The 2019 hospital Outpatient Prospective Payment System (OPPS) and Physician Fee Schedule (PFS)proposed rules are out, and the ACCC Government Affairs Committee and policy team are hard at work analyzing the significant changes and draft comments and how they may impact our membership. Though this impact will vary depending on care setting and care delivery model, patient access to quality care is our common goal and finding a tide that raises all ships should be the focus of our recommendations to the Centers for Medicare & Medicaid Services.
Not surprising, a theme in the OPPS rule is movement toward more site-neutral payments for off-campus provider-based departments (PBDs). Specific proposed measures include:
| • | Expanding the Average Sales Price (ASP) –22.5 percent payment rate for Part B drugs to nonexempted off-campus PBDs at 340B hospitals. | ||||
| • | Reducing clinic visit payments at excepted off-campus PBDs to 40 percent of the OPPS rate. | ||||
| • | Reducing service line expansion in excepted off-campus departments so that payments in these new service lines would be at 40 percent of OPPS. | ||||
The impact of these changes could be detrimental to small, hospital-based cancer programs, particularly those in rural areas where payer mix is not as favorable and treating patients closer to home means having the ability to expand services to meet their needs. For example, I know of one hospital-based cancer program located in a rural area of Washington State with an 82 percent Medicare/Medicaid payer mix and a razor thin operating margin. This hospital needs to grow its cancer program to serve patients who would otherwise travel one to three hours for needed services. Thus, it is vital for ACCC to advocate for payment policy that maintains patient access to care—regardless of practice setting—and incentivizes both private practices and hospital-based cancer programs to eliminate disparities in patient care.
The PFS proposed rule contains several concerning changes as well. Reduction in payment for new Part B drugs from Wholesale Acquisition Cost (WAC) plus 6 percent to WAC plus 3 percent until ASP data are available could make it difficult for practices to offer new therapies for patients. Consolidation of evaluation and management codes will most likely mean lower reimbursement for specialists who see complex patients—which as we know includes most cancer care providers. Instead, a welcome change would be adequate office visit payments with decreased documentation requirements that could reduce provider burnout. Sounds reasonable, right? It reflects language that the ACCC has put forth during many comment periods.
Finally, the Centers for Medicare & Medicaid Services has proposed several changes to the Merit-based Incentive Payments System (MIPS) program. One such change will reassign the “advancing care information” category to the “promoting interoperability” category. Though we all are in favor of more interoperability, there is concern as to where the burden of ensuring interoperability will fall and how much control providers and cancer programs realistically have over ensuring interoperability.
ACCC enjoys a favorable reputation with legislative and regulatory authorities. We have a good track record of positively influencing policy, thanks to the expertise of our health policy team and dedicated Government Affairs Committee. We encourage all members to share their ideas and suggestions, to participate in policy webinars, and to become informed and active advocates for patients and themselves, so that ACCC remains the leading organization for education and advocacy for the multidisciplinary cancer team.