/ en Sun, 27 Apr 2025 00:47:28 -0500 Mon, 07 Apr 25 15:17:08 -0500 /role-hospitals-kent-hospitals-spaulding-rehabilitation-teams-offer-life-changing-health-care-patients-all-ages <div class="container"><div class="row"><div class="col-md-9"><div class="row"><div class="col-md-5"><p><img src="/sites/default/files/2025-04/ths-rhode-island-rehab-700x532.jpg" alt="Kent Hospital’s Spaulding Rehabilitation teams offer life-changing health care to patients of all ages - image of young female physical therapist working with a middle aged man who is holding light dumbells" width="700" height="532"></p></div><p>Involved in many sports and athletic activities, David played semipro football for six years but experienced several injuries and faced major health challenges beginning in 2010. He weighed 400-plus pounds and struggled walking. After having both hips replaced (eight weeks apart) in 2024, he started physical therapy at Spaulding Outpatient Centers at Kent Hospital in Rhode Island, part of Care New England. David says physical therapy has “completely changed” his life: “<a href="https://www.youtube.com/watch?v=GOEllEWXC6g" target="_blank">It’s bright now</a> — before it was dark.”</p><p>Kent Hospital’s Spaulding Rehabilitation teams offer inpatient and outpatient services, caring for patients recovering from sports injuries, stroke, traumatic brain injury, amputations, concussions, Lyme disease, Parkinson’s disease and more. A multidisciplinary team is led by a physiatrist — a physician specializing in physical medicine and rehabilitation — and includes health professionals from physical therapy, occupational therapy, speech-language pathology, rehabilitation nursing, social work, neuropsychology, nutrition and respiratory therapy, depending on a patient’s needs. The team works to help patients regain strength, mobility and independence and considers patients and their family members as an integral part of the journey.</p><p>In addition, the Pawtucket, R.I., location provides a range of physical, occupational and speech therapy services for children, from newborns to teens. Therapists work closely with parents or guardians and the child’s primary care physician to assess a child’s needs and goals and create a specialized treatment program. Christine Brewster, an occupational therapist at Spaulding Pediatric Rehabilitation, says <a href="https://www.kentri.org/services/spaulding-rehab/pediatric-specialty-services" target="_blank">pediatric occupational therapy services</a> may include helping infants with feeding issues, working with toddlers to improve and refine their motor skills, and helping older children develop more sophisticated interpersonal skills to foster friendships and participation in groups and on sports teams.</p><p><a class="btn btn-primary" href="https://www.kentri.org/services/spaulding-rehab" target="_blank">LEARN MORE</a></p></div></div><div class="col-md-3"><div><h4>Resources on the Role of Hospitals</h4><ul><li><a href="/center/population-health">Improving Health and Wellness</a></li><li><a href="/roleofhospitals">All Case Studies</a></li></ul></div></div></div></div> Mon, 07 Apr 2025 15:17:08 -0500 Ambulatory and Outpatient Care /lettercomment/2025-02-28-aha-comments-medpac-rural-medicare-beneficiary-cost-sharing <p>February 28, 2025</p><p><br>Michael Chernew, Ph.D.<br>Chairman<br>Medicare Payment Advisory Commission<br>425 I Street, NW, Suite 701<br>Washington, D.C. 20001</p><p>Dear Dr. Chernew: </p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations; our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) appreciates the opportunity to share our comments regarding Medicare beneficiary cost-sharing in rural facilities.</p><p>In particular, we thank the Medicare Payment Advisory Commission (MedPAC) for recognizing that critical access hospitals (CAHs) are vital care access points for their communities and, as such, their financial stability and sustainability are critical. We support the Commission’s recommended changes to beneficiary cost sharing in CAHs, including to ensure that total payments to CAHs remain unchanged. However, rural health clinics (RHCs) also serve as important access points; as such, we encourage the commission to examine more closely the potential impact of its proposed changes to their beneficiary cost-sharing structure.</p><h2>COST SHARING FOR OUTPATIENT SERVICES AT CAHS</h2><p>During the January 2025 meeting, commissioners discussed patient cost sharing for outpatient services in CAHs and its impact on care access. The commission voted to recommend that CAH outpatient beneficiary cost-sharing be set at 20% of the payment amount and subject to a cap equal to the inpatient deductible. <strong>The AHA appreciates MedPAC’s consideration of outpatient patient cost sharing in CAHs and agrees it poses challenges to Medicare beneficiaries.</strong></p><p>Currently, CAHs receive cost-based fee-for-service (FFS) Medicare payments. As the commission concluded, these payments provide them with much-needed financial support. However, under this system, Medicare calculates beneficiaries’ cost-sharing for outpatient services as a percentage of <em>charges</em>, as compared to the outpatient prospective payment system (PPS) where beneficiary cost-sharing is a percentage of the outpatient PPS <em>payment rate</em>. As a result, half of CAH FFS Medicare outpatient payments are from beneficiary coinsurance.<sup>1,2</sup> The majority of rural Medicare beneficiaries do not directly pay this coinsurance because many have supplemental coverage in Medigap or Medicaid. However, for the small proportion that do not have this coverage, these costs may be an undue financial burden and a barrier to accessing care. <strong>We share in the concerns presented by the commission regarding the implications of this cost-sharing structure for patient access to care and financial burden, especially in these historically underserved communities.</strong></p><p>Commission staff presented a policy solution to reduce beneficiary cost-sharing for outpatient services in CAHs. Under this solution, cost-sharing would be reduced from 20% of charges to 20% of the outpatient PPS payment rate. Additionally, a cap would be placed on the CAH outpatient coinsurance amount equal to the inpatient deductible; for 2025, this amount is $1,676. Importantly, the policy solution also would ensure that total payments to CAHs remain unchanged. That is, any reductions in CAH payments resulting from reductions in beneficiary cost-sharing would be made up by the Medicare program. <strong>We agree with this framework and emphasize the importance of maintaining stable and consistent total payments for CAHs.</strong> <strong>Indeed, any reductions in CAH payments would be extremely detrimental to their financial sustainability and, in turn, to beneficiary access to care.</strong> The commission itself recognized that “many CAHs would struggle financially if they did not receive [cost-based] FFS payment rates.” In fact, 70 CAHs have already closed or had to significantly scale back their services since 2005, including the closure of inpatient units.<sup>3</sup></p><p>Staff indicated that its recommendation, however, would mean an <em>additional $1.3 billion would flow to MA plans in capitation payments</em>. The fact that this would happen at a time when MedPAC itself has found that MA plans were overpaid by $88 billion is of great concern to the AHA<sup>.4 </sup><strong>As such, we continue to urge the commission to fully study the role MA plays in rural communities and the impact plan policies and practices have on patients’ access to care and the financial solvency of rural providers. </strong>In particular, both the AHA and MedPAC have detailed numerous problems with MA prior authorization denials and other utilization review practices and their effects on timely access to care for patients.<sup>5 </sup>These dynamics are increasingly problematic as MA penetration grows in rural areas. Specifically, some plans are restricting patient access to Medicare-covered services, delaying patient care, and adding tremendous administrative burden to small hospitals without the resources to absorb these costs.<sup>6</sup> Paying plans more in the face of such practices is misguided.</p><h2>COST SHARING FOR RURAL HEALTH CLINICS</h2><p>Commissioners also discussed challenges to RHC patient cost sharing and its impact on patient access to care.<strong> The AHA appreciates MedPAC’s consideration of this important topic and agrees that wide variation in RHC cost-sharing poses challenges to Medicare beneficiaries.</strong> <strong>However, we urge the commission to consider the impact payment cuts to RHCs would have on their financial sustainability, especially given payment cuts implemented in recent years.</strong></p><p>RHCs must be located in nonurbanized areas and predominantly serve underserved and rural populations. They provide outpatient services and are intended to increase access to primary care. Currently, Medicare pays RHCs 80% of an all-inclusive rate (AIR) per visit.<sup>7</sup> Medicare beneficiary cost sharing at RHCs is set at 20% of RHC charges. Therefore, RHC payments are 80% of the AIR (from Medicare) and 20% of charges (from patient cost-sharing).<sup>8</sup> As such, there is wide variation in beneficiary liability. For example, in independent RHCs, the average beneficiary cost sharing as a share of the AIR is 34%, whereas in provider-based RHCs, the average beneficiary cost sharing as a share of the AIR ranges from 17% to 38%.</p><p>Staff presented a potential policy solution to address this variation — to reduce cost sharing by capping it at 20% of an RHC’s AIR. MedPAC found that for 2022, this would have reduced beneficiary cost sharing by 43% in independent RHCs and 8% to 49% in provider-based RHCs. However, unlike for CAHs, staff did not propose to ensure that total payment to RHCs remains unchanged. As such, AHA’s analysis indicates that the proposed policy would have translated to a $111 million payment cut to RHCs in 2024.</p><p>These cuts come at a time when RHCs are still working to reconcile existing Medicare payment reductions. Specifically, the Consolidated Appropriations Act of 2021 set new payment limits capping reimbursement and only allowing growth by medical inflation. These cuts are particularly troubling because these facilities predominantly serve historically underserved communities and provide increased access to primary care, mental health care, pharmacy and dental services for these communities. RCHs act as safety net clinics designed to increase access to care for rural residents.<sup>9</sup> Research has shown that over half of RHCs have night or weekend hours and the majority accept walk-in services and provide language interpretation services. <strong>Therefore, we urge MedPAC to carefully consider the impact these payment cuts would have on patient access to care. In particular, we urge the commission to ensure that total payments to RHCs remain unchanged. That is, any reductions in RHC payments resulting from reductions in beneficiary cost-sharing would be made up by the Medicare program.</strong></p><p>We thank you for your consideration of our comments. Please contact me if you have questions or feel free to have a member of your team contact Shannon Wu, AHA’s director of policy, at <a href="mailto:swu@aha.org">swu@aha.org</a> or 202-626-2963.</p><p>Sincerely,<br>/s/<br>Ashley B. Thompson<br>Senior Vice President<br>Public Policy Analysis and Development </p><p>Cc: Paul Masi, M.P.P.<br>MedPAC Commissioners</p><div><p>__________</p><div id="ftn1"><p><small class="sm"><sup>1</sup> RTI International. (2016). Medicare Copayments for Critical Access Hospital Outpatient Services – Update.  </small><a class="ck-anchor" href="https://www.medpac.gov/wp-content/uploads/import_data/scrape_files/docs/default-source/contractor-reports/medicare-copayments-for-critical-access-hospital-outpatient-services-update.pdf" id="https://www.medpac.gov/wp-content/uploads/import_data/scrape_files/docs/default-source/contractor-reports/medicare-copayments-for-critical-access-hospital-outpatient-services-update.pdf"><small class="sm">https://www.medpac.gov/wp-content/uploads/import_data/scrape_files/docs/default-source/contractor-reports/medicare-copayments-for-critical-access-hospital-outpatient-services-update.pdf</small></a><br><small class="sm"><sup>2</sup> HHS Office of the Inspector General. (2014). Medicare Beneficiaries Paid Nearly Half of the Costs For Outpatient Services at Critical Access Hospitals. </small><a class="ck-anchor" href="https://oig.hhs.gov/reports/all/2014/medicare-beneficiaries-paid-nearly-half-of-the-costs-for-outpatient-services-at-critical-access-hospitals/" id="https://oig.hhs.gov/reports/all/2014/medicare-beneficiaries-paid-nearly-half-of-the-costs-for-outpatient-services-at-critical-access-hospitals/"><small class="sm">https://oig.hhs.gov/reports/all/2014/medicare-beneficiaries-paid-nearly-half-of-the-costs-for-outpatient-services-at-critical-access-hospitals/</small></a><br><small class="sm"><sup>3</sup> </small><a class="ck-anchor" href="https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/" id="https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/"><small class="sm">https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/</small></a><br><small class="sm"><sup>4</sup> </small><a class="ck-anchor" href="https://www.medpac.gov/wp-content/uploads/2023/10/MedPAC-MA-status-report-Jan-2024.pdf" id="https://www.medpac.gov/wp-content/uploads/2023/10/MedPAC-MA-status-report-Jan-2024.pdf"><small class="sm">https://www.medpac.gov/wp-content/uploads/2023/10/MedPAC-MA-status-report-Jan-2024.pdf</small></a><br><small class="sm"><sup>5 </sup></small><a class="ck-anchor" href="/lettercomment/2023-11-30-aha-urges-medpac-examine-medicare-advantage-denials-hospital-market-basket" id="/lettercomment/2023-11-30-aha-urges-medpac-examine-medicare-advantage-denials-hospital-market-basket"><small class="sm">/lettercomment/2023-11-30-aha-urges-medpac-examine-medicare-advantage-denials-hospital-market-basket</small></a><br><small class="sm"><sup>6</sup></small><a href="/guidesreports/growing-impact-medicare-advantage-rural-hospitals-across-america"><small class="sm">/guidesreports/growing-impact-medicare-advantage-rural-hospitals-across-america</small></a><br><small class="sm"><sup>7</sup> As of 2021, they have been subject to a national statutory payment limit per visit (i.e., in 2025, this payment limit is $152).