Value-Based Care Management Medicare Program Changes for 2020 and Beyond

Joe Bailes, MD; Gena Cook

December 2019, Vol 10, No 6 - Online First, Value-Based Care


Medicare models for value-based care in oncology started with the Oncology Care Model (OCM), which was launched in July 2016 and will run until June 2021. Value-based care is here to stay, as the Centers for Medicare & Medicaid Services (CMS) continues to develop and test more value-based models and tools through the Center for Medicare & Medicaid Innovation. CMS recently released an informal Request for Information on a proposed Oncology Care First model to succeed the first OCM. Commercial payers and state governments are also introducing their own value-based agreements with community oncology practices, hospitals, and health systems.

CMS released the final rule for calendar year 2020 Medicare Physician Fee Schedule on November 1, 2019. The rule contains specific changes to value-based care models and rules that will have a significant impact on providers.1 CMS responded to more than 42,000 comments on the proposed rule. We review changes from the final rule and some of the feedback from oncology organizations.

Changes to Come for MIPS

The final rule included significant changes to the Quality Payment Program (QPP).1 The QPP includes the Merit-based Incentive Payment System (MIPS) and the Alternative Payment Model programs. CMS proposed decreasing the weight for “quality” while increasing the weight for “cost” by 5% increments, until each category will equal 30% in 2022. In the final rule, CMS opted not to change the weights for 2020 (Figure). The decision to hold for 2020 and not finalize new weights for 2021 or 2022 is a reprieve for providers, but by law the “cost” category must be weighted at 30% for 2022. CMS will revisit these weights again in next year’s rule.1

Figure

CMS has also increased several thresholds for provider-reporting requirements.The threshold to avoid a penalty will increase from 30 to 45 points in 2020 and to 60 points in 2021. The exceptional performance threshold will increase from 75 to 85 points in 2020. Data completeness was increased from 60% to 70%. The penalty for not reporting in 2020 will be a negative adjustment of –9% compared with –7% previously.1

Preparing for Major Changes in 2021

Beginning in 2021, CMS will implement MIPS Value Pathways (MVPs) to help streamline provider reporting for the 4 MIPS categories, with a distinct set of measure options more relevant to a provider’s practice. The MVP framework is designed to simplify reporting requirements for MIPS and lead to more meaningful patient care through high-value care and low administrative burden. Consistent reporting across MVP groups by specialty or by condition will allow for performance data to be shared publicly so that patients can make informed decisions about providers. CMS set the implementation for MVPs to 2021, to allow time for feedback and collaboration with provider groups.

What Oncology Groups Are Saying

Many of the major oncology organizations responding to this section of the rule focused on similar concerns. The American Society of Clinical Oncology (ASCO) and the Community Oncology Alliance (COA) stated that the increased weight for the cost category can hurt oncologists because the cost of drugs cannot be controlled. Given such feedback, CMS decided not to move forward with weight adjustments for the “cost” and “quality” categories for 2020.

Several groups, including ASCO, COA, the US Oncology Network, and the National Comprehensive Cancer Network, stated concerns about the MVP framework that it is new and untested and should not be mandatory. Because cancer care can vary greatly by the type of cancer and the treatment protocol, MVPs must allow for nuance such as appropriate attribution and risk adjustment. CMS stated in the final rule that it plans to partner with stakeholders during the development of the MVPs.

The New Chronic Care Management Codes

Chronic care management (CCM) codes were first introduced in 2015 with the aim to reimburse providers caring for patients with chronic conditions. Providers were often already providing care to these patients between regular visits, so introducing codes to bill for these services was a pivotal moment for Medicare. CCM codes have allowed providers to bill for disease management services that are not face-to-face with patients with ≥2 chronic conditions.

However, CCM services are still underutilized. Although CMS no longer requires direct supervision of clinical staff for billing CCM codes, the incremental changes over the years have not increased utilization.

CCM Code Changes for 2020
CMS proposed several code changes for noncomplex CCM and for complex CCM services. In the final rule, CMS only introduced one additional G-code for noncomplex CCM services to account for additional time spent on care. For complex CCM services, CMS is retaining the existing Current Procedural Terminology (CPT) codes but revising the care-planning element to be interpreted as a visit in which the comprehensive care plan is established, implemented, revised, or monitored. Providers will now get reimbursed for the highly complex medical decision-making without requiring changes to the patient’s comprehensive care plan.

