ACR, Others Push for Imaging-agent Pay Fix as House Leaders Plan Hearing on Topic
By Marty Stempniak | September 14, 2023
The American College of Radiology and three other advocacy groups are urging the federal government to strengthen payment for diagnostic imaging agents. Meanwhile, leaders of the U.S. House are planning an upcoming hearing on related legislation.
ACR et al. pleaded their case to the Centers for Medicare & Medicaid Services in comments submitted to the feds on Monday. They noted that radiopharmaceuticals play an essential role in diagnosing difficult-to-pinpoint diseases such as Alzheimer’s Parkinson’s and prostate cancer.
However, the way in which the agency currently reimburses for these critical drugs is impeding care delivery, they contend.
“Diagnostic radiopharmaceuticals are not interchangeable and substitutions with conventional imaging can impact patient care,” ACR et al. wrote to Administrator Chiquita Brooks-LaSure on Sept. 11. “CMS’s decision to ‘policy package’ diagnostic radiopharmaceuticals creates a disincentive for hospitals with outpatient imaging service lines to utilize the most innovative diagnostic radiopharmaceuticals because they are not adequately reimbursed through the [outpatient prospective payment system] which impacts patient care.”
The comments come in response to a July request for comment from the agency, which is exploring the possibility of issuing separate payment for such diagnostic imaging agents. Others signing the comment letter included the Council on Radionuclides and Radiopharmaceuticals, Medical Imaging & Technology Alliance, and the Society of Nuclear Medicine and Molecular Imaging.
Bipartisan members of the U.S. House and Senate introduced companion bills earlier this year to address this longstanding issue. The Facilitating Access to Innovative Diagnostics (or FIND) Act would eliminate this obstacle by requiring HHS to issue separate payment for such imaging agents, using a per-day cost threshold of $500.
The House Energy and Commerce Committee announced Tuesday that it plans to hold a hearing to discuss the FIND Act, among other policy proposals. Slated for Sept. 19 at 10 a.m. Eastern Time, the hearing is titled “Examining Policies to Improve Seniors’ Access to Innovative Drugs, Medical Devices, and Technology.”
“Millions of Americans rely on Medicare to access lifesaving and life-sustaining treatment and care,” Committee Chair Cathy McMorris Rodgers, R-Wash., said in a Sept. 12 announcement. “Despite the importance of the program, some of its outdated policies and procedures leave many of our seniors with fewer options or unable to receive the most innovative and effective means of care.”
In their comments to CMS, the four groups contended that continued use of CMS current policy will lead to “diminished patient access” while discouraging the use of cutting-edge imaging.
“To ensure that patients have access to the best diagnostic radiopharmaceuticals in readily accessible healthcare settings, we strongly urge CMS to separately pay for diagnostic radiopharmaceuticals which exceed a specified threshold,” ACR et al. wrote. “This will ensure that patients have access to the most sophisticated diagnostic radiopharmaceuticals and receive the most medically appropriate treatment plan.”
To read more, go to Radiology Business.
Provider Groups Oppose Proposed Payment Cuts in Physician Fee Schedule
By Victoria Bailey | September 13, 2023
Provider organizations have made it clear they are not happy with the payment cuts CMS proposed in the 2024 Medicare Physician Fee Schedule (PFS). Additionally, groups have voiced concerns about proposed changes to the Medicare Shared Savings Program (MSSP), coding additions, and threshold increases in the Merit-Based Incentive Payment System (MIPS).
The American Medical Association (AMA), American Hospital Association (AHA), Medical Group Management Association (MGMA), American Medical Group Association (AMGA), and American College of Rheumatology (ACR) penned letters to CMS Administrator Chiquita Brooks-LaSure expressing their thoughts on the proposed PFS.
Opposition to payment cuts was a common theme in the letters. CMS proposed a 3.34 percent decrease to the conversion factor in 2024, reducing payment rates by 1.25 percent. Some specialties would see reimbursement increases, including internal medicine and family practices, while others would face cuts, including radiation oncology and emergency medicine.
The provider organizations said the proposed payment cuts would exacerbate workforce shortages and impact patient access to care.
“It is evident that these payment cuts are counterproductive to our shared goal of providing high-quality care to Medicare beneficiaries, and simultaneously eroding the financial sustainability of physician practices,” AMA wrote.
