/ en Fri, 15 Aug 2025 03:31:30 -0500 Wed, 16 Jul 25 17:10:18 -0500 /advisory/2025-07-16-cms-issues-hospital-outpatient-ambulatory-surgical-center-proposed-rule-cy-2026 <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) July 15 issued a <a href="https://www.federalregister.gov/public-inspection/2025-13360/medicare-and-medicaid-programs-hospital-outpatient-prospective-payment-and-ambulatory-surgical">proposed rule</a> that would increase Medicare hospital outpatient prospective payment system (OPPS) rates by a net 2.4% in calendar year (CY) 2026 compared to CY 2025. The rule also includes proposals to pay at the site-neutral rate for drug administration services furnished in grandfathered off-campus hospital outpatient departments (HOPDs) and to phase out the inpatient-only (IPO) list. It also would expedite the timeline for repayment for non-drug services and propose conducting a new drug acquisition cost survey. CMS will accept comments on the proposed rule for 60 days following its publication in the Federal Register. </p><div class="panel module-typeC"><div class="panel-heading"><p><strong>KEY HIGHLIGHTS</strong></p><p>CMS’ proposed policies would:</p><ul><li>Increase Medicare hospital OPPS rates by a net 2.4% in CY 2026.</li><li>Pay for drug administration services furnished in grandfathered off-campus HOPDs at the site-neutral rate of 40% of the OPPS and request comment on expanding site-neutral payment to on-campus clinic visits.</li><li>Phase out the IPO list over three years, starting by removing 285 musculoskeletal services in 2026.</li><li>Expedite the timeline for repayment for $7.8 billion for non-drug services through a 2% annual cut to the OPPS conversion factor (CF), concluding by CY 2031.</li><li>Weaken the criteria for excluding services from coverage in ambulatory surgical centers (ASC) covered procedures list (CPL) and add 547 procedures to the ASC CPL.</li><li>Permanently revise the definition of direct supervision for cardiac rehabilitation (CR), intensive cardiac rehabilitation (ICR) and pulmonary rehabilitation (PR) services and diagnostic services furnished to hospital outpatients to include virtual direct supervision.</li><li>Remove three measures on health equity and one on COVID-19 vaccination among healthcare personnel from the Outpatient, ASC and Rural Emergency Hospital (REH) quality reporting programs.</li><li>Adopt a new emergency department (ED) timeliness measure for the Outpatient and REH quality reporting programs and a new patient-reported outcome measure for the ASC program.</li><li>Change the methodology for the Overall Hospital Star Rating to emphasize Safety of Care measures.</li><li>Make several changes to the hospital price transparency requirements, including adding new data elements to the machine-readable file, updating the attestation statement language and changing the enforcement process.</li></ul></div></div><h2>AHA TAKE</h2><p>The AHA is disappointed that CMS proposes an inadequate Medicare outpatient hospital payment update as many hospitals — especially those in rural and underserved communities — operate under challenging financial pressures.</p><p>We oppose the proposal to expand “site-neutral” cuts and eliminate the inpatient-only list, as both policies fail to account for the real and crucial differences between hospital outpatient departments and other sites of care. Studies show hospital outpatient departments are more likely to serve Medicare patients who are sicker, more clinically complex, and more likely to be disabled or living in poorer, rural communities than patients treated in independent physician offices.</p><p>We are also concerned with CMS’ proposal to claw back billions of dollars from hospitals at a far faster rate than originally promised. It is important to remember that this claw back punishes 340B hospitals for the agency’s own mistake in implementing a policy that a unanimous Supreme Court held to be unlawful. Doubling down on that unlawfulness, the proposed recoupment is both illegal and unwise, and it should not be finalized.</p><p>Finally, we are concerned about the proposal to pursue a burdensome acquisition cost survey, especially if the agency’s goal is to drastically reduce Medicare payments to hospitals that serve the nation’s most vulnerable communities.</p><p>We look forward to reviewing these proposals in more detail and participating in the comment process with the agency.</p><p>Highlights of the CY 2026 OPPS/ASC proposed rule follow.</p><h2>CY 2026 OPPS PROPOSED RULE CHANGES</h2><h3>Proposed Payment Update</h3><p>CMS proposes to update OPPS rates by a net 2.4% for CY 2026. This includes a proposed market-basket update of 3.2% and a statutorily required productivity cut of 0.8 percentage points. These payment adjustments, in addition to other proposed changes in the rule, are estimated to result in a net increase in OPPS payments to hospitals of 2.0% compared to CY 2025 payments. For hospitals that do not publicly report quality measure data, CMS would continue to impose the statutory 2.0 percentage point additional reduction in payment, resulting in a 0.4% OPPS update. In addition, the agency notes that under its proposal, payments for services at hospitals subject to the 340B remedy offset will be reduced by 2.0 percentage points.