On November 2, 2023, the Centers for Medicare & Medicaid Services (CMS) released its final rule for the 2024 Medicare Physician Fee Schedule (MPFS) and updates to the Quality Payment Program (QPP). The agency also released the 2024 Medicare Hospital Outpatient Prospective Payment System (HOPPS) and Ambulatory Surgical Center (ASC) Payment System final rule, along with the 340B remedy final rule.
The Association for Clinical Oncology (ASCO) is still assessing these rules, but based on a preliminary analysis, key provisions for the cancer care community include:
2024 Medicare Physician Fee Schedule
CMS has finalized a 2024 physician conversion factor (CF) of $32.7442. This represents a 3.37% reduction from the 2023 physician conversion factor of $33.8872. The CF is the result of a statutory 0% update scheduled for the MPFS in 2024, a negative 2.18% budget neutrality adjustment, and a funding patch Congress passed at the end of 2022 through the Consolidated Appropriations Act of 2023, which partially mitigated a cut to the 2023 CF and offset part of the reduction to the 2024 CF.
CMS will also implement the third year of a phased clinical labor pricing update and reinstitute add-on evaluation and management (E/M) code G2211 for medical complexity. In December 2020, Congress passed the Consolidated Appropriations Act of 2021, which delayed use of G2211 until 2024 due to significant budget implications as the agency estimated it would be billed with 90% of all office visit claims, redistribute around $3.3 billion, and cause an overall 3% cut to the CF in 2021.
CMS will implement code G2211 in 2024, but with a significantly revised utilization assumption of 38%, per the 2024 MPFS final rule. The decrease in the CF, however, is primarily because of the addition of code G2211, a decrease in the Congressional funding patch from 2023 to 2024, and statutory budget neutrality.
CMS estimates a positive 2% overall impact for the hematology/oncology specialty and a negative 2% overall impact for the radiation oncology specialty in 2024. However, this estimate does not factor in the full 3.37% reduction in the CF. The actual impact on individual clinicians will vary based on geographic location and the mix of Medicare services billed.
Advancing Health Equity and Caregiver Support
CMS finalized coding and payment for several new services to help clinicians address unmet health-related social needs that can potentially interfere with the diagnosis and treatment of medical conditions in underserved populations including:
Caregiver Services – CMS will pay for certain caregiver training services in specified circumstances, so that practitioners are appropriately paid for engaging with caregivers to support people with Medicare in carrying out their treatment plans.
Community Health Integration – CMS finalized separate coding and payment for community health integration services, which include person-centered planning, health system coordination, promoting patient self-advocacy, and facilitating access to community-based resources to address unmet social needs that interfere with the practitioner’s diagnosis and treatment of the patient.
Principal Illness Navigation – CMS finalized coding and payment for principal illness navigation services, which describe care navigation services—similar to those for community health integration—for individuals with high-risk conditions including cancer.
Social Determinants of Health Risk Assessment – This rule also finalizes coding and payment for social determinants of health risk assessments, which can be furnished as an add-on to an annual wellness visit or in conjunction with an E/M or behavioral health visit.
Evaluation and Management Services
Complex Care Add-on Code G2211 – As mentioned above CMS is finalizing implementation of code G2211. This add-on code will recognize the resource costs associated with evaluation and management visits for primary care and longitudinal care. Generally, it will provide an additional payment for outpatient and office visits, to recognize the inherent costs involved when clinicians are the continuing focal point for all needed services, or are part of ongoing care related to a patient’s single, serious condition or a complex condition.
Split/Shared Visits – For 2024, CMS will define the “substantive portion” of a split (or shared) visit to mean more than half of the total time spent by the physician or nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making. This responds to ASCO comments asking that CMS allow either time or medical decision making to serve as the substantive portion of a split (or shared) visit.
CMS is making several updates to the Medicare Telehealth Services List for 2024, including finalizing its proposal to add the code for Social Determinants of Health Risk Assessments on a permanent basis.
CMS also finalized implementation of several telehealth-related provisions from the Consolidated Appropriations Act, 2023, including the temporary expansion of originating sites and geographic location, audio-only, and the expanded list of telehealth practitioners to include qualified occupational therapists, qualified physical therapists, qualified speech-language pathologists, and qualified audiologists.
