ASCO Asks CMS to Revisit Its Payment Policy to Support Optimal Cancer Care

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Julie M. Vose, MD, MBA, FASCO

ASCO has called on the Centers for Medicare & Medicaid Services (CMS) to reconsider revisions to payment policies that could be administratively burdensome to oncology practices and result in reimbursement that inadequately supports optimal cancer patient care.

In a comment letter to CMS on the Proposed Rule for the Medicare Physician Fee Schedule, ASCO makes 23 specific recommendations that focus on patient care, physician payment, quality of care, and other important issues.

ASCO raises concerns, specifically, about changes in rules on “incident to” billing, the methodology used to identify potentially misvalued reimbursement codes, the elimination of the cancer staging measure in the CMS quality reporting system, and new requirements for chronic care management.

“CMS payment policies should support this nation’s transition to a healthcare system that provides high-quality, high-value cancer care for all patients with cancer,” said ASCO President
Julie M. Vose, MD, MBA, FASCO. “We believe that many of the proposed 2016 fee schedule policies will be foundational to changes planned for 2019 and beyond. We strongly encourage CMS to implement policies that move us closer to the agency’s own stated goals for transforming the cancer care delivery system—rather than creating barriers.”

ASCO Concerns and Related Recommendations ‘Incident To’ Billing

ASCO Recommendation: CMS should not implement its proposal to change the incident to rules without clarifying that the ordering physician may differ from the supervising physician for chemotherapy administration.

Background: Modern oncology practices treat patients by working as integrated teams in which oncologists often supervise several clinical sites, and ASCO notes that it would be extremely disruptive, counterproductive, and inefficient to require the same physician both to order and supervise “incident to” services, such as chemotherapy administration. Yet, under the new CMS rule, the billing physician must be the person who supervises auxiliary personnel who are performing “incident to” services. The rule further eliminates language that permits an ordering and supervising physician to be different providers. ASCO is concerned this may cause ambiguity and compliance difficulties for oncology practices in providing efficient cancer treatment.

Potentially Misvalued Codes

ASCO Recommendation: CMS should use methodologies other than the “high expenditure by specialty screen” to identify potentially misvalued codes. 

Background: By law, CMS must reduce expenditures by revaluing misvalued reimbursement codes in order to meet targeted cost savings and avoid across-the-board reimbursement cuts. In 2015, CMS added the “high expenditure by specialty” screen for identifying services that are potentially misvalued. According to ASCO, the methodology proposed by CMS is overly inclusive, fails to target codes that are likely to be misvalued, and places unnecessary administrative burdens on CMS staff and medical societies. ASCO is also concerned that the CMS-proposed rule specifically lists a number of chemotherapy administration codes as being potentially misvalued. Reducing reimbursement for these codes would leave practices with fewer resources for providing chemotherapy to patients who need it, ASCO contends. 

Furthermore, ASCO recommends that CMS keep the Refinement Panel—a group of medical professionals who help CMS determine the value of CPT codes—as an additional way to evaluate codes. Public comment does not replace the independent and reasoned consideration of a diverse set of medical professionals, notes ASCO.

Cancer Staging Measure

ASCO Recommendation: CMS should not finalize its proposal to eliminate the cancer staging measure from registry reporting in the Physician Quality Reporting System (PQRS). ASCO urges CMS to retain this measure and consider refining it to apply only to a period of time following the initial office visit. 

Background: ASCO asserts that CMS has wrongly determined that the cancer staging quality reporting measure does not add clinical value to PQRS. The cancer staging measure is clinically important to PQRS, because capturing a patient’s initial treatment stage is critical for providers to assess prognosis and appropriate treatment options, and it is one of the few oncology-specific measures in a system that lacks adequate measures of high-quality cancer care. 

Chronic Care Management

ASCO Recommendation: Chronic care management (CCM) services have the potential to provide meaningful opportunities to improve oncology care management and lower Medicare’s overall expenditures. CMS should continue to focus resources on providing beneficiaries with access to medical advice and eliminating counterproductive administrative burdens on providers that hamper patient access.

Background: According to ASCO, oncologists have been undermined while trying to implement CCM services by overly burdensome and confusing administrative requirements and a limitation permitting only one provider to deliver CCM services to a Medicare beneficiary, unnecessarily limiting patient access to these important services. The care of individuals with cancer is complex and often includes managing multiple comorbidities by multiple providers. ASCO also notes that current CMS policy does not ensure that the most appropriate physician is receiving CCM reimbursement, and that reimbursement levels are inadequate to support compliance with all requirements, including having adequate health information technology, providing 24/7 beneficiary access, providing nursing staff, and covering related overhead costs.