AHA’s letter highlighted how the reduction would hurt providers serving historically marginalized communities, especially as they continue to manage ongoing financial pressures stemming from the COVID-19 pandemic.
Similarly, MGMA called the cuts “unsustainable” and urged Congress to provide a positive update to the conversion factor in 2024.
E/M CODE G2211
CMS proposed implementing a separate add-on payment for the HCPCS code G2211. This would be used with codes for evaluation and management (E/M) visits to recognize the costs clinicians incur when longitudinally treating a patient’s single, serious, or complex chronic condition.
While most provider groups appreciated the reimbursement adjustment that accounts for clinical complexity, they requested more guidance around the change.
“For CMS to properly implement this code, the agency must further refine its utilization assumption, clarify ongoing questions surrounding utilization of the code, and share robust guidance with the provider community,” MGMA wrote.
Additionally, groups are worried about the add-on code’s impact on future conversion factors.
AMGA said it is concerned the add-on code will lead to additional across-the-board cuts, while AHA questioned the redistributive impact of the code.
To read more, go to Revcycle Intelligence.
RBMA Association Warns CMS that Specialty is Reaching a ‘Tipping Point’
By Marty Stempniak | September 13, 2023
The Radiology Business Management Association warned the federal government on Monday that the specialty may be reaching a “tipping point” in its ability to continue providing adequate access to care.
In comments submitted to the CMS chief, the trade group highlighted several concerns fueling its pessimistic outlook. Imaging volumes continue to climb due to an aging population, while the industry is still grappling with a shortage of radiologists to accommodate growth. This has forced physicians to work longer hours and read exams faster, spelling an “alarming increase in concerns over diminished interpretive accuracy and widespread accounts of radiologist burnout.”
RBMA noted that the latest proposed Medicare physician fee schedule, released in June, includes yet another reimbursement reduction to the specialty, despite these troubling trends.
“After 16 straight years of cuts to radiology this is an unsustainable environment in medicine,” RBMA Executive Director Bob Still wrote to CMS Administrator Chiquita Brooks-LaSure on Sept. 11. “There continue to be factors within medicine and radiology that point to a system that may be at a tipping point regarding access to care by Medicare beneficiaries.”
Still also highlighted an increasing volume of radiology procedures generated from CMS-funded therapeutics.
Those include Alzheimer’s treatments lecanemab and aducanumab, which are anticipated to “enormously increase MRI volumes.” Demand for cardiac CTA as a first-line imaging exam for patients with stable angina also is increasing, as is interest in interventional procedures.
RBMA believes CMS must enact an inflation-based payment increase for physicians to help counteract these trends.
“Without such an update, there is a genuine risk of providers becoming increasingly financially strained, which could lead to a further reduction in services or diminished willingness to treat Medicare beneficiaries,” Still wrote. “This would be detrimental to the Medicare program’s goal of ensuring beneficiary access to care.”
CMS was accepting feedback on the proposed 2024 Medicare Physician Fee Schedule until Tuesday. Others submitting comments included the American Medical Association, the American Hospital Association, and the Medical Group Management Association. All three echoed similar concerns about access to care and the financial strain physicians are facing.
“This negative update would pose significant risks to patients’ access to care and health systems’ financial stability, particularly for providers serving historically marginalized communities,” the AHA wrote. “Our concern is heightened by the fact that this cut is coming in the wake of over three years of unrelenting financial pressures on the healthcare system due to COVID-19, along with rising inflation, increasing input costs, and persisting staffing shortages and supply chain disruptions.”
To read more, go to Radiology Business.
Hospitals Call on CMS to Raise FY24 OPPS ‘Unrealistic’ 2.8% Pay Bump, Be Flexible on Price Transparency
By Dave Muoio | September 12, 2023
The Centers for Medicare & Medicaid Services’ (CMS’) proposed 2.8% pay bump for outpatient facilities is in the firing line for providers, who broadly urged the agency to reconsider its annual update methodology in light of prior years’ limited increases and persistent high expenses.
In July, CMS released its calendar year 2024 Outpatient Prospective Payment System (OPPS) proposed rule.
