Oncology Rounds

The 2020 HOPPS final rule brings major changes to physician supervision—and more—for cancer programs

by Deirdre Saulet and Ashley Riley

Editor's note: This blog post was updated on November 20, 2019.

Last week was action-packed. On top of the World Series (go Nats!), Halloween, and daylight savings, CMS decided to loosen physician supervision requirements for outpatient therapeutic services! Keep reading to find out what else CMS finalized in its 2020 Hospital Outpatient Prospective Payment System (HOPPS) final rule and the implications for cancer programs. 

Dec. 12 webinar: Learn what the 2020 HOPPS final rule means for your cancer program

1. Loosening physician supervision requirements for outpatient therapeutic services, including chemo and radiation

Physician supervision has been a hot topic for years—especially in oncology, where it can often be challenging to ensure direct supervision for chemotherapy and radiation at all sites. It's been a while since CMS has revisited the topic of supervision in depth, but this year CMS finalized its proposal to change the minimum required level of supervision from direct supervision to general supervision for all hospital outpatient therapeutic services provided by hospitals. In case you need a refresher:

  • General supervision: The physician or advanced practitioner (AP) must be available by telephone to provide assistance and direction if needed.

  • Direct supervision: The physician or AP providing supervision must be "immediately available" and "interruptible" to provide assistance and direction throughout the performance of the procedure; however, he or she does not need to be present in the room when the procedure is performed.

This change applies to all hospitals, including critical access hospitals (CAHs) and small rural hospitals, for which CMS reinstated the non-enforcement policy for direct supervision of outpatient therapeutic services for CY 2018 and 2019 in the 2018 HOPPS final rule. CMS believes that this change will reduce the burden that the direct supervision requirement places on providers by giving them more flexibility to provide medical care and get rid of "what is effectively a two-tiered system of supervision levels…between CAHs and small rural hospitals and all other hospitals."

In its proposal, CMS sought public comments on whether specific types of services, such as chemotherapy administration and radiation therapy, should be excepted from this change. This led us to believe this might not go through, but the agency finalized the change for all hospital outpatient therapeutic services. That said, CMS noted that it retains "the ability to consider a change to the supervision level of an individual hospital outpatient therapeutic service to a level that is more intensive than general supervision through notice and comment rulemaking."

2. Full steam ahead with phase 2 of site neutrality rate cuts for G0463

Just a week before CMS finalized its 2020 HOPPS rule, a district court vacated CMS' calendar year (CY) 2019 rate cuts for clinic visits intended to equalize payment across off-campus hospital outpatient departments (HOPDs) and physician offices. CMS noted in the final rule that it is "working to ensure affected 2019 claims for clinic visits are paid consistent with the court's order," but it will still complete the second phase of the payment reduction for off-campus HOPD clinic visits in 2020. CMS will cut an additional 30% from the reimbursement for G0463 to bring payment for all off-campus HOPDs down from $116 to $46, which is 40% of what it pays on-campus HOPDs.

Determine the best infusion center billing strategy (HOPD vs. freestanding)

3. CMS still struggling to develop contingency plan if its 340B appeal is denied

CMS is continuing its appeal of the December 2018 district court ruling that HHS exceeded its authority by adjusting the Medicare payment rates for drugs acquired under the 340B Program to Average Sales Price (ASP)-22.5%. The agency announced in its final rule that it will continue paying ASP-22.5% for all 340B-acquired drugs for CY 2020 since the appeal has yet to be ruled on.

However, CMS crowdsourced a contingency plan in case its appeal is denied. It requested public comment in the 2020 HOPPS proposed rule on how much to pay for 340B-acquired drugs and how to remedy underpayments in CYs 2018 and 2019. As a starting point, CMS suggested paying ASP+3% for CY 2020. It also suggested two potential ways to make up for the reduced reimbursement 340B-eligible providers received in 2018 and 2019: retrospective (e.g., made on a claim-by-claim basis) or prospective (e.g., upward adjustment to 340B claims in the future to account for underpayments in the past). But, it welcomed any other budget-neutral suggestions from the public.