</small><br><small class="sm"><sup>8</sup> In contrast, beneficiary cost-sharing for clinician services in other settings such as federally qualified health centers (FQHCs) is set at 20% of the lesser of the physician fee schedule or FQHC charges.</small><br><small class="sm"><sup>9</sup> University of Minnesota, Rural Health Research Center. (Dec. 2019). Access and Capacity to Care for Medicare Beneficiaries in Rural Health Clinics. </small><a href="https://rhrc.umn.edu/wp-content/uploads/2019/12/UMN-access-to-care-RHCS-policy-brief-12.10.19.pdf"><small class="sm">https://rhrc.umn.edu/wp-content/uploads/2019/12/UMN-access-to-care-RHCS-policy-brief-12.10.19.pdf</small></a><small class="sm"> </small></p></div></div> Fri, 28 Feb 2025 10:02:03 -0600 Ambulatory and Outpatient Care <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) Nov. 1 released its calendar year (CY) 2025 outpatient prospective payment system (OPPS) and ambulatory surgical center (ASC) <a href="https://www.federalregister.gov/public-inspection/2024-25521/medicare-and-medicaid-programs-hospital-outpatient-prospective-payment-and-ambulatory-surgical">final rule</a>. The rule increases OPPS rates by a net 2.9% in CY 2025 compared to CY 2024. CMS also establishes a new obstetrical services Condition of Participation (CoP) and updates existing quality assessment performance improvement (QAPI), emergency readiness and discharge planning CoPs for hospitals and critical access hospitals (CAHs). The policies and payment rates will generally take effect Jan. 1, 2025.</p><div class="panel module-typeC"><div class="panel-heading"><h2>Key Highlights</h2><p>CMS’ final rule will:</p><ul><li>Increase OPPS rates by a net 2.9% in CY 2025 compared to CY 2024.</li><li>Pay separately for diagnostic radiopharmaceuticals with per-day costs above $630.</li><li>Exclude qualifying cell and gene therapies from comprehensive ambulatory payment classification (C-APC) packaging in CY 2025.</li><li>Implement temporary additional payments for certain non-opioid treatments for pain relief dispensed in hospital outpatient departments (HOPDs) and ASCs.</li><li>Adopt three new measures related to health equity for the Outpatient, ASC and Rural Emergency Hospital (REH) Quality Reporting Programs (QRP).</li><li>Extend the voluntary reporting period for two Inpatient QRP measures for two years.</li><li>Establish a new CoP for hospitals and CAHs offering obstetrical services and update the CoPs for QAPI, emergency services, and discharge planning.</li><li>Cover and pay for HIV Pre-Exposure Prophylaxis (PrEP) drugs and related services in HOPDs as additional preventive services.</li></ul></div></div><h2>AHA TAKE</h2><p>According to a <a href="/press-releases/2024-11-01-aha-statement-cy-2025-opps-final-rule" target="_blank">statement</a> by AHA Senior Vice President of Public Policy Analysis and Development Ashley Thompson, “Medicare's sustained and substantial underpayment of hospitals has stretched for almost two decades, and today's final outpatient rule only worsens this chronic problem. The agency's final increase of less than 3% for outpatient hospital services will make the provision of care, investments in the health care workforce, and addressing new challenges, such as cybersecurity threats, more difficult. These inadequate payments will have a negative impact on patient access to care, especially in rural and underserved communities nationwide.”</p><p>“The AHA fully shares CMS’ goals of improving maternal health outcomes and reducing inequities in maternal care,” said Thompson. “While we appreciate that the final rule provides hospitals with additional implementation time and greater flexibility in how they meet certain requirements, we remain concerned about CMS’ excessive use of Conditions of Participation to drive its policy agenda and the potential risk for these requirements to inadvertently reduce access to maternal care. We believe a less punitive and more collaborative approach would be more effective given that the key drivers of maternal health outcomes are highly complex and involve multiple stakeholders. The AHA remains committed to working with the Administration and other stakeholders to advance a full range of solutions to improve maternal outcomes.”</p><h2>WHAT YOU CAN DO</h2><ul><li><strong>Participate in an AHA members-only webinar on </strong><a><strong>Dec. 2</strong></a><strong> at 12:30 p.m. ET </strong>to share your questions and feedback on this regulation for AHA’s comment letter to CMS. Register for this 90-minute webinar <a href="https://events-na13.adobeconnect.com/content/connect/c1/2260329217/en/events/event/shared/2316170480/event_registration.html?sco-id=10604881043&_charset_=utf-8" target="_blank">here</a>.</li><li><strong>Share this advisory with your senior management team </strong>and ask your chief financial officer to examine the impact of the payment changes on your Medicare revenue for CY 2025. Spreadsheets comparing the final changes in the Ambulatory Payment Classification (APC) payment rates and weights from 2024 to 2025 will soon be available on the AHA’s OPPS <a href="/topics/outpatient-pps" target="_blank">webpage</a>. To access these, you must be logged on to the website.</li><li><strong>Share this advisory with your billing, medical records, quality improvement and compliance departments and your clinical leadership team </strong>to apprise them of the final rule’s APCs, CoPs and quality measurement requirements.</li></ul><p>View the detailed regulatory advisory below.</p></div><div class="col-md-4"><a href="/system/files/media/file/2024/11/hospital-outpatient-ambulatory-surgical-center-final-rule-for-cy-2025-advisory-11-20-2024.pdf"><img src="/sites/default/files/inline-images/cover-hospital-outpatient-ambulatory-surgical-center-final-rule-for-cy-2025-advisory-11-21-2024-f.png" data-entity-uuid="4cb0e7b3-5bc8-4444-a02c-c0b436d413ce" data-entity-type="file" alt="Image Cover Regulatory Advisory" width="642" height="836"></a></div></div></div> Thu, 21 Nov 2024 12:13:37 -0600 Ambulatory and Outpatient Care <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) Nov. 1 released its calendar year (CY) 2025 outpatient prospective payment system (OPPS) and ambulatory surgical center (ASC) <a href="https://www.federalregister.gov/public-inspection/2024-25521/medicare-and-medicaid-programs-hospital-outpatient-prospective-payment-and-ambulatory-surgical" target="_blank">final rule</a>. The rule increases OPPS rates by a net 2.9% in CY 2025 compared to CY 2024.</p><p>The policies and payment rates in the rule will generally take effect on Jan. 1, 2025.</p><div class="panel module-typeC"><div class="panel-heading"><h3 class="panel-title">Key Highlights</h3></div><div class="panel-body"><p>CMS’ final rule will:</p><ul><li>Increase Medicare hospital OPPS rates by a net 2.9% in CY 2025.</li><li>Pay separately for diagnostic radiopharmaceuticals with per-day costs above $630.</li><li>Exclude qualifying cell and gene therapies from comprehensive ambulatory payment classification (C-APC) packaging.</li><li>As required by law, implement temporary additional payments for certain non-opioid treatments for pain relief dispensed in the hospital outpatient department (HOPD) and ASC settings.</li><li>Adopt three measures related to health equity for the Outpatient, ASC and Rural Emergency Hospital (REH) Quality Reporting Programs (QRP) and extend voluntary data reporting for two hybrid measures in the Inpatient Quality Reporting Program.</li><li>Establish a new Condition of Participation (CoP) for hospitals and critical access hospitals (CAHs) offering obstetrical services, and update quality assessment performance improvement (QAPI), emergency services and discharge planning CoPs.</li><li>Cover and pay for HIV Pre-Exposure Prophylaxis (PrEP) drugs and related services in HOPDs as additional preventive services under the OPPS.</li></ul></div></div><h2>AHA Take</h2><p>According to a statement by AHA Senior Vice President of Public Policy Analysis and Development Ashley Thompson, “Medicare's sustained and substantial underpayment of hospitals has stretched for almost two decades, and today's final outpatient rule only worsens this chronic problem. The agency's final increase of less than 3% for outpatient hospital services will make the provision of care, investments in the health care workforce, and addressing new challenges, such as cybersecurity threats, more difficult. These inadequate payments will have a negative impact on patient access to care, especially in rural and underserved communities nationwide.</p><p>“The AHA fully shares CMS’ goals of improving maternal health outcomes and reducing inequities in maternal care,” said Thompson. “While we appreciate that the final rule provides hospitals with additional implementation time and greater flexibility in how they meet certain requirements, we remain concerned about CMS’ excessive use of Conditions of Participation to drive its policy agenda and the potential risk for these requirements to inadvertently reduce access to maternal care. We believe a less punitive and more collaborative approach would be more effective given that the key drivers of maternal health outcomes are highly complex and involve multiple stakeholders. The AHA remains committed to working with the Administration and other stakeholders to advance a full range of solutions to improve maternal outcomes.”</p><p>Highlights of the CY 2025 OPPS/ASC final rule follow.</p><h2>CY 2025 OPPS Final Rule Changes</h2><h3>Payment Update</h3><p>CMS updates OPPS rates by a net 2.9% for CY 2025. This includes a market-basket update of 3.4% and a statutorily required productivity cut of 0.5 percentage points. These payment adjustments, in addition to other changes in the rule, are estimated to result in a net increase in OPPS payments of 3.2% in CY 2025 compared to CY 2024. For hospitals that do not publicly report quality measure data, CMS will continue to impose the statutory 2.0 percentage point additional reduction in payment, resulting in a 0.9% OPPS update.</p><p>CMS estimates that the total increase in Federal Government expenditures under the OPPS for CY 2025, compared to CY 2024, due to the changes to the OPPS in the final rule, will be approximately $1.98 billion. Taking into account estimated changes in enrollment, utilization and case mix for CY 2025, CMS estimates that OPPS expenditures for CY 2025, including beneficiary cost-sharing, would be approximately $87.7 billion, which is approximately $4.7 billion higher than estimated OPPS expenditures in CY 2024.</p><p>CMS increases the conversion factor to $89.169 in CY 2025 compared to $87.382 in CY 2024. This update reflects several factors: the 2.9% OPPS payment update, the wage index budget neutrality adjustment, the 5% annual cap for individual hospital wage index reductions budget neutrality adjustment, the cancer hospital payment budget neutrality adjustment and an increase of 0.10 percentage points for the difference in pass-through spending. CMS will use a reduced conversion factor of $87.439 in the payment calculation for hospitals that fail to meet the Hospital Outpatient QRP.</p><h3>Data Used in CY 2024 OPPS/ASC Rate Setting</h3><p>CMS used the CY 2023 claims data and the most updated cost report extract from the Healthcare Cost Report Information System, which primarily includes cost reports from CY 2022, to set OPPS and ASC payment rates.</p><h3>Packaging Policy for “Threshold-packaged” and “Policy-packaged” Drugs, Biologicals and Radiopharmaceuticals</h3><p>CMS pays for drugs, biologicals and radiopharmaceuticals that do not have pass-through status in one of two ways: packaged payment or separate payment (individual Ambulatory Payment Classifications (APCs)). For CY 2025, CMS maintains the packaging threshold for “threshold-packaged” drugs, including non-implantable biologicals and therapeutic radiopharmaceuticals, of $140 per day. This means that such products with a per-day cost of $140 or less will have their cost packaged in the procedure with which they are billed.</p><p>There are exceptions to this threshold-based packaging policy for certain “policy-packaged” drugs, biologicals and contrast agents. CMS will continue to package the costs of all anesthesia drugs; drugs, biologicals, and contrast agents and other drugs that function as supplies when used in a diagnostic test or procedure; and drugs and biologicals that function as supplies when used in a surgical procedure (e.g., skin substitutes), regardless of whether they meet the $140 per day threshold.</p><h4>Diagnostic Radiopharmaceuticals Separate Payment</h4><p>CMS finalizes its proposal to pay separately for diagnostic radiopharmaceuticals with per-day costs above $630 —approximately two times the volume-weighted average cost amount currently associated with diagnostic radiopharmaceuticals in the Nuclear Medicine APCs. It will update the $630 threshold in CY 2026 and subsequent years by the Producer Price Index for Pharmaceutical Preparations. Finally, CMS will pay for separately payable diagnostic radiopharmaceuticals based on their mean unit cost derived from OPPS claims for CY 2025.