Changes proposed by the Centers for Medicare and Medicaid Services (CMS) would slash reimbursements and patients’ copayments to hospitals’ off-campus treatment facilities, making them approximately equal to payments to ambulatory surgical centers (ASCs).
At present, PBDs enjoy significantly higher reimbursements than ASCs. CMS says this “site neutrality” change both benefit patients and “control unnecessary increases in the volume of covered hospital outpatient department services.”
The change seems to be aimed at two trends: one, hospitals buying up physician practices and reducing the number of competitors in health care markets, and two, an ever-growing number of procedures in those facilities, which CMS calls off-campus Provider-Based Departments (PBDs).
The CMS proposal would apply a Physician Fee Schedule (PFS)-equivalent payment rate for clinic-visit services when provided at a PBD, which are paid under the Outpatient Prospective Payment System (OPPS). “The clinic visit is the most common service billed under the OPPS and is often furnished in the physician office setting,” CMS said in a discussion of the plan.
CMS estimates that this change in the method for calculating increases would increase total payments to ASCs (including copayments) $300 million in 2019 compared to 2018.
The sum of all the changes would save Medicare $760 million and would save patients an estimated $150 million in copayments in 2019 alone, CMS says.
“For an individual Medicare beneficiary, current Medicare payment for the clinic visit is approximately $116, with $23 being the average beneficiary copayment. The proposal to adjust this payment to the PFS equivalent rate would reduce the OPPS payment rate for the clinic visit by the PFS relativity adjuster of 40 percent to an amount of $46 and a beneficiary copayment of $9, thus saving beneficiaries an average of $14 each time they visit an off-campus department,” CMS said.
The existing system of differing reimbursements “has resulted in inefficient care, increased consolidation of physician practices into hospital systems, and increased costs to Medicare patients who face higher co-pays for outpatient services compared to services provided in an office setting,” said American Academy of Orthopaedic Surgeons President David Haymer in a prepared statement. Also, the change “will empower patients to make their own health care decisions such as choosing the site of service that is most convenient.”
The proposed rule would also change the basis on which ASCs receive annual increases, from the current urban Consumer Price Index (CPI-U) to the hospital market basket, which is used for OPPS payments to hospitals. Presumably, this would prevent the two reimbursement rates from diverging again in the future.
More Procedures Proposed at ASCs; Possibly Take-Aways
For CY 2019, CMS is proposing to allow certain Common Procedural Terminology (CPT) codes outside of the surgical code range, but which directly crosswalk to or are clinically similar to procedures within the CPT surgical code range to be included on the ASC Covered Procedures List (CPL).
However, also, “CMS is proposing to review all procedures added within the past three years to reassess recent experience with the procedures in the ASC and to determine whether such procedures should continue to be on the ASC CPL.”
Opioid Proposals, Both Hopeful and Strange
CMS is proposing to pay separately for some non-opioid pain management drugs in ASCs and is seeking feedback on whether it should make extra payments for still other non-opioid treatments for acute or chronic pain under both the OPPS and ASC payment systems.
However, one opioid-related change in the proposed rule is puzzling. The fact sheet on the proposed rule says CMS is “proposing … to eliminate questions regarding pain communication from the hospital patient experience survey” starting in 2022.
On its face, choosing not to ask patients about pain seems like intentionally turning a blind eye to pain as an indicator. We have an inquiry into CMS seeking clarification of the rationale for removing the pain questions from patient post-treatment surveys.
CMS Seeks Views on Patient Price Transparency
CMS is also asking for comment on “whether providers and suppliers can and should be required to inform patients about charges and payment information for healthcare services and out-of-pocket costs, what data elements the public would find most useful, and what other changes are needed to empower patients,” a fact sheet on the proposed rule says.
The rule, which was proposed in late July, would take effect for Calendar Year 2019 if implemented. The period for commenting on it closes Septembr 24.
A fact sheet on the site neutrality plan, is at the CMS website, and the entire proposed site neutrality rule is in the Federal Register online.
