2019 Medicare Physician Fee Schedule Proposed Rule

Transcription

1 2019 Medicare Physician Fee Schedule Proposed Rule

2 Welcome Thank you for joining today s 2019 Medicare Physician Fee Schedule webinar Webinar materials will be available after the meeting ends

3 Questions? Please submit questions by clicking on the Chat panel from the down arrow on the Webex tool bar (at the top of the screen): 1. Open the Chat panel 2. Send to: David Harter (Host) 3. Type your question in the text box and hit send Additional questions after the webinar can be sent to

4 Today s Speakers Stephen Grubbs, MD, FASCO Vice President Clinical Affairs Sybil Green, JD, RPh, MHA Director, Coverage and Reimbursement Policy and Advocacy Brian Bourbeau Associate Director, Business Metrics and Analysis Clinical Affairs

5 2019 Medicare Physician Fee Schedule Proposed Payment Rates Formula Updates

6 Physician Reimbursement and Adjustments Adjustments Physican Fee Schedule Payment QPP Adjustments Final Reimbursement

7 Summary: 2019 MPFS Proposed Policies and Changes Projected 4% reimbursement cut for Hematology/Oncology Specialty Projected 2% reimbursement cut for Radiation/Oncology Specialty Changes in Evaluation and Management Code Payment Adjustment to Add-On Payment for Part B Drugs Paid through Wholesale Acquisition Cost Methodology Payment Rates under the Medicare Physician Fee Schedule for Non-Excepted Items and Services Furnished in Non-Excepted Hospital Outpatient Provider-Based Departments Addition of New Technology-Based Patient Care Codes Implementation of New Survey Data Set to Define Equipment and Supply Costs

8 Projected reimbursement cuts for Oncology Projected: -4% Hematology/Oncology and -2% Radiation Oncology Includes: Changes related to 2019 conversion factor Changes in work, malpractice and practice expense RVUs Phased-in drug administration changes Proposed E/M code consolidation and blended rates Proposed new E/M add-on G codes Multiple Procedure Payment Reduction

9 Changes related to 2019 conversion factor 2019 Conversion Factor: $ Used to convert the value of RVUs to the national amount paid for services 0.13% overall update (2018 CF $ ) Statutory MACRA update 0.25% Budget Neutrality Adjustment -0.12%

10 Changes in work, malpractice and practice expense RVU Implementation of New Survey Data Set to Define Equipment and Supply Costs: Update of direct PE inputs for supply and equipment pricing Changes to over prices for 1268 items associated with oncology services Implementation: Immediately for new codes Over four years for existing codes Oncology services 63% of associated supplies will increase 41% of associated equipment will increase

11 Changes in work, malpractice and practice expense RVUs The majority of the updates related to the existing direct PE inputs for supply and equipment pricing could result in an increase, but there some exceptions. However, these increases are being overwhelmed by other decreases to the drug admin codes and do not reflect emerging equipment costs associated with USP changes.

12 Phased-in drug administration changes Phased-in drug administration changes Identified as misvalued codes in 2017 Reductions implemented in 2018 Max 19% per year 2019 Reductions inj iv Push (19%) inj iv addon (16%) hydration iv infusion init (19%; 7% in 2020) inj sc/im (19%; 6% in 2020)

13 Phased-in drug administration changes ASCO is continuing to evaluate how such policy changes influenced changes in payment for individual codes under the proposed rule. Possible Identification of additional misvalued codes in oncology could result in reductions in future years. We urge CMS to take a more global view that promotes quality, value, and financial support for the full scope of medically necessary oncology services, rather than implementing a series of changes in a piecemeal fashion that undermine the oncology care system.

14 Proposed Evaluation and Management Changes Streamlining Documentation Requirements Evaluation and Management Code Consolidation Blended Rates

15 Proposed E/M code consolidation and blended rates Rationale: Streamline documentation and reduce clinician burden Providers have a choice in documentation 1995 or 1997 documentation guidelines Medical decision-making only Face-to-face time with patient History and Exam may focus on what has changed since the last visit Physicians may review and verify information entered by other staff

16 Proposed E/M code consolidation and blended rates E/M Code Consolidation Office and outpatient E/M visits Consolidates 5 existing E/M visit code levels into 2 levels Compresses levels 2-5 into one single level Single blended payment rate for each new level

17 Proposed E/M code consolidation and blended rates Proposed Payment for Office/Outpatient Based E/M Visits Established Patient New Patient Level CY 2018 Payment Proposed Payment CY 2018 Payment Proposed Payment 1 $22 $24 $45 $43 2 $45 $76 3 $74 $110 $92 4 $109 $167 $134 5 $148 $172 Proposed Payment based on CY2019 proposed RVU and CY2018 Payment Rate