</p><h4>Exclusion of Cell and Gene Therapies from C-APC Packaging</h4><p>CMS finalizes its proposal to exclude qualifying cell and gene therapies from C-APC packaging.</p><h4>Add-on Payment for Radiopharmaceutical Technetium-99m (Tc-99m)</h4><p>For CY 2025, CMS will continue its current policy to apply an add-on payment to radiopharmaceuticals that use Tc-99m produced without the use of highly enriched uranium. However, for CY 2026, CMS finalizes its proposal to replace this add-on payment with an add-on payment for radiopharmaceuticals that use Tc-99m derived from domestically produced Mo-99.</p><h4>Payment for HIV PrEP in HOPDs</h4><p>CMS finalizes its proposal to cover and pay for HIV PrEP drugs and related services as additional preventive services under the OPPS, as described by CMS through a National Coverage Determination issued and effective Sept. 30, 2024.<a href="#fn1"><sup>1</sup></a> Covered services include the HIV PrEP drugs, drug administration, HIV and hepatitis B screening, and individual counseling performed by physicians or certain other health care practitioners.</p><h3>Intensive Outpatient and Partial Hospitalization Programs</h3><p>CMS will maintain the existing rate structures for Intensive Outpatient Program (IOP) and Partial Hospitalization Program (PHP) services as established in the previous rulemaking. The agency will calculate cost information using CY 2023 claims data and the OPPS data set to identify services eligible for payment under the IOP and PHP benefits.</p><h3>Cancer Hospital Payment Adjustment</h3><p>CMS will continue providing additional payments to cancer hospitals so that a cancer hospital’s payment-to-cost ratio (PCR) after the additional payments is equal to the weighted average PCR for the other OPPS hospitals using the most recently submitted or settled cost report data. Current law also requires this weighted average PCR to be reduced by 1.0 percentage points. Therefore, for CY 2025, CMS will use a target PCR of 0.87 to determine the CY 2025 cancer hospital payment adjustment to be paid at cost report settlement. That is, the payment adjustments will be the additional payments needed to result in a PCR equal to 0.87 for each cancer hospital.</p><h3>Quality Reporting Programs</h3><p>For the Inpatient QRP, CMS will continue voluntary reporting of certain data elements for the Hybrid Hospital-wide Mortality and Readmissions measures that will impact the fiscal year (FY) 2026 payment determination as proposed and already communicated to hospitals outside of the rulemaking process; in response to public comment, the agency finalizes an additional year of voluntary reporting of these data elements so that data reporting also will not affect FY 2027 payment.</p><p>For the Hospital Outpatient QRP, CMS finalizes its proposal to adopt a patient-reported outcome measure of the patient’s understanding of information related to recovery after outpatient surgery beginning with voluntary reporting in CY 2025 and mandatory reporting beginning CY 2026. The agency will also remove two measures found to have little to no effect on patient outcomes.</p><p>CMS makes programmatic updates to the ASC QRP and the REH QRP regarding data reporting requirements upon conversion to REH status and the reporting period for one existing quality measure in the program.</p><p>For the Outpatient, ASC and REH QRPs, CMS finalizes the adoption of three measures related to health equity as proposed; these measures have already been adopted in the Inpatient QRP. These include the Hospital Commitment to Health Equity measure, with mandatory reporting beginning CY 2025, Screening for Social Drivers of Health measure and Screen Positive Rate for Social Drivers of Health, with voluntary reporting in CY 2025 and mandatory reporting beginning CY 2026.</p><h3>Remote Outpatient Therapy, Diabetes Self-management Training and Medical Nutrition Therapy</h3><p>Barring congressional action, providers can no longer bill for remote outpatient therapy, diabetes self-management training and medical nutrition therapy beginning Jan. 1, 2025. CMS reiterates that extensions of statutory waivers expanding the list of telehealth-eligible providers are necessary for CMS to update these billing policies.</p><h3>Periodic In-person Visits for Mental Health Services Furnished Remotely by Hospital Staff to Beneficiaries in their Homes</h3><p>In previous rulemaking, CMS finalized a requirement that payment for remote mental health services may only be made if the beneficiary receives an in-person service within six months prior to the provision of remote service and then annually. CMS reiterates that these in-person visit requirements are currently set to take effect for services furnished on or after Jan. 1, 2025. Congress would need to extend previous statutory waivers to continue to waive the in-person visit requirements beyond Jan. 1, 2025.</p><h3>Changes to the Inpatient-only List</h3><p>For CY 2025, CMS finalizes the addition of three liver allograft services to the inpatient-only list. The American Medical Association CPT Editorial Panel for CY 2025 created the CPT codes for these three services. Additionally, CMS finalizes removing a pelvic fixation code from the inpatient-only list for CY 2025.</p><h3>Access to Non-opioid Treatments for Pain Relief</h3><p>As directed by the Consolidated Appropriations Act of 2023, CMS implements temporary additional payments for specific non-opioid treatments for pain relief dispensed in the HOPD and ASC settings from Jan. 1, 2025, through Dec. 31, 2027. CMS finalizes a calculation methodology to determine the payment limitation as required by statute. The agency finalizes six drugs and five devices that qualify for these payments, which will be paid separately.</p><p>The qualifying drugs have FDA-approved indications to reduce post-operative pain or produce postsurgical analgesia, and the qualifying medical devices have demonstrated through evidence that they reduce opioid usage when used in the postoperative setting.</p><h3>Changes to the Review Timeframes for the HOPD Prior Authorization Process</h3><p>CMS reduces the permissible review timeframe for prior authorization requests for relevant covered outpatient department services from 10 business days to seven calendar days for standard reviews.</p><h2>CY 2025 ASC Final Rule Changes</h2><h3>ASC Payment Update</h3><p>For CYs 2019 through 2023, CMS adopted a policy to update ASC payment rates using the hospital market basket. In light of the impact of the COVID-19 public health emergency on health care utilization, the agency extends this policy through CYs 2024 and 2025. As such, it will increase payment rates by 2.9% for ASCs that meet the quality reporting requirements under the ASC QRP.</p><h3>Changes to the List of ASC-covered Surgical Procedures</h3><p>CMS evaluates the ASC-covered procedures list (CPL) each year to determine whether procedures should be added to or removed from the list. For CY 2025, the agency finalized, with modification, the addition of 21 medical and dental procedures to the ASC CPL based on its existing regulatory criteria.</p><h2>other Final Rule Policies</h2><h3>Health and Safety Standards for Obstetrical and Other Services in Hospitals and CAHs</h3><p>CMS finalizes a new obstetrical services CoP for hospitals and CAHs as part of its efforts to improve maternal health outcomes. This new CoP encompasses organization and supervision of services, delivery of care and staff training. CMS also finalized updates to the QAPI and emergency services CoPs. In addition, the final rule includes an update to the hospital discharge planning CoP.</p><h3>Obstetrical Services</h3><h4>Organization, Supervision of Services and Delivery of Care</h4><p>Beginning Jan. 1, 2026, hospitals and CAHs offering obstetrical services must offer such services in a “well-organized” fashion and per “nationally recognized standards of practice” for both physical health and behavioral health (including mental health and substance use disorders). The final CoP also requires that hospitals delineate obstetrical privileges for all practitioners per the competencies of each practitioner and requires all units providing obstetrical services to be supervised by an experienced, trained professional.</p><p>In a departure from the proposed rule, hospitals and CAHs with obstetrical care units must keep certain supplies readily available instead of maintaining equipment for each patient care room. In addition to a call-in system, cardiac monitor, and fetal doppler or monitor, hospitals and CAHs must maintain and keep readily available protocols and provisions, including equipment, supplies and medications necessary to treat obstetric emergencies.</p><h4>Staff Training</h4><p>Beginning Jan. 1, 2027, hospitals and CAHs offering obstetrical services must train relevant staff on selected topics that reflect the services’ scope and complexity, including facility-identified evidenced-based protocols to improve care delivery in the hospital or CAH.</p><h4>QAPI</h4><p>Under the final rule, hospitals and CAHs offering obstetrical services must regularly assess and work to improve maternal health disparities and outcomes among patients. Effective Jan. 1, 2027, hospitals and CAHs must track and analyze maternal health data, quality indicators and outcomes as part of their QAPI plans and use these findings to inform and update the staff training required under the obstetrical services CoP. CMS also requires the leadership of hospital obstetrical services to engage in QAPI activities, including data collection and monitoring. Finally, hospitals and CAHs must conduct at least one QAPI project focused on improving maternal health outcomes and disparities each year. Hospitals and CAHs in state, tribal or local jurisdictions with a maternal mortality review committee must also maintain a process to incorporate publicly available data into the hospital or CAH’s QAPI program.</p><h4>Emergency Services Readiness</h4><p>CMS has also finalized updates to the existing emergency services CoP for all hospitals and CAHs that offer emergency services, regardless of whether such hospital or CAH offers obstetrical services. Effective July 1, 2025, hospitals and CAHs must maintain adequate provisions and protocols to meet the emergency needs of patients per the offered emergency services’ complexity and scope, including but not limited to obstetrical emergencies. For hospitals, these provisions must include readily available equipment, supplies and medication necessary for treating emergency cases and a call-in system for each patient; no changes were made to existing requirements for equipment, supplies and medications for CAHs. For both hospitals and CAHs, applicable staff must be trained on these protocols and provisions annually, and findings from the hospital or CAH’s QAPI program should inform training topics and updates or other revisions to the training program.</p><h4>Transfer Protocols</h4><p>Beginning July 1, 2025, CMS will require hospitals to develop and maintain policies for transferring patients to the appropriate level of care, including among units within a facility and transfers to other hospitals. Relevant staff must receive annual training on these protocols. CMS did not change discharge planning requirements for CAHs.</p><h3>Changes to Medicaid Clinic Services Four Walls Exceptions</h3><p>CMS finalizes its proposal to add three exceptions to the four walls requirements for Medicaid clinic services: a mandatory exception for Indian Health Service (IHS) and Tribal clinics and optional exceptions for behavioral health clinics and clinics located in rural areas. Medicaid clinic services are distinct and separate from services provided in a Federally-Qualified Health Center (FQHC) or FQHC look-alike. In finalizing provisions related to clinics in rural areas, CMS allows states to adopt a definition of rural in use by certain federal agencies or a state’s rural policy-making agency and requires the state to attest that the definition best captures the rural population.</p><h3>IHS and Tribal Hospitals All-inclusive Rate</h3><p>Currently, IHS and tribal outpatient departments are excluded from the Medicare OPPS and are paid the Medicare outpatient hospital all-inclusive rate (AIR). IHS determines the AIR from cost reports and updates these rates annually. IHS and tribal hospitals have increasingly provided higher-cost drugs along with more complex and expensive services, such as cancer-related services. CMS believes that the AIR may no longer be adequate for these hospitals’ costs to provide these complex services and finalizes its proposals to pay an add-on to the AIR for certain high-cost drugs for people with Medicare who receive care at IHS or tribal hospitals.</p><h2>Further Questions</h2><p>The policies and payment rates in the final rule will take effect Jan. 1, 2025. Watch for a more detailed analysis of the final rule in the coming weeks.</p><p>If you have further questions, contact Roslyne Schulman, AHA’s director of outpatient payment policy, at <a href="mailto:rschulman@aha.org?subject=RE: Special Bulletin: CMS Outpatient PPS and ASC Final Rule for CY 2025 ">rschulman@aha.org</a>.</p><hr><ol><li id="fn1">The final National Coverage Determination can be found at <a href="https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=310&fromTracking=Y&" target="_blank">NCA - Preexposure Prophylaxis (PrEP) Using Antiretroviral Therapy to Prevent Human Immunodeficiency Virus (HIV) Infection (CAG-00464N) - Decision Memo</a>.