This week’s update includes information on our advocacy to oppose a Centers for Medicare & Medicaid Services policy allowing Medicare Advantage Plans to use step therapy for Part B covered drugs, to support several provisions of the Medicare Physician Fee Schedule on telemedicine and to support of the Good Samaritan Health Professionals Act.
Stark Law: Alliance of Specialty Medicine, AUA Urge Exemptions for those in Alternative Models
Last week, the AUA joined its colleagues in the Alliance of Specialty Medicine in signing on to a letter responding to the Centers for Medicare & Medicaid Services’ (CMS) request for information regarding the physician self-referral law, better known as the Stark law. “Some specialists have an interest in moving toward alternative models of care and delivery, yet they are unable to overcome multiple hurdles, including the Stark law,” the Alliance says in its letter. The Alliance further contends that alternative payment models (APMs) create strong incentives to protect the Medicare program and beneficiaries from unscrupulous provider behavior, as providers in these models must both improve quality and reduce resource use to avoid financial penalties and earn shared savings or bonus payments. The coalition acknowledges that “CMS recognizes the strength of these incentives to deter abuse and gaming in the Medicare program, which is why participants of several APMs were included in CMS’ recent pilot program to reduce medical record review.” Consistent with that approach, the Alliance urges CMS to exempt all participants of alternative models of care and delivery who bear financial risk from the Stark regulations.
With the push from volume to value in the Medicare system, the Administration and Congress has placed the Stark law under greater scrutiny. In a July update
, we informed you of a hearing in the House Ways and Means Committee aimed examining the effects of Stark law on alternative payment model participation. As this issue continues to develop, we will be to keep you updated on any and all changes to the Stark law and how it affects the practice of urology.
Part B Step Therapy: AUA Signs onto Letters to Congress and CMS to Rescind 2018 Memo
The AUA has partnered with the American Medical Association, Alliance of Specialty Medicine, and the Part B Access for Seniors and Physicians (ASP) Coalition to send a message to CMS: Withdraw a 2018 memo that allows Medicare Advantage Plans (MA) to use step therapy for Part B covered drugs, unless also required in Medicare fee-for-service. Each group sent letters requesting that CMS keep in place the prohibition on step therapy in Part B included in a 2012 CMS guidance. Step therapy, also called “fail first,” requires a patient to fail on one treatment before receiving the treatment recommended as the first choice by their provider.
The 2018 memo lays out a foundational change to the Part B benefit that could severely harm patient care. Additional concerns include the following:
- There is insufficient detail on key implementation requirements.
- The five-month implementation window –in which there is no formal commenting opportunity– is insufficient to ensure protection of vulnerable patients who need access to Part B medications.
- CMS describes step therapy as a “type of prior authorization for drugs that begins medication for a medical condition with the most preferred drug therapy and progresses to other therapies only if necessary.”
- This policy will undercut statutory protections, threatens timely access to life-saving medicines for patients with cancer and other serious conditions.
These letters will be delivered this week. For a copy, please contact Stephanie Stinchcomb at sstinch@AUAnet.org
Telemedicine: AUA Drafts Medicare Physicians Fee Schedule Comments
Telemedicine Workgroup co-chairs Drs. Eugene Rhee and Aaron Spitz, Regulatory Workgroup chairs Drs. Josh Langston and CJ Stimson, Coding and Reimbursement Committee Chair Dr. Jonathan Rubenstein, AUA CPT Advisor Dr. Ron Kaufman and Regulatory Workgroup member Dr. Matthew Gettman prepared draft comments on three provisions of the Centers for Medicare & Medicaid Services’ (CMS) Medicare Fee Schedule Proposed Rule: Non face-to-face communication to assess whether the patient needs an office visit (Virtual Check In), Remote Evaluation of Pre-Recorded Patient Information, and the Interprofessional Check In. Over the next week, AUA policy analysts and certified coders will be finalizing comments with your policy leadership. Read a preview of our comments.
Medical Liability Reform: Contact Your Senators Now
The AUA currently is running a grassroots campaign
to urge support of the “Good Samaritan Health Professionals Act” (S. 781). The request is to have the bill included in the Pandemic and All-Hazards Preparedness Reauthorization Act (PAHPA). The Good Samaritan Health Professionals Act would help ensure patients have access to vital, on-site medical services in the wake of a natural or man-made disaster. Adopting the Good Samaritan legislation would help protect medical volunteers from lawsuits during a large-scale disaster or national emergency.
We are asking that you please contact your Senators and ask them to cosponsor S. 781, the Good Samaritan Health Professional Act, and to support including this bill language in the PAHPA. Learn more about the campaign.
Research Advocacy: AUA Coalition Activity and Appropriations UpdateOn June 12
, we informed you that the Senate markup of the fiscal year (FY) 2019 National Defense Authorization Act (NDAA) did not contain threatening language that would harm the Congressionally Directed Medical Research Programs (CDMRP) and other medical research conducted by the U.S. Department of Defense. This was a relief to the medical research community, as the insertion of damaging language that would have essentially prohibited medical research on diseases and disorders that affect our nation’s men and women who serve or have served in uniform, including prostate, kidney and bladder cancers was attempted in previous years.
On August 23, the Senate approved the Labor, Health and Human Services (LHHS)/Defense minibus package that contained no damaging amendments offered to the CDMRPs, which is good news as the programs remain intact heading to conference with the Senate. No additional actions are expected until both the House and Senate are back in session after Labor Day.
The Senate voted and approved H.R. 6157, the combined Department of Defense and LHHS Appropriations bills. As a reminder, the Senate Fiscal Year (FY) 2019 LHHS bill includes a $2 billion funding increase for the National Institutes of Health and a $190 million funding boost for the National Cancer Institute. The bill also preserves funding for Centers for Disease Control (CDC) cancer programs with an additional $2 million going to cancer registries. The bill also preserves current funding levels for other programs at the Division of Cancer Prevention and Control (DCPC) at the CDC.
It is still unclear what the House plans to do on LHHS when they return in the fall. As a reminder, the full House Appropriations Committee approved their bill in July but it has yet to be considered on the House floor. Ideally, the House will pass its version, and then the House and Senate will be able to conference their bills quickly in September.
Insurance Updates: Week of August 27, 2018
Each week, the AUA publishes weekly updates on the lasted insurance issues pertaining to urology. This week’s update includes information on the new coverage article for Rezum System from CGS Administrators as well as an update on Palmetto GBA’s ConfirmMDx Epigenetic Molecular Assay (L35632). Read more here.