18 Proposed E/M code consolidation and blended rates Projected Impact: ~10% Reduction for Oncology E/M Services Established Patient New Patient Benefit: physicians billing levels 2 and 3 visits Reduction: physicians billing levels 4 & 5 visits Level CY 2018 Payment Proposed Payment CY 2018 Payment Proposed Payment 1 $22 $24 $45 $43 2 $45 106% $76 76% 3 $74 24% $110 22% $92 $134 *non-facility setting 4 $109 16% $167 20% 5 $148 38% $211 22%

19 Proposed E/M code consolidation and blended rates Proposed Payment for Office/Outpatient Based E/M Visits Level Documentation Requirements for Established Office Visits 1 2 Medical Necessity, and 2 of the following: Problem Focused Hx Limited exam Straightforward medical decision making Straightforward medical decision making Face-toface time spent with patient

20 Proposed E/M code consolidation and blended rates Proposed Payment for Office/Outpatient Based E/M Visits ASCO s preliminary estimated impact for proposed E/M consolidation and RVU policy changes: -6.7% % impact on total MPFS reimbursement

21 Proposed Add-on Codes and Adjustments Add-on payments for Complex Visits GPC1X Primary Care add-on $5 adjustment Performed for primary care purposes Yet to be defined GCG0X Specialty Care add-on $14 adjustment Specialties typically reporting higher level visits 10 Specialties, including Hematology/oncology Application, TBD GPRO1 Prolonged Service addon $67 adjustment Office visits lasting more than 30 minutes Beyond office visit

22 Proposed Add-on Codes and Adjustments Add-on payments for Complex Visits GPC1X Primary Care add-on $5 adjustment Performed for primary care purposes Yet to be defined Oncologist reporting a level 5 E/M visit and spending more than 60 minutes with a patient would be paid $215. GCG0X Specialty Care add-on $14 adjustment Specialties typically reporting higher level visits 10 Specialties, including Hematology/oncology Application, TBD Report: ( ) + (GCG0X) + (GPRO1) $ $ 14 + $ 67 = $ 215 GPRO1 Prolonged Service add-on $67 adjustment Office visits lasting more than 30 minutes Beyond office visit

23 Proposed Add-on Codes and Adjustments Add-on payments for Complex Visits ASCO s preliminary estimated Impact for proposed specialty G- code add-on: 7.5% % impact on total MPFS reimbursement

24 Multiple Procedure Payment Reduction Proposed 50% reduction for same day services Least expensive procedure or visit Same physician or practice Separately identifiable E/M visit

25 Multiple Procedure Payment Reduction Conflicting methodology laid out in the rule: Scenario 1: Using the surgical MPPR as a template, we are proposing that, as part of our proposal to make payment for the E/M levels 2 through 5 at a single PFS rate, we would reduce payment by 50 percent for the least expensive procedure or visit that the same physician (or a physician in the same group practice) furnishes on the same day as a separately identifiable E/M visit, currently identified on the claim by an appended modifier -25. Scenario 2: Table 22 shows the proposed impacts of adopting the proposed single payment rates for new and established patient E/M visit levels 2 through 5, the application of a MPPR to E/M visits when furnished by the same practitioner (or practitioner in the same practice) on the same-day as a global procedure code, the add-on G-codes for primary care-focused services and inherent visit complexity, and the technical adjustments to the PE/HR value. Scenario 3: We estimate based on CY 2017 Medicare claims data that applying a 50 percent MPPR to E/M visits furnished as separately identifiable services in the same day as a procedure would reduce expenditures under the PFS by approximately 6.7 million RVUs.

26 Multiple Procedure Payment Reduction ASCO s preliminary estimated impact MPPR, when applied to E/M services rather than the least costly service on the same date: - 5.0% % impact on total MPFS reimbursement

27 2019 Medicare Physician Fee Schedule ASCO Preliminary Impact Analysis - Details

28 ASCO Model: Drug Administration Notes: This shows the impact of the practice expense RVU changes in the drug administration codes Uses preliminary 2017 data available on data.cms.gov Use RVU values contained with the addendum

29 ASCO Model: Other Changes >$20k Notes: This shows the impact of the RVU changes in other codes Uses preliminary 2017 data available on data.cms.gov Use RVU values contained with the addendum

30 ASCO Model: Summary Policies Hematology (82) Hematology/ Oncology (83) Medical Oncology (90) Grand Total 2018 Allowed Charges 63,479,039 1,290,510, ,085,950 1,741,075,952 Pct. Impact E&M Consolidation & RVU Changes (5,224,894) (81,259,589) (29,442,775) (115,927,258) -6.7% GCG0X Impact 4,959,564 96,293,768 29,999, ,252, % MPPR Impact (2,748,956) (66,689,661) (18,156,190) (87,594,806) -5.0% Change in Drug Admin (1,224,919) (36,592,451) (10,600,219) (48,417,588) -2.8% Other Changes (66,933) (2,424,753) (721,944) (3,213,629) -0.2% 2019 Estimated Allowed Charges 59,172,902 1,199,838, ,164,112 1,617,175,292 Total Change (4,306,137) (90,672,684) (28,921,838) (123,900,660) -7.1% Pct. Impact -6.8% -7.0% -7.5% -7.1% Assumptions: GCG0X is applied to all E/M services using values from RVU addendum RVU values in the rule and the addendum are different Application of G-code to all E/M services is still unclear MPPR is applied to E/M services rather than the least costly service on the same date We estimate based on CY 2017 Medicare claims data that applying a 50 percent MPPR to E/M visits furnished as separately identifiable services in the same day as a procedure would reduce expenditures under the PFS by approximately 6.7 million RVUs. 3 different methodologies are included in the proposed rule (see next slide for more information)