</li></ol></div><div class="col-md-4"><p><a href="/system/files/media/file/2024/11/Special-Bulletin-CMS-Issues-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2025.pdf" target="_blank" title="Click here to download the Special Bulletin: CMS Outpatient PPS and ASC Final Rule for CY 2025 PDF."><img src="/sites/default/files/inline-images/Page-1-Special-Bulletin-CMS-Issues-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2025.png" data-entity-uuid="350cb966-8e0d-481d-b427-38503d8bfd7f" data-entity-type="file" alt="Special Bulletin: CMS Issues Hospital Outpatient, Ambulatory Surgical Center Final Rule for CY 2025 page 1." width="696" height="900"></a></p></div></div></div> Mon, 04 Nov 2024 15:20:37 -0600 Ambulatory and Outpatient Care /lettercomment/2024-09-09-aha-comments-cms-outpatient-ambulatory-surgery-center-cy-2025-proposed-payment-rule <div class="container"><div class="row"><div class="col-md-8"><p>September 9, 2024</p><p>The Honorable Chiquita Brooks-LaSure<br>Administrator<br>Centers for Medicare & Medicaid Services<br>Hubert H. Humphrey Building<br>200 Independence Avenue, S.W., Room 445-G<br>Washington, DC 20201</p></div><div class="col-md-4"><div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2024/09/AHA-Comments-on-CMS-Outpatient-Ambulatory-Surgery-Center-CY-2025-Proposed-Payment-Rule.pdf" target="_blank" title="Click here to download the AHA Comments on CMS Outpatient, Ambulatory Surgery Center CY 2025 Proposed Payment Rule letter PDF.">Download the Full Letter PDF</a></div></div></div><div class="row"><div class="col-md-8"><p><em><strong>Re: CMS–1809–P: Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems; Quality Reporting Programs, Including the Hospital Inpatient Quality Reporting Program; Health and Safety Standards for Obstetrical Services in Hospitals and Critical Access Hospitals; Prior Authorization; Requests for Information; Medicaid and CHIP Continuous Eligibility; Medicaid Clinic Services Four Walls Exceptions; Individuals Currently or Formerly in Custody of Penal Authorities; Revision to Medicare Special Enrollment Period for Formerly Incarcerated Individuals; and All-Inclusive Rate Add-On Payment for High-Cost Drugs Provided by Indian Health Service and Tribal Facilities (Vol. 89, No. 140), July 22, 2024.</strong></em></p><p>Dear Administrator Brooks-LaSure:</p><p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, and our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) appreciates the opportunity to comment on the Centers for Medicare & Medicaid Services’ (CMS) hospital outpatient prospective payment system (OPPS) and ambulatory surgical center (ASC) payment system proposed rule for calendar year (CY) 2025.</p><p>We support many of the OPPS proposed rule provisions, including unpackaging and paying separately for certain high-cost diagnostic radiopharmaceuticals, unpackaging from the comprehensive ambulatory payment classifications (C-APCs) and paying separately for certain cell and gene therapy products, and establishing new add-on payment for hospitals that use Technetium-99m (Tc-99m) derived from domestically produced Molybdenum-99 (Mo-99). We also appreciate that in response to comments from AHA and its members, the agency is considering reducing the reporting burden of its policy that helps offset the marginal costs that hospitals face in procuring domestically made surgical N95 respirators.</p><p>At the same time, the AHA continues to have strong concerns about the shortcomings in the annual payment update for hospital outpatient departments (HOPDs), in particular the market basket forecast and update. This is especially concerning considering past underwhelming market basket increases, specifically from CYs 2022 through 2024. Indeed, the forecasts on which CMS relies have consistently under-predicted cost growth, and the actual market basket increases are falling well short of inflation. <strong>Therefore, AHA urges CMS to consider whether adjustments are necessary in its approach to annual market basket updates to ensure that beneficiaries continue to have access to high-quality outpatient care. We also urge CMS to eliminate the productivity cut for CY 2025, as detailed below.</strong></p><p><strong>Further, the AHA shares CMS’ commitment to improving maternal health outcomes. However, we are concerned that CMS’ proposed CoPs fail to address the root causes behind poor maternal outcomes and may further reduce access to safe, high-quality obstetric care.</strong> Any potential solution to this crisis must consider the entire maternal health continuum and should prioritize the needs of pregnant and postpartum women. Instead of issuing duplicative and unnecessary regulations, the AHA urges CMS to partner with patients and the hospitals and health systems that serve them to address maternal morbidity and mortality causes. We believe a collaborative approach focused on patients not facilities will lead to meaningful patient outcome improvements while preserving access to safe, high-quality maternal health care.</p><p>We appreciate your consideration of these issues. Our detailed comments are attached. Please contact me if you have questions or feel free to have a member of your team contact Roslyne Schulman, AHA’s director for policy, at <a href="mailto:rschulman@aha.org?subject=RE: AHA Comments on CMS Outpatient, Ambulatory Surgery Center CY 2025 Proposed Payment Rule">rschulman@aha.org</a>.</p><p>Sincerely,</p><p>/s/</p><p>Ashley B. Thompson<br>Senior Vice President<br>Public Policy Analysis and Development</p><p><a href="/system/files/media/file/2024/09/AHA-Comments-on-CMS-Outpatient-Ambulatory-Surgery-Center-CY-2025-Proposed-Payment-Rule.pdf" target="_blank" title="Click here to download the AHA Comments on CMS Outpatient, Ambulatory Surgery Center CY 2025 Proposed Payment Rule letter PDF.">Download the complete letter PDF.</a></p></div><div class="col-md-4"><div class="external-link spacer"><a href="/system/files/media/file/2024/09/AHA-Comments-on-CMS-Outpatient-Ambulatory-Surgery-Center-CY-2025-Proposed-Payment-Rule.pdf" target="_blank" title="Click here to download the AHA Comments on CMS Outpatient, Ambulatory Surgery Center CY 2025 Proposed Payment Rule letter PDF."><img src="/sites/default/files/inline-images/Page-1-AHA-Comments-on-CMS-Outpatient-Ambulatory-Surgery-Center-CY-2025-Proposed-Payment-Rule.png" data-entity-uuid="3db1f84b-c317-425e-aa5a-f5e73a1f41b2" data-entity-type="file" alt="AHA Comments on CMS Outpatient, Ambulatory Surgery Center CY 2025 Proposed Payment Rule letter page 1." width="761" height="900"></a></div></div></div></div> Mon, 09 Sep 2024 15:07:48 -0500 Ambulatory and Outpatient Care /aha-center-health-innovation-market-scan/2024-08-13-4-ways-prep-where-health-care-will-be-delivered-2035 <div class="container"><div class="row"><div class="col-md-8"><p><img src="/sites/default/files/inline-images/4-Ways-to-Prep-for-Where-Health-Care-Will-Be-Delivered-in-2035.jpg" data-entity-uuid="c6eb547b-e1af-44ba-b557-0fbc70b6f189" data-entity-type="file" alt="4 Ways to Prep for Where Health Care Will Be Delivered in 2035. A hospital executive looks through a telescope to see what 2035 has in store for health care." width="100%" height="100%"></p><p>Big changes are coming to health care over the next decade, with technology innovation supporting significant shifts that will necessitate operational changes for providers.</p><p>Technology will continue to get faster, cheaper and smarter. So-called <a href="https://www.graphcore.ai/posts/graphcore-announces-roadmap-to-ultra-intelligence-ai-supercomputer" target="_blank" title="Graphcore: Graphcore Announces Roadmap to Ultra Intelligence AI Supercomputer">“ultra intelligence”</a> artificial intelligence (AI) supercomputers this year are expected to possess four times more parametric capacity than the human brain and be nearly 10 times faster in the number of computations that can be run every second.</p><p>As for how the field will be impacted by the rapidly evolving tech landscape, the consultancy Oliver Wyman recently published an <a href="https://www.oliverwyman.com/our-expertise/insights/2023/dec/fostering-change-in-where-and-how-care-is-delivered.html" target="_blank" title="Oliver Wyman: Fostering Change in Where and How Care Is Delivered">analysis</a> as a follow-up to its <a href="https://www.oliverwyman.com/our-expertise/insights/2023/sep/designing-for-2035.html" target="_blank" title="Oliver Wyman: Designing a Healthcare System for the Next Decade">Designing for 2035 report</a>.</p><h2><span>Forecasting for 2035</span></h2><p>Among the authors’ projections:</p><ul><li><strong>Health care costs will continue to come down</strong> even as workforce expenses and the actionability of data collected remain challenges.</li><li>By 2035, <strong>comprehensive genome sequencing</strong> will be a standard part of medical evaluations, providing insights into an individual’s predisposition to diseases and guiding personalized treatment plans.</li><li><strong>Advanced diagnostic capabilities will expand.</strong> Point-of-care devices and at-home testing kits will provide quick and accurate results for a wide range of conditions, enabling early detection and timely treatment.</li><li>Pharmaceutical companies will <strong>use predictive models to design and test potential drugs</strong> in a matter of days or weeks rather than the years it now takes. Doing a better job of incorporating data into clinical workflows will help ease the burden and burnout that clinicians currently feel from cumbersome technology systems.</li></ul><p>The overall increase in information on outcomes and practice patterns, along with more effective dissemination of data, will enable faster and more accurate treatment decisions. Current struggles with interoperability will be overcome, and data will follow patients in a more efficient manner.</p><h2><span>4 Takeaways for Provider Organizations</span></h2><h3><span>1</span> <span>|</span> Focus on value-added clinical tasks.</h3><p>Some current technological advances already are providing administrative support. Further improvements will come from modifying ChatGPT-like solutions for creating more efficiencies of back-office and other administrative functions. Additionally, AI will support and evolve work completed by nurses, case managers and social workers. Smart implementation of AI systems has the potential to fully automate some tasks, including prior authorizations, care planning and consultations triggered by assessments.</p><h4><span>2035 Outlook</span></h4><p>Keep an eye on robotic medication administration. These systems can identify routine drugs that serve select patients. While these advances significantly will improve everyday efficiency, the rate of adoption will be limited by cost and resource shortages, the report notes. Once this barrier is overcome, hospitals can implement fully baked solutions to optimize operations.</p><h3><span>2</span> <span>|</span> Redistribute care to optimal settings.</h3><p>Hospitals have been important sites of care for two main reasons: economies of scale — reducing the unit cost of care delivery through asset utilization and economies of scope — and using various capabilities and expertise to bend the cost curve and respond to patient variance. But as care delivery has advanced, the impact of economies of scale and scope has diminished. Scale no longer requires being everything to everyone. Likewise, scope needs are lessened through the ability to manage risk and reliance on more precise diagnoses.</p><h4><span>2035 Outlook</span></h4><p>The current inpatient model is capital- and staff-intensive and therefore expensive. It also is not always the safest or most consumer-friendly place to be treated, the report states. Patient preferences and logistics may make being at home the optimal site of care and the authors predict care settings will shift dramatically over the next decade.</p><h3><span>3</span> <span>|</span> Move care from inpatient to outpatient where appropriate.</h3><p>Coming tech advances will lessen the need for inpatient admissions for certain conditions and surgical procedures. Shifts in care protocols, including minimally invasive procedures and improved rehabilitation techniques, will accelerate this transition.</p><h4><span>2035 Outlook</span></h4><p>Expect retail clinic settings to have an impact in this area with their easy accessibility, lower cost structure and a strong focus on preventive care.</p><h3><span>4</span> <span>|</span> Explore moving some inpatient services to home care.</h3><p>The most disruptive transition between now and 2035 could come in this area. The authors project that 64% of inpatient admissions could be moved to the home by 2035, enabled by both improved therapeutics and more effective virtual care.</p><h4><span>2035 Outlook</span></h4><p>At-home care has limitations. Shifting out of an inpatient setting is not feasible for high-risk situations or overly invasive procedures. And not everything that is available to move to the home should, the report states.</p><p>The overall infrastructure still isn’t robust enough to match the potential transition. Only about 40% of U.S. homes were considered to have the most basic aging-ready features, according to a <a href="https://www.census.gov/newsroom/press-releases/2023/aging-ready-homes.html#:~:text=Highlights%3A,aging%2Dready%20homes." target="_blank" title="United States Census Bureau: Census Bureau Releases New Report on Aging-Ready Homes">2023 Census Bureau report</a>, and large areas of rural America, as well as some inner cities, still lack <a href="https://www.census.gov/newsroom/press-releases/2024/computer-internet-use-2021.html" target="_blank" title="United" states census computer and internet use in the united>access to broadband</a>. Still, significant growth could occur in the home care setting.