Remote symptom management is becoming increasingly important in cancer care. CMS finalized 2 CPT codes for chronic care remote physiologic monitoring for 2020 to account for initial time spent and an add-on code for additional time.

What Oncology Groups Are Saying
Many comments on the proposed changes to CCM codes indicate that oncology providers are supportive of new codes that allow for additional time increments, as well as the move toward better payment accuracy.

ASCO stated concerns that the G-codes introduced to replace the CPT codes have the potential for confusion and should be delayed. CMS agreed and decided to move forward with only 1 new G-code at this time.

Evaluation and Management Code Changes

CMS announced a significant reversal to its proposed evaluation and management (E/M) code changes announced in 2018.1,2 In response to last year’s comments, CMS will not move forward with the single blended rate for level 2 to 4 visits. CMS will maintain separate rates for each reimbursement level. The final rule largely contains changes that were laid out by the American Medical Association CPT Editorial Panel and will be implemented in 2021.

Details of the Rule
The new rule will still have 5 coding levels for established patients and 4 for new patients. CMS also introduced new values called Relative Value Units for office or outpatient E/M visits and an add-on new CPT code for prolonged service time. The new rule outlines changes in payments based on medical specialty, with a table detailing the impact of a decreased or increased payment. The E/M level will also be decided by the level of medical decision-making or the time spent by the reporting providers (in person or not).

What Oncology Groups Are Saying
Oncologists typically use the E/M codes at level 4 or 5, given the complex nature of oncology treatment and care, and comments received from key oncology groups indicate they are pleased with the decision to maintain separate codes, even with the removal of the level 1 code for new patients.

Radiation Oncology Model

On July 10, 2019, CMS announced the details of their proposed Radiation Oncology Model (ROM).3 CMS has spent several years exploring the best way to test payment and service delivery reform, leading to this announcement. This proposed model would test whether prospective episode-based payments across 17 different cancer types in radiotherapy would lead to cost-savings and improved patient care.

Concerns Voiced
Currently proposed as a 5-year model, the ROM could be implemented on January 1, 2020, or April 1, 2020, and end on December 31, 2024. Several major organizations raised concerns about the proposed model. The overarching concerns were:

  • The mandatory nature of the model
  • The start date of January 1, 2020.

Key voices in the commentary to this proposed model include COA, the Association of Community Cancer Centers, the American Heart Association, and the American Society for Radiation Oncology. All these organizations believe that the ROM needs significant revisions to allow for greater flexibility in requirements, as well as protections for practices to manage the risk of such an arrangement.

Next Steps
It is likely that the final rule for the ROM will be delayed, ensuring that the details are ironed out and practices have enough time to prepare. Given the public pushback so far, the final rule may push implementation to mid-2020 or later. Stay tuned.

Conclusion

As CMS continues to test new models and implement new changes around value-based arrangements, practices must invest the time and resources to prepare. Practice transformation is necessary to stay on top of these changes and ensure compliance.

Oncology practices need access to reliable data and reporting to improve the patient experience. A technology solution can help make that transformation easier, by automating certain processes and allowing clinic and practice staff to focus on their patients. People, processes, and technology are the key elements to transforming a practice successfully to handle value-­based care agreements.

Visit NavigatingCancer.com for infographics covering the changes to the 2020 Medicare Physician Fee Schedule.


References

  1. Centers for Medicare & Medicaid Services. Medicare Program; CY 2020 revisions to payment policies under the physician fee schedule and other changes to Part B payment policies; Medicare Shared Savings Program requirements…Proposed rule. November 15, 2019. Fed Regist. 2019;84:40482-41289. www.federalregister.gov/documents/2019/11/15/2019-24086/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-­fee-schedule-and-other. Accessed November 20, 2019.
  2. American Medical Association. CPT Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) code and guideline changes. 2019. www.ama-­assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf. Accessed September 15, 2019.
  3. Centers for Medicare & Medicaid Services. Radiation Oncology Model. Updated August 7, 2019. https://innovation.cms.gov/initiatives/radiation-oncology-model. Accessed September 15, 2019.