</p><p>CMS estimates that total payments to hospitals (including beneficiary cost sharing and estimated changes in enrollment, utilization and case-mix) would increase by approximately $8.1 billion in CY 2026 compared to CY 2025. </p><p>CMS proposes to increase the conversion factor to $91.747 in CY 2026, as compared to $89.169 in CY 2025. This update reflects several proposed factors: the 2.4% OPPS payment update, the wage index budget neutrality adjustment of 1.0116, the 5% annual cap for individual hospital wage index reductions adjustment of 0.9955, the cancer hospital payment adjustment of 1.0000 and a decrease of 0.22 percentage point for the difference in pass-through spending. CMS proposes to use a reduced conversion factor of $89.958 in the calculation of payments for hospitals that fail to meet the Hospital Outpatient Quality Reporting (OQR) Program.</p><h3>Data Proposed for Use in CY 2026 OPPS/ASC Rate Setting</h3><p>To set proposed OPPS and ASC payment rates, CMS would use the most updated cost reports and claims data available. Therefore, the agency proposes using the CY 2024 claims data and the most updated cost report extract available from the Healthcare Cost Report Information System.</p><h3>Proposed 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 2026, CMS proposes to maintain 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 would 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 proposes to 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><h3>Diagnostic Radiopharmaceuticals Separate Payment</h3><p>In the CY 2025 final rule, CMS established a policy to pay separately for diagnostic radiopharmaceuticals with per-day costs above a threshold of $630 — which was approximately two times the volume-weighted average cost amount then associated with diagnostic radiopharmaceuticals. It also finalized a policy to update the $630 threshold in CY 2026 and subsequent years by the Producer Price Index for Pharmaceutical Preparations.</p><p>Using this methodology, CMS proposes to set the packaging threshold for diagnostic radiopharmaceuticals at $655 per day for CY 2026 and proposes to pay for diagnostic radiopharmaceuticals with a per-day cost above this threshold based on their Mean Unit Cost derived from OPPS claims data.</p><h3>Add-on Payment for Radiopharmaceutical Technetium-99m</h3><p>In CY 2025, CMS finalized for CY 2026 an add-on payment for radiopharmaceuticals produced without the use of Technetium-99m (Tc-99m) derived from non-Highly Enriched Uranium (HEU) sources, replacing it with an add-on payment for radiopharmaceuticals that use Tc-99m derived from domestically produced Molybdenum-99 (Mo-99). For CY 2026, CMS proposes a $10 per-dose amount for this add-on payment. To qualify for this add-on payment, at least 50% of the Mo-99 used in the Tc-99m generator that produces a dose of Tc-99m must be domestically produced for the dose. CMS also proposes to further define domestically produced Mo-99 and to establish a new Healthcare Common Procedure Coding System (HCPCS) C-code C917X to identify Tc-99m from domestically produced non-HEU Mo-99.</p><h3>Proposal to Expedite Recoupment Timeline Under 340B Remedy Rule</h3><p>Beginning in CY 2018 through CY 2022, CMS instituted a policy to reduce payments for certain providers for separately-payable Part B drugs purchased under the 340B Drug Pricing Program from Average Sales Price (ASP) plus 6% to ASP minus 22.5%. Due to budget-neutrality requirements, this nearly 30% payment cut was offset by increasing payments for non-drug services to all hospitals paid under the OPPS by 3.19%. Upon successful litigation led by the AHA, the U.S. Supreme Court unanimously ruled that the agency’s policy was unlawful. The agency subsequently finalized a remedy that would repay 340B hospitals in one-time lump sum payments totaling $10.6 billion, as well as seek recoupment of $7.8 billion in funds from all hospitals for the increased payments received for non-drug services. The intended goal was to undo the unlawful policy and restore all providers to the same position as if the policy had never been in place. The agency had finalized a recoupment strategy that would reduce the OPPS conversion factor by 0.5% annually beginning in CY 2026 until the full $7.8 billion was recouped, which was estimated to occur in CY 2041.</p><p>CMS is now proposing to expedite the timeline for this recoupment by adjusting the reduction in the OPPS conversion factor from 0.5% to 2%. As a result, the agency estimates that it will recoup the entire $7.8 billion by CY 2031, or about six years. The agency’s stated rationale for a shorter recoupment timeline is to minimize the impact of potential changes in non-drug services over time and ensure a more equitable impact on all hospitals. Specifically, CMS states, “…the longer it takes for us to fully recover the $7.8 billion, the less likely that the relative burden on hospitals from the adjustments will match the relevant benefits those hospitals previously received.”</p><p>CMS also noted that it is considering an alternative proposal that would expedite the timeline even further by adjusting the reduction in the OPPS conversion factor to 5% which would result in the full $7.8 billion being recouped in approximately three years.