Navigating the CMS' CY 2024 proposed rule: part 2

Introduction

On July 13, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule related to policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues, effective on or after January 1, 2024 (1). 

The proposal, titled "Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule (PFS) and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment Policies and Basic Health Program,” (2) was open for public comments through September 11, 2023.

CMS-1784-P (2): Diving deeper into the proposed rule

Clinical Diagnostic Laboratory Tests (CDLTs) (3)

Lisa Harrison (LH): Beth, thank you for joining me for another discussion on CMS’ proposed rule for calendar year 2024. Let’s pick back up with the
potential impacts to clinical diagnostic laboratory tests (CDLTs) and MIPS Value Pathways (MVPs). Can you tell us more about these areas?

Beth Mitchell (BM): Absolutely, Lisa. As a part of the suggested rule, CMS proposed to implement portions of the Consolidated Appropriations Act of 2023 (4) regarding reporting and payment for clinical diagnostic lab tests (CDLTs). (1) We stress the potential impact of CMS's proposed implementation of the Consolidated Appropriations Act of 2023 on CDLTs, particularly for practices establishing their testing capabilities. The implementation of these policies could have an outsized effect on practices, particularly when multiple CPT codes are charged for one CDLT. Adequate reimbursement is crucial to ensure these diagnostics remain accessible and sustainable for patients.

MIPS Value Pathways (MVPs)

BM: MIPS Value Pathways (MVPs) represent a significant shift in how quality reporting is structured under the Merit based Incentive Payment System (MIPS) program. These pathways are designed to streamline reporting and make it more relevant to specific specialties or clinical conditions. (5) The goal is to simplify the reporting process for clinicians, focusing on measures that are most meaningful to their practice.

We would like to continue to see MVPs added so that there is not a bifurcated system, and all specialists are represented in available pathways. (6) Many specialists have not had to report under MIPS, and therefore do not have the processes for such reporting in place yet. For example, the recent launch of the Enhancing Oncology Model (EOM) has seen limited participation amongst oncology practices. (7) As such, many oncologists have not participated in MIPS and will need time to establish the necessary processes to support their practices entering an entirely new reporting system. 

Telehealth (8)

 
LH: Transitioning to value-based care is a significant shift, and it's essential to provide the support and resources necessary for specialty practices to navigate this change successfully. 

Next, let's explore the topics of telehealth and dental coverage in more detail. Telehealth has become increasingly important, especially during the pandemic. Can you explain the proposed changes related to these services under Medicare?

BM: I couldn’t agree more, Lisa. Telehealth has been instrumental in reaching underserved communities and reducing patient burden. The proposed rule introduces several changes and additions to telehealth services covered under Medicare, including health and wellbeing coaching services and permanent inclusion of SDOH Risk Assessments via telehealth. (1) 

This is a significant step forward because addressing social determinants of health is critical to improving patient outcomes. By allowing these assessments to be conducted via telehealth, practices can better identify and address patients' social needs, which can have a substantial impact on their overall health.

Dental Coverage (9)

LH: That certainly is a positive development for patient-centered care. The proposal also mentions allowing payment for certain dental services necessary for the treatment of certain cancers. Could you elaborate on the importance of this proposal and what it means for oncology providers?

BM: Medicare coverage of dental services has been a long-debated issue, and existing rules have sometimes posed challenges when dental care is needed in the context of other medical treatments, such as cancer treatment. The proposal acknowledges this and seeks to provide dental coverage when necessary, during cancer treatment services like chemotherapy, CAR-T cell therapy, and antiresorptive therapy. (1)

This is essential because it removes administrative barriers that practices may have faced in the past. Ensuring that providers receive reimbursement for necessary care allows them to focus on delivering comprehensive care to patients without worrying about dental services being excluded.

IRA Codification & Conforming Changes (10)

 
LH: Thank you, Beth. What potential impacts does the proposed rule have regarding IRA Codification & Conforming Changes and the Appropriate Use Criteria (AUC) for the Advanced Diagnostic Criteria Program?

BM: Let's start with IRA Codification & Conforming Changes, Lisa. This part of the proposed rule involves CMS codifying portions of the Inflation Reduction Act (IRA) and making conforming changes to previous sub-regulatory guidance. (1) It may seem like technicalities, but these changes can have significant impacts, particularly on specialty practices. While we do recognize the need for codification, we're concerned about the potential outsized impact of IRA policies on specialty practices. 

Specialty practices often rely on next-generation drugs, and these drugs can make up a substantial portion of their input costs. (10) The implementation of these policies, while well-intentioned, can result in significant financial stress for specialty practices, especially when combined with other financial challenges.

LH: Codifying portions of the IRA to increase access to important drugs is commendable. However, it's crucial for CMS to be cautious and consider the potential financial impact on practices, which are already navigating a complex financial landscape. These policies can inadvertently lead to further consolidation or practice closures, which isn't in the best interest of patients.

Appropriate Use Criteria (AUC) for Advanced Diagnostic Criteria Program (11) 

 
BM: The AUC Program was designed with the intention of ensuring that advanced diagnostic imaging services are used appropriately, hoping to reduce unnecessary radiation exposure and healthcare costs. (12) However, introducing such legislation has come with its own set of challenges. 

The proposed rule by CMS suggests permanently pausing this program, indicating that more time is needed to determine the best approach for its implementation. (1) We are in support of this proposal, as it recognizes the complexities and challenges involved in implementing such a program effectively. It acknowledges that more modifications are necessary to ensure that access to these important diagnostic services is not unintentionally hindered.

