Practice Manager Insider

Physicians Unfamiliar with Part D Formularies, Kaiser Survey Says

A national survey about perceptions of and experience with the Medicare Part D formulary reports that 59% of physicians with at least a few patients enrolled in the drug benefit rarely or never check their patients’ formulary when prescribing. This finding comes from an evaluation conducted last spring and early summer by the Kaiser Family Foundation. The organization surveyed 834 randomly selected office-based physicians and separately conducted a similar study of 802 pharmacists. A total of 69% of physician respondents said that they are “not too familiar” or “not at all familiar” with their patients’ drug formularies.

Other findings suggest that Medicare formularies influence prescribing choices. Nearly half (46%) of physician respondents said that they have talked to a patient about switching from a brand to a generic drug in order to save money under a Medicare drug plan.

Pharmacists reported that access problems surface when patients attempt to fill prescriptions. Two-thirds (67%) of responding pharmacists said that customers have left the pharmacy without a medication because the prescribed drug was not on their Medicare drug plan’s formulary. Nearly 6 in 10 (58%) of pharmacists said that customers have paid out-of-pocket for their drugs due to inability to verify whether the customer was enrolled in a Medicare drug plan. Nearly half of pharmacists (49%) reported having customers leave without a prescription because they could not afford the co-pay charged under the Medicare drug plan.

On the whole, Part D received mixed reviews. An overwhelming majority of respondents in both groups said that the Medicare drug benefit is too complicated (91% of pharmacists, 92% of physicians). Among physicians, less than half said that Part D works “very” or “somewhat” well for lowering patients’ out of pocket costs (42%) or for helping patients gain access to needed prescription drugs (43%).

http://www.kff.org/kaiserpolls/pomr090706nr.cfm

http://www.kff.org/kaiserpolls/upload/7554.pdf

OIG to Congress: CMS Oncology Demonstration Data Are Unreliable

A highly critical report from the Department of Health and Human Services Office of Inspector General (OIG) characterizes data from the Medicare 2005 chemotherapy demonstration project as unreliable due to inconsistent data collection methods. The 12-month-long project is on track to cost about $275 million, making it by far the most expensive research program undertaken by the Centers for Medicare & Medicaid Services (CMS). Because CMS did not waive the 20% beneficiary coinsurance, patients paid about $55 million of the project’s cost. The OIG analyzed demonstration project claims that CMS had received through the end of 2005.

Under the 2005 demonstration project, office-based physicians could bill $130 for visits at which a patient received chemotherapy by infusion or push for a cancer diagnosis—if the office reported an assessment of the patient’s nausea and vomiting, pain, and fatigue. Demonstration project codes described on a 4-point scale the degree to which the beneficiary experienced each of these 3 conditions.

A major reason for the unreliability of the data is that CMS did not specify how to collect information. Therefore, oncology practices used varying methods. This limits the usefulness of the data. For example, one nurse told the OIG that if a patient had vomited several times in the past week but was feeling fine on the date of the assessment, then she would report the lowest level of nausea and vomiting. Another practitioner legitimately could choose to report the highest level, based on the patient’s symptom during the prior week.

CMS did not require participants to document demonstration assessments in the patient’s medical record. Therefore, CMS cannot verify the accuracy of the data. CMS provided no list of valid diagnostic codes for the demonstration; lists developed by carriers varied.

The OIG also found that Medicare overpaid $17 million in demonstration claims because of issues such as duplicate billings, reimbursements for demonstration activities not performed concurrent with chemotherapy, and payments for services associated with patients not diagnosed with cancer.

http://oig.hhs.gov/oei/reports/oei-09-05-00171.pdf

Medicare To Beneficiaries: Here’s How to Reimburse Us

The Centers for Medicare & Medicaid Services (CMS) mistakenly issued refund checks to about 230,000 Medicare beneficiaries in August, and is now trying to get the word out about how to repay the government. Refunds occurred due to a computer glitch and totaled $50 million, according to the San Francisco Chronicle. The average individual refund was $215. The checks were erroneously repaying beneficiaries for their drug plan or Medicare Advantage plan premium. Beneficiaries received the refunds along with their Social Security benefit checks or direct deposits. Persons who received the refunds will not lose coverage, according to CMS.

Those affected will receive a letter from Medicare in early September explaining the error and the procedure for returning the money. Beneficiaries can call a toll-free number for information about repayment options (866-292-8080). CMS has asked those who have already returned their overpayment to call this number and let Medicare know that.

