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A quarterly newsletter from the Alliance of Wound Care Stakeholders
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Q3 2018 - In This Issue:
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Welcome to Alliance Advocacy Update, the
Alliance of Wound Care Stakeholders' quarterly update on our ongoing advocacy initiatives to ensure access, coverage and payment to wound care procedures and technologies for patients and providers.
Please share this update within your specialty society, association or company.
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CMS, Commercial Payers and Capitol Hill
Each year, CMS's proposed annual updates to the Physician Fee Schedule and Hospital Outpatient Prospective Payment System (HOPPS) demand significant time and resources to understand the specific impacts to wound care providers and patients. This year, our comments were not just "comments as usual," they were in several cases
a call to arms
. For example:
- We voiced our strong opposition to the Physician Fee Schedule's proposed consolidation of Evaluation and Management codes and the corresponding reduction in payment for E/M services for those that provide the most complex care. Together, we stood up to the "singling out" of podiatric physicians in the Schedule's proposed creation of separate E/M codes and reimbursement for these specialists.
- We mobilized both our clinical associations and manufacturer members to take action on the commercial payer front when insurance giant United Healthcare issued a policy that removed coverage for most CTPs. While the policy had no formal comment mechanism, we quickly convened a workgroup, brought in a former commercial payer medical director to give guidance, and sent a letter and meeting request to UHC.
- We turned attention to Capitol Hill, and built consensus to submit a letter of support for the Lymphedema Treatment Act (S. 498, H.R. 930), which would grant CMS the statutory authority to cover compression bandages for lymphedema under the Medicare benefit.
Looking ahead, expect more of our attention on Capitol Hill on an issue near and dear to us: LCD transparency.
On Sept.23, the
U.S. House of Representatives passed the
Local Coverage Determination Clarification Act
(H.R. 3635). The Act revises the process by which Medicare Administrative Contractors issue and reconsider local coverage determinations (LCDs).
While we support this legislation, we don't believe it goes far enough and are exploring an advocacy path forward for policy articles to also be included.
We've already seen that MACs are more liberally using policy articles, which don't require the notice-and-comment procedure of LCDs. Many of these policy articles are providing much more than clarification, they are oftentimes setting new policy.
While the legislation likely won't be moved to the Senate this year, we are hopeful the legislation can have a path forward in 2019. We'll keep you up to date on its progress and our advocacy.
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Q3 Submitted Comments:
Ensuring Alliance's Clinical Expert Perspective is Heard
U
nited Healthcare CTP Policy
The Alliance flagged a concerning new policy from UHC that removed coverage for most CTPs. Despite there being no formal comment process to UHC policies, the Alliance convened a member work group, hired a former commercial payer medical director to guide our strategy, held a series of discussions, and submitted a September
letter
to UHC medical directors. The letter outlined the policy's unintended consequences and patient care interruptions and requested UHC to reconsider and delay the scheduled Oct. 1st implementation of its "Commercial Medical Policy 2018T0592A, Skin and Soft Tissue Substitutes." The Alliance requested a meeting with UHC for a more in-depth discussion on the policy and its patient care impacts.
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"
The policy will cause significant disruption in the care of your members in outpatient, hospital, rehabilitation, skilled nursing and other settings who are currently receiving skin and soft tissue substitutes for the management of their chronic wounds...
We request a meeting with you to discuss our concerns, address issues regarding improvement in health outcomes with these therapies, and to offer recommendations that will serve to improve the clinical outcomes for your member patients at lower cost of care."
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CY2019 Hospital Outpatient PPS
comments
to CMS in response to its proposed CY 2019 Hospital Outpatient Prospective Payment System (PPS). Following a series of conference call discussions, the Alliance focused its comments on provisions related to
:
CTP packaging and payment methodology, pass through status for CTPs, methods to control unnecessary increases in the volume of outpatient services, ways to control unnecessary costs, and price transparency.
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"CMS should return to the basics of coding, coverage, and payment for CTPs by paying for the products separately from the procedure, based on the reported invoice price of the CTP and by paying for the add-on procedure codes.
By returning to this methodology, CMS will be able to collect data built on accurate clinical application, quality information and true product costs... CMS should then have accurate clinical and cost data which could be used for adjusting payment methodologies. This information would then be available to stakeholders which will provide transparency that has
been lacking in the current system."
