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CHA has prepared the attached summary detailing the Centers for Medicare & Medicaid Services’ (CMS) proposed rule addressing rate updates and policy changes to the Medicare outpatient prospective payment system (OPPS) system for calendar year (CY) 2019.
CHA is concerned about — and will oppose — a number of site-neutral payment provisions outlined in the proposed rule. Specifically, CMS proposes to reduce payments for outpatient clinic visits in excepted off-campus provider-based departments (PBDs) to 40 percent of the OPPS rate — the same payment rate for services furnished in a nonexcepted off-campus PBD. CHA believes the agency’s rationale is flawed. CMS further proposes to revise the definition of “excepted items and services” and to reduce payments for new services furnished at excepted off-campus PBDs at 40 percent of the OPPS rate.
CMS also proposes to pay for separately payable drugs and biologicals, other than drugs on pass-through payment status and vaccines, acquired under the 340B program and furnished by either excepted or non-excepted off-campus PBDs at a rate of average sales price (ASP) minus 22.5 percent.
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.
The proposed rule includes changes to the inpatient-only list, the Outpatient Quality Reporting Program and packaging policies. In the rule, CMS requests information about efforts to improve price transparency and interoperability, as well as creating a competitive acquisition or value-based program for Part B drugs under the Center for Medicare & Medicaid Innovation.
CHA DataSuite has issued hospital-specific analyses to show providers how Medicare outpatient fee-for-service (FFS) payments will change from CY 2018 to CY 2019 based on the proposed rule’s policies. The analyses incorporate changes to outpatient payments mandated by Congress and implemented by CMS, including a market basket update, Affordable Care Act-mandated market basket reductions, an updated wage index adjustment, a pass-through spending and outlier budget-neutrality adjustment, updated wage index values and other ambulatory payment classification factor updates.
The analyses also model, for affected hospitals, the estimated impact of two changes that would be calculated separately:
- Estimated impact of 60 percent reduction to excepted off-campus PBDs
- Estimated impact of 340B biosimilar payment rate changes
CHA will host a member forum on Sept. 14 at 10 a.m. (PT) to review the proposed rule’s provisions and CHA’s draft comments, as well as to solicit additional member input. Register for this forum by noon on Sept. 13.
