D.C. Download – Healthcare policy updates for oncology practices

Congress has officially left Washington D.C. for its summer recess, but they have recently been very busy working on several pieces of legislation that have implications for oncology practices. From examining the role of Pharmacy Benefit Managers (PBMs), to new payment models and significant updates to MIPS, here is a brief overview of healthcare policy news to help your practice stay informed.

Although the Trump Administration declined to end “safe harbor” protections under the federal anti-kickback statute for rebates paid to PBMs, efforts to rein in DIR fees and ease the pressures on in-office dispensing programs are still ongoing, involving both sides of the aisle. 

In April, Senate Finance Committee Chairman Chuck Grassley (R-IA) and Senator Maria Cantwell (D-WA) introduced legislation that would require the Federal Trade Commission (FTC) to study the role of PBMs and recent merger activity to examine the effects of consolidation on pricing and other potentially-abusive behavior.

In an effort to increase transparency, the Prescription Pricing for the People Act of 2019 would seek reporting from the FTC on whether PBMs:

• Charge payers a higher price than their reimbursement rate for competing pharmacies
• Steer patients to pharmacies in which they have ownership interest
• Audit or review proprietary data from competing pharmacies for anticompetitive purposes
• Design formularies to increase market share of higher-cost drugs and depress lower-cost drugs

The bill passed the Senate Judiciary Committee without objection, but it remains to be seen if the bill will be passed.

In June, 105 representatives and 28 senators sent letters to President Trump to express their disappointment that DIR reform was not included in the finalized Part D and Medicare Advantage rule.

Most recently, the Phair Relief Act was introduced, which seeks to put a five-year freeze on DIR fees and establish oversight, as well as create standardized quality metrics for PBMs to assess any fees after this period ends. Similar policies proposed by the CMS in 2018 estimated that reducing these retroactive fees would reduce out-of-pocket costs for patients by up to $9.2 billion. 

The Centers for Medicare and Medicaid Services (CMS) recently announced a proposed advanced alternative payment model (APM) for radiation oncology. This proposed APM would be a mandatory episodic payment model covering radiotherapy services in a 90-day episode for 17 cancer types (representing up to 84 percent of all radiotherapy episodes). The model would seek to make payments site-neutral by establishing a national base payment for the episode split between professional and technical components.

The structure of this APM closely resembles that of the RO-APM proposed by the American Society for Radiation Oncology (ASTRO). ASTRO praised this proposal as a “step forward in allowing the nation’s 4,500 radiation oncologists to participate in the transition to value-based care that improves outcomes for cancer patients.”

CMS will take comments on the proposed rule now through mid-September. 

On July 29, CMS released its proposed rule for the 2020 Medicare Physician Fee Schedule (MPFS). Proposed policies for the Quality Payment Program, which includes the Merit-Based Incentive Payment System (MIPS) and APM tracks, were also included in this release.

Within its proposed MIPS updates, the Trump administration is introducing a new framework known as MIPS Value Pathways (MVPs), which is intended to ease the quality reporting burdens associated with the program. Under MVPs, MIPS would migrate to a system in 2021 that features a smaller set of reporting measures based on a physician’s specialty and outcomes. These measures more closely align with new alternative payment models. CMS Administrator Seema Verna commented that this will hopefully make it easier for physicians to participate and reduce administrative costs associated with reporting requirements.

The MVP model will allow providers to select measure sets applicable to their service lines, meaning an oncologist could select an oncology-specific measure set. The model will also connect measures and activities across the current performance categories.

CMS is seeking comments on the proposed rule through September 27, 2019. 

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