Heart of Health Policy

The Rules Are Out: Final Medicare Physician Fee Schedule and Hospital OPPS

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The Centers for Medicare and Medicaid Services (CMS) released final rules on both the 2018 Physician Fee Schedule (PFS) and the Hospital Outpatient Prospective Payment System (OPPS).

Under the PFS rule physicians will see a less than 0.1 percent conversion factor payment increase on Jan. 1, 2018. CMS estimates the rule will increase payments to cardiologists by one percent from 2017 to 2018. It also pushes implementation of the Appropriate Use Criteria mandate from 2018 to 2020, among other changes. Read More >>>

“The ACC is pleased to see CMS finalize the requirement that clinicians consult with appropriate use criteria (AUC) for advanced imaging services starting in 2020 as an educational year, rather than 2018. The College hopes that CMS will continue to work with stakeholders to ensure that the AUC program supports improved, cost-effective patient care without excessively burdensome requirements,” said ACC President Mary Norine Walsh, MD, FACC. “The ACC is committed to the use of AUC in clinical decision-making and is pleased to see that CMS is providing additional time to prepare for this program.”

Under the OPPS rule, CMS estimates an overall 1.4 percent payment increase for services paid in 2018. CMS listened to several recommendations made by your ACC including: maintaining the current ambulatory payment classification structure for imaging procedures; avoiding cuts to cardiac MR and contrast echocardiography; and the addition of AMI PCI to the inpatient-only list to alleviate two midnight rule challenges.

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FDA Update Coincides With Release Of New Data From ABSORB Studies

JACCThe U.S. Food and Drug Administration (FDA) issued an updated letter informing health care providers of increased rates of major adverse cardiac events in patients receiving the Absorb GT1 bioresorbable vascular scaffold (BVS) based on latest findings from the ABSORB III three-year and ABSORB IV 30-day analyses, presented at TCT 2017. Study results showed BVS was associated with significantly more target lesion failure (TLF) and other adverse events when compared with the everolimus-eluting stent (EES).

ABSORB III, also published in the Journal of the American College of Cardiology, evaluated clinical outcomes over three years in 1,322 patients implanted with BVS and 686 patients implanted with EES. Read More >>>

At one year, BVS was non-inferior to EES. At three years, the primary endpoint of TLF had occurred in 13.4 percent and 10.4 percent of BVS and EES patients, respectively (p = 0.06). Target vessel failure (TVF) and the composite of all death, all myocardial infarction (MI) or all revascularization through three years occurred more frequently with BVS than EES. BVS vs. EES implantation was an independent predictor of TLF and device thrombosis through three years.

ABSORB IV was conducted in an expanded patient population in which small vessels were avoided and aggressive pre-dilatation and routine high-pressured post-dilatation were encouraged. Patients were randomized to BVS or EES (1,300 per arm). The primary endpoints were TLF at 30 days (non-inferiority) and TLF between three and seven to 10 years (pooled with ABSORB III).

At 30 days, TLF occurred in 5.0 percent and 3.7 percent of BVS and EES patients, respectively (p = 0.11). In BVS patients vs. EES patients, the rate of TVF was 5.1 percent and 3.7 percent (p = 0.07); composite of death, MI and revascularization was 5.2 and 4.1 percent (p = 0.17); and device thrombosis was 0.6 percent and 0.2 percent (p = 0.06).

The FDA continues to recommend that health care providers: Follow the instructions for target heart vessel selection (e.g., avoid BVS use in small heart vessels) and optimal device implantation per BVS physician labeling; Advise patients experiencing new cardiac symptoms such as irregular heartbeats, chest pain or shortness of breath to seek clinical care; Advise BVS patients to follow recommendations for dual antiplatelet therapy as prescribed; Report adverse events related to BVS through MedWatch.

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Final 2018 QPP Rule Gets Mixed Reviews

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The Centers for Medicare and Medicaid Services (CMS) this month released the 2018 Medicare Quality Payment Program (QPP) final rule, addressing participation requirements for 2018 and future years under the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (Advanced APM) pathways. Policies under the final rule go into effect Jan. 1, 2018, the start date for Year Two of QPP.

The second year of QPP is intended to provide clinicians with one more year to prepare for a more robust program in the third year. Based on 2018 performance, clinicians and groups will be eligible to receive a bonus of up to +5 percent or higher based on budget neutrality or a –5 percent penalty on Medicare Part B services provided in 2020 under MIPS. Qualifying participants in an Advanced APM will continue to be eligible to receive a five percent lump sum bonus. Read More >>>

Additional highlights of the final rule include:

  • MIPS Cost will begin to count toward the MIPS composite score in the 2018 Performance Year/2020 Payment Year. The MIPS category weights for most clinicians are finalized as:
    • 50 percent weight for Quality, a decrease from 60 percent in 2017.
    • Maintained 25 percent weight for Advancing Care Information; clinicians can use 2014 or 2015 certified electronic health record technology (CEHRT), with a bonus for using only 2015 CEHRT.
    • Maintained 15 percent weight for Improvement Activities.
    • 10 percent weight for Cost based on total per capita costs for all attributed beneficiaries and the Medicare Spending per Beneficiary (MSPB) measure. CMS will not use episode-based cost measures in 2018.
  • MIPS composite score performance threshold for avoiding a penalty set at 15 points, an increase from the three-point threshold for the 2017 performance year.
  • Implementation of bonus points to recognize improvement in the Quality and Cost performance categories.
  • Up to five bonus points available to recognize clinicians who treat complex patient populations, based on a combination of Hierarchical Condition Categories (HCCs) and the dual eligible population treated.
  • Continued flexible participation requirements for MIPS/APM participants.
  • Finalized increase in the low-volume threshold to less than or equal to $90,000 in Medicare Part B allowed charges or less than or equal to 200 Part B patients.
  • Additional assistance for small practices (equal to or less than 15 MIPS-eligible clinicians) including bonus points to the final MIPS composite score and credit for quality measures submitted below data completeness standards.
  • Implementation of virtual groups starting in 2018, allowing small groups and solo practitioners under two or more taxpayer identification numbers to participate in MIPS as a single group. Registration for virtual group participation is open through Dec. 1, 2017.
  • Continued recognition of qualified clinical data registries like the NCDR PINNACLE Registry and Diabetes Collaborative Registry MIPS data reporting options.

Advanced APMs

  • Maintained nominal risk and qualifying participant thresholds for the Advanced APM pathway.
  • Implementation of the ‘All-Payer Combination Option’ for the Advanced APM pathway starting in the 2019 performance year. CMS confirmed that Medicare Advantage models will apply to the All-Payer option and will not be counted toward Medicare A-APM qualifying status.
  • CMS maintains the current definition of Physician-Focused Payment Models to only include payment arrangements where Medicare is a payer.

“Much work remains to be done to ensure these programs are implemented in a way that encourages high-quality patient care without needlessly burdening clinicians. It is encouraging to see CMS recognize 2018 as another learning year for clinicians. However, the College is disappointed to see CMS incorporate cost into the 2018 performance year MIPS score while so much is still being done to develop reliable measures in this area. We anticipate working further with CMS to ensure that the addition of this category does not negatively impact clinicians or patient care,” said ACC President Mary Norine Walsh, MD, FACC.

The ACC will continue to review the final ruling and develop educational resources on the reflected changes for the 2018 performance year. QPP updates will be in focus at ACC’s Cardiovascular Summit, Feb. 22 - 24, in Las Vegas, NV. Continue to watch ACC’s MACRA Hub (ACC.org/MACRA) for instruction on 2017 participation and forthcoming information on the 2018 requirements.

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Clinical Topics: Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and Imaging, Echocardiography/Ultrasound

Keywords: ACC Publications, Cardiology Magazine, Medicare Part B, Medicare Part C, Centers for Medicare and Medicaid Services (U.S.), Motivation, Inpatients, Research Design, Drug-Eluting Stents, Absorbable Implants, Area Under Curve, Dilatation, Outpatients, United States Food and Drug Administration, Medicaid, Fee Schedules, Thrombosis, Myocardial Infarction, Chest Pain, Patient Care, Registries, Electronic Health Records, Diabetes Mellitus, Echocardiography, Prospective Payment System, Dyspnea


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