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CMS' Healthcare Reform Efforts Make Waves

Deborah Abrams Kaplan
Published: Wednesday, Feb 20, 2019
Jeffrey Ward, MD

Jeffrey Ward, MD

Although some policy efforts on healthcare reform fell by the wayside when the Obama administration left office, the past 2 years under President Donald J. Trump have seen much action in this regard, making it an active time on Capitol Hill for lobbyists representing the oncology industry. The charge into healthcare reform over the past 2 years by the Centers for Medicare and Medicaid (CMS) has been spurred by the Trump administration’s blueprint, American Patients First.1 Many of these initiatives have, in turn, spawned vigorous and vigilant lobbying efforts by oncologists to ensure that any changes are not disruptive to their vision for appropriate and sustainable clinical care.

Clearly, fresh battle lines have been drawn in 2019, but the past 2 years of the reform process have involved much give-and-take, and some initiatives have been more impactful than others. Some efforts represent reformulated ideas that failed to launch successfully under previous administrations. Below is a summary of the highlights of this interplay, along with commentary from the oncology provider community.

Medicare Part B Physician Fee Schedule

One strongly contested CMS initiative in 2018 was an attempt to simplify coding and payment under the Medicare Physician Fee Schedule and Quality Payment Program. The agency sought to consolidate payment levels for evaluation and management (EM) services, a move that oncologists, among other physicians, said would result in underpayment for complex analysis. “It would have valued a case of sniffles—level 2 code—the same as metastatic breast cancer—level 5,” said Ted Okon, MBA, executive director of the Community Oncology Alliance (COA), an association of independent practices.

Table. Select Healthcare Reforms Impacting Oncology Under the Trump Administration1-10

Table. Select Healthcare Reforms Impacting Oncology Under the Trump Administration1-10 CMS reversed course and preserved the fifth, or highest, level of payment— 1 for patients with the most complex needs—and said it would consolidate the 4 lower tiers of EM into a single payment. So far, for hematology and oncology, the overall result is an estimated 1% reduction in EM payment. This is an improvement from the originally proposed 4% decrease, according to the American Society of Clinical Oncology.3
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