Saturday, October 12, 2024

CMS "Hold Harmless" Rule for Part B Fraud: They're Better at "Holding Harmless" than "Holding Responsible"

There's been an unusual zone of activity in CMS policy, in their area of ACO and "Shared Savings" calculations when the patient billing records contain large dollar amounts of abuse and fraud.   CMS is better at "holding harmless" themselves and others, than "holding responsible."

Recall that ACO's generally have Part B fee for service members, and the ACO is held "responsible" for all Part B spending (not just when the bene visits the ACO's own health system.)   Abuse and fraud in "regular" Part B adds to the costs "attributed" to the ACO's overall patient management.   In a special rule September 24, 2024, CMS created a "hold harmless" escape valve for ACO's whose patients racked up mysterious large bills for catheteres (A4352, A4353). The latter code rose by 5000X as the payments continued to pour out.  (89FR79156; All references at bottom).

They turned the rule around quickly (draft, July 3, final, September 24, less than 90 days).   Public awareness of the problem dates back to at least 2/15/2024 (here).

CMS awareness dates, at least, to the beginning of the year in question, CY2023 (CMS writes in the press release, "In early 2023, CMS identified a concerning rise in urinary catheter billings, which was attributed to a small group of durable medical equipment supply companies. CMS determined that the beneficiaries did not receive catheters and were not billed directly, physicians did not order these supplies, and supplies were not needed."  CMS calls this SAHS billing, "Significant, Anomalous, and Highly Suspect" billing.

Billing vs Payments

CMS cleverly attributes the problem to a small group of companies with erroneous billing.   Does anyone see the problem yet? It's not erroneous billing, it's erroneous payments.  

It doesn't require "AI" or super software to detect this.  The massive increase in ludicrous amounts of catheters, coming in as "bills," should never (after a month or two) continue to result in payments.  It's exactly the same as the completely insane, nonsensical, billion dollars of payments for obscure full sequencing gene codes, often a dozen per each patient, arriving at MACs in 2018-2022.  Some MAC systems were able to completely thwart such crazy payments (NGS MAC, the various MolDx MACs) while others paid out patently ludicrous claims patterns and volumes for years on end.  

While it's OK to hold harmless the ACO's, who are unaware of fraudulent billing to Part B MACs in real time, the CMS announcements say far too little about firing the idiots in charge of the payments trigggered by the billing.

CMS's weak reply to the payment problem seems to be *(89FR79156), "The proposed changes do not impose new rules or requirements related to provider billing and payment. The proposed changes are specific to ACOs" [and their profit calculations]. 

###

CMS press release here:

https://www.cms.gov/newsroom/fact-sheets/final-rule-mitigating-impact-significant-anomalous-and-highly-suspect-billing-activity-medicare

Here's the final rule at 89 FR 79152 (9-27-24, 21pp):  "Mitigating the Impact of Significant, Anomalous, and Highly Suspect Billing Activity on Medicare Shared Savings Program Financial Calculations in Calendar Year 2023 

https://www.govinfo.gov/content/pkg/FR-2024-09-27/pdf/2024-22054.pdf

See Fierce Healthcare:

"Catherer fraud rule finalized...ACO survival concerns"

https://www.fiercehealthcare.com/payers/catheter-fraud-rule-finalized-after-mssp-and-aco-survival-concerns

See Healthcare Dive:

"CMS holds ACOs harmless for highly suspect Medicare billing"

https://www.healthcaredive.com/news/medicare-suspect-catheter-billing-accountable-care-organization-final-rule/727991/

###


AMA CPT Publishes New Proposed PLA Codes

Header: AMA publishes new proposed PLA codes.  Public comment is possible.  Final results will be released 12/31/2024.

##

Every quarter, AMA CPT takes applications for new PLA codes, publishes them for possible public comment, and quickly finalizes them.   Results are published at the end of the quarter, and codes become effective one quarter later.

In the current round, applications were submitted in September.  AMA releases them for comment in mid-October.    The CPT Editorial Panel will vote on them in November (usually a quick online roll call), and codes will be released around January 1 2025 and effective for use April 1 2025.  CMS will consider them for national pricing in Summer 2025.

There are about 35 action items, but about 5 of them are minor revisions.

Here's the link to the new PLA list:

https://www.ama-assn.org/system/files/november-2024-pla-public-agenda.pdf

Here's the AMA web page for PLA matters:

https://www.ama-assn.org/practice-management/cpt/cpt-pla-codes

Here's the prior finalized list (which ran up to 0530U):

https://www.ama-assn.org/system/files/cpt-pla-codes-long.pdf



Thursday, October 10, 2024

Multiple MACs Quickly Finalize New LCD for AI Assisted Coronary Angiography

HEADER: On October 10, 2024, several MACS - NGS MAC, Palmetto, CGS, and WPS MACs - all finalized a new complex LCD for AI-assisted coronary angiography.  Several take-home lessons.

Chat GPT could have made the convoluted coverage rules far more clear.

##

  • Here's the proposed LCD, DL39840.
  • Here's the final LCD, L39840.
  • Here's the request letter, from CLEERLY, 2/2/2023, 12pp.
  • Here's the response to comments A59928.
  • Here's the billing and coding A59716.
    • Note the billing and coding for these AI CCTA codes 0623T-0626T, only make sense in light of separate LCDs for CCT and CCTA (L33947) and computer-assisted fractional flow reserve FFR (L38771).
  • Get all the documents PLUS the redline in a zip file.

Some take home lessons.

  • REQUEST TO DRAFT
    • The time from request letter to draft LCD was 15 months (Feb 2023, May 2024).
  • LONG
    • The LCD is long, 14000 words and 80 citations in the final version.
  • REDLINES
    • There were extensive comments and extensive redlining of the final LCD 
    • (I made a redline in Word, but I didn't attempt to decipher all the changes.)
  • DRAFT TO FINAL: FIVE MONTHS
    • The multiple MACs (some inside and some outside of "MolDx") were able to issue the LCD, take complex comments, add numerous citations, and finalize it from May to October.
  • CONTEXT: 
    • The LCD's value only makes sense in the context of other codes.  There is traditional "invasive" coronary angiography, then, computer-assisted (non invasive, CT based) coronary angiography, to which can be added FFR fractional flow reserve.  The RVU valuation of that has been a hot potatoe for CMS Part B for years.   Finally, there is the newest layer, AI-assisted CCTA.
    • The AI CCTA codes 0623T forward, are probably unpriced by CMS RVUs, so the "delta" the AI captures is not easily visible but is a key outcome.
  • TERMINOLOGY
    • The LCD has a good terms & definitions & abbreviations section.

Convoluted Coverage Rules: Can AI Help?

The coverage rules start out simple with 3 rules, but then have multiple asterisk-based complexities.  I'm just cutting and pasting, note the asterisks.  The bracketed numbers [1] refer to 2021 and 2022 national guidelines [3 is a correction to [2]).

