Hospital Outpatient Prospective Payment System proposed rule moves forward with site neutrality, other changes

On July 25, 2018, the Centers for Medicare and Medicaid Services (CMS) released the proposed rule for the 2019 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center Payment System (ASC), laying out proposals aimed at moving forward the Administration’s efforts on site-neutral payment policy as part of an effort to address health care spending growth.

In particular, the proposed rule includes proposed changes to payments for off-campus provider-based departments (PBDs), including a proposal that would reimburse clinic visits at non-excepted PBDs using the Physician Fee Schedule (PFS)-equivalent payment rate rather than the outpatient payment rate. In addition, CMS proposes to allow ASCs to provide a wider array of services, potentially creating a new incentive to deliver more care in non-hospital settings in certain circumstances.

Continue reading “Hospital Outpatient Prospective Payment System proposed rule moves forward with site neutrality, other changes”

CMS releases rule clearing way to move forward with risk adjustment payments and collections for 2017 benefit year for ACA exchange plans

On July 24, 2018, the Centers for Medicare and Medicaid Services (CMS) issued an Interim Final Rule that provides additional explanation around the risk adjustment methodology used for qualified health plans (QHPs) offered in Exchanges established under the Affordable Care Act (ACA). CMS is issuing the interim final rule in response to a recent federal court decision; the rule is intended to satisfy an administrative requirement in order for CMS to move forward with risk adjustment collections and payments for the 2017 benefit year.

Importantly, the interim final rule does not make any changes to the previously published Department of Health and Human Services (HHS)-operated risk adjustment methodology for the 2017 benefit year. Instead, the rule provides an additional explanation of the rationale behind the use of statewide average premium and the budget-neutral approach that CMS used to implement the program.

Continue reading “CMS releases rule clearing way to move forward with risk adjustment payments and collections for 2017 benefit year for ACA exchange plans”

CMS proposes higher performance standards for year 3 of MACRA Quality Payment Program, significant changes to part B coding requirements

On July 12, 2018, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule detailing the payment updates and policy proposals for the Medicare Part B Physician Fee Schedule (PFS) and the Quality Payment Program (QPP) under the Medicare Access and CHIP Reauthorization Act (MACRA).

As CMS moves forward with implementation of MACRA, the agency proposes raising the performance thresholds under the Merit-based Incentive Payment System (MIPS) for 2019. As a result, a greater percentage of clinicians participating in MIPS would face larger negative payment adjustments in 2021, while a lesser percentage of clinicians would qualify for an additional positive payment adjustment for exceptional performance. The proposed increase in the weight of the Cost measure in MIPS would be an additional challenge for many clinicians, especially as they work to adapt to new performance measures including measures that focus on the efficiency of care delivery in eight episodes of care.

The proposed rule would present unique opportunities for health plans as the All Payer Combination Option begins on January 1, 2019, and CMS opens up the payer-initiated process for commercial and other private payers to submit payment models to CMS for qualification as an Other Payer Advanced APM for the 2020 performance year. In addition, a demonstration project under consideration would present a unique opportunity for Medicare Advantage organizations (MAOs) who incorporate certain risk-based payment arrangements into their contracts with clinicians.

For other health care stakeholders, the higher performance standards under MIPS and the move away from fee-for-service reimbursement will present opportunities to partner with clinicians on efforts to more effectively monitor and improve performance in the Cost and Quality performance categories.

With regard to proposed coding changes under the PFS, health care provider organizations may want to consider an analysis as to how the proposed workflow and payment changes might affect them.

The proposed rule also moves forward with implementation of health care provisions of the Bipartisan Budget Act of 2018 (BBA).

The proposed rule is scheduled to be published in the Federal Register on July 27, 2018. Public comments are due to CMS by September 10, 2018.

Highlights of key provisions of the proposed rule are detailed below.
Continue reading “CMS proposes higher performance standards for year 3 of MACRA Quality Payment Program, significant changes to part B coding requirements”

MEDICAID NEWS: CMS approves first state Medicaid plan aimed at value-based purchasing of prescription drugs, rejects application for formulary restrictions; court blocks approval of Kentucky Medicaid waiver for work requirements

On June 27, 2018, the Centers for Medicare and Medicaid Services (CMS) approved a Medicaid State Plan Amendment (SPA) allowing Oklahoma to negotiate with drug manufacturers for supplemental rebates under value-based purchasing agreements. Other states have won approval for Supplemental Rebate Agreements (SRAs), but Oklahoma’s SPA is the first specifically to provide for additional rebates to be made to the state if a prescription drug falls short of negotiated clinical benchmarks.

