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Year: 2020

SW Medical Consulting- Healthcare ConsultantsBlog2020
By Keith Sei Medicare

NEW 2021 CPT Code Set released by the AMA

American Medical Association (AMA) reported that is has published the first major overhaul in more than 25 years to the codes and guidelines for office and other outpatient evaluation and management (E/M) services in the release of the 2021 Current Procedural Terminology (CPT) code set.

These foundational modifications were designed to make E/M office visit coding and documentation simpler and more flexible, freeing physicians and care teams from clinically irrelevant administrative burdens. The changes to CPT codes ranging from 99201-99215 are proposed for adoption by the Centers for Medicare and Medicaid Services on Jan. 1, 2021.

The E/M office visit modifications include:

  • Eliminating history and physical exam as elements for code selection.
  • Allowing physicians to choose the best patient care by permitting code level selection based on medical decision-making (MDM) or total time.
  • Promoting payer consistency with more detail added to CPT code descriptors and guidelines.

The AMA has developed an extensive online resource library that includes a checklist, videos, modules, guidebooks, as well as other tools and resources to help transition to the revised E/M office visit codes and guidelines. The revised E/M office visit codes are among 329 editorial changes in the 2021 CPT code set, including 206 new codes, 54 deletions, 69 revisions. The CPT code set continues to see growth in new and novel areas of medicine, with the majority (63 percent) of new codes this year involving new technology services described in Category III CPT codes and the continued expansion of the Proprietary Laboratory Analyses (PLA) section of the CPT code set.

Changes to the CPT code set are considered through an open editorial process managed by the CPT Editorial Panel, an independent body convened by the AMA that collects broad input from the health care community and beyond to ensure CPT content reflects the coding demands of digital health, precision medicine, augmented intelligence, and other aspects of a modern health care system. This rigorous editorial process keeps the CPT code set current with contemporary medical science and technology, so it can fulfill its vital role as the trusted language of medicine today and the code to its future.

Among this year’s important additions to the CPT code set are new medical testing services sparked by the public health response to the COVID-19 pandemic. The CPT code set has been modified with several code additions and revisions that have been approved for immediate use and published for the 2021 CPT code set.

The CPT code set continues to be modified to respond to the fast pace innovation among digital medicine services that can improve access to health care and improved health outcomes for patients across the country. This is illustrated by new codes for retinal imaging and external extended electrocardiogram (ECG) monitoring.

The addition of code 92229 for retinal imaging with automated point-of-care, and revision of codes 92227 and 92228, better support the screening of patients for diabetic retinopathy and increase early detection and incorporation of findings into diabetes care. Innovative solutions like the augmented intelligence technology described by new code 92229 have the potential to improve access for at-risk patient populations by bringing retinal imaging capabilities into the primary care setting.

Technological advances in the field of continuous cardiac monitoring and detection have prompted the addition of codes 93241, 93242, 93243, 93244, 93245, 93246, 93247, 93248, along with associated guideline revisions. These codes will replace Category III codes 0295T, 0296T, 0297T and 0298T, which were deleted. These new codes utilize an innovative algorithmic technology that works in concert with a patch that is much easier to wear for patients and provides more accurate and complete data for physician interpretation.

To assist the healthcare system in an orderly annual transition to a newly modified CPT code set, the AMA will release each new edition four months ahead of the January 1 operational date and develop an insider’s view with detailed information on the new code changes.

By Keith Sei Managed Care

CMS Proposed Rule Redefines Value-Based Payment Negotiations for Gene Therapy

The proposed rule significantly changes payer value-based payment negotiations, allowing for more long term value-based contracting.

CMS has proposed a rule that allows payers to adopt new value-based payment models for gene therapies.

CMS’s rules for ensuring that Medicaid receives the lowest price available for prescription drugs have not been updated in thirty years and are blocking the opportunity for markets to create innovative payment models. By modernizing rules, CMS is creating opportunities for drug manufacturers to have skin in the game through payment arrangements that challenge them to put their money where their mouth is.

Gene therapies have been effective precision medicine tools to stop diseases early. There are only a few gene therapies on the market, however, and the price tags on these products are always headline news, with one recent gene therapy costing over $2 million.

