This week, attention focuses on several aspects of Medicare. CMS will delay modifications to E/M codes until 2021 thanks in large part to push back from doctors. Site-neutral payments are in the news related to Medicare along with Medicare Part B. In other news, CVS plans some testing of new programs to address chronic health conditions once its merger with Aetna finalizes. These and more in this week’s Innovation Partners BioBlog.
CMS modifies proposed changes to E/M codes, delays implementation until 2021
CMS delayed changes on Medicare codes until 2021. Doctors worried that the proposed changes could hurt revenues when they treated patients with complex medical conditions. The agency will move ahead with plans to consolidate codes for Medicare patients.
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American Hospital Association plans to sue CMS over final site-neutral payment rule
CMS finalized its 2019 Outpatient Prospective Payment System (OPPS) rule on Friday morning. The new rule will gradually institute site-neutral payments in the Medicare program over the next two years. The agency said site-neutral payments for clinic visits will lower out-of-pocket costs for beneficiaries and save the program as much as $380 million in 2019. However, the American Hospitals Association has already signaled its intent to challenge the new rule, claiming the administration overstepped its boundaries.
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HHS set to implement long-delayed 340B final rule in January
The Department of Health and Human Services issued a notice that it intended to finally implement final rule on 340B on Jan. 1, cutting off seven months of time from a previously announced July 1 start date. The rule would set price ceilings for drugs and punish pharmaceutical companies that knowingly overcharge 340B hospitals. It has been delayed five times by the Trump Administration.
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Trump administration faces uphill battle in convincing provider skeptics to back new drug pricing plan
Providers are skeptical of a new Trump Administration plan to bring down Medicare Part B prices. Similar plans from previous administrations were also derailed. The Department of Health and Human Services unveiled a new payment model called the International Pricing Index (IPI) on Thursday, saying it will lower Part B costs by aligning them with the prices paid in other countries. Medicare, at present, pays the average sales price for drugs, plus a 6% add-on fee to the provider, in Part B.
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Proposed changes to Medicare Advantage audits could put insurers on the hook for billions
The Centers for Medicare & Medicaid Services (CMS) unveiled a major change to the way it audits MA insurers that would extrapolate data generated from risk adjustment audits. Since plans are reimbursed based on each member’s sickness level, CMS uses Risk Adjustment Data Validation (RADV) audits to ensure data submitted by insurers matches the patient’s diagnoses. Unlike provider audits for traditional Medicare payments, data from RADV audits are not extrapolated. This news was buried among coverage of the new support for telemedicine and deserves scrutiny as well. A look at the additional proposed changes to Medicare Advantage.
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CVS to test stores with added health services early next year after Aetna deal closes
CVS remains hopeful that its $69 billion acquisition of Aetna will close before Thanksgiving. With that hope comes word of its proposed plans for the future. New “pilot stores” will launch centers for managing five common chronic conditions: diabetes, cardiovascular disease, hypertension, asthma, and behavioral health. Other changes coming to CVS include optimizing and extending primary care, including to expand the scope of services available at CVS’ MinuteClinics to help identify and manage chronic diseases. Additional plans are under discussion. CVS intends to launch programs at test stores to assess which ones may be the most beneficial if rolled out nationally.
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4 things you need to know about the administration’s latest Part B proposal
The Department of Health and Human Services (HHS) recently released an Advance Notice of Proposed Rulemaking regarding Medicare Part B that puts patient access to medicines and Part B at risk. Referred to as the International Pricing Index Model, the proposal would use the Center for Medicare & Medicaid Innovation (CMMI) to test a mandatory demonstration that would set U.S. prices for medicines based on the pricing policies of foreign governments. With all the ongoing conversations about this proposal, we wanted to set the record straight on a few key points. This article examines several important key points, including replacing a market-based system with government price setting, patient access issues, and more.
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