LUGPA recently commented to Centers for Medicare and Medicaid Services (CMS) regarding its recent Outpatient Prospective Payment System (OPPS) Final Rule for 2017.
LUGPA’s comments focus on CMS’s implementation of Section 603 of the Bipartisan Budget Act of 2015 (“BBA”). This law mandates that an off-campus provider-based department (“PBD”) will no longer be reimbursed under the OPPS, but instead under another “applicable payment system,” unless the PBD was in operation prior to November 2, 2015. As CMS recognized in the OPPS Proposed Rule issued in July, Section 603 “is intended to curb the practice of hospital acquisition of physician practices that then result in receiving additional Medicare payment for similar services.”
LUGPA commends CMS for finalizing many provisions of the Proposed Rule in a manner that reflects Congress’s important site-neutrality goals. Unfortunately, in certain important respects, the Final Rule creates interim policy that appears to contradict the language and purpose of Section 603 of the BBA. Without certain revisions, we believe that “the exceptions will swallow the rule” and CMS will have failed to implement a site-neutral payment structure as Congress directed. We are particularly concerned with the following:
- The Final Rule appears to remove all limitations on the services for which an “excepted PBD” may bill under the OPPS-even if these services are entirely different from the types of services the PBD provided prior to November 2, 2015; and
- The Final Rule creates a new payment system for “non-excepted PBDs” that will perpetuate the dramatic payment disparity Congress sought to remedy in Section 603 of the BBA. The data we present in this comment letter shows that, if left unchecked, this payment disparity could approach half a billion dollars annually with respect to commonly performed urologic services alone.
LUGPA believes that the creation of a truly site neutral reimbursement for each CPT Code is the only way to achieve Congress’s goal of curbing the practice of hospital acquisition of physician practices; a practice that results in additional out-of-pocket costs for Medicare beneficiaries and greater expenses for the healthcare system as a whole.
LUGPA ‘s formal request for action provides CMS specifics regarding how the interim rule could be modified so that the Medicare Physician Fee Schedule (which governs non-facility reimbursement) can be effectively implemented in non-excepted PBDs.
Thank you to all LUGPA members for your continued support of our health policy advocacy efforts. LUGPA will maintain its dedication to be the voice of independent urology practices.
LUGPA Mid-Year Government Affairs Update
- 2017 Physician Fee Schedule Proposed Rule
- Medicare Fee Schedule Comparison Tool
- Stark Modernization
- MACRA – MIPS and APMs
- Proposed Part B Drug Payment Model
2017 Physician Fee Schedule Proposed Rule
Currently, LUGPA is considering commentary to CMS in response to the July 7, 2016 Medicare Physician Fee Schedule Proposed Rule. Upon initial review, it appears that while urology as a specialty has approximately a 1% overall reduction in global RVUs, the decrease in reimbursement is greater than that when the decrease in conversion factor (CF) is included; in addition, there may be changes based on member practice Geographical Practice Cost Index (GPCI) variations – in some cases these changes are significant. Thanks to legislative changes instituted from advocacy efforts championed by the Radiation Therapy Alliance (RTA – of which LUGPA is a member), radiation oncology codes are flat overall, and any reimbursement decrease can be attributed to changes in the CF and GPCI. The most significant change in pathology payments is a decrease in reimbursement for prostate biopsies of 9.1%; an increase of 17% in professional revenue is more than offset by a 19% decrease in technical revenue. Regarding diagnostic imaging, CPT codes for in-office sonograms are essentially flat, as are those for common urological CT scanning procedures.
Specifically, within urology, cystoscopy, EMG and greenlight laser (CPT codes 52000, 51784 and 52648, respectively) have very substantive decreases in professional fees. CPT codes 52000 and 51784 were singled out as misvalued in the fee schedule rule. The table below illustrates the fees for these procedures:
Also cited by CMS was prostate biopsy (55700); however, a near 25% decrease in work RVUs was compensated by an increase in practice expense RVUs; overall, this code increased by 3.6% – unfortunately, this nominal increase in reimbursement was the largest fee increase for GU codes.
CMS also devoted attention in the proposed rule to the robotic prostatectomy code (55866); they acknowledged that the refinement panel (which was a cooperative effort between LUGPA and the AUA) recommended an increase in RVUs; however, they declined to accept the recommendation. CMS has indicated that additional commentary may be submitted, suggesting that they may be open to revisiting this issue as part of the final rule.
LUGPA will continue its review of the proposed rule and will advise the membership of any further areas of concern. Full LUGPA comments on the proposed rule will be provided at a later date.
Medicare Fee Schedule Comparison Tool
The RVU analysis mentioned in the previous section was prepared using a Medicare fee schedule comparison tool that is available for your use. This tool will compare RVUs and reimbursement for any geographic area in the United States, and will incorporate not only the CF but all relevant GPCI codes as well. The worksheet is prepared as a Microsoft Excel freeware application. In order to use the tool, you must be using a current version of Microsoft Excel with macros enabled, and must accept the end user license agreement (EULA) to proceed. There is no charge to use or distribute the comparison tool, but it may not be used for any commercial purpose.
LUGPA continues to advocate for reformation of the Stark Law and has been working closely with other stakeholders, including the AUA, to ensure that our goals for Stark reform are aligned.
