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Rheumatology Practice Management June 2016 Vol 4 No 3 - CMS News

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Medicare Health, Drug Program Payment and Policy Updates for 2017 Finalized

The final Medicare Advantage and Part D Prescription Drug Program changes for 2017 have been released by the Centers for Medicare & Medicaid Services (CMS). These changes strive to provide plans with stable payments, and improve the program for plans that provide high-quality care to enrollees who are most vulnerable. In addition, CMS is confirming its policies to further combat opioid overuse, by encouraging the use of safeguards prior to dispensing an opioid prescription at a pharmacy, and retaining access to necessary medications.

Although these final policies bear semblance to those that were proposed in February, they include several changes that address feedback received during the public comment period. Without accounting for expected growth in coding acuity—which has typically added 2.2%—the expected revenue change, on average, is 0.85%. CMS notes that, largely because of technical updates in the risk adjustment normalization factor, the final revenue growth is a bit smaller than what was estimated in the February Advance Notice; however, the revenue increase is consistent with last year’s update, and mirrors a similar pattern in Medicare fee-for-service. Plans that improve the quality of care they provide to beneficiaries can get higher updates that, in turn, enrich the benefits they offer to enrollees.

“We continue to strengthen Medicare Advantage and Medicare Part D, in particular for enrollees who need additional investments in their health, such as dually Medicare-Medicaid eligible individuals and those with complex socioeconomic needs,” according to Andy Slavitt, Acting Administrator, CMS, Baltimore, MD. “With these policies, we will continue to see improvements in growth, affordability, benefits, and quality for millions of seniors and people living with disabilities.”

New policies will advance the accuracy of payments to Medicare Advantage plans that serve vulnerable populations (eg, dually eligible or low-income beneficiaries); risk-adjusting payments to plans using a revised methodology will more precisely reflect the cost of care for dually eligible beneficiaries.

The organization will also be implementing a temporary adjustment to the Star Ratings policy that reflects the socioeconomic and disability status of a plan’s enrollees. In addition, the finalized policies from CMS will provide the Medicare Advantage program in Puerto Rico with much needed stability. CMS asserts that this announcement regarding finalization of Medicare Health and Drug Program payment and policy updates drives payment improvements for Medicare Advantage plans, and continues promoting improvements to quality of care for beneficiaries.

“Together, these changes will ensure the Medicare program remains strong and stable for current and future enrollees,” the CMS press release concludes.

Centers for Medicare & Medicaid Services. CMS finalizes 2017 payment and policy updates for Medicare health and drug plans. www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-04-04.html. Published April 4, 2016. Accessed May 31, 2016.

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CMS Increases Transparency of Medicare Part B Program

The third annual Physician and Other Supplier Utilization and Payment Public Use data released by CMS, which includes summarized information regarding Part B services that physicians and other healthcare professionals provide to beneficiaries of Medicare, increases the transparency of the Part B program, according to a recent announcement by CMS. The organization has also announced the accessibility of more timely data for researchers.

These updated 2014 data have been released in tandem with the conduction of the 7th annual Health Datapalooza conference in Washington, DC, and includes information for >986,000 different healthcare providers—compared with the 950,000 covered in 2013—who collectively received $91 billion in Medicare payments (vs $90 billion in 2013).

Information about payment, submitted charges, and bills for services and procedures provided by each physician or supplier is relayed in the Physician and Other Supplier Utilization and Payment Public Use data update, and can be compared by physician, specialty, location, types of medical services and procedures delivered, Medicare payment, and submitted charges.

There is also new information about the Medicare standardized payment amount, which eliminates discrepancies in payment rates for individual services based on geographic variances (eg, those that account for local wages or input prices), and makes them comparable. Of note, beneficiaries’ personal information is protected in all of CMS’ data releases.

“This week’s announcements underscore CMS’ ongoing commitment to releasing data and information to promote a vibrant health information economy,” stated Niall Brennan, Chief Data Officer, CMS, Baltimore, MD.

For researchers accessing Medicare claims data via Limited Data Sets (LDS), CMS is making the information timelier. In the past, researchers could only use the LDS request process for annual extracts of Medicare data, but with the new changes CMS has announced, updates to LDS claim files can be requested by researchers as frequently as every quarter. This will make it easier for important research to be carried out, which will, in turn, result in better quality and lower costs in the healthcare system.

CMS has stressed that, as Medicare gradually pays healthcare providers based on the quality—versus quantity—of care they provide to patients, the release of timely, privacy-protected data is particularly vital.

Centers for Medicare & Medicare Services: Updates to data initiatives increase transparency of the Medicare Program. www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-05-05.html. Published May 5, 2016. Accessed May 26, 2016.

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Part B Faces Backlash from the Rheumatology Community

In a recent comment letter submitted to the CMS, the American College of Rheumatology (ACR) urged CMS to remove or significantly edit their controversial Part B payment proposal. The ACR purports that the CMS proposal will have a distressing impact on rheumatology patients who rely on Medicare Part B for gaining access to the biologic therapies they need.

Citing that the CMS neglected to involve the physician community when deciding the best ways to address the complex policy issues surrounding the effective treatment of patients with different needs, the ACR stressed that a “one-size-fits-all” solution is not appropriate for the complexity of this issue.

The letter also elaborates on the negative impact the Part B payment proposal would have on patients with regard to more expensive copays and fees, travel times, and administration of therapies without the supervision of their rheumatologist, as well as on practices and physicians.

“Although we certainly seek to control costs for patients and Medicare wherever possible, the proposed new methodology does not adequately consider the higher average costs many of our physicians have acquiring, handling, administering, and billing for drugs and biologics,” the letter stated. “We are deeply concerned that because the new methodology will frequently not properly cover the costs of physician administration of infused drugs, they will be forced to stop offering patients the ability to receive infusion treatments.”

The ACR asserts that, because of the new proposal, patients—some of whom already travel lengthy distances to access vital services—will have no choice but to seek more costly or less safe alternatives at outpatient services and freestanding infusion treatment centers that do not have onsite physician supervision, or skip treatment altogether.

Furthermore, concerns are expressed about reimbursements accurately reflecting physicians’ acquisition and administration costs. “We encourage CMS to re-evaluate the fixed fee and align such an add-on payment to reflect costs of administering the infusion,” the letter adds. “In addition, we believe that CMS should evaluate undertaking a demonstration proposal to permit physicians to pool together in order to purchase drugs from manufacturers.”

Notably, the ACR stresses that, if CMS implements the proposed new methodology, it should be done in a limited geographic area to evaluate and identify weaknesses of the policy (eg, beneficiary access issues) before being established on a national level.

American College of Rheumatology. Rheumatology community urges CMS to withdraw or significantly modify Part B payment demo, citing devastating impact to rheumatology patients and providers. www.rheumatology.org/About-Us/Newsroom/Press-Releases/ID/744/Rheumatology-Community-Urges-CMS-to-Withdraw-or-Significantly-Modify-Part-B-Payment-Demo-Citing-Devastating-Impact-to-Rheumatology-Patients-and-Providers. Published May 5, 2016. Accessed May 26, 2016.

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Last modified: July 7, 2016
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