AI-QCT/AI-CPA using CCTA* is considered reasonable and medically necessary as a diagnostic study when:


ONE
The patient has acute or stable chest pain with no known CAD1 and is eligible for CCTA*, AND

TWO
CCTA classifies patient as:
Intermediate risk ** OR  CAD-RADs [1], CAD-RADS [2] or CAD-RADS [3] *** category on CCTA [1,2]  AND

THREE

Cardiac evaluation is negative or inconclusive for acute coronary syndrome (ACS) [1]
####
ALSO NOTE ASTERISKS:

*    See L33947 for criteria for CCTA. AI-QCT/AI-CPA should not be performed until after the base study (CCTA) has been completed and interpreted. Software to perform AI-QCT/AI-CPA must be FDA cleared or approved.

**     Intermediate and high-risk as defined in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain [1]


***     CAD-RADS 1-CAD-RADS 3 category as defined by CAD-RADS™ 2.0–2022 Coronary Artery Disease Reporting and Data System (CAD-RADS): an Expert Consensus document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR), and the North America Society of Cardiovascular Imaging (NASCI).  [2 ,3]

XXXXXX
XXXXXX

I asked CHAT GPT to read the whole LCD, then, to focus on the top-line coverage rules and explain them in English if possible.  I do not guarantee that the Chat GPT re-writing exactly captures the Medicare rules.   However, I do guarantee, that if an LCD author wrote his confusing rules, then, started again with the CHAT GPT rules, and then, did any final editing to be sure the AI English exactly matched his maze-like coverage plan in his head, the end result would be a lot more clear than the published final rules in the LCD.

Here's Chat GPT 4o:

Coverage Conditions:

  1. Patient Eligibility:

    • The patient must have either acute or stable chest pain.
    • The patient should have no history of coronary artery disease (CAD).
    • The patient must be eligible for a Coronary CT Angiography (CCTA).
  2. CCTA Results:

    • The CCTA should show the patient as intermediate risk (based on specific guidelines).
    • Alternatively, the CCTA may classify the patient under CAD-RADS 1, 2, or 3, indicating varying levels of non-obstructive to moderate stenosis.
  3. Cardiac Evaluation Outcome:

    • A prior cardiac evaluation must show no signs of acute coronary syndrome (ACS) or have inconclusive results.

Additional Notes:

  • The CCTA must be done and interpreted before using AI-QCT/AI-CPA.
  • The software used for AI-QCT/AI-CPA must have FDA clearance or approval.

This summary simplifies the rules while retaining the essential coverage criteria for clarity. Let me know if any further details are needed!

###

SIDEBAR

For curious readers, I include as a sidebar, a Chat GPT 4o comparison of the draft and final LCDs.  I have labeled this clearly as FYI only, because I have not verified the AI comparison of the two long  documents.   No doubt, it's directionally correct and it shows an approach to strucutring the comparison.  Sidebar HERE.

Tuesday, October 8, 2024

A Bible for Labs Facing FDA IVD Regulations: From CLSI

One of the interesting parts of the proposal to regulate LDTs via the FDA medical device manufacturing laws, is the degree of overlap with CLIA.

It's not just a little, it's a lot, and quickly each aspect of the overlap becomes painfully complex.

For a guide, see the curretly free 120 page guide to FDA QSR for LDTs (quality system regulations for lab developed tests) issued in September 2024 by CLSI, the Clinical Lab Standards Institute.

Access it here:

https://clsi.org/standards/products/quality-management-systems/documents/qsrldt/

Learn for example  what it means to track vender records, supply quality, and reagent validation under FDA vs CLIA.    Dive into the FDA labeling recommendations, which are new and complex for LDTs and have an iron grip on promotional claims and remarks as well.


Examples (of 130 pp)





FDA LDT: Two New Amicus Briefs

The FDA brought out its final rule about regulating lab developed tests in May.   Within a month, ACLA had filed a lawsuit.   By late summer, AMP had filed its own lawsuit.   (Both lawsuits were in Texas jurisdictions and have been combined now.)

The week of October 6, two new items.

CAP files a friend-of-court (amicus) brief supporting ACLA/AMP. (21pp).

https://www.cap.org/member-resources/articles/college-of-american-pathologists-challenges-fda-ldt-regulation-with-amicus-brief-filing

ADLM (former AACC) files an amicus brief supporting ACLA/AMP, too. (25pp).  Joined by ASCP, ASM, IDSA, and others.

https://www.myadlm.org/media/press-release-archive/2024/10-october/adlm-files-an-amicus-brief-backing-aclas-lawsuit-against-the-fda

##

Other arguments, not emphasized here, are there  that is a great deal of overlap among specific rules and regulations used by both CLIA and CAP (see the CLSI's excellent guide to the new DFA device regulations "for labs," which exists in part to show the overlaps and variances between CLIA and "FDA-LDT." Plus it's currently free.)

See an article by van Wijk and McMillin in J Appl Lab Med, 4 October, on the FDA final rule and pharmacogenomics (hint: bad).  Here.  (Not open access).


##

AI Corner (Chag GPT 4o)

The College of American Pathologists (CAP) argues that the FDA’s Final Rule on laboratory-developed tests (LDTs) is arbitrary and capricious, asserting that the agency failed to justify the immense compliance costs imposed, which will hinder innovation and harm patients. CAP contends that the FDA’s reliance on nonbinding “enforcement discretion policies” fails to provide the stability needed for LDT development and that these policies introduce uncertainty and prosecution risks that will chill innovation. CAP urges the court to vacate the rule on these grounds and avoid addressing broader statutory authority questions. If the court does address FDA's authority, CAP suggests limiting the ruling to avoid unintended consequences for LDT regulation, including avoiding characterizing LDTs as “the practice of medicine” and implying that existing CLIA oversight renders FDA involvement unnecessary.

The Association for Diagnostics & Laboratory Medicine (ADLM) and other allied organizations argue that FDA’s Final Rule will drastically limit access to LDTs, essential for prompt and effective patient care, especially in underserved communities. They claim that LDTs, developed under CLIA, offer necessary flexibility and rapid response capabilities that FDA’s device-based regulatory framework would undermine. The brief emphasizes that the rule's immense costs, potentially reaching billions, would force labs, particularly smaller and specialized ones, to shut down, leading to delays and reduced access to critical diagnostic services. ADLM and co-amici assert that the FDA's enforcement discretion is inadequate and arbitrary, risking severe patient harm, and urge the court to vacate the rule as exceeding the FDA’s statutory authority.

##

Comment (BQ).  "CAP urges the court to vacate the rule on these grounds and avoid addressing broader statutory authority questions".   CAP urges that the simplest and complete reason to vacate the regulation is that it was arbitrary and capricious.    They note that if so, the court will not need to consider statutory grounds (what is the original meaning of "device" as used by Congress in 1976) or constitutional grounds (e.g. "major questions doctrine.")   There is a longstanding principal to make a finding on one aspect of the case, and leaving other topics unnecessary to decide, as they are not 'reached.'  A similar principal is, if a plaintiff has a constitutional objection, and he/she is found to lack "standing" to bring the case, the court drops the case, and has no need to ask the constitutional question "as if" the plaintiff had had standing.

