In a letter to the Centers for Medicare & Medicaid Services (CMS), the Association for Clinical Oncology (ASCO) commented on provisions in the 2021 Medicare Physician Fee Schedule (MPFS) and Quality Payment Program (QPP) proposed rule that would impact cancer care for Medicare beneficiaries.
As a result of the public health emergency (PHE) declared earlier this year for the COVID-19 pandemic, CMS has included several proposals which aim to increase flexibility in the Medicare program and reduce regulatory burden for physicians in 2021 in addition to other customary updates and changes to the fee schedule.
ASCO’s extensive comments offer the Association’s perspective in a number of areas as part of ASCO’s commitment to working with CMS to help ensure access to high-quality, equitable cancer care for all patients no matter who they are or where they live.
2021 MPFS Proposal
- Budget Neutrality – CMS is proposing a negative adjustment to the physician fee schedule conversion factor (CF)—a budget neutrality adjustment required by law. The 2021 proposed CF is $32.2605, a decrease of $3.83, or 10.6% from the 2020 CF of $36.0896. This negative adjustment will impact all services across the fee schedule. At a time when the COVID-19 pandemic has already caused unforeseen and unexpected financial consequences for oncologists, ASCO is concerned that the financial insecurity resulting from this PHE will only be worsened by the proposed CF adjustment. ASCO urges CMS to work with Congress to implement positive CF updates to offset the appropriate increases costs from office visits.
- Evaluation and Management (E&M) – ASCO supports the E&M payment policy updates going into effect in 2021, which include code selection based on total time spent or medical decision making, an additional code for visit complexity, and a prolonged service code. ASCO thanks CMS for collaborating with stakeholders during this process and encourages CMS to continue to do so as the payment policy for the remaining E&M service categories are re-evaluated in the coming years.
- Telehealth – ASCO urges CMS to permanently cover and reimburse audio-visual services and, when appropriate, audio-only services and continue to expand coverage for all modes of delivery of telemedicine beyond the COVID-19 PHE.
- Electronic Prescribing of Controlled Substances – ASCO supports delaying the e-prescribing of controlled substances requirement until January 1, 2022, to allow CMS sufficient time to address ASCO and other stakeholder recommendations.
- Medicare Part B Drug Payment for Drugs Approved Through the Pathway Established Under Section 505(b)(2) of the Food, Drug, and Cosmetic Act – ASCO urges CMS to list the drugs approved through the Section 505(b)(2) pathway that would be moved from single-source codes to multi-source codes and to make public the financial impact this proposal would have on the Medicare program.
- National Coverage Determinations – CMS is seeking comments on its proposal to remove nine National Coverage Determinations (NCDs) it believes may no longer contain pertinent or clinically relevant information and are rarely used by beneficiaries. ASCO’s comments express concern that if this proposal is finalized, CMS will set a precedent to facilitate removal of increasingly relevant and more widely used NCDs, which has the potential to reduce patient access to care.
Updates to the QPP
- Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs) – The 2020 MPFS final rule established that QPP participation through MIPS Value Pathways (MVPs) would begin with the 2021 performance period. However, due to stakeholder concerns about this timeline and with clinicians working hard to address the spread of COVID-19 within their practices and communities, CMS will not be introducing any MVPs into the program for the 2021 performance period. ASCO supports this decision as clinicians are focused on caring for their patients during a pandemic and will not have the additional resources required to learn and implement what is essentially an overhaul of the MIPS program. ASCO would further urge CMS to consider delaying MVP implementation beyond 2022 based on the Association’s earlier arguments—and those of other stakeholders—that such an overhaul of the MIPS program should be phased in gradually in order for clinicians to familiarize themselves with the new requirements.
- Alternative Payment Model (APM) Performance Pathway (APP) – ASCO supports CMS’ proposal to make the new APM Performance Pathway (APP) for MIPS APMs optional, but is concerned about the mandatory nature of the APP for Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program (MSSP) and opposes the abrupt retirement of the CMS Web Interface (“GPRO”) for group reporting of quality measures.
- APM Scoring Standard – ASCO urges CMS to allow for a transition year between the APM scoring standard and the MIPS scoring standard for MIPS APMs.
- Subgroup Reporting – ASCO supports flexibility for practices to engage in optional “subgroup” reporting of measures and cautions that CMS must recognize the additional practice burden involved with subgroup reporting via incentives such as scoring incentives or lessened reporting burden elsewhere.
- Performance Threshold and Performance Category Weights – ASCO supports CMS’ proposal to set the MIPS performance threshold at 50 points instead of the 60 points originally finalized given the difficult circumstances practices are facing during the COVID-19 pandemic. ASCO also supports the continued phase-in of performance category weights to the final weights required by statute in 2022.
- Specific Performance Category Proposals – ASCO urges CMS not to finalize its proposal to apply the 7-point achievement cap to quality measures that are found to be “topped out” for two consecutive years if that finding is based on data from the 2021 performance period. ASCO agrees with CMS that, due to the pandemic and ensuing reporting flexibilities allowed for 2019 data submission, it is likely that the agency may not have a representative sample of historic data from 2019 in order to create historic measure benchmarks for the 2021 performance period. Due to this concern, the agency is proposing to use performance period benchmarks for 2021 instead of possibly skewed historical benchmarks. ASCO is concerned that this could lead to an artificial lowering of scores beyond the clinician’s control and may disincentivize the reporting of measures that would otherwise be considered for reporting.
- Cost Measures – ASCO urges CMS to discontinue the use of certain cost measures in MIPS until it can be shown that the measures are valid, reliable, and can be attributed appropriately.
- Other Scoring Proposals (COVID-19 Flexibilities for PY 2020) – ASCO supports CMS’ proposal to increase the maximum number of points available for the complex patient bonus for performance year 2020. The Association also supports the agency’s proposal to allow individuals, groups, virtual groups, and APM entities to submit an application to reweight MIPS performance categories as a result of extreme and uncontrollable circumstances, such as the COVID-19 pandemic. Additionally, ASCO supports CMS’ proposals for flexibilities for ACOs including the application of the “Extreme and Uncontrollable Circumstances” policy.