.

Highlights of 2016 OPPS Final Rule

CMS finalized its proposed cut in hospital outpatient payment rates of – 0.3 percent. Within this calculated –0.3 percent rate update is a –2 percent cut, applied due to the agency’s calculation of excess packaged payment for laboratory services in 2014. As a result of this year’s rate cut due to miscalculations in packaging policies, ACCC urged CMS to proceed cautiously with any additional packaging proposals to ensure future negative adjustments would not be necessary. However, CMS finalized its proposal to expand conditionally packaged services to include three new APCs: level 4 minor procedures, and level 3 and 4 pathology services. CMS notes that packaging of these services is consistent with the agency’s overall packaging policy.

Advance Care Planning

ACCC had also advocated for separate payment under advance care planning codes in the hospital outpatient setting. The 2016 OPPS final rule calls for conditionally packaging payment for these services, permitting separate payment in the hospital outpatient setting in limited circumstances.

Biosimilars

In the 2016 OPPS final rule, CMS finalized its proposals to pay biosimilars based on ASP+ 6% of the reference biologic product, and to allow biosimilars to be eligible for pass-through status. ACCC supported these proposals, noting that providing equivalent payment rates in the physician office and outpatient setting for biosimilars removes incentives to select one setting over another.

Two-Midnight Rule

CMS also finalized proposed changes to its two-midnight rule regarding hospitalization payment status. CMS will now allow certain patients not expected to meet the two-midnight stay requirement for inpatient status to still be classified as inpatient. CMS indicates that qualifying patients are those that require inpatient hospital care, as determined by the admitting physician and supported by the medical record, despite the expectation that their stay will last less than two midnights.

ACCC continues to analyze the 2016 payment rules and will update its members in the coming weeks.