2006 proposed fee schedule - American Society of Clinical Oncology

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248 data which, despite updates by the PPI, do not necessarily reflect current market conditions. As discussed below, the chances increase that Medicare payments will either overpay or underpay for drugs, thus, resulting in payments that are inconsistent with the goal of making accurate payments for drugs. We also considered whether actual acquisition cost data could be periodically updated. However, we do not believe that it would be feasible to base Medicare payments over the long term on continually acquiring data on actual acquisition costs from ESRD facilities. This approach would provide incentives for manufacturers and facilities to increase acquisition costs without constraint. It also would not necessarily provide data regarding current market rates. Therefore, we believe it is appropriate for the payment methodology for all ESRD drugs when separately billed by freestanding ESRD facilities during CY 2006 to be paid the amount determined under section 1847A of the Act. This payment amount is the ASP +6 percent rate. In reaching the conclusion about establishing payment using the amount determined under section 1847A of the Act rather than actual acquisition costs, we analyzed the ASP +6 percent payment rates for all separately billable ESRD drugs, including the top 10, for both the first and second quarters of CY 2005. (We note that the ASP payment rates are updated quarterly. The new rates are made available
each quarter at the following web site: http://www.cms.hhs.gov/providers/drugs/asp.asp.) 249 Additionally, we analyzed the CY 2005 payment rates, based on OIG data, updated by the PPI to reflect inflation as well as the potential CY 2006 payment rates, based on the OIG data, also updated by the PPI to reflect inflation for the top 10 separately billable ESRD drugs. As indicated in the “Top 10 Separately Billable ESRD Drugs” chart, the payment rates for the top 10 separately billable ESRD drugs based on the acquisition costs (as determined by the OIG), updated by the PPI would increase by 7 percent for CY 2006. In contrast, the percentage change in the ASP +6 percent payment rates for the top 10 separately billable ESRD drugs based on the first and second quarters of CY 2005 varied on a drug-by-drug basis. Top 10 Separately Billable ESRD Drugs Estimated 2006 Payment Rate Estimated 2006 Percent Change Based on OIG Data Payment Rate Based in ASP+6 Rates 2005 (2003 data inflated on ASP+6 Between Payment 16.2% to 2006 by the (2nd Quarter 1st Quarter and Drug Name Rate Estimated PPI) 2005 rates) 2nd Quarter 2005 Epoetin alpha $9.760 $10.440 $9.250 -1% Paricalcitol Sodium Ferric $4.000 $4.270 $3.971 -1% Gluconate $4.950 $5.290 $4.726 -2% Iron Sucrose $0.370 $0.390 $0.365 1% Levocarnitine $13.630 $14.560 $11.122 -24% Doxercalciferol $2.600 $2.780 $2.784 -0.5% Calcitriol $0.960 $1.030 $0.859 21% Iron Dextran $10.940 $11.700 $11.218 1% Vancomycin $2.980 $3.190 $3.188 32%
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DEPARTMENT OF HEALTH AND HUMAN SERV
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2. By mail. You may mail written co
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Rick Ensor (410) 786-5617 (for issu
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service of the U.S. Government Prin
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4. Proposed Revisions to §413.170
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AGA American Gastroenterological As
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GAO General Accounting Office GPCI
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PLI Professional liability insuranc
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Initially, only the physician work
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This resource-based system was base
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effect in 1997, published on Novemb
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● Revised requirements for superv
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efinement of work RVUs; and solicit
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historical allowed charges. This le
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November 1, 2001 (66 FR 55246).) Th
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The CPEPs identified specific input
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codes that the RUC has not yet revi
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procedure: $27,305,408. In this exa
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as a whole. Indirect costs include
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● The unscaled indirect expense a
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BNF is applied to (multiplied by) t
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NPWP Step 2--Calculation of Charge-
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In Table 11, the scaled total direc
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TABLE 13--Budget Neutrality and Fin
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The following discussion outlines t
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exist, and suggests that the need f
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TABLE 14--Practice Expense Per Hour
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We believe that we have consistentl
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Due to the ongoing refinement by th
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indirect PE methodology is inaccura
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multi-specialty PEAC that were base
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the needed survey or other data or
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PERC/RUC recommendations for these
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eflect the typical number of cast c
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on comments received and additional
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We have reviewed the PE database an
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the ACR. We have accepted the follo
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● Clinical Labor for G-codes Rela
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proposed associated prices that we
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Supply Code Supply Description Unit
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● Supply and Equipment Items Need
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Code 2005 Description Unit Unit Pri
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Code 2005 Description Price EQ212 p
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Effective January 1, 2006, this pro
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challenge the validity of a new loc
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ones reconfigured). Yet we also rec
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The issue of payment locality desig
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specialties listed infrequently as
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for premium rating purposes. ISO co
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psychology to the nonsurgical risk
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to anesthesiology which is 2.84 rat
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103 However, as noted previously in
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● Category #1: Services that are
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G0270, G0271 and 97802 through 9780
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Group Medical Nutritional Therapy (
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111 furnished in the group setting
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CMS Review 113 As noted previously,
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system that permits the physician a
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117 associated with the provided se
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119 overlapping surgeries, the teac
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anesthesia programs that have arran
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123 Section 623 of the MMA also req
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125 hospital-based facilities; whil
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127 The next step would be to devel
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Drugs Second Quarter ASP +6 Percent