Monday, October 7, 2024

MAC Medical Directors: CMS Updates Directory (2024-06)

CMS publishes an Excel directory of current MAC medical directors.

See the June 2024 update:

https://www.cms.gov/medicare/coverage/infoexchange



Note that tab 2 is a change history (14 changes in 1H2024).

Note that by scrolling down, you get CMD's at DME MACs, at QIC's, and others.

For regular Part A/B MACs, I tallied 11 at Palmetto, 10 at Noridian, 5 at NGS MAC, 4 at WPS, 3 at CGS, 23 at FCSO, and 2 at NOVITAS.  That's 38.


###
###
AI Corner

I challenged Google Notebook LM, an AI service, to write a briefing memo based on my short blog and the Excel spreadsheet.  Here's what it came up with.  And at bottom, there's even ... wait for it ... a Google Automatic AI Podcast (with two voices) talking about the spreadsheet.

Briefing Document: CMS Medical Directors and Healthcare Policy Insights


This briefing document analyzes information from two sources: a blog post by Bruce Quinn MD PhD on healthcare policy ("2024 QUINNLLC 1007 MAC CMD List Blog.pdf") and a CMS directory of MAC Medical Directors ("2024 cms 0624 CMD Directory 2024-06-24 with Maps.pdf").


Key Themes:

  • Transparency in Medicare Administration: CMS's publication of an updated MAC Medical Directors directory in June 2024 highlights their commitment to transparency within the Medicare program. This publicly accessible directory provides contact information for medical directors across various jurisdictions and specialties.
  • Decentralized Structure of Medicare Oversight: The directory reveals the complex, decentralized structure of Medicare administration. Numerous entities like Palmetto GBA, Noridian Healthcare Solutions, and CGS Administrators employ medical directors across diverse geographical regions (Jurisdictions JM, JJ, JE/JF, J15, etc.). This structure underscores the intricate web of organizations involved in overseeing different aspects of Medicare.
  • Role of Medical Directors in Medicare: While not explicitly stated, the existence of medical directors within MACs, QICs, and other organizations suggests their crucial role in shaping and implementing Medicare policy. They likely provide medical expertise for coverage decisions, review claims, and potentially contribute to the development of medical guidelines within their respective jurisdictions and specialties.
  • Evolution of Healthcare Policy: Dr. Quinn's blog, focused on "Discoveries in Health Policy," signifies the ongoing evolution of the healthcare landscape. The blog post itself announces the updated CMS directory as a noteworthy event, implying the significance of these medical directors in navigating the complexities of healthcare policy changes.


Important Facts:

  • Directory Scope: The directory encompasses a wide range of medical specialties, from common ones like Family Practice and Internal Medicine to highly specialized areas like Molecular Pathology and Genetic Medicine.
  • Organizational Distribution of Directors: Some organizations employ a significant number of CMDs, reflecting their larger role within the Medicare program. For instance, the directory lists 38 CMDs working for regular Part A/B MACs, with Palmetto (11), Noridian (10), and FCSO (23) leading the count.
  • Directory Updates: The CMS directory is a dynamic document, undergoing frequent updates to reflect changes in personnel and contact information. The June 2024 update, for example, documented 14 changes within the first half of 2024 alone.


Quotes:

  • Dr. Quinn: "CMS publishes an Excel directory of current MAC medical directors."
  • CMS Directory: "CMD Public Directory Last Revised: 6/24/2024"


Further Research:

  • Investigating the specific roles and responsibilities of MAC Medical Directors within different organizations and jurisdictions.
  • Analyzing the impact of recent healthcare policy changes on the work of these medical directors.
  • Examining trends in the specialization and geographical distribution of MAC Medical Directors over time.

GOOGLE  NOTEBOOK LM - STUDENT STUDY GUIDE

Quiz

Instructions: Answer the following questions in 2-3 sentences each, based on the provided source material.

  1. What is the primary function of the CMS MAC Medical Director Directory?
  2. Which organization employed the highest number of Part A/B MAC medical directors according to the blog post from October 7, 2024?
  3. What is Dr. Bruce Quinn's area of expertise?
  4. How many times was the CMS CMD Public Directory updated in the first half of 2024?
  5. Identify two different MAC jurisdictions covered by Noridian Healthcare Solutions.
  6. What are the primary specialties of the MAC medical directors employed by CGS Administrators, LLC?
  7. Which organization is responsible for QIC Part D in the provided directory excerpt?
  8. What is the role of a RAC Validation Contractor?
  9. What does the acronym "CERT" stand for in the context of the directory?
  10. Which organization does Dr. Richard Whitten, specializing in Internal Medicine/Critical Care, work for?

Answer Key:

  1. The CMS MAC Medical Director Directory provides an updated list of medical directors working for various Medicare Administrative Contractors (MACs), along with their contact information, jurisdictions, and specialties.
  2. According to the blog post, First Coast Service Organization (FCSO) employed the highest number of Part A/B MAC medical directors with 23.
  3. Dr. Bruce Quinn is an expert on health reform, innovation, and Medicare policy.
  4. The CMS CMD Public Directory underwent 14 revisions in the first half of 2024.
  5. Noridian Healthcare Solutions covers jurisdictions JE/JF and DME MAC - A, among others, as indicated in the directory.
  6. CGS Administrators, LLC employs MAC medical directors specializing primarily in Internal Medicine, Pediatrics, and Emergency Medicine.
  7. MAXIMUS Federal Services is responsible for QIC Part D, as per the directory excerpt.
  8. RAC Validation Contractors are responsible for reviewing medical records and documentation to validate the accuracy of claims submitted to Medicare.
  9. "CERT" stands for Comprehensive Error Rate Testing in the context of the directory.
  10. Dr. Richard Whitten works for Noridian Healthcare Solutions.

Essay Questions:

  1. Analyze the geographic distribution of MAC medical directors across different states based on the provided directory. What potential implications might this distribution have on Medicare beneficiaries and healthcare providers in different regions?
  2. Discuss the importance of having medical directors with diverse specialties within a single MAC. How does this diversity contribute to the effective administration of the Medicare program?
  3. Compare and contrast the roles and responsibilities of MAC medical directors with those of QIC and QIO medical directors. How do their respective functions contribute to ensuring quality healthcare for Medicare beneficiaries?
  4. Critically evaluate the role of technology in disseminating information about MAC medical directors and other CMS updates. How can technology be further leveraged to improve transparency and communication within the Medicare program?
  5. Considering the constant evolution of healthcare policies and regulations, how crucial is it for MAC medical directors to stay informed about the latest developments? Discuss the potential consequences of inadequate knowledge and preparedness among these key personnel.