Headlining the proposal was a 3% hospital market basket increase and a 0.2 percentage point reduction reflecting required productivity adjustment as well as language locking in hospital price transparency requirements, among other updates.
In public comment letters submitted to the agency, groups including the American Hospital Association (AHA), America’s Essential Hospitals (AEH), the Association of American Medical Colleges (AAMC) and numerous state-level hospital associations each railed against the 2.8% increase as unrealistic and “insufficient.”
AHA, for instance, wrote that the bump “does not capture either the unprecedented inflationary environment or the other persistent financial headwinds hospitals and health systems are experiencing.”
Comments from the Illinois Health and Hospital Association pointed to a two-year, 4.5% to 5% increase in labor costs alone among its hospital membership. AEH cited an industry analysis from Kaufman Hall that showed a 4% increase in year-over-year hospital expenses as of June that is “not expected to abate anytime soon.”
The groups urged CMS to—within the limits of its statutory authority—reassess the data and methodology used to determine the annual market basket update.
The agency could begin by divorcing the OPPS market basket update from that of the Inpatient Prospective Payment System (IPPS) or by relying on “alternative cost data sources, such as Medicare cost report data, [that are] a truer representation of hospital-reported cost increases to support providing a market basket update of at least 5%,” AEH wrote.
To read more, go to Fierce Healthcare.
Bipartisan Legislation Seeks to Increase Healthcare Price Transparency
By Jeff Lagasse | September 11, 2023
New bipartisan legislation intended to increase healthcare price transparency and lower overall costs for patients and employers was introduced late last week in the U.S. House of Representatives and seeks to provide patients with accurate information about the cost of procedures and services.
The Lower Costs, More Transparency Act was introduced by House Energy and Commerce Committee Chair Cathy McMorris Rodgers (R-WA), Ranking Member Frank Pallone, Jr. (D-NJ), House Ways and Means Committee Chair Jason Smith (R-MO), and House Education and the Workforce Committee Chair Virginia Foxx (R-NC).
The bill requires healthcare price information from hospitals, insurance companies, labs, imaging providers, and ambulatory surgical centers, which would be compelled to publicly list the prices they charge patients in machine-readable files. In a bid to lower costs for patients and employers, it would require health insurers and pharmacy benefit managers (PBMs) to disclose negotiated drug rebates and discounts.
On the prescription drug front, it purports to lower out-of-pocket costs for seniors who receive medication at a hospital-owned outpatient facility or doctor’s office; expand access to more affordable generic drugs; and equip employers with drug price information that could help them get a better deal for employees.
Beyond that, it also claims to fully pay for investments into programs that strengthen the healthcare system, in part by funding community health centers and supporting training programs for doctors new to their communities.
It would also preserve Medicaid funding for hospitals that take care of uninsured and low-income patients and extend funding for research to find better treatments and a cure for diabetes.
To read more, go to Healthcare Finance.
Imaging Advocacy Group Hopes to Counteract ‘Dangerous Care Delays and Denials’ in PET Payment
By Marty Stempniak | September 8, 2023
An imaging advocacy group has issued a new model coverage policy, hoping to spur insurers to more consistently and correctly cover PET scans for certain indications.
The American Society of Nuclear Cardiology announced the development Sept. 7, contending that there are several clinical indications where cardiac positron emission tomography should be “universally covered” by all payer types. Leaders have compiled current clinical evidence, urging health insurers to quash “unnecessary” prior authorization requirements ASNC believes can lead to “dangerous care delays and denials.”
“Unfortunately, some payers are not fully aware of the extensive literature supporting cardiac PET in many clinical scenarios, including the newer indications for evaluating coronary microvascular dysfunction, cardiac sarcoidosis and inflammation, and cardiovascular infection,” ASNC President Mouaz H. Al-Mallah, MD, who also is director of cardiovascular PET at Houston Methodist, said in a statement. “ASNC’s new model coverage policy describes each clinical situation where a cardiac PET study is currently indicated, including symptoms, references and cross-references to the appropriate use criteria.”
A team of top authorities on the modality developed the document, which ASNC published Sept. 5 in the Journal of Nuclear Cardiology . It also details corresponding ICD-10 codes to aid referring physicians and billing staffers in seeking payment for cardiac PET.
To read more, go to Radiology Business.
