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2019 Payment And Health Care Delivery

Ensuring Access For Patients In Need

The advanced medical technology industry creates life-saving and life-enhancing innovations every day, and Medicare patients are a major beneficiary of these advances. AdvaMed’s Payment and Health Care Delivery department works closely with the Centers for Medicare and Medicaid Services (CMS) to ensure patient access to innovations through appropriate coverage, coding and payment policies – the importance of which is magnified when such policies are replicated by private payers.


Coverage, Coding & Payment

AdvaMed advocacy paid off in 2019 with issuance of several CMS rules that will go a long way toward improving payment and coverage for transformational medical technologies and supporting their development for the benefit of patients. This included CMS’s Inpatient Prospective Payment System (IPPS) final rule in August and Outpatient Prospective Payment System (OPPS) final rule in November that reflect several AdvaMed priorities.

Under the IPPS final rule, FDA-designated breakthrough technologies will more easily qualify for increased inpatient New Technology Add-on Payments (NTAP) if certain cost thresholds are met. Under the OPPS final rule, breakthroughs will more easily qualify for technology add-on payments under the hospital outpatient transitional pass-through payment program. Legislation introduced in the House in December, and a proposed rule that the Office of Management and Budget began reviewing in July, are anticipated to further streamline Medicare coverage of breakthrough and innovative technologies in response to AdvaMed advocacy.

Meanwhile, CMS’s End-Stage Renal Dialysis Prospective Payment System final rule, issued in November, establishes a new transitional add-on payment adjustment for certain new and innovative renal dialysis equipment and supplies designated as services that meet substantial clinical improvement criteria.

On the coding front, improvements announced by CMS in May will switch the timing for applications for HCPCS codes from once per year to twice annually, allowing companies to more frequently apply for and receive codes – and get faster reimbursement. The agency also clarified that local coverage policy changes finalized in 2018 will ensure Medicare Administrative Contractors cannot automatically deny coverage for Category III CPT codes – as was previously common practice.

Supporting Members With Research & Education

In 2019, AdvaMed released a value framework toolkit to assist members in identifying drivers of medical technology value and the evidence essential to securing appropriate coverage and payment. Training on use of the toolkit was promoted through an interactive value assessment workshop in October.

The association also hosted its fifth annual Payment Policy Conference in April, which highlighted the challenges and opportunities surrounding new payment models, demonstration of value and payer decision making, and implications for device innovation. As part of the conference and throughout the year, the Payment department engaged with private payors as well as CMS officials to advance appropriate medtech reimbursement. AdvaMed also created a Private Payer Engagement Program to improve collaboration and engagement with private payers.