For more information about this error, call 1-800-MEDICARE (1-800-633-4227).

http://www.cms.hhs.gov/partnerships/downloads/PremiumWithholdRefundIssue.pdf

http://www.sfgate.com/cgi-bin/article.cgi?f=/n/a/2006/08/28/national/w142209D63.DTL&type=politics

ACCC Criticizes Proposed Changes to RVUs

The Association of Community Cancer Centers (ACCC) has expressed concern about the Centers for Medicare & Medicaid Services (CMS) proposed changes to the work relative value units (RVUs) under the physician fee schedule, and to the practice expense methodology. These were published in the Federal Register on June 29, 2006 and covered in Practice Manager Insider on July 5. They are scheduled to take effect on January 1, 2007 and would be phased in over 4 years.

ACCC expressed concern that the proposals would reduce beneficiary access to quality cancer care. It recommended that CMS:

Postpone any changes to the RVUs that would reduce reimbursement for drug administration services, including administration of radioimmunotherapies, until CMS can ensure that beneficiary access to care will not be reduced. The proposed method for calculating practice expense RVUs would reduce RVUs for many drug administration services by 2% to 8% in 2007, according to ACCC. When fully implemented, RVUs for many drug administration services would fall by 4% to 33%.

Postpone reductions to RVUs for imaging services until CMS has measured effects of the payment decrease for certain multiple imaging services. CMS in 2006 reduced payment for the technical component of multiple imaging procedures on contiguous body parts by 25%. It also has separately proposed limiting payment for multiple imaging procedures to the amount paid when those services are performed in hospital outpatient departments.

Finalize the proposed work RVUs for radiation oncology services, delay changes in assumptions regarding equipment utilization, and review the proposed practice expense RVUs for medical physics services in radiation oncology. ACCC notes that CMS has proposed reducing practice expense RVUs drastically for medical physicists’ services – eg, by nearly 77% over 3 years in the case of the CPT code for “set radiation therapy field.”

http://a257.g.akamaitech.net/7/257/2422/01jan20061800/edocket.access.gpo.gov/2006/pdf/06-5665.pdf

http://www.accc-cancer.org/PUBPOL/pdf/pubpol_PFScomments.pdf

CMS Warned Organ Transplant Programs Failing to Meet Standards

The Centers for Medicare & Medicaid Services (CMS) funds the majority of US transplant centers and requires them to achieve certain benchmarks. The Los Angeles Times reported in June that 20% of the 236 federally funded heart, liver, and lung transplant programs do not meet minimum CMS standards for the number of procedures performed and for survival rates. A total of 9 lung transplant programs and 36 heart transplant programs did not meet CMS standards. Those programs accounted for 71 more deaths than expected under normal conditions, based upon a government analysis of survival rates. CMS can revoke the certification of transplant programs that do not meet its standards.

The Los Angeles Times reported earlier this month that CMS sent warning letters to about 35 programs that have failed to meet its standards, offering them a last chance before taking enforcement action. That action could include loss of federal funding. The failing transplantation centers have not been identified publicly.

CMS plans to issue revised standards for transplantation programs before the end of 2006, rather than in 2007 as previously planned.

http://www.latimes.com/news/local/la-me-transplant4aug04,1,3858771.story?ctrack=1&cset=true

CMS Plans to Propose a 5.1% Cut in 2007 Physician Rates

Medicare payments to physicians are governed by a statutory formula. The Centers for Medicare & Medicaid Services (CMS) has recently recalculated the projected reimbursement rate to be proposed for 2007, and arrived at the -5.1% figure. The proposed fee schedule is expected to be published in the Federal Register on August 22 as part of a proposed rule including other suggested policy changes. Comments will be accepted until October 10, and a final rule will be published in the fall.

Other proposals put forth by the CMS include:

• Exempting the colorectal cancer screening benefit from the Part B deductible, eliminating a potential financial barrier to using this benefit.


• Changes in how to consider the bundling of drug discounts and other parameters in calculation of the average sales price on which Part B reimbursement is based.


• Maintain a 25% reduction in payment for the technical component of multiple imaging procedures on contiguous body parts. CMS has indicated that it would increase the reduction to 50% in 2007 but is not proposing to do that at this time.


• Cap payment for multiple imaging procedures to the amount paid when those services are performed in hospital outpatient departments.


