Concerns With 2019 Medicare Physician Fee Schedule and Quality Payment Program Proposed Rule

Concerns With 2019 Medicare Physician Fee Schedule and Quality Payment Program Proposed Rule

Clifford A. Hudis, MD, FACP, FASCO

@CliffordHudis
Sep 11, 2018

 

Editors note: Dr. Hudis hosts the ASCO in Action Podcast, which focuses on policy and practice issues affecting providers and patients. An excerpt of a recent episode is shared below; it has been edited for length and clarity. Listen to the full podcast online or through iTunes or Google Play.

Today I want to give you a quick update on what is, every year, a much-anticipated announcement by the Centers for Medicare & Medicaid Services (CMS): the Medicare Physician Fee Schedule. Recently, CMS released its proposed rule for 2019 [and ASCO has since responded in a comment letter].

For those of you who are not familiar with this, the Physician Fee Schedule is a complete listing of all the fees used by Medicare to pay doctors or other providers and suppliers. This comprehensive listing of fee maximums is updated every year and it's used to reimburse a physician or other providers on a fee-for-service basis. It differentiates the reimbursement rates for different medical specialties as well.

At ASCO, we always review this proposed rule very closely because it's important to understand how it might impact our members and then, through them, the beneficiaries of Medicare: our patients.

The bottom line for this year is that CMS estimates that in 2019 there will be a negative 4% reduction in reimbursement for hematology and oncology specialty services, and there will be a negative 2% reduction in radiation oncology. Fundamentally, these reductions reflect a statutory adjustment factor related to the Medicare Access and CHIP Reauthorization Act, which you may know as MACRA, and also the Relative Value Units (RVUs) of specific CPT codes.

The actual impact on individual physician practices will depend on the mix of services that any specific practice actually provides. Nonetheless, it is very worrisome to us that under Medicare Part B this year, CMS is also proposing to reimburse new drugs and drugs that do not yet have an average sales price (ASP) at wholesale acquisition costs (WAC) plus 3%. Right now, Part B drugs are currently reimbursed at WAC plus 6%.

These cuts really represent a serious concern for us at ASCO and we outlined our concerns for CMS in comments to the agency while the proposal’s open comment period was operative. Our goal is to make sure the agency fully understands how these cuts, both in physician fees and in Part B drug reimbursement, could impact oncology practices.

Beyond this, I want to talk a little bit about the impact on the Quality Payment Program (QPP). The rule proposes changes to QPP for 2019. We're still analyzing the proposal and trying to fully assess its potential impact on the oncology community. But one key update for cancer care providers is in the Merit-Based Incentive Payment System (MIPS). This is one of two QPP tracks. The change that we're concerned about is how those performance categories are weighted and the effect that has on the overall score that a practitioner must achieve to avoiding negative payment adjustment.

For 2019, the QPP proposal would weight MIPS' Quality category at 45% of a provider’s or practice's total score. This used to be 50%, so it's a little bit of a reduction in terms of the proportion that is attributed to the Quality category. In terms of electronic records and interoperability, this is called the Promoting Interoperability category (it used to be called Advancing Care Information/Meaningful Use; many of you are familiar with that "Meaningful Use" term)—this will remain at 25%. The Improvement Activity category remains as it was at 15%. But the Cost category increases from 10% up to 15%. That's where the missing 5% is being added back in. The performance threshold is also slated to go up to 30 points from 15 in order to avoid a negative payment adjustment, and the MIPS performance period will now be 12 months starting January 1, 2019.

At ASCO, we remain very concerned that the CMS proposal could harm Medicare beneficiaries who have cancer by triggering major cuts to physician reimbursement, especially for the Part B drugs and especially, beyond that, for those drugs that have been newly introduced to the market. This could make an already turbulent cancer care delivery system even more unstable. We're concerned that these cuts might hinder patient access to some of the newer and innovative therapies and might, therefore, stall some of the progress that we're making against cancer. This in turn will make it more difficult for oncologists to provide some of the essential services they must provide to patients with cancer. Always, our goal is to ensure that oncologists are able to provide the right treatment to the right patient at the right time. We are concerned that these payment cuts, as well as Part B cuts, might be an impediment to that, and we are concerned about the impact on our members and our patients.

If you want to learn more about the Physician Fee Schedule, I encourage you to visit ASCO in Action, where we have a link to the proposed rule and share our comments to CMS.

Listen to the full podcast online or through iTunes or Google Play

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