Senate Bill Proposes More Transparency, Accountability In Reforming LCD Process

Contact: Apoorva Stull
Phone: 202-354-7102
E-mail: MEDIA@CAP.ORG

The CAP Strongly Supports Legislation to Improve Patient's Access to Care

Washington, DC—The College of American Pathologists (CAP) commended the re-introduction of Local Coverage Determination Clarification Act of 2017. The bill would improve transparency and accountability when Medicare contractors set local coverage determination (LCD) policies for physician services provided to Medicare beneficiaries. These decisions affect millions of Medicare beneficiaries and impact critical access to innovative technologies and procedures.

Senators introduced this key piece of legislation for physicians and patients on March 30. The Senate bill's sponsors Sen. Johnny Isakson (R-GA), Sen. Tom Carper (D-DE), Sen. Debbie Stabenow (D-MI) and Sen. John Boozman (R-AR) have long supported this issue and have been working with the CAP on improving the LCD process.

"Reforms in this legislation would ensure that Medicare local coverage determinations do not supersede physician medical judgment and deny patients access to medically necessary care. The Senate bill would ensure that coverage decisions are made by qualified, independent health experts through a transparent process that is based on sound medical evidence," said CAP President Richard C. Friedberg, MD, PhD, FCAP after the bill was introduced in the Senate. "The CAP thanks Senators Isakson, Carper, Stabenow and Boozman for sponsoring this important legislation on behalf of patients and the physicians who treat them."

"Medicare's current Local Coverage Determination process is broken, and as a result, senior citizens and people with disabilities are at risk for being denied access to innovative health care services," said bill sponsor Sen. Johnny Isakson (R-GA). "I'm proud to join in this effort to introduce legislation which will help ensure patients get the best possible care by improving the transparency and communication during the coverage determination process."

"Currently the Local Coverage Determination process lacks transparency, accountability, and stakeholder input," said bill sponsor Sen. Tom Carper (D-DE). "The Local Coverage Determination Clarification Act of 2017 will improve the process by including key stakeholder input from doctors and patients, which will provide constructive expertise and guidance for Medicare contractors. This will, in turn, help determine local coverage policies for health care services that are in the best interest for Medicare patients."

"Today, seniors in Michigan lack access to critical treatments and tests that are available in other parts of the country," said bill sponsor Sen. Debbie Stabenow (D-MI). "Our bill ensures that Michigan's seniors and their doctors play a stronger role in determining what options are available through Medicare."

"The Local Coverage Determination process lacks transparency, accountability and key third party input needed to protect American health care," said bill sponsor Sen. John Boozman (R-AR). "The Local Coverage Determination Clarification Act of 2017 incorporates input from doctors and patients, providing much needed expertise for Medicare contractors, and will help to determine local coverage policies for physicians' services that are in the best interest for our nation's seniors."

Key provisions in the Senate bill include:

• Open Meetings: Medicare Administrative Contractor'’'s (MAC) Carrier Advisory Committee (CAC) meetings must be open, public, and on the record. Minutes should be posted to the MAC’s website for public inspection. The gravity of limiting or precluding coverage for both beneficiaries and practitioners heightens the need for transparency where meetings are currently closed.
• Upfront Disclosure: MACs should include at the outset a description of the evidence considered when drafting an LCD as well as the rationale they rely on to deny coverage. If this information is not provided until the final LCD, it hinders meaningful stakeholder exchange and makes the MAC’s decision to deny coverage almost a foregone conclusion.
• Meaningful Reconsideration and Options for Appeal: A meaningful LCD reconsideration process gives Medicare providers and suppliers the opportunity to have a secondary review by a qualified disinterested party. Under current Centers for Medicare & Medicaid Services (CMS) rules, MAC LCDs are essentially unreviewable for providers and suppliers without new evidence submitted to the very MAC that issued the LCD.
• Stopping the use of LCDs as a backdoor to National Coverage Determinations (NCDs): Prohibit the CMS from appointing a single MAC, either expressly or in practice, from making determinations to be used on a nationwide basis in a given specialty. The CAP has witnessed the carbon copy adoption of MAC LCDs by other MACs without the benefit of meaningful solicitation or independent assessment of comments and concerns from the public or medical community of the adopting MAC. The policy then can become of such geographic magnitude it approaches becoming a NCD in practical terms without having followed more rigorous requirements.

The CAP, along with coalition members Advanced Medical Technology Association, the Amputee Coalition, the American Society of Clinical Oncology, the American Society of Radiation Oncology, and the US Oncology Network have come together because they believe that LCDs should not limit patient access to needed technologies and services. This legislation would make significant improvements to the LCD process and ensure that medical evidence is not used selectively to deny appropriate coverage to Medicare beneficiaries.

The CAP will continue to monitor LCD legislation.

About the College of American Pathologists

As the world's largest organization of board-certified pathologists and leading provider of laboratory accreditation and proficiency testing programs, the College of American Pathologists (CAP) serves patients, pathologists, and the public by fostering and advocating excellence in the practice of pathology and laboratory medicine worldwide. For more information, read the 2017 CAP Annual Report at CAP.ORG.