• Propose assigning work relative value units to medical nutrition therapy services (CPT codes 97802, 97603, and 97804, and HCPCS codes G0270 and G0271).

http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1939

http://www.accc-cancer.org/MEDIA/media_newsfeed.asp

Senators Sponsor Bill to Forestall Cuts in Imaging Reimbursement

A bipartisan group of nearly 70 senators is cosponsoring a bill that calls for a 2-year hold on changes in Medicare reimbursement for medical imaging that are projected to result in deep cuts. The reductions will limit payment for imaging services in a physician’s office or imaging center to no more than that of a hospital outpatient department. This change is projected to reduce reimbursement rates for physician offices or imaging centers by 30% to 50%. The change in payment is scheduled to take effect on January 1, 2007.

The bill, S. 3795 (Access to Medicare Imaging Act), also requests that the Government Accountability Office (GAO) study the use of such imaging services by Medicare beneficiaries. The House already had introduced a similar bill. The Medicare savings projected to result from the change in payment account for more than one-third of the total Medicare savings in the Deficit Reduction Act of 2006.

80 Senators Urge Higher MD Medicare Rates

In a letter sent recently to the Senate majority and minority leaders, the senators urged that Congress act before its pre-election October adjournment to avert projected cuts of about 5% in the Medicare physician reimbursement rate.

The reduction is projected due to the Medicare sustainable growth rate formula, which the 80 senators called “flawed.” If no action is taken, the roughly 5% reduction would take effect January 1, 2007. “At a minimum, we must provide physicians with a positive Medicare payment update for 2007,” the letter states. Average 2006 Medicare physician reimbursement rates, said the senators, are equivalent to those of 2001. “If the 2007 cut is imposed, then the aggregate payment rates since 2001 will have fallen 20% below the government’s conservative measure of inflation for medical practice costs,” the senators asserted.

The letter quotes a 2006 American Medical Association survey as stating that if the payment cuts go into effect in 2007, then 45% of physicians plan to decrease the number of new Medicare patients they accept.

ASCO to Feds: Consider Peer-Reviewed Literature in Off-Label Coverage

The American Society of Clinical Oncology (ASCO) is urging the Department of Health and Human Services (DHHS) to require that Medicare and other insurers consider articles in peer-reviewed journals when determining coverage of medications for off-label uses. In a statement published in a recent issue of the Journal of Clinical Oncology, ASCO notes that cancer patients experience problems with access to off-label therapies that represent the standard of care because insurers refuse to cover them. “Medicare contractors are routinely ignoring significant reports of clinical benefit from off-label uses of cancer drugs reported in peer-reviewed journals,” the ASCO statement asserted. Such coverage denials occur with Medicare, Medicaid, managed care, and other private health insurers, ASCO said.

The law requires Medicare and Medicaid to cover off-label uses supported by approved drug compendia. Most states also require such reimbursement. ASCO cited a few problems with the current system, and offered solutions.

• State law does not apply to health insurance self-funded by employers as such plans are protected by the Employee Retirement Income Security Act (ERISA). ASCO urged federal legislation to remove this exemption and make all private plans subject to the same requirement as Medicare.
• “Concerns have been expressed” about the speed with which approved drug compendia update based upon new evidence. ASCO urged DHHS to augment the list of qualified compendia if the currently approved one do not update quickly enough. The Center for Medicare & Medicaid Services (CMS) has received requests to increase the number of approved compendia, and the Medicare Coverage Advisory Committee (MCAC) recommended characteristics of any new compendia added in April.
• ASCO also suggested that DHHS identify peer-reviewed journals for carriers to use in determining coverage, as allowed by statute. It asked that DHHS work with the cancer community to develop the list of approved journals. ASCO urged that DHHS use its authority to require contractors to consider peer-reviewed literature as well as compendia, and to consider high-quality Phase II trials as sufficient evidence to justify reimbursement.

How the CAP Vendor Proposes to Fix CAP

The CEO of the sole specialty pharmacy vendor for the Medicare Part B Competitive Acquisition Program (CAP) testified at the July 13 hearing of the House Ways and Means Subcommittee on Health hearing about how to address problems that may account for the very low participation in the program. Only 307 physicians had signed up as of July 10, of whom 18 are medical oncologists.

Richard Friedman, CEO of BioScrip, spent much of his oral testimony summarizing issues with CAP and how to address them. He listed the following barriers and proposed solutions:

• Lack of on-site inventory → Supply physicians’ offices with limited inventory for emergencies


• Must ship to site of drug administration → Permit shipments to multiple locations designated by MDs


• Added MD billing requirements → MDs bill for administrative fee only


• Patient copay concerns → Enable MDs to support copay for beneficiaries on a case-by case basis


• Physician need for education about CAP → Allow MD open enrollment