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131 independent facilities, to acco
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133
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distributed this over a total proje
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137 additional 0.7 percent addition
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139 billed drugs regardless of sett
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141 than 0.9000 are paid more than
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adoption of the new hospital wage i
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of geographic designations for purp
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and they may or may not be suitable
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the Medicare Geographic Classificat
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(2) Metropolitan Divisions Under OM
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153 applying revised composite paym
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ased on the labor components establ
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157 actual cost structure faced by
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159 ESRD facilities is 53.711, as s
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from the cost reports. To avoid dou
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from Worksheet A. The resulting mar
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(1) Hospital Data Used In this prop
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wage data ended. However, since the
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approach to phasing-in the proposed
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facilities that would receive lower
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173 wage index values and then simu
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175 Because Neighborhood Dialysis C
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177 detected through our receipt of
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179 CBSA Code Urban Area Wage (Cons
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Page 197 and 198: 197 CBSA Code Urban Area Wage (Cons
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Page 219 and 220: ● Extraordinary circumstances (§
Page 221 and 222: effect as long as the rate exceeds
Page 223 and 224: ● Adding a definition of a “ped
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Page 227 and 228: their intermediaries. Current parag
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Page 233 and 234: H. Payment for Covered Outpatient D
Page 235 and 236: calculation. We also discuss the su
Page 237 and 238: customers (for example, physicians)
Page 239 and 240: 239 We believe the weighted average
Page 241 and 242: number of 11-digit NDCs sold for ea
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Page 247: 247 section 1847A of the Act for th
Page 251 and 252: 251 We also note MedPAC’s recomme
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Page 257 and 258: pharmacy activities required to get
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Page 261 and 262: 261 basic pharmacy services such as
Page 263 and 264: seek comment on the potential impac
Page 265 and 266: 265 overpaying for the costs associ
Page 267 and 268: 267 and information about how pharm
Page 269 and 270: 269 takes good faith efforts to res
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Page 273 and 274: supplies. Using billing data, we id
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Page 281 and 282: is less than 2 percent of spending
Page 283 and 284: (2) entities determined by the Secr
Page 285 and 286: 285 We are proposing a supplemental
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Page 291 and 292: 291 conclude that Hispanic persons
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we would resolve any doubt on the m
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facility payment rather than a TC c
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ventures and leases, pose a risk of
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305 Underlying the projected rate r
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decisions are central to the health
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however. We are particularly intere
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The collection requirement in this
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eporting requirements are discussed
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IV. Response to Comments Because of
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achieve the objectives with less si
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319 The analysis and discussion pro
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321 for a new code may change becau
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323 TABLE 30--Impact of Practice Ex
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hour for these specialties. As note
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Both physical/occupational therapy
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329 proposing to add cardiology cat
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Speciality Impact of Removing Aberr
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Family TABLE 32--Impact of Multiple
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335 column includes the current est
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Specialty Medicare Allowed Charges
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339 Non-Facility Facility % % HCPCS
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341 have undertaken a similar analy
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of the updated GPCI data. For the R
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C. Medicare Telehealth Services In
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347 TABLE 37--Impact of Proposed Ch
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349 of the increase to the drug add
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plus current AAP priced drug paymen
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353 the center up to what it would
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satisfies the requirements of the i
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357 certainty the extent of these s
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delivery arrangements and would hel
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List of Subjects 42 CFR Part 405 Ad
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(including by refunding amounts in
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(2) Any financial incentives provid
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7. The authority citation for part
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* * * * * PART 413--PRINCIPLES OF R
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371 D. Redesignating paragraphs (l)
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373 (3) The additional nursing hour
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cost components relating to trainin
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CAPD and CCPD) when the facility ac
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Indirect Sales means from the manuf
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amount for the quarter to the neare
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383 25. The heading for Part 426 is
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385 (Catalog of Federal Domestic As
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1. CPT/HCPCS code. This is the CPT
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grace period. This indicator is no
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5. Physician work RVUs. These are t
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ADDENDUM B: RELATIVE VALUE UNITS (R
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CPT Code Short Descriptors 21480 Re
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CPT Code Short Descriptors 92284 Da
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Addendum D 2006 GEOGRAPHIC PRACTICE
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Carrier Locality Locality name Work
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Carrier Locality Locality Name 2006
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Addendum F ESRD FACILITIES- METROPO
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715 SSA State/County Code County an
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