Glossary of Key Terms:

  • MAC (Medicare Administrative Contractor): A private insurance company that contracts with CMS to process Medicare claims for a specific geographic region.
  • CMS (Centers for Medicare & Medicaid Services): The federal agency responsible for administering the Medicare program.
  • CMD (Contractor Medical Director): A physician who provides medical expertise and leadership within a MAC.
  • DME (Durable Medical Equipment): Medical equipment that is designed for repeated use, such as wheelchairs, oxygen tanks, and hospital beds.
  • QIC (Quality Improvement Organization): An organization that contracts with CMS to review the quality of care provided to Medicare beneficiaries.
  • QIO (Quality Innovation Network-Quality Improvement Organization): A program that works with healthcare providers, stakeholders, and Medicare beneficiaries to improve the quality, effectiveness, and patient safety of Medicare.
  • RAC (Recovery Audit Contractor): A private company that contracts with CMS to identify and recover overpayments made to healthcare providers.
  • UPIC (Unified Program Integrity Contractor): A contractor responsible for detecting and preventing fraud, waste, and abuse in both the Medicare and Medicaid programs.
  • ZPIC (Zone Program Integrity Contractor): A type of UPIC that focuses on a specific geographic region.
  • Specialty: A particular area of medicine in which a physician has specialized knowledge and skills.
  • Jurisdiction: The geographic area over which a MAC has responsibility.


Don't Forget the Podcast! (Crazy, yes?

Incredibly, GOOGLE NOTEBOOK also generated an automated, two-voice, lively podcast about the Excel spreadsheet. Open access to the audio HERE, but Google sign in might be required:


Here's an Auto Transcript of the crazy Google AI Podcast about the spreadsheet.



Friday, October 4, 2024

AHRQ: Bonanza of Information Related to Sepsis

Header: AHRQ has released a Report to Congress on Sepsis, as well as supporting a bundle of new hospital policy articles on the topic.

##

About the last time I mentioned AHRQ, the House had proposed to de-fund it in July 2024.

Flurry of news from AHRQ about Sepsis, including a 95-page new Congressional report.

  • See the AHRQ capsule news page here.
  • See the full press release and links here.
  • See the 95 page report here.
    • See 166 page appendix here.
  • See the AHRQ home page for Sepsis, here.
  • See AHRQ highlight three new hospital policy articles:
    • Sankaran (2024) Identifying sources of inter hospital variation in episode spending for hospital care.  Med Care 62:441.
    • Barbash (2024) Association between SEP-1 and documentation of sepsis in the clinical record.  Med Care 62:388.
    • Ellenbogen (2024) Developent of a hospital coding intensity measure for sepsis.  J Hosp Med 19:505.
    • These three articles don't appear to be open access.

####
Side note: See Lee Fleisher MD's blog post on AMR recently at both U.N. and AARP.
####

AI Corner

In its 95-page Report to Congress on the burden of sepsis in the United States, the Agency for Healthcare Research and Quality (AHRQ) offers a comprehensive analysis of hospital care related to sepsis, underscoring the significant and growing impact of the condition on the healthcare system. 

The report responds to a congressional directive included in the Fiscal Year 2023 Omnibus Spending Bill, which mandated AHRQ to study morbidity, readmission, and mortality rates associated with sepsis, along with the effects of the COVID-19 pandemic on the burden of sepsis​.

Key findings of the report show that sepsis-related hospitalizations increased sharply from 1.8 million in 2016 to 2.5 million in 2021, a trend accelerated by the COVID-19 pandemic. Sepsis is one of the most expensive conditions treated in U.S. hospitals, with aggregate hospital costs rising from $31.2 billion to $52.1 billion over the same period​. The report provides an in-depth look at hospital utilization, mortality, and the financial strain caused by sepsis, with a focus on disparities in outcomes based on race, ethnicity, sex, geographic location, and social vulnerability.

The report also highlights key patient populations affected by sepsis, including non-maternal adults, maternal patients, and pediatric populations, and examines state-level and hospital-level variations in care. The majority of sepsis-related hospitalizations begin in the emergency department, where timely recognition and intervention are critical​. The report underscores the importance of early recognition and the use of standardized sepsis care bundles, such as those promoted by the Surviving Sepsis Campaign, which have been shown to improve outcomes but remain underutilized.

AHRQ's findings emphasize the need for continued investments in surveillance and quality improvement programs to ensure better sepsis care and reduce the burden on hospitals. Disparities and geographic variations present opportunities for targeted interventions aimed at improving patient outcomes and addressing financial strains on the healthcare system​.


##

AHRQ also highlights three new health policy articles that explore critical issues surrounding hospital management of sepsis and associated costs. These studies delve into hospital coding intensity, the impact of Medicare's sepsis reporting policy, and the variation in hospital spending on sepsis care.

  1. "Development of a Hospital Coding Intensity Measure Based on Sepsis Diagnoses" by Michael Ellenbogen et al. explores how variations in hospital coding practices affect sepsis diagnoses. The authors developed a novel measure to compare hospital coding intensity using sepsis-related diagnoses among patients hospitalized for common infections. This measure aims to correct reimbursement inequities and improve the accuracy of risk adjustment for quality metrics, offering a more targeted approach to coding intensity evaluation across hospitals​.

  2. "Association Between Medicare's Sepsis Reporting Policy (SEP-1) and the Documentation of a Sepsis Diagnosis in the Clinical Record" by Ian Barbash et al. evaluates the effect of Medicare’s SEP-1 reporting policy on sepsis documentation in clinical records. The study found that implementation of SEP-1 modestly increased sepsis diagnosis rates, particularly among patients who did not require vasopressors. Despite the incremental increase, the study calls attention to the policy’s potential influence on documentation practices and raises questions about its clinical impact​.

  3. "Identifying Sources of Inter-Hospital Variation in Episode Spending for Sepsis Care" by Roshun Sankaran et al. investigates the factors contributing to significant variation in 90-day episode spending for sepsis care across hospitals. The study found that post-acute care spending was the primary driver of these variations, with the most expensive hospitals spending nearly double on post-acute care compared to the least expensive hospitals. The analysis points to the need for targeted policies to address these cost discrepancies, particularly in the realm of post-acute care​.

These articles provide important insights for policymakers looking to improve hospital efficiency, coding accuracy, and spending management in sepsis care.

Thursday, October 3, 2024

CMS Posts Transcript of Sept. 23 TCET Webinar.

HEADER: CMS held a webinar on September 23, 2024, to explain operations of the "TCET" NCD CED program which was announced on August 6, 2024.  Now, CMS releases a trancript.

###

TCET NCD CED for BT Devices - Let's parse the abbreviations  Transitional Coverage for Emerging Technologies; applicable only to FDA Breakthrough (BT) Devices; for National Coverage Decisions on an accelerated 6-month basis, deploying "Coverage with Evidence Development."

CMS has now released a 14 page transcript of its TCET webinar.  The transcript includes a link to the archive video.  There was several interesting slides in the video that were novel to me, but CMS didn't release a separate PDF presentation deck.

Below, I provide an AI "News Story" and a full AI summary of the Q&A, both from Chat GPT.   Then I pivot to a new services, Google Notebook LM.   GNLM lets you create a folder, load several documents too it, and then it will provide at least four pre-designed reports; (1) a briefing, (2) a study guide with AI Q&A; (3) a timeline and list of speakers; and finally and most notable (4) a ten minute AI podcast with two AI voices chatting to one another - a fully synthetic"podcast."