CMS hasn't landed on a suitable remedy yet, but the agency announced in the final rule that it would survey 340B hospitals to collect drug acquisition cost data for CY 2018 and 2019 to potentially use to set future payment rates or devise a remedy for prior years if needed. If the survey data is not helpful in identifying a remedy, CMS stated that it will consider ideas submitted in response to the 2020 proposed rule and will suggest a remedy in the 2021 HOPPS proposed rule.

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4. Potential game changer? CMS finalizes proposal requiring hospitals to post standard charges for services online.

Two weeks after releasing the 2020 HOPPS final rule, CMS finalized its proposal that all hospitals—whether or not they are enrolled in Medicare (except federally owned or operated hospitals)—be required to publish a "machine-readable file" with their gross charges (what's reflected in a hospital's chargemaster) and payer-specific negotiated charges for all items and services they provide in inpatient and outpatient settings. Hospitals will also would have to display payer-specific negotiated charges for at least 300 common "shoppable" services (defined as a service that can be scheduled in advance) in a consumer-friendly format online. This rule will go into effect on January 1, 2021.

But CMS didn’t stop there. It also proposed a rule to increase price transparency requirements for health insurers. The proposed rule would require most group health plans (including self-insured health plans) and health insurance issuers to disclose cost-sharing and price information to enrollees, beneficiaries, and other participants via internet-based self-service tools, and in paper form upon request. This rule would also go into effect on January 1, 2021, if finalized.

Get our initial take on CMS' new price transparency rules

5. Favorable reimbursement outlook for radiation therapy (for providers who will not be enrolled in Radiation Oncology Model), drug administration holds steady

Reimbursement for radiation therapy ambulatory payment classifications (APCs) is increasing across the board, with finalized payment increases ranging from 4% for Levels 3 and 7 to 16% for Level 5.

We wonder if this bump in radiation payments is CMS' attempt to proactively offset the reimbursement cuts providers will face if they're enrolled in the Radiation Oncology Model. Make sure you're up to speed on what CMS is planning by reading our initial takeaways and answer to top questions from your peers. And pre-register for our webinar on December 19th at 3 p.m. ET to get the scoop on the finalized Model once it's released.

Read the Takeaways Get the Answers

Reimbursement for drug administration APCs remain largely the same as last year with the exception of Level 4, which will increase by almost 10%.

6. OQR changes: Sunsetting radiation therapy measure, but keeping cancer patient ED utilization measure

CMS finalized its proposal to remove the External Beam Radiotherapy for Bone Metastases quality measure (OP-33) from the Hospital Outpatient Quality Reporting (OQR) Program because the costs associated with the measure outweigh the benefit of its continued inclusion in the program. This change will begin with October 2020 encounters for CY 2022 payment determination.

No measures were added to the Hospital OQR Program this year, but OP-35 is still included in the measure set that will affect CY 2020 payment determination. OP-35 looks at cancer patient ED visits and inpatient admissions for 10 potentially preventable conditions within 30 days of receiving chemotherapy. It's important to note that there is no financial penalty tied to individual hospital performance on this measure, and providers' payment rates will be based on reporting alone (which CMS actually pulls from hospital claims data itself).

While performance on this measure won't directly impact your payment, CMS will publish individual hospital performance on OP-35 on the Hospital Compare website for patients, referring providers, and payers to see when choosing a cancer care provider.

How to keep your cancer patients out of the ED

To learn more about the 2020 HOPPS final rule and its implications for cancer programs, register for our upcoming webinar on December 12th at 3 p.m. ET. And in the meantime, tune into these two upcoming webinars for Medicare Physician Fee Schedule (MPFS) and Quality Payment Program (QPP) updates:

  • November 21st: Register for this session for the most important takeaways from the 2020 MPFS final rule, including how we expect the rule to impact physician reimbursement and high-level changes to the QPP.

  • December 5th: Register for this session for a deep-dive on the details of the 2020 QPP policies, action items, and how to prepare for success.

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In this infographic, we've complied our top findings from the 2019 Cancer Patient Experience survey, so you can better understand patient priorities and preferences for care.

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