Tag Archives: Centers for Medicare & Medicaid Services (CMS)

Going the Distance: What We Heard at the OCM Workshop

By Leah Ralph, DIrector of Health Policy, ACCC

ACCC-OCM-CollaborativeWe are now 10 months into the groundbreaking Center for Medicare and Medicaid Innovation (CMMI) Oncology Care Model (OCM). Just a few weeks ago during the ACCC 43rd Annual Meeting, a number of OCM practices came together to share updates, pain points and successes, and to collaborate on innovative approaches to meeting OCM requirements during ACCC’s OCM Workshop.

Shaping Up
Participation in the OCM has been likened to “training for a marathon,” requiring cancer programs to do an honest self-assessment of their financial and operational capabilities, and double down on their investment in workflows, staffing, and data collection—all while trying to reduce costs and meet a number of beneficiary-level reporting requirements. EHRs (electronic health records) play a critical role in these efforts, and practices are finding that much of the quality and clinical data CMS is asking for is not readily accessible, requiring time-consuming chart abstraction and manual reporting. In addition to data analytics, other major challenges include:

  • increased staffing needs,
  • investment in IT systems, and
  • clinician education and engagement.

Some practices have hired full-time patient care coordinators—similar to research coordinators for clinical trials—to manage OCM requirements, including identifying and tracking patients, coordinating episodes and required measures, and billing the Monthly Enhanced Oncology Services (MEOS) payments.

While there is agreement that the OCM’s policy goals—improving care quality and reducing costs—are the right ones, operationalizing the program has proven to be far more complex than originally anticipated. Even by CMS. And, like all major payment reform initiatives, course corrections will be needed along the way.

Some Pain, Some Gain
Despite challenges, ACCC OCM Workshop participants are also finding that the OCM’s  “practice transformation” requirements are strengthening their programs. Many have taken a “good, hard look” at palliative care and pain documentation, care coordination, and end-of-life conversations. Others have implemented social work and dietitian services that they were not previously able to make available to patients. While many cancer programs were engaged in these activities in some form before the OCM, participation in CMMI’s demonstration program has made these components robust and consistent, improving patient care. One practice called it an “awesome byproduct” of the program.

Another byproduct? Practices are also finding that the OCM is creating an imperative for the C-suite to make certain investments and providing leverage with EHR vendors; requests that were previously considered optimization items are now considered “must haves” to meet OCM requirements.

Dealing with Data
Last month OCM practices faced their first big data reporting deadline and they also received their first feedback reports following the first episode of care, breaking out cost per episode and comparing performance to other OCM practices. These data came in a format that was not easy to interpret, and required several practices to outsource the data analysis and interpretation. With the feedback reports practices are seeing their spending on OCM patients, and getting a sense of how they may fare with performance-based payments down the road, but practices won’t see reconciliations against target prices until early 2018.

Watchful Waiting
Where OCM practices succeed and struggle carry important implications for all cancer programs and the transition to value-based care. As one practice put it, the OCM is “the pebble in the pond for us.” We should all be watching the ripples closely. And taking notes.

To learn more about the ACCC OCM Collaborative, visit  accc-cancer.org/OCM. All OCM participating programs are invited to join our online community at ocmcollaborative.org to hear what else your colleagues are saying.

 

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.