##

Before we pivot to the AI material, here's an essay by Joe Grogan:

Republican health policy expert Joe Grogan has just listed some downsides of the TCET policy in a new article at The Hill,

https://thehill.com/opinion/healthcare/4889436-biden-harris-medical-innovation/

Grogan writes, 

[Past the FDA,] innovators must still confront an uncooperative CMS, which keeps finding excuses to deny coverage at every turn.  

One strategy used by the agency is “Coverage with Evidence Development,” which requires additional clinical trials on top of those conducted for the FDA. 

These requirements can span decades. Of the 27 devices or procedures subjected to this procedure since 2005, only four were not still undergoing it as of April 2022. The evidence development system has been corrupted. 

Originally designed to accelerate innovation, it now poses a huge obstacle. A moratorium on new Coverage with Evidence Development programs is needed until it can be fixed or scrapped.

(Not Shown: When  Grogan's view was shared with Google Notebook, which had trained on the CMS-origin materials, Google Notebook said that CMS was at least trying to rebut his concerns, and provided a hotlink to paragraphs in the 14-page transcript with regard to each point made in Grogan's essay.)

##

AI CORNER - CHAT GPT Report and Q&A

Chat GPT writes up the transcript.  Plus the Q&A after.

##

CMS Hosts Webinar on TCET Pathway, 

Highlighting Changes in Coverage for Breakthrough Devices

The Centers for Medicare & Medicaid Services (CMS) held a public webinar on September 23, 2024, to educate stakeholders on its newly established Transitional Coverage for Emerging Technologies (TCET) pathway. This pathway is designed to accelerate Medicare coverage decisions for FDA-designated Breakthrough Devices. The event featured presentations by Dr. Dora Hughes, CMS Chief Medical Officer, and Dr. Steve Farmer, Chief Strategy Officer in the Coverage and Analysis Group, who elaborated on the TCET pathway’s significance and functionality.

The TCET pathway is aimed at facilitating faster Medicare access to medical innovations while ensuring safety and effectiveness for Medicare beneficiaries. It supports manufacturers by providing a predictable and transparent review process that coordinates both coverage and evidence development. This is achieved through CMS’s use of the National Coverage Determination (NCD) and Coverage with Evidence Development (CED) frameworks, allowing for the incorporation of fit-for-purpose studies into the approval process. As Dr. Hughes noted, “CMS is committed to fostering innovation while ensuring that people with Medicare have faster access to technologies that will improve their health outcomes.”

Dr. Farmer provided further insights into the operation of the TCET pathway, which builds on existing CMS authorities and emphasizes early engagement with manufacturers. The pathway is structured in different stages: premarket, near-market, and postmarket. In the premarket stage, manufacturers can engage with CMS to clarify coverage expectations, ensuring alignment with FDA requirements. A key feature of the pathway is the Evidence Preview, which assesses the available evidence on a device’s safety and effectiveness. Manufacturers can collaborate with CMS and the Agency for Healthcare Research and Quality (AHRQ) to identify and address any evidence gaps before market authorization.

One notable aspect of the TCET pathway is its capacity for flexibility in evidence generation. Manufacturers can conduct fit-for-purpose studies to provide data suited to the specific needs of the Medicare population, which typically differs from the populations included in FDA trials. “Fit-for-purpose studies, including those using real-world data, provide complementary perspectives that enhance the evidence base for coverage decisions,” explained Dr. Farmer.

The webinar also covered specific criteria for devices eligible for the TCET pathway. These include FDA Breakthrough designation, alignment with a Medicare benefit category, and the absence of an existing NCD for the device. A key advantage of the pathway is the ability to expedite the NCD process, with CMS aiming to finalize NCDs within six months of FDA market authorization.

Attendees raised several questions about the logistics of the new pathway. A significant portion of the discussion focused on how devices that are nearing FDA approval would be prioritized. Lori Ashby, a member of the CMS team, clarified that while devices close to receiving FDA market authorization might not qualify for TCET due to the expedited nature of the pathway, they can still pursue coverage through other established processes, such as Local Coverage Determinations (LCDs) by Medicare Administrative Contractors.

CMS plans to expand the transparency and efficiency of the TCET pathway with future guidance documents. These will include detailed protocols for fit-for-purpose studies and real-world data use, as well as prioritization factors for determining which devices enter the pathway. Manufacturers interested in the pathway are encouraged to submit a voluntary letter of intent up to 24 months before FDA market authorization to allow CMS to track potential candidates.

This webinar marks a significant step in CMS’s efforts to modernize the Medicare coverage process and better integrate new medical technologies into the healthcare system. As Dr. Farmer concluded, “The TCET pathway represents a balanced approach that promotes early beneficiary access to breakthrough technologies while maintaining rigorous evidence standards.”

For more information on the TCET pathway and upcoming guidance documents, visit the CMS website or review the full transcript from the September 23 webinar.

Chat GPT continues by summaries the Q&A found in the latter part of the transcript of the webinar.

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Question 1: When does the one-year clock start for nominations? Is it August 12th since that is the date the policy was effective? Or after the first quarter review? And then what happens if there are delays in FDA market authorization?

Answer: Lori Ashby explained that the one-year clock starts approximately 12 months before anticipated FDA market authorization, not tied to the August 12th policy effective date or the quarterly review. Delays in FDA authorization don’t affect acceptance into the pathway, but CMS aims to complete TCET steps within that 12-month window.


Question 2: Is there a lookback period for Breakthrough Devices nearing FDA market authorization or those recently achieving it?

Answer: There is no lookback period. Devices already in the market or nearing FDA market authorization (less than 12 months) are not eligible for TCET and are better suited for other pathways like Local Coverage Determinations (LCDs) or claim-by-claim adjudication.


Question 3: How do software as a medical device and other digital health innovations fit into the TCET pathway?

Answer: CMS clarified that such technologies could be eligible if they meet the criteria outlined in the TCET notice. However, these technologies must fit within a Medicare benefit category under Part A or Part B. CMS is actively exploring this area in policy development, with ongoing interest from Congress.


Question 4: Why are diagnostic lab tests excluded from the TCET pathway?

Answer: CMS recognizes that diagnostic lab tests are regulated as medical devices and eligible for FDA Breakthrough designation. However, diagnostic tests are considered a highly specific area of coverage, typically reviewed by Medicare Administrative Contractors (MACs). NCDs for diagnostic tests are rare, but possible if manufacturers believe additional evidence is needed for Medicare coverage.


Question 5: How will CMS prioritize TCET nominations? Will they consider the impact on Medicare beneficiaries, particularly those with high-cost or less common diseases? Will health equity be a factor?

Answer: Lori Ashby stated that until further guidance is released, CMS will prioritize based on a 2013 Federal Register notice, which considers the magnitude of impact on the Medicare program. CMS will also consider health equity, giving priority to devices that address health disparities.


