Weekly Roundup - June 26 - 30, 2023
Physician payment, coding, coverage, and quality reporting news highlights.
Note that Congress is in recess until July 10, 2023.
PAYMENT
CY 2024 Medicare Physician Fee Schedule Proposed Rule Still at OMB for Review. As of the writing of this posting on the afternoon of Friday, June 30, 2023, the 2024 Medicare Physician Fee Schedule (PFS) Proposed Rule, typically released on or around July 1, is still under review at the Office of Management and Budget. This is the final step before the rule is released for review and comment. The PFS sets payment rates and policies for over 7,000 services physicians and other qualified healthcare professionals provide. While the proposed policies are kept under wraps, some educated prognosticating can be done. Continue reading HERE.
Medicare’s New Primary Care Model Includes Payment for Specialists. To incentivize collaborations, the Centers for Medicare & Medicaid Innovation included payments for specialists as part of the design for its newest model, Making Care Primary (MCP). The purpose of these payments is to support ongoing communications and collaborations of patients the specialist shares with the MCP participant. This design feature is also part of a larger specialty integration strategy the agency implements throughout its various models. Continue reading HERE.
CMS Revises Drug Negotiation Guidance. On June 30, 2023, the Centers for Medicare and Medicaid Services (CMS) released Medicare Drug Price Negotiation Program guidelines. Under authority granted by the Inflation Reduction Act, Medicare can negotiate Medicare drug prices with drugmakers for certain high-cost, single-source drugs and biological products. For the Medicare Part B program, CMS will negotiate for drugs in 2023 and 2024, effective for prices in 2026.
The noted change in the revised document is that drug makers can now publicly discuss the negotiations, whereas, under the previous guidance, these discussions were considered confidential. Drugmakers objected to the confidentiality provisions and other features of the program. In fact, several drugmakers and PhRMA filed lawsuits challenging the drug negotiation program. By all indications, CMS continues to move forward with implementing it. The next major milestone for the program is that by September 1, CMS will publish the first ten drugs selected for negotiation.
PAYMENT INNOVATION
Medicare’s New Oncology Model Set to be Smaller than Predecessor Model. On June 27, 2023, the Centers for Medicare and Medicaid Innovation (Innovation Center) announced that 67 practices are expected to participate in the new Enhancing Oncology Model (EOM), a volunteer payment model for practitioners providing chemotherapy for select cancer conditions. Significantly fewer participants were announced for the EOM than participated in the Oncology Care Model (OCM), the predecessor to the EOM. The OCM ran from July 2016 through June 2022, with 122 participating practices at its close.
Stakeholders have raised concerns that, unlike the OCM, the EOM requires practices to take on downside risk from the beginning. The lower monthly payment of the EOM has also raised concerns. The agency did apply lessons learned from the OCM to the design of the EOM. At least one study of the OCM found that “… [the] OCM led to a relative savings of $297 per episode…these savings were not sufficient to cover the monthly payments to practices which averaged $704 per episode.”
The EOM is scheduled to launch in July 2023 and to run five years through June 2028.
ASTRO Floats Proposal to Revise Radiation Oncology Medicare Payments. This week the American Society for Radiation Oncology (ASTRO) proposed a radiation oncology (RO) payment reform proposal: the Radiation Oncology Case Rate (ROCR), which would apply to all RO practices participating in Medicare (Medicare Advantage would be excluded). This proposal would require Congressional action to implement. ASTRO is sharing this proposal with the larger RO community before reaching out for Congressional support.
Payments would be based on per fraction; include an annual inflationary adjustment; a savings adjustment largely tied to technical payments would be applied; and payment incentives are established for meeting specified health equity criteria and earning practice accreditation. Standard geographic and Medicare sequestration adjustments would still apply.
ASTRO developed this proposal after years of scrutiny around Medicare spending for RO services. The Trump Administration finalized an RO model that would have been mandatory in select locations, but Biden Administration placed an indefinite pause on this model. While studies have shown that, overall, radiation oncology represents a low portion of all oncology spending, radiation oncology spending costs have increased significantly in the past few years. RO providers respond that they have experienced disproportionate payment cuts on top of rising practice costs.
CODING
Onsite and Virtual Registration Now Open for the September 2023 CPT Editorial Panel Meeting. The American Medical Association will host the meeting on September 21-23, 2023, in New Orleans, LA. The CPT Editorial Panel meets three times yearly to consider changes to the CPT code set. The September meeting is the final meeting for the calendar year 2025 CPT and Medicare Physician Fee Schedule cycle. The public agenda will be posted on July 14.
SUPREME COURT
Many in Healthcare Community are Alarmed that SCOTUS Affirmative Action Decision Could Undermine Efforts to Improve Diversity in the Medical Profession and Address Healthcare Disparities. On June 28, 2023, the Supreme Court of the United States (SCOTUS) overturned years of affirmative action policies by ruling that it is unconstitutional for colleges and universities (this includes medical and nursing schools) to consider race as a factor in admissions. The ruling does allow applicants to write about how their racial identity has shaped them.
Many in the healthcare community have met this decision with a chorus of disappointment and frustration. Medical schools and institutions are concerned that eliminating affirmative action would “… impede diversity efforts and worsen health inequities….” The current lack of a diverse medical profession (e.g., for example, while African Americans make up approximately 12% of the population, a recent report by the American Association of Medical Colleges found that only 5.7% of practicing physicians identify as Black or African American) is thought to contribute to health disparities in the U.S. and that a more diverse medical profession would be better able to serve the needs of the population.
As a result of this SCOTUS decision, medical and nursing schools will need to pivot and develop new policies to improve the diversity of their student populations; these new policies will take time to develop, resources to implement, and political will to lead the way forward. Unfortunately, for some institutions, one or more may be in short supply.
Modern Healthcare compiled statements released in response to this ruling from major medical and nursing organizations.
For more information and questions, please contact:
Sheila Madhani, MA, MPH
Madhani Healthcare Consulting, LLC
Email: smadhani@madhani-health.com
www.madhani-health.com
Tel: (202) 679-2977