</p></div><div class="col-md-4"><p><a href="/center" title="Visit the AHA Center for Health Innovation landing page."><img src="/sites/default/files/inline-images/logo-aha-innovation-center-color-sm.jpg" data-entity-uuid="7ade6b12-de98-4d0b-965f-a7c99d9463c5" alt="AHA Center for Health Innovation logo" width="721" height="130" data-entity- type="file" class="align-center"></a></p><p><a href="/center/form/innovation-subscription"><img src="/sites/default/files/2019-04/Market_Scan_Call_Out_360x300.png" data-entity-uuid data-entity-type alt width="360" height="300"></a></p></div></div></div>.field_featured_image { position: absolute; overflow: hidden; clip: rect(0 0 0 0); height: 1px; width: 1px; margin: -1px; padding: 0; border: 0; } .featured-image{ position: absolute; overflow: hidden; clip: rect(0 0 0 0); height: 1px; width: 1px; margin: -1px; padding: 0; border: 0; } Tue, 13 Aug 2024 06:15:00 -0500 Ambulatory and Outpatient Care <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) July 10 released its calendar year (CY) 2025 outpatient prospective payment system (OPPS) and ambulatory surgical center (ASC) <a href="https://public-inspection.federalregister.gov/2024-15087.pdf" target="_blank" title="Federal Register: Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems; Quality Reporting Programs, including the Hospital Inpatient Quality Reporting Program; Health and Safety Standards for Obstetrical Services in Hospitals and Critical Access Hospitals; Prior Authorization; Requests for Information; Medicaid and CHIP Continuous Eligibility; Medicaid Clinic Services Four Walls Exceptions; Individuals Currently or Formerly in Custody of Penal Authorities; Revision to Medicare Special Enrollment Period for Formerly Incarcerated Individuals; and All-Inclusive Rate Add-On Payment for High-Cost Drugs Provided by Indian Health Service and Tribal Facilities">proposed rule</a>. The rule would increase OPPS rates by a net 2.6% in CY 2025 compared to CY 2024. The rule also includes proposals for new conditions of participation (CoPs) focused on obstetrical services and maternal care, separate payment for high-cost diagnostic radiopharmaceuticals and three years of separate payment for certain non-opioid drugs and devices that provide pain relief.</p><p>The final rule will be published on or around Nov. 1 and take effect Jan. 1, 2025. CMS will accept comments on the proposed rule through Sept. 9.</p><div class="panel module-typeC"><div class="panel-heading"><h2>Key Highlights</h2><p>CMS’ proposed rule would:</p><ul><li>Increase Medicare hospital OPPS rates by a net 2.6% in CY 2025.</li><li>Pay separately for diagnostic radiopharmaceuticals with per-day costs above $630.</li><li>Exclude qualifying cell and gene therapies from comprehensive ambulatory payment classification (C-APC) packaging in CY 2025.</li><li>As required by law, implement temporary additional payments for certain non-opioid treatments for pain relief dispensed in the hospital outpatient department (HOPD) and ASC settings.</li><li>Adopt three new measures related to health equity for the Outpatient, ASC and rural emergency hospital (REH) Quality Reporting Programs.</li><li>Establish a new obstetrical services CoP and update existing quality assessment performance improvement (QAPI), emergency readiness and discharge planning CoPs for hospitals and critical access hospitals.</li><li>Extend virtual direct supervision of cardiac rehabilitation (CR), intensive cardiac rehabilitation (ICR) and pulmonary rehabilitation (PR) services and diagnostic services furnished to hospital outpatients through Dec. 31, 2025.</li><li>Remove barriers to providing certain clinic services outside the four walls of a clinic, which could improve access for some Medicaid beneficiaries.</li></ul></div></div><h2>AHA Take</h2><p>We are disappointed that CMS again proposed an inadequate update to hospital payments. This increase for outpatient hospital services of only 2.6% would come despite the fact that many hospitals across the country continue to operate on negative or very thin margins that make providing care and investing in their workforce very challenging. Hospitals and health systems’ ability to continue caring for patients and providing essential services for their communities may be in jeopardy, and we urge CMS to provide additional support in the final rule.</p><p>In addition, we fully share CMS’ goals of improving maternal health outcomes and reducing inequities in maternal care. However, we are deeply concerned by CMS’ continued and excessive use of CoPs to drive its policy agenda. We believe a less punitive and more collaborative and flexible approach is far superior. We will carefully review CMS’ proposals to determine whether they are feasible, sufficiently flexible for the wide variety of hospitals to which they would apply and do not inadvertently exacerbate maternal care access challenges.</p><h2>What You Can Do</h2><ul><li><strong>Participate in an AHA members-only webinar on Aug. 6 at 2:30 p.m. ET</strong> to share your questions and feedback on this regulation for AHA’s comment letter to CMS. <a href="https://aha.adobeconnect.com/cy2025oppsasc/event/registration.html" target="_blank" title="AHA: Members-ONLY Webinar for the CY 2025 OPPS/ASC Proposed Rule">Register for this 90-minute webinar.</a></li><li><strong>Share this advisory with your senior management team</strong> and ask your chief financial officer to examine the impact of the proposed payment changes on your Medicare revenue for CY 2025. Spreadsheets comparing the proposed changes in the APC payment rates and weights from 2024 to 2025 are available on the <a href="/topics/outpatient-pps">AHA’s OPPS webpage</a>. To access these, you must be logged on to the website.</li><li><strong>Share this advisory with your billing, medical records, quality improvement and compliance departments and your clinical leadership team</strong> to apprise them of the proposals around the APCs, CoPs and quality measurement requirements.</li><li><strong>Submit comments to CMS with your specific concerns by Sept. 9 at </strong><a href="https://www.regulations.gov" target="_blank" title="Regulations.gov homepage"><strong>www.regulations.gov</strong></a><strong>.</strong></li></ul><p><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf">View the full Regulatory Advisory PDF</a> or use the table of contents below to navigate to specific sections.</p><h2>Contents</h2><ol><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=5">OPPS Proposed Rule Changes</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=5">OPPS Update and Linkage to Hospital Quality Data Reporting</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=5">Data Proposed for Use in CY 2025 OPPS and ASC Rate Setting</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=5">Proposed Site-neutral Payment Policies for Off-campus Provider-based Departments (PBDs)</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=6">Proposed Payments for Drugs, Biologicals and Radiopharmaceuticals</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=7">Proposed Payment Change for Diagnostic Radiopharmaceuticals</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=8">Add-on Payment for Radiopharmaceutical Technetium-99m</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=9">Request for Information on Cardiac computerized tomography Services</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=9">Proposed Recalibration and Scaling of APC Relative Weights</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=10">Area Wage Index</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=10">Rural Sole Community Hospital Adjustment</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=11">Cancer Hospital Adjustment</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=11">Comprehensive APCs</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=12">Proposed Non-Opioid Policy for Pain Relief Under the OPPS and ASC Payment System</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=13">Proposed Changes to the Inpatient-Only List</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=14">Hospital Outpatient Outlier Payments</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=14">Transitional Pass-through Payments</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=14">Beneficiary Coinsurance</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=14">Outpatient Quality Reporting Program 14</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=19">Proposed Payment for Intensive Outpatient and Partial Hospitalization Programs</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=20">Remote Services</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=20">Outpatient Therapy, Diabetes Self-management Training, and Medical Nutrition Therapy</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=21">Proposed Health and Safety Standards for Obstetrical Services in Hospitals and critical access hospitals</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=21">New and Updated CoPs Related to Maternal Health</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=22">ASC Proposed Rule Changes</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=22">ASC Payment Update</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=23">Proposed Changes to ASC Covered Procedures List</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=23">ASC Quality Reporting Program</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=26">REH Quality Reporting Program</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=27">Other Quality-Related Provisions</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=29">Other Issues</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=29">All-Inclusive Rate Add-on for High-Cost Drugs Provided by the Indian Health Service and Tribal Hospitals</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=29">RFI: Paying all IHS and Tribally Operated Clinics the IHS Medicare Outpatient AIR</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=30">Coverage Changes for Colorectal Cancer Screening Services</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=30">Request for Comment on Payment Adjustments under the Inpatient PPS and OPPS for Domestic Personal Protective Equipment</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=31">Payment for HIV Pre-Exposure Prophylaxis in HOPDs</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=31">Proposed Payment Policy for Devices in Category B Investigational Device Exemption, Clinical Trials Policy and Drugs with Medicare Coverage with Evidence Development Designation</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=32">Proposed Changes to Medicaid Clinic Services Four Walls Exceptions</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=32">Proposed Changes to the Review Timeframes for the HOPD Prior Authorization Process</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=33">Next Steps</a></li><li><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf#page=33">Further Questions</a></li></ol></div><div class="col-md-4"><p><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.pdf" target="_blank" title="Click here to download the Regulatory Advisory: Hospital Outpatient, Ambulatory Surgical Center Proposed Rule for CY 2025 PDF."><img src="/sites/default/files/inline-images/Page-1-Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2025.png" data-entity-uuid="297c2a11-29ab-4be0-9750-bb2378d95325" data-entity-type="file" alt="Regulatory Advisory: Hospital Outpatient, Ambulatory Surgical Center Proposed Rule for CY 2025 page 1." width="695" height="900"></a></p></div></div></div> Tue, 23 Jul 2024 13:55:59 -0500 Ambulatory and Outpatient Care /aha-center-health-innovation-market-scan/2024-07-02-4-takeaways-coming-shift-health-services-demand <div class="container"><div class="row"><div class="col-md-8"><p><img src="/sites/default/files/inline-images/4-Takeaways-on-Coming-Shift-in-Health-Services-Demand.png" data-entity-uuid="cc5ff1a8-a784-4924-96b8-17d95e977efd" data-entity-type="file" alt="4 Takeaways on Coming Shift in Health Services Demand. A business man stands on a raised path that forks into three arrows pointing in different directions." width="100%" height="100%"></p><p>The coming decade will present significant challenges for hospitals and health systems as they strive to meet a shifting demand for services.</p><p>Rising volumes will require a greater focus on managing patient flow and reducing emergency department (ED) bottlenecks as providers seek to reduce wait times for those needing beds.</p><p>The evolving landscape will be led by an aging population, increased incidence of chronic disease and a higher demand for mental health services — all of which will cause inpatient and outpatient volumes to rise, notes the <a href="https://vizientinc-delivery.sitecorecontenthub.cloud/api/public/content/47212a11b76244d2b3bc7f0e0db086e5" target="_blank" title="Sg2: 2024 Impact of Change® Forecast Highlights">Sg2 2024 Impact of Change report</a>.</p><p>The report’s disease-based forecasting model analyzes patient-level data across service lines and sites of care for more than 27,000 unique disease and procedure combinations, helping organizations understand their care delivery opportunities in the decade ahead.</p><h2><span>Assessing Inpatient and Outpatient Volumes</span></h2><p>Inpatient utilization can be expected to rise 3% to 31 million annual discharges while inpatient days will increase 9% to 170 million, the report states. This will impact patient flow in a variety of ways.