LH: Agreed, Beth. For specialty practices, this is particularly relevant, as they often rely on advanced diagnostic imaging services. An improperly implemented AUC Program could impact patients' access to these crucial services and create unnecessary administrative burdens for practices.

MDPP Flexibilities (14)

 
LH: Let's wrap up our discussion by exploring two more aspects of the proposed rule: the Medicare Diabetes Prevention Plan (MDPP) flexibilities and the proposed increase in the performance threshold. Can you provide more insights into these areas?

BM: Absolutely. Let's start with the MDPP flexibilities. These flexibilities were introduced during the pandemic when in-person care was limited. They allowed for the provision of MDPP services via telehealth, ensuring that patients could continue to access essential care and support. Now, CMS is proposing to extend these flexibilities for four more years. (1) (15) (16)

LH: How does extending MDPP flexibilities benefit patients and practices?

BM: Extending MDPP flexibilities for telehealth services is a significant benefit for both patients and practices. Patient care coordination and coaching services are well-suited for telehealth, as they can save time for patients and practitioners. This extension ensures that individuals can continue to access preventive care and support to prevent or manage diabetes effectively.

For practices, it provides the flexibility needed to meet patient needs, especially in situations where in-person care may not be possible or preferable. It aligns with the broader trend of telehealth's importance in healthcare delivery, ensuring that this critical aspect of care remains accessible.

Performance Threshold Increase (17)

 
LH: It's clear that these extended flexibilities can contribute to better patient outcomes and care accessibility. To focus now on the proposed increase in the performance threshold, what does this entail, and how might it impact practices?

BM: The proposed increase in the performance threshold is an important aspect of the MIPS program. CMS is suggesting raising the threshold from 75 points to 82 points in CY 2024. (11) This increase is based on statutory requirements, specifically the use of mean or median scores from a prior period, in this case, data from 2017-2019 MIPS performance periods. (11)

The main challenge here is that the data used for benchmarking, which spans from 2017 to 2019, doesn't accurately reflect the current healthcare landscape. During this period, practices have been navigating significant disruptions, including inflation, market volatility, and the COVID-19 pandemic.

These external pressures have had a profound impact on the financial stability and operations of healthcare practices. Increasing the performance threshold based on outdated data can place an additional burden on practices already grappling with various challenges.

Conclusion

Thank you, Beth and Lisa, for sharing your insights on these crucial topics today. Our commitment is to support specialty physicians in delivering the best possible care to their patients, and staying informed about these policy changes is a significant part of that mission.

References

1. Centers for Medicare & Medicaid Services (CMS). Calendar Year (CY) 2024 Medicare Physician Fee Schedule Proposed Rule. cms.gov. [Online] 07 13, 2023. [Cited: 09 25, 2023.] https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-proposed-rule.
2. —. PFS Federal Regulation Notices. CMS.gov. [Online] 08 07, 2023. https://www.cms.gov/medicare/medicare-fee-service-payment/physicianfeesched/pfs-federal-regulation-notices/cms-1784-p.
3. Federal Register. 9 88 Fed. Reg. 52411.
4. U.S. Congress. Congress.gov. H.R.2617 - Consolidated Appropriations Act, 2023. [Online] 12 29, 2022. [Cited: 09 27, 2023.] https://www.congress.gov/bill/117th-congress/house-bill/2617/text.
5. Centers for Medicare and Medicaid Services. MIPS Value Pathways (MVPs). Quality Payment Program. [Online] [Cited: 09 25, 2023.] https://qpp.cms.gov/mips/mips-value-pathways.
6. —. Explore MIPS Value Pathways (MVPs). Quality Payment Program. [Online] [Cited: 09 27, 2023.] https://qpp.cms.gov/mips/explore-mips-value-pathways.
7. Centers for Medicare & Medicaid Services. Enhancing Oncology Model. cms.gov. [Online] [Cited: 09 25, 2023.] https://www.cms.gov/priorities/innovation/innovation-models/enhancing-oncology-model.
8. Federal Register. 88 Fed. Reg. 52326.
9. —. 88 Fed. Reg. 52374.
10. 12 88 Fed. Reg. 52384.
11. Federal Register. Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage; Medicare and Medicaid Provider and Suppl. federalregister.gov. [Online] 08 07, 2023. [Cited: 09 25, 2023.] https://www.federalregister.gov/documents/2023/08/07/2023-14624/medicare-and-medicaid-programs-cy-2024-payment-policies-under-the-physician-fee-schedule-and-other.
12. —. 88 Fed. Reg. 52508.
13. Centers for Medicare and Medicaid Services. Appropriate Use Criteria Program. cms.gov. [Online] [Cited: 09 25, 2023.] https://www.cms.gov/medicare/quality/appropriate-use-criteria-program.
14. Federal Register. 88 Fed. Reg. 52502.
15. Centers for Medicare and Medicaid Services. Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19. cms.gov. [Online] [Cited: 09 25, 2023.] https://www.cms.gov/files/document/physicians-and-other-clinicians-cms-flexibilities-fight-covid-19.pdf.
16. U.S. Department of Health and Human Services. HHS Fact Sheet: Telehealth Flexibilities and Resources and the COVID-19 Public Health Emergency. hhs.gov. [Online] 05 10, 2023. [Cited: 09 25, 2023.] https://www.hhs.gov/about/news/2023/05/10/hhs-fact-sheet-telehealth-flexibilities-resources-covid-19-public-health-emergency.html.
17. Federal Register. 88 Fed. Reg. 52554.