On July 13, 2023, the Centers for Medicare & Medicaid Services (CMS) released its proposed rule for the 2024 Medicare Physician Fee Schedule (PFS) and updates to the Quality Payment Program (QPP). The agency also released the 2024 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule.
The Association for Clinical Oncology (ASCO) continues to analyze the full proposals, but based on a preliminary analysis, key provisions for the cancer care community include:
2024 Physician Fee Schedule
Conversion Factor
CMS has proposed a 2024 physician conversion factor (CF) of $ 32.7476. This represents a 3.36% reduction from the 2023 physician conversion factor of $33.8872. The proposed CF is the result of a statutory 0% update scheduled for the PFS in 2024, a negative 2.17% 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, in addition to maintaining use of add-on evaluation and management (E/M) code—G2211—for medical complexity. CMS finalized code G2211 in the 2021 PFS final rule, but it had significant budget implications, since the agency estimated it would be billed with 75% of all office visit claims. This was expected to redistribute around $3.3 billion and cause an overall 3% cut to the CF in 2021.
In December 2020, Congress passed the Consolidated Appropriations Act of 2021, which delayed G2211 until 2024. CMS has decided to reinstitute the code in 2024, but the agency significantly revised its utilization assumptions and now estimates that G2211 will be billed with 38% of all office visit claims initially.
Specialty Impact
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 3.36% reduction in the CF. The actual impact on individual clinicians will vary based on geographic location and the mix of Medicare services billed.
Split/Shared Visits
CMS is proposing to maintain the current definition of the “substantive portion” of an E/M service performed by both a physician and a non-physician practitioner in a facility setting through 2024. Clinicians who furnish the split/shared visit will continue to have a choice of history, physical exam, medical decision making, or more than half of the total practitioner time spent to define the substantive portion to determine which practitioner will bill the visit. CMS has further delayed changing the definition of “substantive portion” to allow time to consider feedback and evaluate whether there is a need for additional rulemaking.
Evaluation and Management Services
Over the last several years, CMS received suggestions/recommendations that it value services based on research and data other than the American Medical Association (AMA) RVS Update Committee’s (RUC) specialty-specific recommendations. As CMS continues working to establish resource-based relative value units for PFS services, it is seeking public comment about the potential range of approaches the agency could take to improve the accuracy of its values for E/M services.
Telehealth
CMS is proposing several updates to the Medicare Telehealth Services List for 2024. The agency is proposing to add health and well-being coaching services to the Medicare Telehealth Services List on a temporary basis in 2024 and Social Determinants of Health Risk Assessments on a permanent basis
The agency is also proposing that, beginning in 2024, telehealth services furnished to people in their homes be paid at the non-facility PFS rate, thereby protecting access to telehealth services by aligning with the telehealth-related flexibilities that were extended via the Consolidated Appropriations Act of 2023.
Additionally, CMS is proposing to 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. The agency believes that this continuation aligns with the Public Health Emergency-related telehealth policies that were extended under the Consolidated Appropriation Act of 2023, and CMS is soliciting comment on whether it should consider extending the policy beyond December 31, 2024.
Advancing Health Equity and Caregiver Support
CMS is proposing coding and payment for several new services to help underserved populations, including addressing unmet health related social needs that can potentially interfere with the diagnosis and treatment of medical conditions.
First, CMS is proposing to pay for certain caregiver training services in specific circumstances, so that practitioners are appropriately paid for supporting caregivers who help people with Medicare carry out their treatment plans. The agency is also proposing separate coding and payment for community health integration services, which would 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.
In alignment with the Cancer Moonshot’s goal that everyone with cancer have access to covered patient navigation services, CMS is proposing payment for Principal Illness Navigation services to help patients navigate cancer treatment and treatment for other serious illnesses. These services include care involving peer support specialists, such as peer recovery coaches for individuals with substance use disorder.
The proposal also includes coding and payment for social determinants of health risk assessments, which could be furnished as an add-on to an annual wellness visit or in conjunction with an E/M visit.
Payment for Dental Services Prior to Certain Cancer Treatments
CMS is also supporting the Cancer Moonshot initiative by proposing that payments can be made for certain dental services prior to and during several different cancer treatments, including, but not limited to, chemotherapy.
The Quality Payment Program
Merit-Based Incentive Payment System (MIPS) Performance Threshold
CMS is proposing to increase the MIPS performance threshold from 75 to 82 points under all three MIPS reporting options: traditional MIPS, MIPS Value Pathways (MVPs), and Alternative Payment Model Performance Pathways (APPs).
In accordance with the Consolidated Appropriations Act of 2023, the Alternative Payment Model (APM) Incentive Payment for payment year 2025 is 3.5%. After the 2023 performance year/2025 payment year; however, the APM Incentive Payment will end. Beginning with the 2024 performance year/2026 payment year, qualifying participants (QPs) will receive a higher Medicare PFS update (“qualifying APM conversion factor”) of 0.75% compared to non-QPs, who will receive a 0.25% Medicare PFS update, which will result in a differentially higher PFS payment rate for eligible clinicians who are QPs. APM QPs will continue to be excluded from MIPS reporting and payment adjustments for the year.
Qualifying APM Participants
CMS is proposing to make QP determinations at the individual eligible clinician-level only and no longer the APM Entity-level. Under current statute, the QP threshold percentages will increase beginning with the 2024 performance year/2026 payment year as follows:
- Medicare Payments
- QP threshold increasing from 50% to 75%
- Partial QP threshold increasing from 40% to 50%
- Medicare Patients
- QP threshold increasing from 35% to 50%
- Partial QP threshold increasing from 25% to 35%
2024 OPPS
Updates to OPPS and ASC payment rates
In accordance with Medicare law, CMS proposes updating OPPS payment rates for hospitals that meet applicable quality reporting requirements by 2.8%. This update is based on the projected hospital market basket percentage increase of 3.0%, reduced by a 0.2% productivity adjustment.
The rule also contains proposals related to health equity, behavioral health, dental services, rural emergency hospitals, and quality reporting programs, among other provisions. Furthermore, CMS proposes strengthening hospital price transparency regulations—which require each hospital operating in the United States to make its standard charges public. The proposal also includes new requirements that would standardize how hospitals display standard charge information in machine-readable files and govern how hospitals must publicly post those files on their websites.
Finally, of special interest to the oncology community given the ongoing and acute shortages of cancer drug treatments, CMS is seeking comment on a separate payment to hospitals for establishing and maintaining access to a buffer stock of essential medicines to foster a more reliable, resilient supply of such medicines.
Bookmark ASCO in Action for updates on these proposals as well as news, advocacy, and analysis on cancer policy.
