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Expert Advises Physicians on What to Expect From Medicare in 2016

Surabhi Dangi-Garimella, PhD
Speaking at the 42nd annual meeting of the Association of Community Cancer Centers, Cancerscape, held in Washington, DC, Lindsay Conway, MSEd, managing director, Advisory Board Company, brought the oncologists in the audience up to speed on Medicare’s reimbursement strategies for the coming year.

“Our team takes up strategic and operational issues that our members view as problematic and seek our advice on,” said Conway, adding that the issues could range from reimbursement to financing.

The following is an outline of the tips Conway provided:
  • Drug payment will hold at average sales price (ASP) + 6% for 2016. However, this may not hold true for prescription drugs covered under the Medicare Part B program. CMS has announced plans to test a model with a lower add on payment for Part B drugs by the end of the year.
  • Biosimilars could potentially lower cost of care for Medicare, and the margin of payment would stay the same for providers, Conway said.
    • Reimbursement would be ASP of biosimilar + 6% add on of reference product.
“Oncologists need to be aware that nearly 700 cancer-related biosimilars could hit the market in the near future,” Conway said, and there’s no escaping this new therapeutic option. She did agree that current barrier seems to be physician awareness about a biosimilar product and their confidence with replacing the reference molecule with the biosimilar.

  • While reimbursement is fixed for radiation therapy, overall, the more complex radiation therapy modalities are seeing a modest increase, while the less complex are seeing slight cuts in payments.
  • Reimbursement for lung cancer screening has begun in 2016. This follows the release of coding and billing instructions by CMS in November 2015. “This means hospitals and clinics can find it financially sustainable to offer lung cancer screening,” Conway said.
  • Hospital outpatient departments will be the testing grounds for new oncology-specific measures, Conway told the audience. This would fall under the umbrella of physician quality reporting system.
  • Come 2017, patient-surveys would be wide spread. While CMS is yet to finalize its decision on which survey would be used, Consumer Assessment of Healthcare Providers and Systems or CAHPS survey is being considered in the cancer realm. The CAHPS survey is an 85 question tool that includes 5 main domains: effective communication, shared decision making, patient self-management, access, and technical communication.
  • Medicare Access and CHIP Reauthorization Act (MACRA) and physician payment stability. Following repeal of the sustainable growth rate patchwork formula, a 0.5% annual increase in physician payment is expected through 2019. MACRA, the SGR replacement, helps hardwire risk-based payments for providers via 2 tracks:
    • Merit-based incentive model system
    • Advanced alternate payment models (APM)
“CMS still has to iron out the details, such as performance categories, provider payment, interchange between the 2 tracks, APM participant qualification criteria, etc.” added Conway.

She ended her review on a high note, speaking to CMS’ decision to reimburse providers for the time they spend on advance-care planning (ACP) discussions with their patients. “CMS has said that all primary care physicians and advanced practitioners should be eligible for ACP conversations with their patients,” Conway said.

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