Question 6: How will CMS prioritize nominations if devices are moved from one quarterly review cycle to the next?

Answer: CMS will automatically reconsider devices not selected in the first review cycle in the next cycle. However, devices within six months of FDA market authorization may not be accepted into TCET due to the short timeframe for CMS to complete the NCD.


Question 7: What level of detail will CMS provide to manufacturers whose nominations are declined for reasons other than the cap being met?

Answer: CMS will provide a justification for declined nominations, including reasons such as the absence of an FDA Breakthrough designation or an existing NCD covering the device.


Question 8: Will CMS notify manufacturers if their device is no longer automatically considered in the next review cycle due to proximity to FDA approval?

Answer: CMS is developing a web-based system to automatically notify manufacturers of their nomination status, including acceptance, reconsideration in future cycles, or withdrawal from the TCET pathway.


Question 9: How will CMS make public the number of TCET applications, device types, and classes accepted into the program after each nomination cycle?

Answer: While the nominations themselves are confidential, CMS will update the NCD dashboard with the number of devices in the pathway, the date of nomination, acceptance, and the initiation of the NCD process. This dashboard will be updated quarterly.


Question 10: How does CMS use TCET nomination material to inform the Evidence Preview? Will the manufacturer’s list of studies be the basis for the Evidence Preview?

Answer: Steve Farmer explained that the Evidence Preview is informed by a systematic literature review conducted by a contractor, which is cross-referenced with the manufacturer's bibliography. Manufacturers can propose technical edits, and the review ensures the evidence is comprehensive.


Question 11: What is the purpose of voluntary letters of intent (LOI) 18 to 24 months before FDA market authorization? How does it benefit manufacturers?

Answer: Lori Ashby clarified that the LOI allows CMS to better predict potential TCET nominations and optimize the review process. While nonbinding, it improves coordination between CMS and the FDA and helps prevent delays in reviews.


Question 12: Is CMS planning any best practice training on how to submit a nomination?

Answer: Yes, CMS plans to conduct workshops to help manufacturers considering LOIs and nominations, with details to be provided soon.


Question 13: How will CMS and FDA coordinate the TCET process, given the reliance on FDA timelines for market authorization?

Answer: CMS regularly engages with FDA and AHRQ, as well as with manufacturers, to help coordinate the process. CMS plans to initiate the TCET process approximately one year before FDA authorization, incorporating trial results and addressing evidence gaps.


Question 14: How will CMS address coding and payment for devices accepted into TCET?

Answer: CMS encourages manufacturers to proactively pursue codes during the TCET process to avoid delays. CMS has also established a Pharmaceutical and Technology Ombudsman to assist with coverage, coding, and payment decisions.


Question 15: How soon before FDA approval can the Evidence Preview and Evidence Development Plan be initiated for follow-on devices?

Answer: Follow-on devices can engage CMS about 12 months before FDA market authorization to initiate an Evidence Preview and develop an Evidence Development Plan. This helps avoid delays in NCD establishment postmarket.


Question 16: Is there noncoverage for follow-on devices until CMS approves a CED study? How can this be minimized?

Answer: Yes, follow-on devices are noncovered until a CMS-approved CED study is in place. To minimize delays, manufacturers should initiate the Evidence Preview as early as possible, ideally 12 months before FDA approval.


Question 17: How will CMS prioritize the Evidence Preview and EDP for follow-on devices?

Answer: CMS believes it has sufficient resources to conduct timely reviews for both first-to-market and follow-on devices.


Question 18: Has the use of a contractor for technical analyses reduced the processing time for NCDs? How will CMS handle the TCET workload?

Answer: CMS has streamlined processes through contractor support, allowing for specialized clinical expertise and greater efficiency. This will help accommodate the additional workload from TCET without affecting other NCDs.


Question 19: What is the anticipated timing of future CMS guidance on fit-for-purpose (FFP) studies, real-world data protocols, and prioritization guidance?

Answer: CMS expects to release guidance on fit-for-purpose studies and real-world data protocols soon. Prioritization guidance will follow after several quarterly review cycles.


Question 20: How will CMS prioritize coverage for devices within six months of FDA market authorization if they are not accepted into TCET?

Answer: Devices nearing market authorization can pursue conventional NCDs if they are not accepted into TCET. CMS will prioritize NCD requests based on their potential impact on the Medicare program and beneficiaries.


Question 21: Will Medicare Advantage plans have to cover devices under TCET?

Answer: Yes, Medicare Advantage plans must cover devices under TCET NCDs just as they do with conventional NCDs.


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Now we switch programs and go over the Google Notebook LM.  We create a folder for TCET.   We  upload the one-hour transcript, just like we gave Chat GPT before.  This time, we let Google Notebook lM do its free pre-fab functions, like "Timeline."  (Below).

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AI Below is All From Google Notebook LM

Timeline of Events (Google Notebook LM auto function)


2015:

  • Ongoing: The FDA Breakthrough Devices Program has granted over 930 Breakthrough Designations.

2022:

  • November: The Agency for Healthcare Research and Quality (AHRQ) publishes a report on Coverage with Evidence Development (CED).

2023:

  • February: The Medicare Evidence Development and Coverage Advisory Committee (MEDCAC) holds a meeting to discuss AHRQ's CED report.

2024:

  • August 6: CMS issues a final procedural notice outlining the Transitional Coverage for Emerging Technologies (TCET) pathway for certain FDA-designated Breakthrough Devices.
  • September 23: CMS hosts a webinar to provide an overview of the TCET pathway and answer stakeholder questions.
  • October 31: Deadline for manufacturers to submit nominations for the first quarterly TCET review cycle.

2025:

  • January 31: Deadline for the second quarterly TCET review cycle.
  • April 30: Deadline for the third quarterly TCET review cycle.
  • July 31: Deadline for the fourth quarterly TCET review cycle.
  • Ongoing: CMS plans to publish additional guidance documents on fit-for-purpose studies, real-world data protocols, and TCET prioritization factors.


Cast of Characters


Centers for Medicare & Medicaid Services (CMS)

  • Dr. Dora Hughes: CMS Chief Medical Officer and Director for the Center for Clinical Standards and Quality. Provides opening remarks at the TCET webinar, emphasizing CMS's commitment to innovation and timely patient access.
  • Dr. Steve Farmer: Chief Strategy Officer in the Coverage and Analysis Group. Presents a detailed overview of the TCET pathway at the webinar.
  • Lori Ashby: CMS representative who answers stakeholder questions during the TCET webinar.


Other Organizations

  • Food and Drug Administration (FDA): Responsible for granting Breakthrough Device designations and overseeing the premarket review process for medical devices. Works closely with CMS on the TCET pathway.
  • Agency for Healthcare Research and Quality (AHRQ): Collaborates with CMS on the CED pathway and provides feedback on Evidence Previews and Evidence Development Plans.
  • Medicare Administrative Contractors (MACs): Process Medicare claims and make local coverage determinations. May continue to review diagnostic lab tests, even if they receive Breakthrough Device designation.
  • Medicare Evidence Development and Coverage Advisory Committee (MEDCAC): Provides CMS with independent advice on coverage issues. Reviewed AHRQ's CED report in February 2023.