</p><p>Growth in medical discharges, meanwhile, will outpace surgical discharges as patients age and are increasingly comorbid, exacerbating pressures in the ED to find patient beds.</p><p>Similar trends will impact the outpatient setting, leading to a 17% jump in these volumes to 5.82 billion. Robust growth is forecasted in outpatient surgical services, driven by expanded capabilities and patients’ procedural needs and chronic care required to manage ongoing conditions like dysrhythmia and dementia.</p><h2><span>4 Takeaways on Coming Care Trends</span></h2><h3><span>1</span> <span>|</span> Double down on integrating primary and behavioral health care.</h3><p>Inpatient behavioral health discharges and outpatient volumes are projected to grow 8% and 26%, respectively, over the next decade. This increased demand will place additional pressure on already constrained access points such as primary care and psychotherapy services.</p><h4>Takeaway</h4><p>Data show that up to 75% of primary care visits can include a mental health component, said Stephanie Snider, Sg2 director, in a recent <a href="https://sg2.podbean.com/e/2024-impact-of-change%C2%AE-primary-care/" target="_blank" title="Sg2 Perspectives: 2024 Impact of Change® Primary Care podcast">podcast</a>. This can include everything from disease management that brings stress to a patient to conditions like anxiety, depression or substance use.</p><p>This means providers will need to double down on the progress they have made in integrating primary care, specialty care and behavioral health to identify patient needs at the earliest stage. Offering more co-located spaces for primary care and behavioral health services also could make care more seamless for patients or offering a virtual hub to connect rural and other patients to services.</p><h3><span>2</span> <span>|</span> Target your virtual care services.</h3><p>The shift to virtual care will continue despite adoption headwinds. By 2034, nearly one in four (23%) evaluation and management visits will be delivered in a virtual setting, the report states. Behavioral health virtual visits will see strong growth and make up a larger portion of psychotherapy visits over the next decade, with 50% of psychotherapy visits delivered virtually by 2034.</p><h4>Takeaway</h4><p>Achieving seamless care coordination and verifying that patients can access your virtual care portal easily can help ensure that patients — particularly those with chronic conditions — stay actively engaged in their care. Hospitals typically will see more uptake in virtual services that are consultative in nature — think chronic disease, notes Tori Richie, senior director of intelligence at Sg2. Surgical-related services, such as orthopedic or spinal conditions, will have less virtual uptake.</p><h3><span>3</span> <span>|</span> Hone your home care strategies.</h3><p>Further enabled by virtual capabilities, home health is expected to grow 22%. As the aging, high-acuity patient population continues to require longer stays in the hospital (with 9% inpatient growth forecast), organizations must be intentional about how they plan their inpatient and outpatient service-line strategies, the report states.</p><h4>Takeaway</h4><p>Organizations should be asking key questions now to inform their future home-care strategies, Richie suggests. How many bed days could be saved by a robust care-at-home program? Lessons learned in the near term as hospitals and health systems refine their home care offerings as a key component of transitional care and interventions in older patients with chronic diseases will pay dividends in the long term.</p><h3><span>4</span> <span>|</span> Expect a slowdown in bariatric surgeries.</h3><p>A 15% decline in inpatient bariatric surgeries is forecast in the next decade, fueled in part by scaled adoption of pharmaceuticals designed to help patients lose weight and/or reduce blood glucose levels.</p><h4>Takeaway</h4><p>It’s worth noting that an increase of 13% is expected in commercial and self-paid bariatric surgical volumes moving to the outpatient setting.</p></div><div class="col-md-4"><p><a href="/center" title="Visit the AHA Center for Health Innovation landing page."><img src="/sites/default/files/inline-images/logo-aha-innovation-center-color-sm.jpg" data-entity-uuid="7ade6b12-de98-4d0b-965f-a7c99d9463c5" alt="AHA Center for Health Innovation logo" width="721" height="130" data-entity- type="file" class="align-center"></a></p><p><a href="/center/form/innovation-subscription"><img src="/sites/default/files/2019-04/Market_Scan_Call_Out_360x300.png" data-entity-uuid data-entity-type alt width="360" height="300"></a></p></div></div></div>.field_featured_image { position: absolute; overflow: hidden; clip: rect(0 0 0 0); height: 1px; width: 1px; margin: -1px; padding: 0; border: 0; } .featured-image{ position: absolute; overflow: hidden; clip: rect(0 0 0 0); height: 1px; width: 1px; margin: -1px; padding: 0; border: 0; } Tue, 02 Jul 2024 06:15:00 -0500 Ambulatory and Outpatient Care <div class="container"> <div class="row"> <div class="col-md-8"> <p>The Centers for Medicare & Medicaid Services (CMS) Nov. 2 released its calendar year (CY) 2024 outpatient prospective payment system (OPPS) and ambulatory surgical center (ASC) <a href="https://public-inspection.federalregister.gov/2023-24293.pdf" target="_blank">final rule</a>. It increases OPPS rates by a net 3.1% in CY 2024 compared to CY 2023 and includes final policies regarding hospital price transparency, behavioral health services and Rural Emergency Hospitals (REHs). The policies and payment rates in the rule will generally take effect Jan. 1, 2024.</p> <div class="panel module-typeC"> <div class="panel-heading"> <h2>Key Highlights</h2> <p>CMS’ final rule will:</p> <ul> <li>Increase OPPS rates by a net 3.1% in CY 2024 as compared to CY 2023.</li> <li>Create standardized formats for hospital price transparency files, including additional required data elements such as contracting methodology and an "estimated allowed amount," and establish additional CMS enforcement mechanisms for reporting requirements.</li> <li>Adopt new measures for the Outpatient, ASC and REH Quality Reporting Programs, modify several others and decline to adopt certain measures.</li> <li>Pay for 340B-acquired drugs and biologicals at the average sales price (ASP) plus 6% and, effective Jan. 1, 2025, require that all 340B hospitals only report the “TB” modifier.</li> <li>Add additional dental procedures to the OPPS and ASC payment systems.</li> <li>Add 10 services to the inpatient-only list.</li> </ul> </div> </div> <h2>AHA Take</h2> <p>The AHA is concerned that CMS has again finalized an inadequate update to hospital payments. CMS’ increase for outpatient hospitals of only 3.1% comes in spite of persistent financial headwinds facing the field. Most hospitals across the country continue to operate on negative or very thin margins that make providing care and investing in their workforce very challenging day to day. Hospitals’ and health systems’ ability to continue caring for patients and providing essential services for their communities may be in jeopardy, which is why the AHA is urging Congress for additional support by the end of the year.</p> <p>In addition, hospitals remain committed to helping patients access the information they need when planning for their care, including meaningful information about the cost of that care. The AHA will be carefully reviewing the changes to the Hospital Price Transparency Rule to ensure they continue to advance our shared objective with CMS of making it easier for patients to access pricing and cost information while reducing unnecessary administrative burden and costs on hospitals and health systems.</p> <h2>What You Can Do</h2> <ul> <li><strong>Participate in a 90-minute AHA members-only webinar on Monday, Dec. 4 at 1 p.m. ET</strong> to understand the changes made in the final rule. <a href="https://aha.adobeconnect.com/cy2024oppsascffr/event/registration.html" target="_blank">Rgister for this 90-minute webinar.</a></li> <li><strong>Share this advisory with your senior management team</strong> and ask your chief financial officer to examine the impact of the payment changes on your Medicare revenue for CY 2024. Spreadsheets comparing the final changes in the APC payment rates and weights from 2023 to 2024 are available on the AHA’s <a href="/topics/outpatient-pps">OPPS webpage</a>. To access these, you must be logged on to the website.</li> <li><strong>Share this advisory with your billing, medical records, quality improvement and compliance departments, as well as your clinical leadership team</strong> to apprise them of the policies around the ambulatory payment classifications (APCs), mental health services, hospital price transparency and quality measurement requirements.</li> </ul> <h2><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=3" title="Click here to download the complete Regulatory Advisory: Hospital Outpatient, Ambulatory Surgical Center Final Rule for CY 2024 PDF.">Contents</a></h2> <p><strong><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=5">OPPS FINAL RULE CHANGES</a></strong></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=5">OPPS Update and Linkage to Hospital Quality Data Reporting</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=5">Data Used in CY 2024 OPPS and ASC Ratesetting</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=5">Site-neutral Payment Policies for Off-campus Provider-based Departments</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=6">Payment for Intensive Cardiac Rehabilitation Provided by an Off-Campus, Non-Excepted Hospital PBD</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=6">Payments for Drugs, Biologicals and Radiopharmaceuticals</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=7">340B Drug Payment Policy</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=8">Recalibration and Scaling of APC Relative Weights</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=9">Area Wage Index</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=10">Rural Sole Community Hospital Adjustment</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=10">Cancer Hospital Adjustment</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=11">Comprehensive APCs</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=11">Changes to the Inpatient-Only List</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=12">Hospital Outpatient Outlier Payments</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=13">Transitional Pass-Through Payments</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=13">OPPS Payment for Dental Services</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=14">Beneficiary Coinsurance</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=14">Outpatient Quality Reporting Program</a></p> <p><strong><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=19">ASC FINAL RULE CHANGES</a></strong></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=19">ASC Payment Update</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=20">Changes to ASC Covered Procedures List</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=20">Packaging Policy for Non-opioid Pain Management Drugs under the ASC Payment System</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=21">ASC Quality Reporting Program</a></p> <p><strong><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=22">REH POLICIES</a></strong></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=23">REH Quality Reporting Program</a></p> <p><strong><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=25">UPDATES TO THE REQUIREMENTS FOR HOSPITALS TO MAKE PUBLIC A LIST OF THEIR STANDARD CHARGES</a></strong></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=25">Standard Template Requirement and New Data Elements</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=27">Additional Definitions</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=27">File Accessibility</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=28">Accuracy and Completeness Affirmation</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=28">Enforcement Timeline</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=29">Changes to Compliance Monitoring and Enforcement Activities</a></p> <p><strong><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=30">BEHAVIORAL HEALTH UPDATES</a></strong></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=30">Intensive Outpatient Program Benefit</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=33">PHP and IOP Payment Methodology</a></p> <p><strong><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=35">REMOTE SERVICES</a></strong></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=35">Remote Outpatient Mental Health</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=36">Remote Outpatient Therapy, Diabetes Self-Management Training and Medical Nutrition Therapy</a></p> <p><strong><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=36">OTHER ISSUES</a></strong></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=36">Request for Comments on Potential Payment Establishing and Maintaining Access to Essential Medicines</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=37">Changes to the IPPS Medicare Code Editor</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=37">Supervision of Cardiac Rehabilitation, Intensive Cardiac Rehabilitation and Pulmonary Rehabilitation Services</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=38">Comment Solicitation on Payment for High-Cost Drugs Provided by Indian Health Service and Tribally Owned Facilities</a></p> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=38">Requiring Manufacturers of Certain Single-Dose Container or Single-Use Package Drugs to Provide Refunds with Respect to Discarded Amounts</a></p> <p><strong><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=39">NEXT STEPS</a></strong></p> <p><strong><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf#page=39">FURTHER QUESTIONS</a></strong></p> </div> <div class="col-md-4"> <p><a href="/system/files/media/file/2023/11/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.pdf" target="_blank" title="Click here to download the complete Regulatory Advisory: Hospital Outpatient, Ambulatory Surgical Center Final Rule for CY 2024 PDF."