Let Your Voice Be Heard: Medicare Part B

Web Exclusives
Ethel D. Owen
Immediate Past President, NORM
Practice Administrator
Arthritis & Rheumatology Associates
West Palm Beach, FL

In our last issue, we discussed ways for rheumatology practice managers, physicians, healthcare professionals, and patients to get involved and raise awareness about concerns surrounding the Medicare Part B Drug Payment Model Proposed Rule by the Centers for Medicare & Medicaid Services (CMS). The National Organization of Rheumatology Managers (NORM) relies on each and every one of you to spread the word and take a role in advocating this important issue.

In line with our mission to promote and support education, expertise, and advocacy for patient access to care in rheumatology practices, we have been actively advocating for CMS to withdraw their proposal and work with physicians and other healthcare professionals to develop an alternative to effectively address the high costs of Part B medications.

The Coalition of State Rheumatology Organizations invited Andrea Zlatkus and me to attend meetings with CMS, CMMI, as well as House and Senate representatives in Washington, DC, with Vice President, Madelaine A. Feldman, MD, and Past President, Michael C. Schweitz, MD, to discuss our concerns with the Part B Demonstration Program. We shared our concerns about the cost of Part B drugs, and the size and scope of the demonstration as well as concerns regarding the ability of small practices to purchase medications at or below ASP. We also voiced our concerns about the aggressive timetables for implementing these changes.

Andrea and I wanted to share our Washington, DC, experience and encourage our membership to continue to oppose the Part B Drug Demonstration Project. We have held our first Town Hall meeting presented by Andrea and I, and moderated by Iris Nichols, Immediate Past President of NORM and founding Editor-in-Chief of Rheumatology Practice Management, to discuss the CMS Part B Demonstration Project, educate our members, and share what we, as an organization, have been doing.

The Town Hall focused on the Part B Demonstration Project, explained how the program is part of CMS’ recent proposal to test new Medicare Part B prescription drug models. It is a 5-year plan with the goal to drive prescribing use of the most effective drugs, and test new payment approaches to reward positive patient outcomes.

The premise of this demonstration project is based on concerns that average sales prices (ASPs) +6% incentivize physicians to prescribe higher-cost drugs. The project comprises 2 phases; phase 1 includes the following groups: (1) ASP +6% control, and (2) ASP +2.5% plus a flat fee of $16.80 per drug daily. Phase 2 further subdivides these groups, adding value-based purchasing tools:

  • Group 1
    • ASP +6% (control)
    • ASP +6% with value-based purchasing tools
  • Group 2
    • ASP +2.5% and a flat-fee drug payment
    • ASP +2.5% and a flat-fee drug payment model with value-based purchasing tools.

It is important to note that the value-based tools have not been clearly defined or developed. CMS is looking at a variety of tools, such as reference pricing, discounting or eliminating patient cost-sharing, indication-based pricing, evidence-based clinical decision support tools, and risk-sharing agreements based on outcomes.

The comment period was closed May 9, and CMS is currently reviewing the comments they received. According to the best estimates, phase 1 of the project may be implemented by October 1, 2016, and phase 2, no earlier than January 1, 2017. Part B demonstration is also subject to sequestration, but what does this mean for drug reimbursement? Under the model of ASP +2.5% plus the $16.80 flat fee, we will be reimbursed approximately ASP +0.86% plus $16.46 per J code daily.

We look forward to our next town hall meeting in July (date to be determined) and hope you will be able to join us in this conversation. For more information, please visit the NORM website. The new Part B tab in the member’s-only page includes recorded webinars, as well as FAQs; notes from our trip to the Hill; and PowerPoint presentations from the webinar are also available. We must continue calling our representatives and thank them for their support.

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