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Yesterday, the Centers for Medicare & Medicaid Services (CMS) released the outpatient prospective payment system (OPPS) proposed rule for calendar year (CY) 2019, which also includes payment updates for ambulatory surgical centers (ASCs).
CHA is currently reviewing the following key provisions:
OPPS Rates:
- CMS proposes to update OPPS rates by 1.25 percent in calendar year 2019 compared to CY 2018. This reflects a projected market basket increase of 2.8 percent minus the productivity and Affordable Care Act-mandated adjustments (0.8 and 0.75 percent, respectively). This payment update is offset by a number of the other changes in the proposed rule, resulting in what CMS estimates to be a net decrease in payments of 0.1 percent.
Site-Neutral Payment Policies
- CMS proposes to reduce the payment rate for hospital outpatient clinic visits provided at all off-campus hospital provider-based departments (HOPDs) to 40 percent of the OPPS rate. This includes excepted and non-excepted off-campus provider-based HOPDs. CMS states in the proposed rule that the clinic visit is the most commonly billed service under the OPPS, and that Medicare payments and beneficiary cost sharing should not vary based on the site of service. CMS estimates this would reduce Medicare expenditures by $760 million for CY 2019. In addition, CMS seeks comments on how best to expand these policies in the future.
- CMS proposes to modify its policy related to excepted off-campus provider-based HOPDs that expand the families of services they offer. Specifically, if a grandfathered off-campus provider-based HOPD adds a new service from a clinical family different from the families for which it provided services during Nov. 1, 2014 through Nov. 1, 2015, those services would be paid a site-neutral rate of 40 percent of the OPPS rate and would no longer be a covered OPPS service. CMS proposes 19 groupings of clinical families of services.
- CMS proposes to extend the payment rate of average sales price (ASP) minus 22.5 percent for drugs acquired under the 340B program to 340B drugs furnished in non-grandfathered (non-excepted) off-campus provider-based HOPDs. In addition, CMS proposes to pay for separately payable biosimilars acquired under the 340B program at a rate of ASP minus 22.5 percent of the biosimilar’s own ASP, rather than ASP minus 22.5 percent of the reference product’s ASP.
- Citing a recommendation made earlier this year by the Medicare Payment Advisory Commission, CMS states it will begin to collect data to assess the extent to which OPPS services are shifting to off-campus provider-based emergency departments. While not relevant for states like California, this will likely have broader payment implications in the future. CMS announced that, effective Jan. 1, 2019, it will create a new Healthcare Common Procedure Coding System (HCPCS) modifier that will be reported with every claim line for outpatient hospital services furnished in an off-campus emergency department.
CHA is extremely disappointed in CMS’ site-neutral proposals, particularly the continuation and expansion of flawed 340B payment policies. CHA will work with its association colleagues to urge the agency to withdraw these inappropriate site-neutral payment policies.
On a more positive note, CMS continues to propose the reduction of quality measures under its Meaningful Measures Initiative. Specifically, CMS proposes to remove 10 measures from the Outpatient Quality Reporting Program; one would be removed for CY 2020 reporting and the remaining nine in CY 2021. CMS also proposes to change the inpatient Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey by removing the new “communication about pain” questions, beginning with January 2022 discharges.
Comments on the proposed rule are due Sept. 24. Additional information on a forthcoming member forum, along with a detailed summary of the proposed rule, will be available in CHA News in the coming weeks and posted to CHA’s Regulatory Tracker. Additional information about the ASC payment rule will also be forthcoming.
