Centers for Medicare & Medicaid Services
Department of Health and Human Services
Room 445-G, Hubert H. Humphrey Building
200 Independence Avenue, SW
Washington, DC 20201
RE: CMS-1590-P, Revisions to Payment Policies Under the Physician Fee Schedule, DME Face-to-Face Encounters, Elimination of the Requirement for Termination of Non-Random Prepayment Complex Medical Review and Other Revisions to Part B for CY 2013
Dear Ms. Tavenner:
The undersigned organizations representing cancer survivors, researchers, and physicians recommend that the physician fee schedule (PFS) for calendar year 2013 (CY 2013) be revised to include a new code for care management services that would be provided to cancer survivors after primary treatment. The proposal we offer is consistent with payments for primary care and care management services provided post-discharge that are proposed in the CY 2013 PFS update. CMS describes the post-discharge care coordination proposal as an element of a “multiple year strategy exploring the best means to encourage care coordination services.“ 77 FR 44722 at 44775. The expansion of the post-discharge care planning proposal to include a separate cancer survivorship care planning service is within the scope of the Proposed Rule and fully consistent with the multi-year effort to enhance care planning and coordination.
The undersigned organizations are dedicated to improving the quality of care and quality of life for cancer survivors. The National Coalition for Cancer Survivorship pursues public policy solutions, including health care delivery and payment reforms, to enhance cancer care quality. The Leukemia & Lymphoma Society is a national organization that supports an innovative basic, translational, and clinical research program focused on hematological cancers and also provides a wide range of support and educational services to blood cancer survivors. LIVESTRONG serves cancer survivors around the world with one-on-one support, cancer information, and other resources. Susan G. Komen for the Cure Advocacy Alliance takes stands on issues, including breast cancer research, early detection, and access to high-quality care, that are of importance to cancer survivors and advocates.
We commend the Centers for Medicare & Medicaid Services (CMS) for initiating, in the context of previous PFS rulemaking processes, discussions regarding strategies for providing care to prevent and manage chronic diseases for individuals after their discharge from hospitals or skilled nursing facilities. CMS reports that these discussions have focused on ways to reimburse for discrete medical services to improve care coordination and to do so in the fee-for-service setting. In the CY 2013 PFS update, CMS recommends payments for post-discharge care coordination services.
A primary goal of post-discharge care coordination is preventing readmissions. The service that is described by CMS in the proposed rule holds great promise not only for preventing hospital readmissions but also for improving the quality of care and life for those discharged from inpatient care. CMS identifies these elements of post-discharge transitional care management: 1) assuming responsibility for the beneficiary’s care without interruptions, 2) establishing or adjusting a plan of care to reflect all elements of care, 3) communicating with the beneficiary and/or caregiver regarding care plan, including medication management, medical matters, and psychosocial issues, 4) communicating with other health care professionals involved in the patient’s care, 5) assisting in coordination of follow-up visits, 6) identifying community resources, and 7) assisting in scheduling follow-up care with community providers and services.
Just as beneficiaries who are discharged from inpatient care have significant health care challenges and a pressing need for care planning and management during the transition from the inpatient setting to community care, so do cancer survivors have urgent health care needs as they transition from primary treatment to survivorship care. In a groundbreaking 2006 study, From Cancer Patient to Cancer Survivor: Lost in Transition, the National Cancer Policy Board of the Institute of Medicine defined the issues that cancer survivors confront at the end of primary treatment and outlined the elements of care that they require in the transition from primary treatment to survivorship care: 1) prevention of recurrent and new cancer and other late effects, 2) surveillance for cancer spread, recurrence, or second cancers and assessment of medical and psychosocial late effects, 3) intervention for consequences of cancer and its treatment, and 4) coordination between specialists and primary care providers to ensure that all of the survivor’s health needs are met.
In recommending a post-discharge care coordination and management code, CMS stated that current evaluation and management services do not adequately describe the care management work involved in primary care. Neither do current evaluation and management services describe the work, including work that is not face-to-face, which is required to plan and coordinate the care that cancer survivors need after primary treatment. The elements of post-discharge care coordination identified by CMS in the CY 2013 PFS update, including the development of a plan, communication and coordination of all medical specialty services, and identification of community resources, are also the elements of cancer survivorship transition planning and coordination.
Just as the establishment of a post-discharge care management service is an appropriate reform of the fee-for-service system that will improve quality of care and reduce readmissions, so would the establishment of a cancer survivorship care planning and coordination service represent an improvement of the fee-for-service system that will ensure cancer survivors access to quality care through the prevention and management of late and long-term effects of cancer and cancer treatment. Although much of the work to plan and coordinate survivorship care is not face-to-face work, we recommend that the cancer survivorship planning and coordination service include a face-to-face encounter to ensure the full and complete communication of the plan to the beneficiary.
We also recommend that CMS consider another discrete medical service – cancer care planning and coordination delivered at the beginning of primary, or active, treatment — as a reform of the fee-for-service system. A primary treatment plan and care coordination service would ensure the coordination of all elements of active treatment and symptom management and would also prompt a discussion between provider and patient regarding the goals of care. The IOM, in the report Ensuring Quality Cancer Care, stated that an “agreed-upon care plan that outlines the goals of care” is a critical element of quality care for each individual with cancer.
CMS has shown impressive flexibility in proposing incremental but important reforms to the fee-for-service system of payment even while testing more comprehensive payment reforms. We strongly urge steps to improve cancer care payment and delivery while more ambitious and far-reaching reform efforts are tested and evaluated.
National Coalition for Cancer Survivorship
The Leukemia & Lymphoma Society
Susan G. Komen for the Cure Advocacy Alliance