The new CMS proposal seeks to ease value-based payment models for gene therapies, increasing payer price negotiating power and ability to arrange payment based on outcome over quantity.

CMS has altered the “best prices” approach in this new proposal so that payers can make changes to their rebates based on outcomes, allowing for more long-term value-based contracting. The new rule also would allow manufacturers to offer more than one “best price” for payers to choose from if they offer it through a value-based payment.

The proposed rule looks to establish a definition for value-based purchasing.

According to the new definition, value-based purchasing is

an arrangement or agreement intended to align pricing and/or payments to an observed or expected therapeutic or clinical value in a population (that is, outcomes relative to costs) and includes (but is not limited to):

  • Evidence-based measures, which substantially link the cost of a drug to existing evidence of the effectiveness or potential value for specific uses of that product, and/or
  • Outcomes-based measures, which substantially link payment for the drug to that of the drug’s actual performance in a patient or a population, or a reduction in other medical expenses.

The proposed rule also suggests a minimum standard for state Medicaid drug utilization review programs which are designed to address the opioids crisis.

The fact sheet explains that the rule would revise some key regulations, including the calculation for average manufacturer price of brand name drugs when a generic exists, when patient assistance programs should be incorporated into the price, reporting requirements for the Medicaid drug rebate program for both states and manufacturers, CMS-authorized supplemental rebate agreement definitions, among other alterations.

These changes would help states, payers, and manufacturers enter into value-based payment agreements for high cost medications, according to CMS.

This is intended to help modernize the interpretation of how manufacturers adapt the interpretation of the ‘best price’ law – which was enacted 30 years ago, and has only allowed one single best price for each drug to be available to state Medicaid agencies – to contemporary arrangements where more than one price could be available for a drug based on its outcomes in a patient.

Whereas major commercial payers have used industry consolidation to bring gene therapy development under their own company roof, the CMS regulation seeks to significantly alter the way that payers and states negotiate with manufacturers.

Only about a year prior to this notice of proposed rulemaking, CMS announced it would cover the first FDA-approved gene therapies for two cancer therapies.

 

By Keith Sei Healthcare

Aetna Offers Atlanta Employers Self-Insured Plans

The Aetna Whole Health plan aims to provide employers fully-insured and self-insured plan options with ACOs and upside risk contracts.

Aetna Whole Health plans to offer employers access to self-insured and fully-insured plan options that focus on better care coordination through accountable care organizations (ACOs) and incorporating upside risk value-based contracting.

Aetna Whole Health partners with accountable care organizations—in this case, Emory Healthcare and Northside Hospital System—with the aim of offering low-cost, high-quality, value-based care.

The model is upside risk for the 900 primary doctors, 3500 specialists, 14 hospitals and over 500 outpatient facilities with which Aetna now partners in Atlanta.

Each patient has a care management program to improve patient outcomes. These care teams enable greater care coordination for individual patients.

All 16 Atlanta CVS HealthHUBs will be included in this new model, as well as the 15 to 20 new HealthHUBs that the company intends to establish in 2020.

Whole Health plans, which orbit around accountable care organizations and strong care coordination, may especially appeal to self-insured employers, who are increasingly becoming employer activists.

These employer activists are relying on accountable care organizations, according to Steve Wojcik, vice president of public policy at the National Business Group on Health. They also rely on centers of excellence and high-performance networks to drive forward positive patient outcomes for their employees.

As Aetna changes its options for fully insured or self-insured employers, private payer giants are revolutionizing the rest of Georgia’s healthcare system as well.

Aetna Whole Health has been active for several years, with Whole Health plans available to employers in Virginia as early as 2012.

Previous Aetna Whole Health plans included the Orlando Health and UnityPoint 2018 partnership in Florida. Like the new plan starting in Atlanta, these agreements were with accountable care organizations and were projected to save employers 15 percent on their overall healthcare spending.

Also an upside risk agreement, the plan outlined four main quality measures which Aetna tracked to determine the accountable care organizations’ rewards:

  • Patient satisfaction scores
  • Preventive screenings
  • Hospital admissions
  • Chronic care management

The partnership goes into effect on April 1, 2020.