31 ASCO Model: Summary ASCO s preliminary estimated impact of all proposed changes : -7.1% % impact on total MPFS reimbursement

32 ASCO Model: Impact on Real Practices 2% 0% -2% -4% -6% -8% -10% -12% -14% -16% PracticeNET Model for MPFS 2019 Proposed Rule

33 Proposed E/M code consolidation and blended rates and MPPR ASCO appreciates some of the positive changes, however they are overcome by proposed policies that result in significant negative impact on oncology practices. Still uncertain about some of CMS assumptions/modeling, either because policies are not clear, or because information/numbers in the appendix are not consistent with those in the body of the rule. ASCO is concerned by CMS s own impact analysis showing a 4% reduction for medical oncology. ASCO s analysis is showing a 7.1% decrease. Oncology has experienced tremendous turbulence over the past several years, including consolidation and practice closure in communities across the country. A 4% cut will worsen this situation, causing additional practices to fold, will impede the ongoing preparations for the QPP, and could cause access problems for patients if practices are no longer there to treat them.

34 2019 Medicare Physician Fee Schedule Proposed Policy Updates

35 Adjustment to Add-On Payment for Part B Drugs Paid through Wholesale Acquisition Cost Methodology Current Reimbursement: WAC + 6% New Reimbursement: WAC + 3% New drugs coming to market During the first quarter, No ASP WAC based on manufacturer list price Does not include discounts and rebates WAC-based reimbursement would apply for a three month period, until an ASP is established

36 Adjustment to Add-On Payment for Part B Drugs Paid through Wholesale Acquisition Cost Methodology The proposed WAC + 3% payment rate does not include payment reductions due to sequestration. Medicare should pursue a comprehensive solution that addresses shortcomings in the current medical oncology reimbursement system and that drives value-based cancer care, rather than addressing components of Part B reimbursement.

37 Non-Excepted Items/Services Furnished in Non-Excepted Hospital Outpatient Provider-Based Departments New Payment Rates under the Medicare Physician Fee Schedule Goal: Align overall payment amounts paid at off-campus hospital departments with physician practices Statutory requirement to pay for items and services furnished in off-campus provider based departments under the appropriate reimbursement system MPFS finalized as appropriate payment system in 2017 No longer eligible for payment under the Hospital Outpatient Prospective Payment System Paid non-facility PFS rate using relativity adjuster 40% of hospital outpatient system rate for the same code Professional component reimbursed at the facility rate PFS

38 Addition of New Technology-Based Patient Care Codes Increased access for beneficiaries to physician services furnished via communication technology New codes Not Medicare telehealth services Discrete services involving communication technology Brief, non face-to-face check in Assesses whether an office visit is necessary Initiated by established patients Real-time evaluation Remote evaluation of pre-recorded patient information Photos or videos provided by the patient Separately billed if there is no associated E/M visit

39 Addition of New Technology-Based Patient Care Codes Interprofessional Consultations Reimbursement for consultation between practitioners Can replace face-to-face visit with consulting practitioner Consultation provided via: Telephone, internet or EHR Requires verbal consent from beneficiary; recorded in EHR

40 Addition of New Technology-Based Patient Care Codes ASCO s early analysis considers the increased use of technology to communicate with patients. Codes to describe the services and appropriate reimbursement are necessary to incentivize and support this communication.

41 Appropriate Use Criteria (AUC) Requires physicians to consult with AUC through a qualified decision support system for imaging services Consulting with AUC precludes prior-authorization for imaging services Voluntary participation through December 2019 Reportable on all technical and professionals claims for imaging services Educational and operations testing beginning in 2020 Claims paid with/without AUC information Proposed Including independent diagnostic testing facilities AUC program-specific Hardship exemptions Development of codes and modifiers to report AUC information Allow non-physicians to consult with AUC

42 ASCO Tools Additional Webinars 2019 Proposed Quality Payment Program Changes PracticeNET Webinar for the Proposed Rule In the near future: Messaging and positions to submit your own comments PracticeNET modeling to determine impact on your practice

43 Questions? Please submit questions by clicking on the Chat panel from the down arrow on the WebEx tool bar (at the top of the screen): 1. Open the Chat panel 2. Send to: David Harter 3. Type your question in the text box and hit send Additional questions after the webinar can be sent to: