• Moving toward site neutral payments for clinic visits offered under OPPS, potentially lowering the average OPPS payment by $70, aligning OPPS payment with the Physician Fee Schedule payment amount.
• Adding 12 cardiac catheterization procedures to the list of covered procedures that can be performed in an ASC.
• Updating ambulatory payment classifications (APCs) for endovascular procedures, particularly those using drug-coated balloons.
• Updating the APC structure for imaging procedures, with and without contrast, an ongoing area of review for the ACC and other societies in recent years.

The proposed rule also includes efforts to continue measure alignment for the Hospital Outpatient Quality Reporting Program and promotes interoperability and data exchange, topics that are also addressed in the 2019 proposed rules for the Hospital Inpatient Prospective Payment System and the Physician Fee Schedule.

On the Physician Fee Schedule front, the 2019 proposed rule would result in most physicians seeing a less than 0.1 percent conversion factor payment increase on Jan. 1, 2019 – keeping in mind that estimates are based on cardiovascular practice in its entirety and can vary widely depending on the mix of services provided in a practice.

CMS estimates that the physician rule will decrease payments to cardiologists by 1 percent from 2018 to 2019 due to changes in practice.

Other highlights include streamlining evaluation and management (E/M) documentation as part of an effort to reduce clinician burden; continuing implementation of the requirement ordering that clinicians consult with appropriate use criteria (AUC) through a qualified clinical decision support mechanism (CDSM) for advanced imaging services starting Jan. 1, 2020; and maintaining the payment rate for certain non-excepted off-campus provider-based departments paid under the PFS (Section 603) at 40 percent of the Hospital Outpatient Prospective Payment System rate. (Check out the August issue of Cardiology for more details.)

ACC staff are actively reviewing each of the proposed rule to identify additional topics of interest to members. The College will submit written comments to CMS in the coming months. Additional information will be available in the ACC Advocate newsletter and on ACC.org.

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• Increasing the MIPS performance threshold for avoiding a penalty to 30 points and the exceptional performance threshold to 80 points.
• Incorporating episode groups into the MIPS Cost score, including STEMI with PCI, elective outpatient PCI and revascularization for lower extremity chronic critical limb ischemia.
• Maintaining the low-volume threshold for MIPS exemption at $90,000 or less in part B allowed charges or 200 or fewer Medicare beneficiaries; adding a third exclusion for clinicians providing 200 or fewer covered professional services under the PFS; and continuing the small practice bonus. Small practice bonus points will be added to the Quality category, not the overall MIPS score.
• Allowing individuals and groups to submit MIPS data using multiple submission types per category.
• Implementing facility-based MIPS scoring that would allow “facility-based clinicians” to use the Hospital Value-Based Purchasing Program performance for the MIPS Quality and Cost categories.
• Maintaining the revenue-based nominal amount threshold for Advanced Alternative Payment Models (APMs) at 8 percent through performance year 2024.
• Requiring at least 75 percent of eligible clinicians in an Advanced APM use certified EHR technology.

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Of note, the document focuses on treating all patients with aortic valve disease and therefore all forms of treatment, including TAVR, SAVR, medical care and palliative care. It also recommends that sites incorporate shared decision-making methods and processes. Like the original document, the updated version continues to place a strong emphasis on a team-based approach for patient management.

The writing group also included a multimodal approach to quality measurement that allows the recommendations and requirements to evolve in anticipation of newer treatment modalities; expansion to younger and lower-risk populations; and emerging evidence regarding patient outcomes, cost, cost-effectiveness and durability.

In the prologue, the document points out there are no recommendations that sites failing to meet all requirements should close their TAVR-SAVR programs. “It is important to patient access that TAVR sites serving low-population density areas remain active even if they don’t meet volume requirements but can document acceptable quality,” it states.

However, the document does recommend that all sites review their quarterly outcome reports and assess if they are within national benchmarks of acceptable quality of care. “An accreditation process is one means to help ensure quality, while also providing external review of programs,” according to the expert consensus document.

In addition to the release of the updated document, the ACC on July 25 participated in a panel of the Medicare Evidence Development and Coverage Advisory Committee (MEDCAC) convened by the Centers for Medicare and Medicaid Services, to discuss procedural volume requirements for hospitals and heart team members to begin and maintain TAVR programs.

Expert consensus document co-chairs, Joseph E. Bavaria, MD, FACC, and Carl L. Tommaso, MD, FACC, summarized recommendations from the Expert Consensus document, while John D. Carroll, MD, FACC, represented the College in discussing lessons from the STS/ACC TVT Registry.

“The ACC appreciated the opportunity to participate in the MEDCAC meeting on TAVR as CMS considers changes to Medicare coverage of this life-saving therapy,” said ACC President C. Michael Valentine, MD, FACC. “The presentations by medical societies and the recently published Expert Consensus document on operator and institutional requirements support infrastructure, volume and outcome standards that ensure quality patient care.”

Feedback from the MEDCAC meeting will inform coverage changes to the TAVR national coverage determination (NCD), currently under review by CMS. On July 27, the ACC partnered with AATS, SCAI and STS to submit formal public comments to CMS regarding the NCD. The comments support using the updated Expert Consensus Systems of Care document as a framework for updates to coverage.

As part of the comments, the societies do not recommend that sites failing to meet all requirements should close their TAVR programs, particularly due to areas of low population density where access to care could be impacted.

“It is essential that all TAVR sites continue reporting data on TAVR procedures to a national registry,” the comments note. “Ongoing data collection and analysis enables quality outcome measurement. Sites should review their quarterly outcome reports to assess performance in relationship to national benchmarks.”

The ACC recognizes that continued investigation of TAVR therapy accessibility is warranted, and striking the balance between maintenance of high-quality outcomes and providing adequate access to care will need to be continually assessed with evidence.

The College will continue to collaborate with CMS and other stakeholders to further advance the field of TAVR therapy.

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