Oncology Rounds

What cancer programs should know about the 2019 HOPPS proposed rule

by Deirdre Saulet and Kate Wister

CMS recently dropped its 2019 HOPPS Proposed Rule. Read on to learn more about CMS' plans to expand site neutrality and 340B reimbursement cuts, along with other proposals affecting cancer programs.

Continued push toward site neutrality

CMS estimates that Medicare expenditures in hospital-based outpatient departments (HOPDs) have doubled over the last decade. To help curb this trend, CMS has proposed two strategies to more closely align payment in the hospital outpatient and freestanding settings:

  1. The agency proposes to pay for all clinic visits billed as G0463 and delivered in a hospital-based outpatient department at 40% of the traditional HOPPS rate. This change would apply to all off-campus HOPDs, including those HOPDs who were not impacted by CMS' previous site neutral payment policies. CMS states that this procedure code accounts for more than half of all codes billed at off-campus HOPDs. The agency estimates that reducing reimbursement for this code from approximately $116 to approximately $46 could save Medicare $610 million on routine clinic visits in 2019.

  2. CMS proposes applying the site-neutral payment rate to certain "expanded services" that off-campus HOPDs offer today, but did not offer the year prior to November 2, 2015. Essentially, this proposal states that if an off-campus HOPD was not billing for certain groups of APCs (defined by CMS in Table 32 of the Proposed Rule) between November 1, 2014 and November 1, 2015, then these HOPDs will be reimbursed at 40% of the HOPPS rate if they provide and bill for any of these services today.

CMS has outlined 19 different clinical families of APCs which will be affected by this proposal, including drug administration and clinical oncology, radiation oncology, and diagnostic/screening tests and related procedures. If this proposal is finalized, off-campus facilities that have recently started providing oncology services will see a significant cut to their reimbursement in 2019.

Read our blog 3 cuts to hospitals in the just-released 2019 HOPPS Proposed Rule for more information on these proposals.

Expansion of 340B reimbursement cuts to non-excepted HOPDs

For 2019, CMS is proposing to keep its 2018 reimbursement cut for drugs purchased at most 340B-covered entities steady at ASP-22.5%. However, the agency is also proposing to expand this payment reduction to the 115 non-excepted HOPDs with 340B drug pricing, which were previously exempted from these 340B reimbursement cuts.

CMMI requesting feedback on Part B drug purchasing

CMS will continue paying for most separately payable drugs as ASP+6%. However, the Centers for Medicare and Medicaid Innovation (CMMI) requests feedback on a pilot to change how Medicare purchases drugs, in which providers would work with approved vendors who could negotiate lower drug costs from manufacturers. Stay tuned for the final rule which is sure to contain provocative and strong reactions to this idea.

Minor changes to drug administration reimbursement

For 2019, CMS has proposed to slightly increase reimbursement for Level 1 and 2 drug administration APCs and slightly decrease reimbursement for Levels 3 and 4. CMS has not proposed to make any changes to its 2018 policy to package certain Level 1 and 2 drug administration codes.

Radiation therapy reimbursement slightly increases

There are no major proposed changes to radiation therapy reimbursement. Almost all levels are expected to see a slight increase in reimbursement.

Cancer patient ED utilization in 2018 still set to impact reimbursement in 2020

Despite proposing to remove 10 quality measures from the Hospital Outpatient Quality Reporting (OQR) Program, OP-35 is still slated to impact payment rates in fiscal year (FY) 2020 and subsequent years. OP-35 measures the rate of cancer patients having an ED visit or inpatient admission for one of 10 conditions within 30 days of receiving chemotherapy. The payment rates for FY2020 will be based on claims data from FY2018.  

This means cancer programs can't afford to wait when it comes to improving urgent symptom management. Check out our brief, How to Keep Your Cancer Patients Out of the ED, to get started.

Don't forget about the Medicare Physician Fee Schedule

In early July, CMS also released the 2019 Proposed Medicare Physician Fee Schedule (MPFS). Catch up on the highlights from that proposal, including changes to reimbursement for drugs purchased under wholesale acquisition cost, expanded telehealth reimbursement, and consolidating physician office visit codes.

To learn more about changes to the MPFS, tune into our webconference.

Learn more: 3 cuts to hospitals in the just-released 2019 HOPPS Proposed Rule

Sustained cuts to 340B payments, an expansion of site-neutral payments, and more: Advisory Board's Eric Fontana and Kenna Hawes lay out what you need to know about the changes in CMS' just-released 2019 Hospital Outpatient Prospective Payment System proposed rule.

Learn More