What You Need to Know About the Final 2019 Medicare Physician Fee Schedule and Quality Payment Program Rule

What You Need to Know About the Final 2019 Medicare Physician Fee Schedule and Quality Payment Program Rule

Clifford A. Hudis, MD, FACP, FASCO

Jan 28, 2019

Editor’s 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.

In an August podcast, I outlined the proposed Medicare Physician Fee Schedule and the Quality Payment Program Rule for 2019. This is commonly referred to as the Physician Fee Schedule. Today, I'm going to provide an update on where we are with this for next year. 

What is the 2019 Medicare Physician Fee Schedule? This is a fee schedule which consists of a complete listing of all of the fees that Medicare uses to pay doctors or other providers and suppliers. It's a comprehensive listing of the maximum fees. It's updated each year and then used to provide reimbursement to physicians and other providers working on a fee-for-service basis.

At ASCO, every year we review this rule very closely, and we try to determine and predict the impact that it will have on our members, and of course, on our patients. There are three provisions in particular that we want to highlight today. The first of these is related to care provided in calendar year 2019. CMS estimates that there will be, overall, a 1% reimbursement cut for hematology and oncology, as well as radiation oncology specialties. It is important to note, however, that the actual impact on any individual physician or physician practice will depend on their mix of services—that is, what it is they exactly provide and bill.

Now the administration has publicly stated its aim to reduce the growing administrative burden that we've all been noting and complaining about for the last few years. And the second item we want to point out is there is some evidence of their sensitivity to this issue in the 2019 fee schedule. They intend to reduce the documentation required for evaluation and management services, frequently referred to as E/M.

What CMS did is finalize provisions that consolidate E/M payments. ASCO had expressed concerns about this previously, which the agency acknowledged, along with other stakeholders, by revising the proposal. If fully implemented, they believe that the impact will be delayed (that is, it will not impact providers until 2021).

By that time, CMS plans to consolidate what have historically been Levels 2, 3, and 4 into a single billing level, and then to pay for Level 5 E/M services separately. So overall, this represents a simplification, and it fulfills one of their stated aims, again, of reducing some of the administrative burden that practitioners face.

Finally, the third area that I want to highlight is a new rule starting in 2019 that refers to the amount of reimbursement you will receive for new Medicare Part B drugs. Currently, those drugs in Part B are reimbursed at wholesale acquisition cost plus 6%. They will, going forward, be reimbursed at wholesale acquisition cost plus 3%. It's critically important to emphasize that this relates only to those new drugs that are introduced into the supply chain this year.

This new provision will also apply to drugs that have not yet reported an average sales price. But the point is it will not apply to drugs that have already been in use. It only applies to new drugs, meaning that its reach is going to be relatively limited. However, what you can imagine going forward with each new year and new drugs being introduced is that the percentage over wholesale acquisition cost will translate into more and more absolute dollars. Therefore, this may be a growing concern for practices.

I want to switch our attention and talk about the Quality Payment Program, or QPP. In the final rule, there is an update to QPP for 2019. The final 2019 payment adjustment for Merit-based Incentive Payment System, or MIPS, practices and providers will become plus or minus 7%. It will have adjustments to maintain budget neutrality, as well as to reward exceptional performance.

Other noteworthy changes will include an increase in the MIPS performance threshold from 15 points, which is where we were in 2018, up to 30 points for 2019. CMS also finalized two new optional opioid-related measures that MIPS providers can use to report on under the Promoting Interoperability category. These measures will give providers an opportunity to earn bonus points and therefore potentially boost their overall MIPS score. One [measure] allows for checking a prescription drug monitoring program, or PDMP, prior to submitting an electronic opioid prescription for any individual patient. The second is an attempt to verify an existing opioid treatment agreement with the patient receiving the prescription.

I hope that this summary of the updates to the Physician Fee Schedule for 2019 is helpful. Ultimately, our goal is to make sure that oncologists can provide the right treatment to the right patient at the right time. We aim to help CMS implement policies that will advance that goal. ASCO will continue to work closely with the administration to ensure that CMS understands the needs of the oncology community and the full impact that the rule is likely to have.

I would encourage you, if you need more information on the Medicare Physician Reimbursement Plan for 2019, to visit ASCO in Action. We also have a helpful webinar that explains the final rule schedule and QPP rule in greater detail. 

Learn more about the Final 2019 MPFS and QPP rule and the latest news on health policy and ASCO’s advocacy efforts at ASCO in Action.

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


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