Heart of Health Policy

Updates on Health Policy News Affecting Practice.

The Rules Are Out: Final Medicare Physician Fee Schedule and HOPPS

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 that 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.

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 the 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.

Final 2018 QPP Rule Gets Mixed Reviews

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 >>>

“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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CMS Officially Cancels EPM and Cardiac Rehab Incentive Payment Models

The Centers for Medicare and Medicaid Services (CMS) has issued a final rule officially canceling the Episode Payment Models (EPMs) for AMI and CABG and the Cardiac Rehabilitation (CR) Incentive Payment Model and rescinding the regulations establishing these models, effective Jan. 1, 2018.

In releasing the final rule, CMS stressed that “value-based payment methodologies will play an essential role in lowering costs and improving quality of care, which will be necessary in order to maintain Medicare’s fiscal solvency” and reiterated its commitment to developing value-based models that would allow for Advanced APM participation in 2018 and beyond. “We believe that focusing on the development of different bundled payment models and engaging more providers in these models is the best way to drive health system change while minimizing provider burden and maintaining patient access to care,” the Agency stated. Read More >>>

Specifically, CMS acknowledged the comments it received on the proposed cancellation rule and noted agreement “with the premise cited by commenters that the CR Incentive Payment Model could provide an opportunity to collect evidence and may support provision of an under-utilized yet effective intervention.” However, the Agency went on to say: “Due to the manner in which the regulations guiding the cardiac EPMs were interwoven with those of the CR Incentive Payment Model, we do not believe it would be feasible to continue the mandatory CR Incentive Payment Model alone at this time since we are cancelling the EPMs and rescinding all of the associated regulations. However, as we stated in the proposed rule, as we further develop the Innovation Center’s portfolio of models, we may revisit the concept of a model with a focus on cardiac rehabilitation and, if we do, will consider stakeholder feedback.”

"We believe that focusing on the development of different bundled payment models and engaging more providers in these models is the best way to drive health system change while minimizing provider burden and maintaining patient access to care." Centers for Medicare and Medicaid Services

The ACC’s comments were among the 85 received by CMS. The College will continue to work with CMS to develop further opportunities for the cardiology community to participate in APM models. In a separate comment letter to CMS on the future direction of the Center for Medicare and Medicaid Innovation, the College outlined support for increasing participation in APMs, physician specialty models and expanding the mandate of the Physician-Focused Payment Model Technical Advisory Committee to include APMs for Medicaid and CHIP. The letter also supports models that give flexibility in cost sharing for high value services, such as cardiac rehabilitation.

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ORBITA: First Placebo-Controlled Randomized Trial of PCI in CAD Patients

“On the Scene” video interview with Peter Block, MD, FACC, and Rasha Al-Lamee, MD at TCT 2017.

Findings from the ORBITA study presented at TCT 2017 and published in The Lancet made news headline in October. As noted in this month’s Editor’s Corner, the results of this first-ever placebo-controlled randomized trial of PCI in patients with medically treated angina and anatomically and hemodynamically severe coronary stenosis, suggest PCI may not increase exercise time, compared with placebo. While study authors noted “the results are consistent with the clinical experience that patients with stable angina report symptom relief after unblinded PCI” and show “that this relief relies on both the true physical effect and the placebo effect,” others urged caution before making practice changes.

ACC.org Editor-in-Chief Kim Eagle, MD, MACC, urges caution before closing the door on PCI given the very small study and no differences in hard endpoints. “Much larger studies are needed before one could justify this approach in patients. What really matters is how patients feel and how long they survive without serious complications. A much larger study to properly address those questions is badly needed in the contemporary era.”

ACC Board of Governors Chair Hadley Wilson, MD, FACC, also urges additional studies. “Even though exercise time was not significantly improved with PCI, ischemia was reduced by objective testing, which has been correlated in findings from the COURAGE nuclear substudy and other studies with improved long-term outcomes,” he said.

Clinical Topics: Noninvasive Imaging, Stable Ischemic Heart Disease, Echocardiography/Ultrasound, Chronic Angina

Keywords: ACC Publications, Cardiology Interventions, Medicaid, Medicare Part B, Centers for Medicare and Medicaid Services (U.S.), Angina, Stable, Cardiac Rehabilitation, Motivation, Advisory Committees, Placebo Effect, Inpatients, Solvents, Outpatients, Fee Schedules, Cost Sharing, Health Policy, Prospective Payment System, Coronary Stenosis, Echocardiography

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