September 11, 2017
[Submitted electronically to www.regulations.gov]
Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
7500 Security Boulevard
Baltimore, MD 21244-1850
Re: Docket CMS-1676-P for “Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared Savings Program Requirements; and Medicare Diabetes Prevention Program.”
ASHP is pleased to submit comments to the Centers for Medicare & Medicaid Services (CMS) regarding the proposed changes to the Physician Fee Schedule (the “PFS”) for calendar year 2018. ASHP represents pharmacists who serve as patient care providers in acute and ambulatory settings. The organization’s more than 44,000 members include pharmacists, student pharmacists, and pharmacy technicians. For 75 years, ASHP has been at the forefront of efforts to improve medication use and enhance patient safety.
ASHP thanks CMS for the opportunity to comment on the proposed rule. We support many of the proposed changes to the PFS and hope that the comments below will assist CMS in refining the PFS to meet our shared patient care and quality goals.
I. Coding: Chronic Care Management (CCM) and Behavioral Health Integration (BHI)
ASHP thanks CMS for its commitment to enhancing the availability of chronic care management (CCM) and transitional care management (TCM) services. In particular, ASHP is pleased by CMS’s proposed implementation of G-codes for CCM and behavioral health integration (BHI) codes for federally qualified health centers (FQHCs) and the rural health clinics (RHCs). We also appreciate CMS’s clarification that these services can be provided under general supervision as opposed to direct supervision. ASHP again thanks CMS for its work in enhancing the availability and quality of chronic care services, and we look forward to working with CMS as it refines CCM, TCM, and BHI requirements.
Additionally, ASHP supports CMS’s proposal to revise the documentation requirements for E/M codes. We appreciate CMS’s acknowledgment that updating the documentation requirements will require a “multi-year, collaborative effort among stakeholders.” As CMS gathers feedback on specific changes, such as the proposal to remove history and physical exam document requirements, we encourage CMS to share the information it receives and to consider other potential forums for stakeholder engagement, such as public meetings.
II. Diabetes Prevention Program Proposed Expansion
ASHP commends CMS for the proposed expansion of the Medicare Diabetes Prevention Program (MDPP). Diabetes is a significant public health issue, and evidence demonstrates that pharmacists can and do play a major role in both its prevention and its management.1 Thus, ASHP encourages CMS to finalize program guidelines that maximize the ability of qualified individuals to provide DPP services. Given the complexity and novelty of the program, we urge CMS, as soon as is practicable, to provide subregulatory guidance or other informational materials to assist suppliers and coaches in navigating the enrollment process. Although we understand that no services can be furnished or billed under MDPP prior to April 1, 2018, suppliers and coaches need sufficient lead time to enroll and to otherwise organize and prepare to see patients.
ASHP strongly supports the development of a robust MDPP program. We appreciate the level of detail the proposed rule offers regarding MDPP supplier and beneficiary enrollment, payment for MDPP services, and beneficiary engagement incentives. As CMS continues to implement the program, we recommend that CMS address the following issues:
- Payment Sufficiency: While we are generally supportive of a value-based payment framework, we question whether a payment of $25 for the initial session will be sufficient to support service provision, particularly as CMS has indicated that this amount is also meant to defray the costs of subsequent sessions. CMS could shift some portion of the payments from the ongoing maintenance phase to the initial visit to encourage provider participation. At minimum, as implementation progresses, CMS should monitor whether the proposed payment amounts appropriately incentivize program participation.
- Lifetime Cap Verification: CMS proposes that instead of relying on beneficiary self-reporting of previous MDPP services, suppliers or coaches must actively verify that a beneficiary has never received the full set of MDPP services. CMS further suggests that it may develop a “tracker” to facilitate the submission of attendance information between MDPP suppliers. Given the variation amongst EHR technology and the potential costs associated with adding new data fields, and so on, we urge CMS to seek additional stakeholder input on any specific proposals for a “tracker” system prior to implementation.
- Documentation of Attendance: Based on the proposed structure of the MDPP program, during the ongoing maintenance intervals, payments will be made to suppliers only after patients achieve certain targets for both attendance and weight loss. However, it remains unclear exactly when suppliers can submit claims for some of these payments (e.g., the date the attendance requirement is met?). We urge CMS to provide additional clarification regarding claim documentation requirements in the additional guidance the agency has indicated it will provide.
ASHP appreciates this opportunity to provide comments. Please contact me if you have any questions regarding ASHP’s comments on the proposed rule. I can be reached by telephone at 301-664-8696 or by email at [email protected].
Jillanne Schulte Wall, J.D.
Director, Federal Regulatory Affairs
1 See, e.g., Simpson SH et al., “Effect of Adding Pharmacists to Primacy Care Teams on Blood Pressure Control in Patients with Type 2 Diabetes: A Randomized Controlled Trial,” DIABETES CARE (Oct. 7, 2010); Morello CM, Hirsch JD, Lee KC, “Navigating Complex Patients Using an Innovative Tool: The MTM Spider Web,” J. AM. PHARM. ASSOC, (2013), available at https://www.pharmacypracticeaccredit.org/resources/navigating-complex-patients-using-an-innovative-tool-the-mtm-spider-web.