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Physician Fee Schedule
The Alliance submitted comments to the proposed CY 2019 Physician Fee Schedule, voicing opposition to the proposed consolidation of Evaluation and Management codes and the corresponding reduction in payment for E/M services for those that provide the most complex care. Commented included specific examples of unintended consequences that the proposal would create. The Alliance also opposed the "singling out" of podiatric physicians in the rule. The Alliance joined many other clinical associations expressing their concern by also signing on to an American College of Rheumatology letter to the House of Representatives.
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"Neither the consolidation of E/M codes nor the proposed reduction in reimbursement will ease documentation requirements...
Of significant concern to the Alliance are the unintended consequences that this proposal will create including: harming patient care, limiting patient access, decreasing the amount of time a physician can spend with a patient, increasing the number of visits required to visit a doctor which results in increasing the number of copayments that a patient will be required to pay."
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CMS Demonstration Project for Home Health Services
The Alliance submitted
comments
to CMS in response regarding its "
Pre-Claim Review Demonstration for Home Health Services
." While the Alliance acknowledged support to address issues of fraud and abuse, comments expressed concern that the policy would create a significant administrative burden on home health agencies.
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"The Alliance has significant concerns:
(1) The lack of transparency on this issue as well as the process by which the Agency will move forward with this demonstration;
(2) This administrative burden on home health agencies, as they will need to hire additional staff in order to keep up with all the paperwork / documentation requirements;
(3) The tremendous negative impact on the access to care for beneficiaries in order for CMS to target a few 'bad apples.'"
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AmeriHealth Caritas HBOT Policy
The Alliance
submitted August
comments
addressing the AmeriHealth Caritas Clinical Policy on Full-body Hyperbaric Oxygen Therapy. The Alliance identified clinically inaccurate and/or unsubstantiated information within the policy to be addressed.
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"The Alliance disagrees with the requirement that a failed response to negative pressure wound therapy must be required prior to the use of HBO2... There is no literature which supports the requirement nor is there evidence to support that the rate of healing when NPWT is used prior to HBO2 therapy is of any benefit
."
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Lymphedema Treatment Act
The Alliance submitted a
letter
to Congress supporting the Lymphedema Treatment Act (S. 498, H.R. 930). The Alliance recommended that Congress grant CMS the statutory authority to cover compression bandages and garments for lymphedema as durable medical equipment under the Medicare benefit.
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"Lack of access to the clinically recognized treatments necessary to best care for these conditions leads to higher costs and poorer health outcomes...The policy changes [in the Act] would have a substantial impact via improved outcomes and quality of life, reduced costs for beneficiaries and the health care system, and decreased federal spending."
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Key Q3 Meetings & In-Person Advocacy
- Health Care Payment Learning & Action Nework Summit: The Alliance attended and alerted membership to this Oct. 22 LAN meeting in Northern Virginia as a terrific opportunity to network with CMS and private payer staff while focusing on "Partnering for the Future" to improve patient outcomes and bend the cost curve.
- Physician Fee Schedule call: Alliance leadership participated on a July 12 conference call with CMS Administrator Seema Verma and her staff as they summarized the Physician Fee Schedule proposed rule relating to documentation requirements and payment for E/M visits and advancing virtual care. A copy of the CMS presentation was circulated to membership.
- OPPS Advisory Panel Meeting: The Alliance alerted membership to, attended and spoke at the Aug. 20 meeting of CMS' Advisory Panel on Hospital Outpatient Payment, an expert outside advisory panel that provides to CMS technical advice regarding the clinical integrity of the Ambulatory Payment Classification (APC) groups, relative payment weights, and supervision levels.
- CMS Home Health Open Door Forum: Alerted members to July CMS forum featuring Hillary Loeffler, Director, Division of Home Health & Hospice at CMS.
- APWCA: Alliance leadership attended and spoke at the APWCA meeting Sept.6-8 in Baltimore.
- APMA: Alliance leadership attended the July APMA annual meeting, and had a "guest speaker" slot at the APMA booth to speak about the Value in Health study.
- Amputee Coalition: hosted its annual meeting July 12-14 in Tucson.
- UPCOMING: Fall SAWC - Join the Alliance at our in-person meeting at the Fall SAWC on Friday, Nov. 2nd, 10:30am-12:30pm PT. A call-in number is also available. Contact Marcia Nusgart to participate.
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Recent Publications & Policies Relevant to Alliance
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The Alliance of Wound Care Stakeholders is an association of physician and clinical organizations focused on promoting quality care and access to procedures and technologies for patients with wounds through advocacy and educational outreach in the regulatory, legislative and public arenas. The Alliance unites leading wound care experts to advocate on public policy issues that may create barriers to patients' access to treatments or care, with a focus on reimbursement, wound care research and wound care quality measures.
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