Products covered under an SRA with Oklahoma will have preferred status on the state’s Medicaid formulary and may be placed on lower tiers of the state’s drug listings, granting exemptions to utilization management policies such as prior authorization. The updated agreement applies to drugs dispensed effective January 1, 2019.

Drugs developed and marketed by manufacturers who do not participate in the supplemental rebate program will still be available to Medicaid recipients.
Continue reading “MEDICAID NEWS: CMS approves first state Medicaid plan aimed at value-based purchasing of prescription drugs, rejects application for formulary restrictions; court blocks approval of Kentucky Medicaid waiver for work requirements”

CMS proposes increase in home health payments for 2019, lays groundwork for implementation of value-based payment provisions

On July 2, 2018, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule that would increase payments to home health agencies (HHAs) by approximately 2.1% for calendar year 2019 and outlines the implementation of policy changes included in the Bipartisan Budget Act of 2018 (BBA) that are intended to hasten the movement to value-based payments in the home health sector.

The proposed rule will be published in the Federal Register on July 12, 2018. Comments are due by August 31, 2018.

Highlights of key provisions of the proposed rule are summarized below.
Continue reading “CMS proposes increase in home health payments for 2019, lays groundwork for implementation of value-based payment provisions”

CMS issues request for information on physician self-referral policy

On June 20, 2018, the Centers for Medicare and Medicaid Services (CMS) released a request for information (RFI) seeking public input on any undue regulatory impact or burden stemming from the physician self-referral law, commonly referred to as the Stark Law.

The RFI will be published in the June 25, 2018, Federal Register. Comments are due by August 24, 2018.

Notably, the RFI follows the inclusion of a proposal in the President’s 2019 budget proposal for a broad statutory exception to the physician self-referral law for financial arrangements under alternative payment models (APMs) and a series of industry roundtables on the self-referral law convened by the House Ways and Means Committee.

Continue reading “CMS issues request for information on physician self-referral policy”

Trump Administration releases broad plan to address drug prices

On May 11, 2018, the President released the American Patients First Trump Administration Blueprint to lower drug prices and reduce out of pocket costs. The Blueprint includes a number of policy proposals focused on the way drugs are priced both in the US and globally, some of which may be achieved through regulatory changes, while others may require legislation or international trade negotiations.

Many of the ideas covered in the Blueprint echo previous policies described both in the Council of Economic Advisors (CEA) report entitled, “Reforming Biopharmaceutical Pricing at Home and Abroad,” as well as items found in the President’s Fiscal Year 2019 budget.

Continue reading “Trump Administration releases broad plan to address drug prices”

CMS issues request for information on Direct Primary Care

On April 23, 2018, the Centers for Medicare and Medicaid Services (CMS) released a Request for Information (RFI) seeking input on opportunities to create Direct Primary Care (DPC) arrangements between traditional fee-for-service Medicare, Medicaid, and Medicare Advantage (MA) plans and primary care or multi-specialty group practices. In addition to potential roles for DPC in CMS programs, CMS also requested comment on how DPC can be a part of current Accountable Care Organization (ACO) initiatives like the Medicare Shared Savings Program.

The RFI also refers to Direct Primary Care as “Direct Provider Contracting.”

Comments are due on May 25, 2018.

Continue reading “CMS issues request for information on Direct Primary Care”

CMS makes changes to electronic health records, price transparency in Inpatient Prospective Payment proposed rule

On April 24, 2018, the Centers for Medicare and Medicaid Services (CMS) released the proposed rule for the Hospital Inpatient Prospective Payment Systems (IPPS) for Acute Care Hospitals and Long Term Care Hospital Prospective Payment System (LTCH PPS) and Proposed Policy Changes and Fiscal Year 2019 Rates. The proposed rule would make updates to the payment rates for Medicare Part A services under the Inpatient Prospective Payment System, as well as rates for LTCHs paid under Medicare.

Under the proposed rule, the net increase of IPPS payments will be 3.4 percent, due in part to a 21.93 percent upward adjustment to disproportionate share hospital (DSH) payments for uncompensated care. CMS projects that LTCH PPS payments would decrease by approximately 0.1 percent in FY 2019, reflecting the continued phase-in of a dual payment rate system, which was recently extended through FY 2019 by the Bipartisan Budget Act of 2018.

Continue reading “CMS makes changes to electronic health records, price transparency in Inpatient Prospective Payment proposed rule”