Other Recommendations

Valuation of Radiation Oncology Services: ASCO advises CMS to be more prudent about developing policies on radiation oncology reimbursement and urges the agency not to finalize its proposed policies that would threaten patient access to radiation oncology services, especially in community-based settings.  

Implementing Policies That Ensure Fair and Adequate Reimbursement for Biosimilars: ASCO supports fair and adequate reimbursement of biosimilar biological drugs to promote patient access to all medically necessary options for treating cancer. Biosimilars are an important tool in cancer treatment, and supporting patient access to these drugs through adequate reimbursement may result in lower out-of-pocket costs for Medicare beneficiaries who are treated with biosimilars and for the Medicare program as a whole. ASCO recommends that CMS establish and revisit its reimbursement policies with an emphasis on supporting patient access while incentivizing biosimilar development, innovation, and cost-effectiveness.

Common Ground in the Proposal 

ASCO also highlights three specific areas in which the Society supports the CMS proposed physician fee schedule proposal, but recommends additional efforts that are needed:

Reimbursement for Advance Care Planning

As oncologists are key sources of information for end-of-life care and planning, ASCO strongly supports the CMS proposal to provide reimbursement for advance care planning. ASCO also applauds the CMS proposal for allowing patients to receive advance care planning services from more than one provider, permitting beneficiaries to seek advice from multiple medical professionals before making decisions regarding complex clinical issues. The Society recommends, however, that CMS issue clear and comprehensive guidance at the national level to avoid geographic disparities in Medicare beneficiary access to advance care planning.

Cognitive Work

ASCO is encouraged by CMS’s acknowledgement that resources are scarce for some specialists who perform extensive planning and critical thinking about the individual chronic care needs of particular subsets of Medicare beneficiaries, and recommends that CMS establish new codes and payments for cognitive services performed in oncology care in a way that promotes high-quality, high-value treatment. ASCO further notes in its comment letter that medical oncology care “requires extensive cognitive work that is not captured by the face-to-face patient encounters and drug administration services that the current, outdated system recognizes.” Cognitive services, including treatment planning and monitoring, are critical to cancer patients because these services improve the quality of care, avoid costly complications and interventions, and promote efficient clinical management of comorbidities.  

Improving and Measuring Quality and Value

In responding to the CMS request for comments on the implementation of the Merit Based Incentive Payment System, ASCO urges CMS to place emphasis on improving healthcare quality through measures that are specifically “tailored to oncology specialists’ day-to-day practices”, as opposed to requiring adherence to measures outside cancer care providers’ scope of practice. The Society encourages CMS to continue to use and further integrate into Medicare’s quality reporting programs qualified clinical data registries, such as ASCO’s Quality Oncology Practice Initiative (QOPI), the nation’s leading quality measurement and quality assurance program for medical oncology care.

Alternative Payment Models

In its comment letter, the Society also calls on CMS to implement and evaluate, as soon as possible, the ASCO Patient-Centered Oncology Payment model, which promotes access to the full range of services needed by individuals with cancer, reduces overall expenditures, and fosters high-quality care. ASCO asserts that the Patient-Centered Oncology Payment model “provides an effective pathway for medical oncologists to participate in alternative payment models in 2019,” as called for and defined under the Medicare Access and CHIP Reauthorization Act of 2015. 

The CMS Center for Medicare and Medicaid Innovation is currently implementing its Oncology Care Model in an effort to explore specialty-specific payment models. ASCO notes, however, that the Oncology Care Model has significant shortcomings that the Patient-Centered Oncology Payment model can address, and that CMS “should avoid a narrow approach that only tests one model for improving oncology care. Testing the Patient-Centered Oncology Payment model alongside the Oncology Care Model would provide the Innovation Center with comparative data on the two models, as well as significantly increase participation by oncologists in [alternative payment models],” writes Dr. Vose.

The proposed 2016 Medicare Physician Fee Schedule is the first opportunity for CMS to gather feedback on the changes in physician payment policy rising from the Medicare Access and CHIP Reauthorization Act. ASCO has devoted considerable resources to developing oncology payment and quality assurance models that improve care coordination and management and promote high-quality, high-value practices in oncology care. The end products of these efforts are Patient-Centered Oncology Payment, QOPI, and CancerLinQ. These innovative programs, notes ASCO, provide CMS with a roadmap for transforming oncology payment policies as required by the Medicare Access and CHIP Reauthorization Act and should be included in the final 2016 Medicare Physician Fee Schedule.   

Review all 23 ASCO recommendations to CMS in the full-text comment letter at ■