Key Terms

  • Breakthrough Devices: Medical devices that demonstrate the potential to offer a more effective treatment for a life-threatening or irreversibly debilitating disease or condition, for which no approved or cleared alternatives exist.
  • Transitional Coverage for Emerging Technologies (TCET): A Medicare coverage pathway that provides expedited coverage for certain FDA-designated Breakthrough Devices.
  • National Coverage Determination (NCD): A national Medicare policy that determines whether a particular item or service is covered by Medicare.
  • Coverage with Evidence Development (CED): A Medicare coverage pathway that allows for coverage of promising new technologies while requiring manufacturers to conduct additional clinical studies to demonstrate long-term safety and effectiveness.
  • Evidence Preview: A focused literature review that provides early feedback on the strengths and weaknesses of the available evidence for a particular technology.
  • Evidence Development Plan (EDP): A plan developed by the manufacturer to address any evidence gaps identified in the Evidence Preview. May include traditional clinical studies and/or fit-for-purpose studies using real-world data.
  • Fit-for-purpose study: A study where the design, analysis plan, and data sources are appropriate to address the specific research question at hand.
  • Real-world data: Data collected from sources outside of traditional clinical trials, such as electronic health records, claims databases, and patient registries.


This timeline and cast of characters should provide a good starting point for understanding the key events and players involved in the TCET pathway.


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Briefing Doc: CMS Transitional Coverage for Emerging Technologies (TCET) Pathway


Date: October 26, 2024

Subject: Overview of the TCET Pathway and Key Takeaways from the September 23rd Webinar


Background:


The Centers for Medicare & Medicaid Services (CMS) has finalized the Transitional Coverage for

Emerging Technologies (TCET) pathway to accelerate Medicare coverage for innovative medical devices designated as "Breakthrough Devices" by the FDA. This briefing document summarizes the key themes and important details of the TCET pathway based on two CMS sources:

  1. CMS Fact Sheet (August 6, 2024): Provides an overview of the TCET pathway, its goals, eligibility criteria, and the process for manufacturers.
  2. CMS Webinar Transcript (September 23, 2024): Offers deeper insights into the TCET pathway, addressing specific questions from stakeholders.


Main Themes:

  • Accelerated Coverage: The TCET pathway aims to reduce the time lag between FDA market authorization and Medicare coverage for Breakthrough Devices, improving patient access to cutting-edge treatments.
  • Predictability and Transparency: The pathway provides manufacturers with a clear and predictable process, outlining evidence requirements and timelines for coverage decisions.
  • Collaboration and Engagement: CMS emphasizes collaboration with FDA, AHRQ, manufacturers, and other stakeholders throughout the process.
  • Evidence Development: TCET encourages the generation of real-world evidence through fit-for-purpose studies to support coverage decisions.


Key Ideas and Facts:


1. TCET Pathway Overview:

  • Target: Certain FDA-designated Breakthrough Devices that fall within a Medicare benefit category.
  • Goal: To finalize a National Coverage Determination (NCD) within six months of FDA market authorization.
  • Process:Pre-Market: Manufacturers submit a nomination, CMS conducts an Evidence Preview and, if necessary, develops an Evidence Development Plan (EDP) with the manufacturer.
  • Post-Market: CMS finalizes an NCD, which may include Coverage with Evidence Development (CED) requirements.
  • Post-TCET: CMS will reconsider the NCD based on the EDP timeline and evidence generated.

2. Device Eligibility:

  • FDA-designated Breakthrough Devices.
  • Within a Medicare benefit category.
  • Not already subject to an existing NCD.
  • Not excluded from coverage by law or regulation.

3. Nominations and Prioritization:

  • Manufacturers self-nominate approximately 12 months before anticipated FDA market authorization.
  • CMS accepts nominations quarterly and prioritizes them based on potential impact on the Medicare program and beneficiaries.
  • A non-binding letter of intent can be submitted 18-24 months before anticipated FDA market authorization.

4. Evidence Development:

  • Evidence Preview: A collaborative review of existing evidence, conducted by CMS, AHRQ, and the manufacturer.
  • Evidence Development Plan (EDP): If evidence gaps exist, an EDP is developed to outline fit-for-purpose studies.
  • Fit-for-Purpose Studies: Studies designed to address specific evidence needs using appropriate designs and data sources, including real-world data.

5. Coverage Duration and Transition:

  • Transitional Coverage: Tied to the completion of the EDP, typically lasting five or more years.
  • Post-TCET Coverage: CMS will reconsider the NCD and make a final coverage determination based on the generated evidence.

6. Key Takeaways from the September 23rd Webinar:

  • Lookback Period: Devices already on the market are not eligible for TCET.
  • Software as a Medical Device: Eligibility depends on meeting the TCET criteria and falling within a Medicare benefit category, which is still under development for SaMD.
  • Diagnostic Lab Tests: Generally excluded from TCET, but manufacturers can contact CMS for individual consideration.
  • Prioritization: CMS considers beneficiary impact, health equity, and available resources when prioritizing nominations.
  • Letters of Intent: Help CMS predict demand and can potentially alleviate delays in the review process.
  • Coordination with FDA: CMS emphasizes regular communication and collaboration with the FDA.
  • Coding and Payment: CMS encourages proactive pursuit of codes and offers resources to assist manufacturers.


Quotes:

  • "CMS is committed to fostering innovation while making sure that people with Medicare have faster access to technologies that will improve their health outcomes." - Dr. Dora Hughes, CMS Chief Medical Officer.
  • "TCET aims to reduce uncertainty about coverage options through a premarket evaluation of potential harms and benefits of technologies while identifying any important evidence gaps." - Dr. Dora Hughes, CMS Chief Medical Officer.
  • "We believe that manufacturers will be better positioned for multiple product development stages if they anticipate both FDA and CMS requirements when developing clinical studies." - Dr. Dora Hughes, CMS Chief Medical Officer.


Next Steps:

  • Review the full CMS Fact Sheet and Webinar Transcript.
  • Submit a letter of intent if you have a device that may be eligible for TCET.
  • Review upcoming CMS guidance documents on fit-for-purpose studies, real-world data protocols, and prioritization factors.


Conclusion:

The TCET pathway represents a significant shift in Medicare's approach to covering emerging medical technologies. By emphasizing early engagement, collaboration, and evidence development, CMS aims to accelerate patient access to innovative treatments while ensuring the safety and effectiveness of care for the Medicare population.


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Transitional Coverage for Emerging Technologies (TCET) Pathway


Google Notebook TCET "Study Guide"


Purpose of TCET:

  • The TCET Pathway is designed to expedite Medicare coverage for innovative medical devices designated as "Breakthrough Devices" by the FDA.
  • It aims to balance timely access for Medicare beneficiaries with the need for robust evidence supporting the safety and effectiveness of new technologies.