><img alt="Regulatory Advisory: Hospital Outpatient, Ambulatory Surgical Center Final Rule for CY 2024 page 1." data-entity-type="file" data-entity-uuid="7a76447e-10f5-40af-b2ed-b477d47d21db" src="/sites/default/files/inline-images/Page-1-Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Final-Rule-for-CY-2024.png" width="695" height="900"> </a></p> </div> </div> </div> Fri, 17 Nov 2023 08:39:21 -0600 Ambulatory and Outpatient Care <div class="container"> <div class="row"> <div class="col-md-8"> <p>The Centers for Medicare & Medicaid Services (CMS) Nov. 2 released its calendar year (CY) 2024 outpatient prospective payment system (OPPS) and ambulatory surgical center (ASC) <a href="https://public-inspection.federalregister.gov/2023-24293.pdf" target="_blank">final rule</a>. The rule increases OPPS rates by a net 3.1% in CY 2024 compared to CY 2023. The rule also includes final requirements for hospital price transparency, behavioral health services and Rural Emergency Hospitals (REHs).</p> <p>The policies and payment rates in the rule will generally take effect on Jan. 1, 2024</p> <div class="panel module-typeC"> <div class="panel-heading"> <h3>Key Highlights</h3> <p>CMS’ final rule will:</p> <ul> <li>Increase OPPS rates by a net 3.1% in CY 2024 as compared to CY 2023.</li> <li>Create standardized formats for hospital price transparency files, including additional required data elements, and establish additional CMS enforcement mechanisms for reporting requirements.</li> <li>Expand access to behavioral health services, including new coverage for intensive outpatient programs (IOPs) for behavioral health conditions.</li> <li>Adopt some of the proposed new measures for the Outpatient and ASC quality reporting programs and all proposed measures for the REH quality reporting program.</li> <li>Pay for 340B acquired drugs and biologicals at the average sales price (ASP) plus 6%.</li> <li>Add additional dental procedures to the OPPS and the ASC payment system.</li> </ul> </div> </div> <h2>AHA TAKE</h2> <p>The AHA is concerned that CMS has again finalized an inadequate update to hospital payments. CMS’ increase for outpatient hospitals of only 3.1% comes in spite of persistent financial headwinds facing the field. Most hospitals across the country continue to operate on negative or very thin margins that make providing care and investing in their workforce very challenging day to day. Hospitals’ and health systems’ ability to continue caring for patients and providing essential services for their communities may be in jeopardy, which is why the AHA is urging Congress for additional support by the end of the year.</p> <p>In addition, hospitals remain committed to helping patients access the information they need when planning for their care, including meaningful information about the cost of that care. The AHA will be carefully reviewing the changes to the Hospital Price Transparency Rule to ensure they continue to advance our shared objective with CMS of making it easier for patients to access pricing and cost information while reducing unnecessary administrative burden and costs on hospitals and health systems.</p> <p>Highlights of the OPPS/ASC final rule follow.</p> <h2>CY 2024 OPPS FINAL RULE CHANGES</h2> <h3>Payment Update</h3> <p>CMS updates OPPS rates by a net 3.1% for CY 2024. This includes a market-basket update of 3.3%, as well as a statutorily required productivity cut of 0.2 percentage points. These payment adjustments, in addition to other changes in the rule, are estimated to result in a net increase in OPPS payments to hospitals of 3.3% compared to CY 2023 payments. For hospitals that do not publicly report quality measure data, CMS will continue to impose the statutory 2.0 percentage point additional reduction in payment, resulting in a 1.1% OPPS update. CMS estimates that total payments to hospitals (including enrollment, utilization, case-mix and beneficiary cost sharing) will be approximately $88.9 billion in CY 2024, an increase of approximately $6.0 billion compared to CY 2023 payments.</p> <p>The conversion factor will be $87.382 in CY 2024, as compared to $85.585 in CY 2023. This update reflects several factors: the 3.1% OPPS payment update, the wage index budget neutrality adjustment of 0.9912, the 5% annual cap for individual hospital wage index reductions adjustment of 0.9997, the cancer hospital payment adjustment of 1.0005 and a decrease of 0.11 percentage points for the difference in pass-through spending. CMS uses a reduced conversion factor of $85.687 in the calculation of payments for hospitals that fail to meet requirements of the Hospital Outpatient Quality Reporting (OQR) Program.</p> <h3>Data Used in CY 2024 OPPS/ASC Ratesetting</h3> <p>To set final OPPS and ASC payment rates, CMS resumes the use of the most recent cost reports and claims data available. Thus, the agency will use the CY 2022 claims data and the most recent cost report extract available from the Healthcare Cost Report Information System. This extract primarily includes cost reporting periods beginning in CY 2021.</p> <h3>340B Drug Payment Policy</h3> <p>CMS will continue to apply the default rate of ASP plus 6% to 340B acquired drugs and biologicals. Therefore, drugs and biologicals acquired under the 340B program will be paid at the same payment rate as those drugs and biologicals not acquired under the 340B program for CY 2024.</p> <p><u>Policy to Use a Single Modifier</u>. CMS finalizes its proposal to consolidate the current “JG” and “TB” modifier identifying separately-payable drugs purchased under the 340B program to a single “TB” modifier beginning Jan. 1, 2025. CMS’ stated rationale for this change is to allow for greater simplicity, especially because both current modifiers are used for the same purpose — to identify separately payable drugs and biologicals acquired under the 340B Program. In addition, it will allow CMS to continue to identify and exclude 340B-acquired drugs and biologicals from the definition of units for the purpose of the Part B inflation rebate liability.</p> <p>The “JG” modifier will remain effective through Dec. 31, 2024. Hospitals that currently report the “JG” modifier may choose to continue to use it in CY 2024 or choose to transition to use of the “TB” modifier during that year. Beginning on Jan. 1, 2025, the “JG” modifier will be deleted, and hospitals will be required to report drugs and biologicals acquired through the 340B program using the “TB” modifier.</p> <h3>Packaging Policy for “Threshold-packaged” and “Policy-packaged” Drugs, Biologicals and Radiopharmaceuticals</h3> <p>CMS pays for drugs, biologicals and radiopharmaceuticals that do not have pass-through status in one of two ways: packaged payment or separate payment (individual APCs). For CY 2024, CMS keeps the packaging threshold for “threshold-packaged” drugs, including non-implantable biologicals and therapeutic radiopharmaceuticals, at $135 per day. This means that such products with a per-day cost of $135 or less will have their cost packaged in the procedure with which they are billed.</p> <p>There are exceptions to this threshold-based packaging policy for certain “policy-packaged” drugs, biologicals and radiopharmaceuticals. Consistent with current policy, the agency will continue to package the costs of all anesthesia drugs; intraoperative items and services; drugs, biologicals and radiopharmaceuticals that function as supplies when used in a diagnostic test or procedure (including contrast agents, diagnostic radiopharmaceuticals and stress agents); and drugs and biologicals that function as supplies when used in a surgical procedure (e.g., skin substitutes), regardless of whether they meet the $135 per day threshold.</p> <p><u>Excepting Biosimilars from the OPPS Packaging Threshold when Their Reference Biologicals Are Separately Paid</u>. CMS notes that the intent of its threshold packaging policy is to create incentives for efficiency, but it has concerns that packaging biosimilars when the reference biological or other marketed biosimilars are separately paid may create financial incentives for providers to select more expensive, but clinically similar, products. Therefore, for CY 2024, CMS will except biosimilars from the OPPS threshold packaging policy when their reference biologicals are separately paid. However, the agency did not finalize its proposal that all the biosimilars related to the reference product would be similarly packaged if a reference product’s per-day cost falls below the threshold packaging policy.</p> <h3>Behavioral Health Updates</h3> <p>Throughout the rule, CMS finalizes several provisions related to behavioral health, many of which implement parts of the Consolidated Appropriations Act of 2023.</p> <p><u>Payment for Remote Mental Health Services</u>. In the CY 2023 OPPS final rule, CMS finalized the establishment of three codes to account for mental health services furnished remotely by HOPD staff. In this rule, the agency will adopt an additional, untimed code describing remote group psychotherapy. In addition, the agency finalizes other technical refinements to how these codes are recorded that would allow for multiple units to be billed on the same day. Finally, CMS will delay the requirements for an in-person visit within six months prior to the first remote mental health service and within 12 months after each remote mental health service until Jan. 1, 2025.</p> <p><u>Intensive Outpatient Program Benefit</u>. CMS establishes programmatic requirements under Medicare for the coverage of IOP services, beginning Jan. 1, 2024. These requirements govern:</p> <ul> <li>The scope of benefits and definition of IOP services paid on a per-diem basis; <ul> <li>In the final rule, the agency will add references to substance use disorder (SUD) services explicitly in the scope of benefits.</li> <li>In response to comments, the agency will add and maintain additional codes in the list of eligible services.</li> </ul> </li> <li>Minimum number of hours of IOP services per week (nine) and frequency (at least every other month) for IOP coverage eligibility; and</li> <li>Payment rates, established as two APCs for each provider type and number of services provided per day.</li> </ul> <p>In addition, CMS makes conforming regulatory text changes to reflect that the newly established IOP requirements will be the same for RHCs and FQHCs as for hospitals. CMS also extends IOP coverage to include programs provided by opioid treatment programs (OTPs) and Community Mental Health Centers (CMHCs).</p> <p><u>Partial Hospitalization Program (PHP) Updates</u>. CMS will make updates to the payment rates for PHP services in HOPDs and CMHCs. The agency will expand the existing rate structure of only one APC for each provider type to include two PHP APCs for each provider type: one for days with three or fewer services per day and one for days with four or more services per day. To calculate the hospital-based and CMHC PHP payment rates for three services per day and four or more services per day, the agency used broader OPPS data that includes both PHP and non-PHP days rather than the current methodology that only uses PHP data. Finally, CMS clarifies that Medicare coverage for PHP services includes services rendered for treatment of SUDs in addition to mental illnesses.</p> <p><u>CMHC Conditions of Participation (CoP)</u>. In addition to the newly added coverage for IOP services described above, CMS will implement a statutorily required benefit category for services from mental health counselors and marriage and family therapists. This involves modifying the CoPs for CMHCs.</p> <h3>Cancer Hospital Payment Adjustment</h3> <p>CMS will continue to provide additional payments to cancer hospitals so that their payment-to-cost ratio (PCR) after the additional payments is equal to the weighted average PCR for the other OPPS hospitals. In light of the COVID-19 public health emergency’s impact on claims and cost data used to calculate the target PCR, CMS has maintained the CY 2021 target PCR of 0.89 through CYs 2022 and 2023.</p> <p>In this final rule, CMS finalizes its proposal to reduce the target PCR by 1.0 percentage point each calendar year until the target PCR equals the PCR of non-cancer hospitals using the most recently submitted or settled cost report data. Therefore, for CY 2024, the agency will set a target PCR of 0.88 to determine the CY 2024 cancer hospital payment adjustment to be paid at cost report settlement. That is, the payment adjustments will be the additional payments needed to result in a PCR equal to 0.88 for each cancer hospital.</p> <h3>Physician Fee Schedule (PFS) Policy to Require HOPDs and ASCs to Report Discarded Amounts of Certain Single-dose or Single-use Package Drugs</h3> <p>The Infrastructure Investment and Jobs Act requires drug manufacturers to provide a refund to CMS for certain discarded amounts from a refundable single-dose container or single-use package drug. The CY 2024 PFS final rule includes policies to operationalize section 90004 of the Infrastructure Act, including those impacting HOPDs and ASCs.