NAACOS: Medicare Payment Incentives Favor Clinicians in Fee-For-Service
By Victoria Bailey | September 8, 2023
Medicare payment incentives favor clinicians participating in fee-for-service models rather than those in advanced alternative payment models (APMs), according to the National Association of Accountable Care Organizations (NAACOS).
Advanced APMS, such as accountable care organizations (ACOs), have demonstrated the ability to generate savings for Medicare and participating providers.
To help encourage accountable care, Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015, which established unified reporting systems and provided financial incentives for clinicians to join APMs.
Specifically, MACRA offered 5 percent incentive payments for clinicians in advanced APMs, which helped participants expand care teams, establish population health infrastructure, and create programs to improve care. Since MACRA was implemented, participation in advanced APMs has increased by more than 173 percent, according to NAACOS.
The 5 percent incentive payment ended in 2022 and Congress introduced a 3.5 percent extension for Performance Year 2023. Congress also provides a higher conversion factor update for clinicians in advanced APMs.
According to the NAACOS blog post, MACRA’s incentives for Payment Year 2026 and Performance Year 2024 will favor clinicians who do not participate in advanced APMs and remain in the Merit-Based Incentive Payment System (MIPS).
In 2026, MIPS clinicians will receive a 0.25 percent conversion factor update and can receive additional positive payment adjustments in MIPS. The average MIPS adjustment is typically 3 percent, meaning the total potential payment adjustment would be 3.25 percent.
Meanwhile, clinicians in advanced APMs will only receive a 0.75 percent conversion factor update. Incentives will not favor clinicians in advanced APMs again until 2032.
Despite the 3.5 percent incentive extension, the increase in MIPS adjustments calls for stronger incentives to encourage participation in risk-based payment models, NAACOS wrote. The organization urged lawmakers to support the Value in Health Care Act, which would extend MACRA’s original 5 percent incentive for two years and adjust the one-size-fits-all approach to qualification thresholds.
The blog post also noted that the $1.8 billion ACOs saved in 2022 surpasses the $644 million spent on incentives.
Congress must develop long-term solutions to incentivize participation in accountable care, NAACOS said.
Lawmakers should separate advanced APMs from MIPS and structure MIPS to incentivize participation in APMs. Additionally, they should simplify the incentive structure to account for providers serving rural and underserved populations.
To read more, go to Revcycle Intelligence.
House Leaders Reveal ‘Major’ Healthcare Bill that Includes Radiologist-opposed Imaging Services Price Transparency Act
By Marty Stempniak | September 8, 2023
Key committees of the U.S. House on Wednesday unveiled a draft package of healthcare bills, which includes the radiologist-opposed Imaging Services Price Transparency Act.
Rep. Mike Carey, R-Ohio, first introduced his proposal on July 25, hoping to better inform patients about the cost of exams provided by radiologists. If approved, the rule would take effect on Jan. 1, 2025, establishing a list of “at least 50” shoppable imaging exams for which providers must publicly disclose pricing on their websites.
The American College of Radiology opposes the focus of the bill, contending that it prioritizes pricing over quality as the primary factor in selecting imaging services. ACR believes patients also should be able to shop based on factors such as facility accreditation, whether equipment is updated and well-maintained, and the skills of radiologists interpreting their exams.
This week’s package of bills, dubbed the “Lower Costs, More Transparency Act,” also would add requirements around pricing for diagnostic laboratory tests, ambulatory surgery center services and group health plans. Other provisions would address oversight of pharmacy benefit managers and seek further insight into vertical integration in the Medicare Advantage market and provider/payer consolidation, according to a summary of the draft legislation.
“These policies will increase price transparency throughout the healthcare system, lower the cost of prescription drugs, bolster treatment and prevention programs for substance use disorders, and take care of mothers and infants,” Energy & Commerce Committee Chair Cathy McMorris Rodgers, R-Wash., and colleagues said in a blog post shared Thursday.
The House Ways & Means and Education & the Workforce committees also were involved in crafting the proposal. Republican representatives’ “major healthcare package” is expected to be pushed this fall, Politico reported Thursday. It is likely to draw opposition from hospitals and pharmacy benefit managers but could gain bipartisan support on the Hill, the news site noted.
To read more, go to Radiology Business.