In its comment letter, LUGPA asked Congress to explore responsible ways to modernize the Stark Law for the benefit of millions of Medicare beneficiaries and taxpayers in the program. In enacting the Stark Law, Congress intended to limit potential incentives for overutilization and unnecessary care present in a fee-for-service payment system. However, in more than 25 years since its passage, the law has become one of the most significant sources of regulatory burden on physicians and, ultimately, for Medicare beneficiaries. Given that the system is rapidly transitioning away from fee-for-service payment, the law is outdated.
The Stark Law’s system of strict liability coupled with extremely narrow and technical exceptions means that every healthcare transaction, partnership, and initiative carries significant legal and operational risk. These restrictions make it more difficult for independent physician practices to coordinate care, creating a competitive advantage for large hospital systems.
In brief, in its comment letter, LUGPA proposed the following reforms to the Stark Law:
- Congress should extend language consistent with the waivers of the Stark Law for Accountable Care Organizations (“ACOs”) participating in the Medicare Shared Savings Program (“MSSP”) to cover relationships necessary to participate in an Alternative Payment Model (“APM”) or private equivalent under MACRA.
- Congress should modify CMS’s authority to create new exceptions and other regulatory changes to the scope of the Stark Law to require CMS to proactively support Congressional payment reform.
- Congress should clarify that the definition of “fair market value” in section 42 U.S.C. § 1395nn(h)(3) of the Stark Law is not intended to prohibit healthcare practices regulated under the law from paying compensation to incentivize high-quality, cost-efficient care, even if such compensation takes into account “the volume or value of referrals.”
- Congress should revise the definition of “group practice” to clarify that members of group practices may be paid on the basis of furnishing high quality care without running afoul of the Stark Law.
MACRA – MIPS and APMs
Current implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) will fundamentally transform the delivery of healthcare. In our comments, we continued to stress to CMS that MACRA provides important opportunities to move toward value-based payment paradigms rather than the traditional fee-for-service model. A successful transition to innovative APMs will require more coordination of care within and across specialties to improve patient outcomes and reduce overall healthcare costs.
While LUGPA commended CMS for its efforts to develop a workable policy framework consistent with the goals of the Medicare Access and CHIP Reauthorization Act (“MACRA”), there are elements of CMS’s proposed policy that will make it difficult for independent urology and other specialty practices that have the capacity to create meaningful APMs, to participate fully in the payment system created by MACRA.
LUGPA’s comments set forth several suggestions that CMS can implement to ensure that specialty providers, generally, and integrated urology practices, in particular, are able to participate meaningfully in the MIPS, APM incentive, and other programs under MACRA. In short, LUGPA asks CMS to do the following:
- Improve the transparency of the model approval process used by the Center for Medicare and Medicaid Innovation (“CMMI”) and ensure that APMs proposed by the Physician-Focused Payment Model Technical Advisory Committee and stakeholders are reviewed and acted upon in timely fashion.
- Clarify that an APM may define a specialty-focused benchmark for purposes of becoming an Advanced APM, rather than using total Medicare costs as the benchmark, and provide certain other clarifications of the Advanced APM rules.
- Use the Center for Medicare and Medicaid Innovation (CMMI) waiver to ensure that participants in APMs that start after 2019 are not unduly discouraged from becoming Qualifying Participants.
- Provide Clinical Practice Improvement Activities that are more meaningful to urologists and other independent specialty practices, and do not allow the “topped out” rules to penalize specialty practices.
- Provide more information on how patients will be attributed to single specialty practices for purposes of measuring resource use, and how patient relationship codes will interact with the proposed primary care-focused, “two-step” attribution process.
- Withhold inclusion of Part D expenditures in CMS’ calculation of resource use.
- Exercise caution in the use of USPSTF recommendations in constructing quality measures for the MIPS.
- Remove CMS-created barriers to provider alignment and collaboration in the physician self-referral Stark law regulations, including ending CMS’ prohibition on “under arrangements” collaboration between hospitals and physician groups where tied to MIPS, CPIA or APM goals.
Proposed Part B Drug Payment Model
Member practices responded in force to the LUGPA request to contact their members of Congress to urge them to send letters to CMS to abandon plans to implement the proposed model to change the way that Part B drugs are paid. Both Republican and Democratic members of Congress submitted joint, as well as individual letters to CMS asking it to withdraw or substantially modify the proposal.
LUGPA firmly believes that this initiative, implemented without sufficient stakeholder input, will adversely affect the care and treatment of Medicare patients with complex conditions such as cancer, macular degeneration, hypertension, rheumatoid arthritis, Crohn’s disease and ulcerative colitis as well as primary immunodeficiency diseases.
In support of our position, LUGPA provided substantive comments to CMS concerning the Proposed Part B Drug Payment Model. Key LUGPA comments included:
- Opposition to a demonstration that could harm patient access to prostate cancer treatment
- Opposition to the major changes in the way that Medicare pays for costs associated with drug administration
- Objection to the model that creates clinically irrational financial incentives in drug ordering
- Identifying the failure to address essential operational considerations associated with the proposed model
- A request for the CMS withdraw the proposed rule until the Agency addresses with stakeholder input, the challenges with the proposal as currently framed
We thank LUGPA members who responded to the call to contact their members of Congress to ask them to stop implementation of the demonstration project. We continue to monitor the situation and are awaiting publication of further information about the proposed model.