</p> <h3>OPPS Payment for Dental Services</h3> <p>CMS newly assigns over 240 Healthcare Common Procedure Coding System codes describing dental services to various clinical APCs to align with Medicare payment provisions regarding dental services in the CY 2024 PFS final rule.</p> <h3>Outpatient Quality Reporting Program</h3> <p>CMS finalizes some, but not all, proposed updates to the measure set used in the OQR, and adopts certain proposals with modification.</p> <p>CMS will not remove the Left Without Being Seen measure as originally proposed, which assesses the percent of patients who leave the emergency department without being evaluated by a clinician; the agency notes there is limited evidence linking the measure to improved patient outcomes. CMS also did not finalize its proposal to re-adopt the Hospital Outpatient Department Volume Data on Selected Outpatient Surgical Procedures. This measure was previously used in the OQR but removed; CMS noted that it will reassess how volume data is publicly displayed as an alternative to re-adopting this measure.</p> <p>CMS will adopt the following two measures into the OQR, but will extend the voluntary reporting period through CY 2027 (instead of CY 2025, as originally proposed) with mandatory reporting thereafter.</p> <ul> <li>Risk-standardized Patient-reported Outcomes Following Elective Primary Total Hip and/or Total Knee Arthroplasty: this measure assesses whether certain patients experienced substantial clinical improvement following procedures based on scores on specific evaluation instruments.</li> <li>Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults: this is an electronic clinical quality measure that attempts to capture instances of unnecessarily high radiation doses during diagnostic imaging.</li> </ul> <p>Finally, CMS finalizes modifications to three existing measures beginning with the CY 2024 reporting period to reflect updated clinical guidelines, including the following.</p> <ul> <li>COVID-19 Vaccination Coverage Among Health Care Personnel: CMS will update the definition of what it means to be “up to date” with vaccination to be in accordance with current guidance from the Centers for Disease Control and Prevention.</li> <li>Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery: CMS will limit the specific survey instruments allowed to be used to inform the measure.</li> <li>Appropriate Follow-up Interval for Normal Colonoscopy in Average Risk Patients: CMS will expand the age range for patients in the denominator to reflect updated clinical guidelines.</li> </ul> <h3>Supervision by Certain Non-physician Practitioners of Cardiac, Intensive Cardiac and Pulmonary Rehabilitation Services Furnished to Outpatients</h3> <p>For CY 2024, to comply with provisions of the Bipartisan Budget Act of 2018, CMS will expand the practitioners who may supervise cardiac rehabilitation, intensive cardiac rehabilitation (ICR) and pulmonary rehabilitation services to include nurse practitioners (NP), physician assistants (PA) and clinical nurse specialists (CNS). The agency also will allow for the direct supervision requirement for these services to include virtual presence of the physician through audio-video, real-time communications technology (excluding audio-only) through Dec. 31, 2024, and, will extend this policy to the above nonphysician practitioners who are eligible to supervise these services.</p> <h3>Payment for ICR Provided by an Off-campus, Non-excepted Provider-based Department (PBD) of a Hospital</h3> <p>Due to a provision in the Medicare Improvements for Patients and Providers Act of 2008, starting in 2010, ICR services provided in physician offices are required to be paid at 100% of the OPPS rate. In addition, since 2017, due to the site-neutral payment provisions of Section 603 of the Bipartisan Budget Act of 2015, payments for ICR services furnished in off-campus, non-grandfathered PBDs of a hospital have been reduced to the “PFS-equivalent” rate of 40% of the OPPS rate.</p> <p>In the CY 2024 OPPS/ASC final rule, CMS reiterates that this site-neutral payment rate for ICR services is inconsistent with the intent of Section 603, which is to remove the disparity in payment rates for the same services, regardless of whether they were furnished in a physician’s office or an off-campus, non-grandfathered PBD of a hospital. Therefore, to correct this unintended reimbursement disparity, CMS will pay for these non-grandfathered ICR services at 100% of the OPPS rate, which is the amount paid for these services under the PFS.</p> <h3>Changes to the Inpatient-only List</h3> <p>For CY 2024, CMS will not remove any services from the IPO list. However, it finalizes its proposal to add nine services to the IPO list (0790T, 22836, 22837, 22838, 61889, 76984, 76987, 76988 and 76989). Additionally, it finalizes its proposal to add an additional CPT code (0646T) to the IPO list based on status indicator change from “EI” (not payable by Medicare) to “C” (Inpatient Only).</p> <p>CMS notes that it has reviewed comments in response to its request for information regarding whether certain gastric restrictive procedures would be appropriate to remove from the IPO list. It states that it continues to believe that these services do not meet the criteria to be removed from the IPO list.</p> <h2>CY 2024 ASC FINAL RULE CHANGES</h2> <h3>ASC Payment Update</h3> <p>For CYs 2019 through 2023, CMS adopted a policy to update the ASC payment system using the hospital market basket update. In light of the COVID-19 public health emergency, the agency will extend this policy through CYs 2024 and 2025. As such, it will increase payment rates by 3.1% for ASCs that meet the quality reporting requirements under the ASC Quality Reporting (ASCQR) Program.</p> <h3>Changes to the List of ASC-covered Surgical Procedures</h3> CMS evaluates the ASC-covered procedures list (CPL) each year to determine whether procedures should be added or removed. For CY 2024, the agency finalizes its proposal to add 26 dental surgical procedures to the ASC CPL. After its review of comments in response to the CY 2024 proposed rule, the agency finalizes the addition of 11 additional procedures to the ASC CPL list for CY 2024. <h2>ASCQR</h2> <p>CMS finalized the same updates to the ASCQR as it did for the OQR, including the same modifications to the three existing measures and the adoption of the patient-reported outcomes following total hip and/or total knee arthroplasty measure. Similarly, the agency did not finalize the adoption of the surgical procedural volume measure.</p> <h2>RURAL EMERGENCY HOSPITALS</h2> <h3>REH Payment Changes</h3> <p>Tribal and IHS hospitals are excluded from payment under the OPPS and instead are paid for hospital outpatient services under an annual all-inclusive rate (AIR). While some tribal and IHS hospitals have expressed interest in converting to an REH, they have also expressed reservations about doing so due to having to transition from their existing AIR payment methodology to the REH payment methodology. As such, CMS finalized its proposal that tribal and IHS hospitals who convert to REHs would be paid under their existing AIR for outpatient services. Additionally, CMS also finalized its proposal that these converted hospitals would receive the REH monthly facility payment consistent with how this payment is made to REHs that are not tribally or IHS operated.</p> <h2>REH Quality Reporting Program (REHQR)</h2> <p>CMS codifies several policies for the REHQR, including those related to:</p> <ul> <li>Statutory authority for the program;</li> <li>Measure retention, removal and modification;</li> <li>Public reporting of data;</li> <li>Foundational requirements related to program participation;</li> <li>The form, manner and timing of data submission for the program;</li> <li>A review and corrections period for submitted data; and</li> <li>An Extraordinary Circumstances Exception process for data submission requirements.</li> </ul> <p>In addition, the agency will adopt four quality measures for the program set for required reporting beginning CY 2024. These include:</p> <ul> <li>Abdomen CT - Use of Contrast Material</li> <li>Median Time from ED Arrival to ED Departure for Discharged ED Patients</li> <li>Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy</li> <li>Risk-Standardized Hospital Visits Within 7 Days After Hospital</li> </ul> <h2>Outpatient Surgery HOSPITAL PRICE TRANSPARENCY</h2> <p>CMS finalizes several changes to the hospital price transparency requirements, previously established under the Public Health Service Act and subsequent CMS rulemaking, which are intended to standardize the format and accessibility of hospital pricing information and strengthen CMS' enforcement mechanisms.</p> <p>Specifically, CMS requires hospitals utilize a standard, machine-readable file template to display their standard charge information. Hospitals must include several additional data elements in the new format, including information on the payer negotiated rate type (e.g., dollar amount, percentage, algorithm), an expected allowed amount, drug type and unit of measurement, location setting, and modifiers. While hospitals need to utilize the new format by July 1, 2024, several of the new data elements will not be required until Jan. 1, 2025.</p> <p>The final rule also establishes new requirements designed to improve CMS’ enforcement of hospital price transparency. Specifically, the rule enables CMS to:</p> <ul> <li>require hospital leaders to certify the completeness and accuracy of their machine-readable file;</li> <li>require hospitals to submit an acknowledgment of any of the agency’s warning notices for hospital noncompliance with the regulations;</li> <li>require hospitals to submit additional information, including contracting documentation, to CMS to aid compliance assessment;</li> <li>contact health system leadership when a hospital within their system is under compliance review; and</li> <li>publish a range of compliance assessment and enforcement actions on CMS' website.</li> </ul> <p>Finally, CMS finalizes additional proposals, including new technical requirements related to how the price transparency information is linked to the hospital’s public facing website and a public attestation of completeness and accuracy.</p> <h2>OTHER CHANGES</h2> <h3>Request for Comments on Potential Payment Establishing and Maintaining Access to Essential Medicines</h3> <p>As part of the Administration’s effort to strengthen the resilience of medical supply chains, CMS sought comments on ways to support practices that can curtail pharmaceutical shortages of essential medicine and promote resiliency to safeguard and improve the care hospitals are able to provide. Specifically, the agency sought comments on potential separate payments under the inpatient prospective payment system (IPPS) and OPPS for the reasonable costs of establishing and maintaining access to a buffer stock of one more essential medicines, one of the 86 identified by the Office of the Assistant Secretary for Preparedness and Response’s report <em>Essential Medicines Supply Chain and Manufacturing Resilience Assessment</em>.</p> <p>CMS did not finalize its proposals in this rulemaking process. The agency states that stakeholders broadly commented that a more multifaceted approach is necessary. The agency states that it intends to propose new CoPs in forthcoming notice and comment rulemaking addressing hospital processes for pharmaceutical supply, including potential payment policies.</p> <h3>Changes to the IPPS Medicare Code Editor (MCE)</h3> <p>CMS continues to evaluate the purpose and function of the MCE with respect to the International Classification of Diseases (ICD)-10. Historically, it has addressed the addition or deletion of MCE edits in the annual IPPS rulemakings. However, CMS included in the CY 2024 OPPS proposed rule a request for comments on removing discussion of the MCE from annual IPPS rulemakings beginning with the FY 2025 rulemaking and to generally address future changes or updates to the MCE through instruction to the Medicare administrative contractors (MACs).</p> <p>After CMS’ consideration and review of the public comments, it finalizes its proposal to remove discussion of the MCE from the annual IPPS rulemakings, beginning with FY 2025 rulemaking, and, to generally address future changes or updates to the MCE through instruction to the MACs. CMS will also continue to analyze data on the current edits to determine utility and whether any edits should be modified or removed from the fee-for-service claims processing systems in the future.</p> <h2>FURTHER QUESTIONS</h2> <p>The policies and payment rates in the final rule take effect Jan. 1, 2024. Watch for a more detailed analysis of the final rule in the coming weeks. If you have further questions, contact Roslyne Schulman, AHA’s director of outpatient payment policy, at <a href="mailto:rschulman@aha.org">rschulman@aha.org</a>.</p> </div> <div class="col-md-4"> <p><a href="/system/files/media/file/2023/11/cms-issues-hospital-outpatient-ambulatory-surgical-center-final-rule-for-cy-2024-bulletin-11-3-23.pdf" target="_blank"><img alt="CMS Issues Hospital Outpatient, Ambulatory Surgical Center Final Rule for CY 2024" data-entity-type="file" data-entity-uuid src="/sites/default/files/2023-11/cover-cms-issues-hospital-outpatient-ambulatory-surgical-center-final-rule-for-cy-2024-bulletin-11-3-23.png"></a></p> </div> </div> </div> Fri, 03 Nov 2023 15:59:55 -0500 Ambulatory and Outpatient Care