Additionally, in 2024 telehealth services furnished to people in their homes will be paid at the higher, non-facility MPFS rate, thereby protecting access to telehealth services and aligning with the telehealth-related flexibilities that were extended via the Consolidated Appropriations Act of 2023. CMS will also continue to define “direct supervision” in a way that allows the supervising practitioner to be present and available through real-time audio and video interactive telecommunications through December 31, 2024.
In response to ASCO comments, through 2024, CMS will not require clinicians to report their home address on Medicare enrollment forms when providing telehealth services from their home. CMS will consider this issue further in future rulemaking and requests that stakeholders provide clear examples of how the enrollment process shows material privacy risks to inform future enrollment and payment policy development.
Payment for Dental Services Prior to Certain Cancer Treatments
In response to ASCO comments CMS will permit payment for certain dental services inextricably linked to other covered services used to treat cancer prior to, or during chemotherapy, Chimeric Antigen Receptor T-Cell (CAR-T) therapy, and the use of high-dose bone modifying agents (antiresorptive therapy).
The 2024 Quality Payment Program
Merit-Based Incentive Payment System Performance Threshold
In response to ASCO comments, CMS did not finalize any policies that would result in an increase to the Merit-Based Incentive Payment System (MIPS) performance threshold. The threshold will remain 75 points for the 2024 performance period instead of increasing to 82 points as proposed.
Qualifying Alternative Payment Model Participants
Additionally, in response to ASCO’s concerns, CMS will not make Qualifying Alternative Payment Model Participant (QP) determinations at the individual eligible clinician-level in 2024. Instead, the agency will make QP determinations at the entity-level. Under current statute, the QP threshold percentages will increase beginning with the 2024 performance year/2026 payment year as follows:
- QP threshold increasing from 50% to 75%
- Partial QP threshold increasing from 40% to 50%
- QP threshold increasing from 35% to 50%
- Partial QP threshold increasing from 25% to 35%
CMS finalized five new MIPS Value Pathways (MVPs) and modifications to the 12 previously finalized MVPs. There will be a total of 16 MVPs available for reporting in the 2024 performance period, including the Advancing Cancer Care MVP.
CMS also finalized a 180-day (minimum) performance period for the Promoting Interoperability performance category. CMS believes this change promotes continuity across CMS programs and aligns with the Medicare Promoting Interoperability Program.
Updates to HOPPS and ASC payment rates
For 2024, CMS increased payment rates under the HOPPS and ASC payment systems by a factor of 3.1%. This update is based on the projected hospital market basket percentage increase of 3.3%, reduced by a 0.2 percentage point for the productivity adjustment. In continuation of an existing policy, hospitals and ASCs that fail to meet their respective quality reporting program requirements are subject to a 2% reduction in the 2024 fee schedule increase factor.
Hospital Price Transparency
To improve hospital compliance and the public’s understanding and automated use of hospital information, CMS is finalizing modifications to the standard charge display requirements. Additionally, CMS is finalizing updates to the enforcement provisions to streamline and improve the transparency of the enforcement process.
Buffer Stock of Essential Medications
In the proposed rule, CMS sought comment regarding separate payment, under the Hospital Inpatient Proposed Payment System, for establishing and maintaining access to a buffer stock of one or more of 86 essential medicines to foster a more reliable, resilient supply of these medicines. CMS is not finalizing a payment policy on this for 2024. It believes that a multifaceted approach is necessary and intends to proceed as such in future rulemaking.
Reimbursement for 340B Drugs
CMS will continue to pay for drugs purchased under the 340B drug pricing program at average sales price (ASP) +6% in 2024. As such, the payment rate for 340B-acquired drugs and biologicals will not differ from the payment rate for drugs and biologicals not acquired through 340B.
CMS also issued a final rule in response to a Supreme Court of the United States opinion that the payment cuts for 340B-acquired drugs the agency implemented in 2018-2022 were not consistent with its authority to set Medicare payments to hospitals for outpatient drugs.
The rule finalized the proposal to make a one-time, lump sum payment to affected providers, and providers will not be able to bill beneficiaries for any cost sharing. CMS is also maintaining its budget neutral policy and implementing a $7.8 billion offset by adjusting the HOPPS conversion factor by -0.5% starting in 2026. CMS will make this adjustment until the $7.8 billion owed is recouped, which it estimates will take 16 years. Providers that did not enroll in Medicare until after January 1, 2018, are excluded from the prospective rate reduction.
Register for an informative ASCO webinar on the 2024 MPFS taking place Thursday, November 9 at 4:30 p.m. ET. ASCO staff will provide more details on the rule and answer questions.
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