Key Features:

  • Voluntary: Manufacturers can choose to participate.
  • Pre-market Engagement: CMS and manufacturers collaborate early to identify evidence gaps and develop Evidence Development Plans (EDPs).
  • Expedited NCD Process: CMS aims to finalize NCDs within six months of FDA market authorization.
  • Coverage with Evidence Development (CED): Coverage can be provided while evidence is being gathered through fit-for-purpose studies, including real-world data.
  • Transitional Coverage: Coverage under TCET is time-limited, tied to the EDP, and typically lasts five or more years.
  • Post-TCET Coverage: CMS will reconsider the NCD based on the generated evidence, leading to either continued coverage, modified coverage, or non-coverage.


Eligibility:

  • FDA-designated Breakthrough Devices.
  • Devices within a Medicare benefit category.
  • Devices not already subject to an existing NCD.
  • Devices not excluded from coverage by law or regulation.


Process:

  1. Pre-Market Stage: CMS publishes guidance documents to clarify evidence expectations and manufacturers submit a Letter of Intent 18-24 months before anticipated FDA market authorization.
  2. Near-Market Stage: Manufacturers formally nominate their device 12 months before anticipated FDA market authorization. CMS conducts an Evidence Preview and holds a stakeholder meeting.
  3. Early Post-Market Stage: If sufficient evidence exists, an expedited NCD is issued. If not, a CED NCD is issued with an agreed-upon EDP.
  4. Post-Market Stage: CMS reviews evidence generated through the EDP and reconsiders the NCD.


Benefits:

  • For Medicare Beneficiaries: Faster access to potentially life-saving or life-improving technologies.
  • For Manufacturers: Reduced uncertainty about Medicare coverage, clear evidence expectations, and a streamlined review process.
  • For the Healthcare System: Encourages innovation and promotes the development of high-value, evidence-based medical technologies.


Google Study Guide Quiz


Instructions: Answer the following questions in 2-3 sentences each.

  1. What is the primary purpose of the TCET Pathway?
  2. Which medical devices are eligible for the TCET Pathway?
  3. Describe the role of the Evidence Development Plan (EDP) in the TCET process.
  4. How does the TCET Pathway benefit Medicare beneficiaries?
  5. What is the typical duration of coverage under a TCET NCD?
  6. What are the potential outcomes of the CMS NCD reconsideration after the completion of the EDP?
  7. How does the TCET Pathway encourage the use of real-world data in evidence generation?
  8. Explain the difference between an expedited NCD and a CED NCD under the TCET Pathway.
  9. What is the significance of the "Breakthrough Device" designation in the context of TCET eligibility?
  10. How does the TCET Pathway streamline the process for manufacturers seeking Medicare coverage for their devices?


Answer Key

  1. The TCET Pathway aims to expedite Medicare coverage for FDA-designated Breakthrough Devices, balancing timely patient access with the need for robust evidence.
  2. Eligible devices are FDA-designated Breakthrough Devices that fall within a Medicare benefit category, are not already subject to an NCD, and are not excluded from coverage by law or regulation.
  3. The EDP outlines a plan for addressing evidence gaps identified in the Evidence Preview and typically includes fit-for-purpose studies. It provides a roadmap for evidence generation that will inform the future NCD reconsideration.
  4. The TCET Pathway benefits Medicare beneficiaries by providing them with faster access to potentially life-saving or life-improving technologies that may not be covered through traditional Medicare pathways.
  5. Coverage under a TCET NCD is time-limited and tied to the EDP, typically lasting for approximately five or more years.
  6. After the completion of the EDP, the NCD will be reconsidered. Potential outcomes include: an NCD without evidence development requirements, an NCD with continued evidence development requirements, a non-coverage NCD, or rescinding the NCD.
  7. The TCET Pathway encourages the use of real-world data through fit-for-purpose studies, recognizing its value in generating evidence that reflects real-world patient populations and treatment settings.
  8. An expedited NCD is issued when sufficient evidence already exists to support coverage, while a CED NCD is issued when there are evidence gaps that need to be addressed through further studies. The CED NCD allows for coverage while evidence is being gathered.
  9. The "Breakthrough Device" designation is a prerequisite for TCET eligibility, as it indicates that the device has the potential to offer significant improvements over existing treatments for serious or life-threatening conditions.
  10. The TCET Pathway streamlines the process for manufacturers by providing clear evidence expectations, a defined timeline for review, and opportunities for early collaboration with CMS, reducing uncertainty and expediting coverage decisions.


Essay Questions

  • Discuss the potential benefits and challenges of the TCET Pathway for Medicare beneficiaries, manufacturers, and the healthcare system as a whole.
  • Explain the rationale for including coverage with evidence development (CED) as a key component of the TCET Pathway. How does CED balance the need for timely access to new technologies with the importance of evidence-based coverage decisions?
  • Analyze the role of real-world data in the evaluation of emerging medical technologies. How can real-world data studies be designed to generate meaningful evidence to support coverage decisions under the TCET Pathway?
  • Describe the collaboration between CMS and the FDA in the TCET process. How do the different mandates and regulatory frameworks of these agencies influence their respective roles in evaluating new medical technologies?
  • Explore the potential long-term impact of the TCET Pathway on the innovation landscape for medical devices. How might the pathway influence the development, clinical trial design, and market access strategies for future Breakthrough Devices?


Glossary of Key Terms

  • Breakthrough Device: A medical device designated by the FDA as offering significant improvements over existing treatments for serious or life-threatening conditions.
  • CED (Coverage with Evidence Development): A CMS coverage pathway that allows for Medicare coverage of a new technology while additional evidence is being collected to support its safety and effectiveness.
  • CMS (Centers for Medicare & Medicaid Services): The federal agency responsible for administering Medicare, Medicaid, and other healthcare programs.
  • EDP (Evidence Development Plan): A plan outlining the studies and data collection activities that will be conducted to address evidence gaps identified in the Evidence Preview.
  • Evidence Preview: A focused literature review conducted by CMS to assess the available evidence on a new technology.
  • FDA (Food and Drug Administration): The federal agency responsible for regulating the safety and effectiveness of medical devices, drugs, and biologics.
  • Fit-for-Purpose Study: A study designed to address specific evidence gaps relevant to Medicare coverage, often incorporating real-world data.
  • NCD (National Coverage Determination): A national policy that determines whether Medicare will cover a particular item or service.
  • Real-World Data: Data collected outside of traditional clinical trials, reflecting real-world patient populations, treatment settings, and clinical practices.
  • TCET (Transitional Coverage for Emerging Technologies): A CMS pathway that provides expedited Medicare coverage for certain FDA-designated Breakthrough Devices.


Google PODCAST of TCET


This is an open link to an AI podcast with two AI voices It runs 15 minutes. It's open access but may require Googe login.


AUDIO:

https://notebooklm.google.com/notebook/438d7289-547d-44a3-9ebf-5aee19755dff/audio


Crude Auto Text of Google PODCAST OF TCET


https://brucedocumentblog.blogspot.com/2024/10/tcet-ai-podcast-by-google-notebook-lm.html