Marilyn Tavenner
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201
Re: CMS-1600-P:
Medicare Program; Revisions to Payment Policies under the
Physician Fee Schedule, Clinical Laboratory Fee Schedule
& Other Revisions to Part B for CY 2014
The undersigned organizations representing cancer
patients, physicians and other health care providers, and
researchers appreciate the opportunity to comment on the
proposed rule that addresses Medicare Part B payment
policies for calendar year 2014. We share the
goal that the payment system should encourage quality
improvement, foster innovation in care delivery, preserve
beneficiary access to care, and protect the Medicare
program for the long term.
“Misvalued Services” and Payment Limits
The Centers for Medicare & Medicaid Services (CMS) has
recommended that payment for a number of services provided
in the physician office or other non-facility settings be
capped at the rate of payment for those services in the
outpatient prospective payment system (OPPS) or ambulatory
surgery center (ASC). For certain of these 200+
services, the cap will result in significant reductions in
the rate of payment in the physician office beginning in
January 2014.
CMS indicates that it has identified these codes as
“misvalued” because the total payment for the service when
furnished in a physician office or other non-facility
setting exceeds the total Medicare payment when the
service is furnished in a hospital outpatient department
or ambulatory surgery center. The agency expresses
the position that OPPS or ASC data are more reliable than
physician office data and agency decisions should be based
on those data. CMS also states that it would
generally expect payments to facilities to be greater,
because of the greater overhead costs and more significant
regulatory requirements that hospitals must
meet. The agency uses assertions about the
reliability of hospital cost data and the expectation of
higher payments in facilities to justify its proposal to
cap payments for certain codes, a proposal that will
reduce payments for care in the physician and non-facility
setting.
We are not persuaded by the agency’s attempts to justify
its payment capping proposal. CMS does not make an
effective case for the greater reliability of hospital
data. Neither does the agency offer a logical
explanation for its decision to limit payments for
services in the physician office. Instead, CMS has
identified those codes for which payments in the physician
office are greater than in the OPPS, while acknowledging
that this is not generally the case, and proposed to
adjust those payments.
If a “site neutral” payment plan is implemented in the
piecemeal fashion that CMS has proposed through its caps
on payments, there is potential for disruptions in care
and increases in patient cost-sharing burdens. The
payment caps in the proposed rule for 2014 would have a
significant impact on pathology, radiation oncology, and
laboratory services that are important for cancer
patients. We are concerned about the possibility
that access to quality cancer care will be negatively
affected if the 2014 proposal is finalized, but we have a
more fundamental concern about the manner in which CMS is
seeking to make these payment adjustments. We do not
dispute that payment adjustments may be appropriate in
some cases, but we are not persuaded by the reasoning for
the limits on payments for more than 200 codes in 2014.
Complex Chronic Care Management Services
We are pleased that CMS has encouraged a number of
experiments, demonstrations, and reforms that facilitate
care planning and coordination and has also sought changes
to the physician fee schedule that will encourage care
planning and coordination. In earlier comments, we
commended the agency proposal for transitional care
management codes that were implemented on January 1,
2013. These services may provide cancer patients
discharged from acute care facilities access to care
planning and coordination that will improve their
survivorship care and the monitoring and treatment of late
and long-term treatment effects. In our comments on
the 2013 fee schedule proposal, we
urged that specialists be permitted to bill for these
services and also noted that many cancer patients would
not be eligible for transitional care management.
CMS has taken another important step in care management by
proposing, for implementation in 2015, a new code for
non-face-to-face complex chronic care management
services. This recommendation represents an
acknowledgement of the amount of time and the
comprehensive and complicated coordination and planning
services that are required – outside the scope of
evaluation and management (E/M) services – to manage
patients with multiple complex chronic conditions.
We believe that many cancer survivors will qualify for and
benefit from this service. Cancer is increasingly a
chronic disease, and many cancer patients have other
chronic conditions in addition to their cancer diagnosis.
The agency has proposed aggressive standards for billing
for the complex chronic care management service, including
use of certified electronic health records, use of written
protocols in delivery of services, consent from the
patient for care management, and provision of the annual
wellness visit in advance of the complex chronic care
management service. We urge that these standards be
carefully evaluated in the year before implementation of
the new service to ensure that they do not create
obstacles to the utilization of the care management
service.
We recommend that CMS complement the complex chronic care
management service with establishment of a cancer care
planning and coordination service. This service
would be available to cancer patients after diagnosis to
facilitate informed treatment decision-making, encourage
detailed planning of active treatment and palliative care,
and ensure coordination of all providers and elements of
care. In addition, this service could replace the
annual wellness visit as a prerequisite for the complex
chronic care management service. The cancer care
planning service will enable the practitioner to capture
the information – including the patient’s current health
care providers and an assessment of the patient’s health
status and health care needs – for complex chronic disease
management.
We believe, based on the experience of oncologists and
cancer centers that have pioneered the practice of cancer
care planning and coordination, that this service will
improve health care for the individual and rationalize the
use of cancer care resources. It will also
contribute to the success of the complex chronic care
management service.
We appreciate the opportunity to comment on the proposed
update of the physician fee schedule for 2014. We
look forward to working with the agency on additional
cancer care delivery and payment reforms.
Sincerely,
Cancer Leadership Council
American Society for Radiation Oncology
American Society of Clinical Oncology
Bladder Cancer Advocacy Network
CancerCare
Cancer Support Community
College of American Pathologists
Fight Colorectal Cancer
International Myeloma Foundation
Kidney Cancer Association
The Leukemia & Lymphoma Society
LIVESTRONG Foundation
Lymphoma Research Foundation
National Coalition for Cancer Survivorship
National Lung Cancer Partnership
Ovarian Cancer National Alliance
Prevent Cancer Foundation
Sarcoma Foundation of America
Susan G. Komen Advocacy Alliance
Us TOO International Prostate Cancer Education and Support
Network