</p><h3>Hospital Drug Acquisition Cost Survey</h3><p>CMS announced a notice of intent to conduct an acquisition cost survey of all hospitals for covered outpatient drugs. This follows an April 18 Executive Order by President Trump (E.O. 14273), the “Lowering Drug Prices by Once Again Putting Americans First,” that directed the Health and Human Services (HHS) Secretary to publish in the Federal Register a plan to conduct a hospital acquisition cost survey for covered outpatient drugs.</p><p>The survey will open starting at the end of CY 2025, and responses will be collected into early CY 2026. Results of the survey will be compiled and used to set payment rates for covered outpatient drugs in the CY 2027 rulemaking. The agency is also considering various approaches to account for hospital non-responses to the survey to meet the statutory requirement of a large enough sample size and statistically significant results for its usability in setting and varying payment rates among hospitals.   </p><h3>Intensive Outpatient and Partial Hospitalization Programs</h3><p>For CY 2026, CMS proposes to maintain the existing rate structures for Intensive Outpatient Program (IOP) and Partial Hospitalization Program (PHP) services as established in previous rulemaking for hospital-based providers only. For Community Mental Health Centers that offer these services, CMS proposes to calculate costs and thus base payment upon 40% of the corresponding hospital-based costs. To calculate cost information, the agency would use CY 2024 claims data and the OPPS data set to identify services eligible for payment under the IOP and PHP benefits.</p><h3>Proposed Cancer Hospital Payment Adjustment</h3><p>CMS proposes to 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 that this weighted average PCR be reduced by 1.0 percentage point. Therefore, for CY 2026, CMS proposes to use a target PCR of 0.87, the same PCR as non-cancer hospitals using the most recently submitted or settled cost report data, to determine the CY 2026 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>Comment Solicitation on Payment Policy for Software as a Service</h3><p>In response to increasing developments in the use of software-based technologies, including artificial intelligence (AI), CMS issues a request for information on alternative and consistent methods of payment for Software as a Service. Specifically, CMS seeks feedback on lessons learned from risk-bearing payment arrangements, sources to accurately capture cost data, and methodology to determine the value of services.</p><h3>Virtual Direct Supervision of CR, ICR and PR Services and Diagnostic Services Furnished to Hospital Outpatients</h3><p>In CY 2025, CMS extended virtual supervision flexibilities for CR, ICR and PR services as well as diagnostic services. Specifically, it allowed direct supervision to be furnished via two-way, audio/visual communication technology (excluding audio-only) for these services.</p><p>For CY 2026, CMS proposes to permanently revise the definition of direct supervision to make permanent the availability of virtual direct supervision of CR, ICR, PR services and diagnostic services via audio-video real-time communications technology (excluding audio-only). This would exclude diagnostic services that have a global surgery indicator of 010 or 090.                                                              </p><h3>Quality Reporting Programs</h3><p>For the Outpatient, ASC and Rural Emergency Hospital (REH) Quality Reporting Programs (QRPs), CMS proposes to remove, beginning with the CY 2025 reporting period, three measures related to health equity that were adopted in previous rulemaking: Hospital/Facility Commitment to Health Equity, Screening for Social Drivers of Health, and Screen Positive Rate for Social Drivers of Health. CMS also proposes to remove the COVID-19 Vaccination Coverage Among Healthcare Personnel measure from all three programs beginning with the CY 2024 reporting period. If finalized, hospitals and ASCs that do not report CY 2025 data for the health equity measures and CY 2024 data for the COVID-19 vaccination measure would not be considered non-compliant. Also, for all three programs, CMS proposes to include extensions of time as a form of relief under the Extraordinary Circumstances Exception policy and to further clarify the policy.</p><p>For the Outpatient QRP, CMS proposes adopting a new electronic clinical quality measure (eCQM), Emergency Care Access and Timeliness, beginning with voluntary reporting for the CY 2027 reporting period, followed by mandatory reporting beginning with the CY 2028 reporting period. Accordingly, the agency would remove the Median Time from ED Arrival to ED Departure for Discharged ED Patients measure as well as the Left Without Being Seen measure. Finally, CMS proposes extending mandatory reporting for the Excessive Radiation eCQM through CY 2027.</p><p>The agency also proposes adopting the Emergency Care Access and Timeliness measure for the REH QRP beginning with the CY 2027 reporting period; if finalized, REHs would have the option of reporting this new measure or the current Median Time for Discharged ED Patients measure. In this rule, CMS also proposes eCQM reporting and submission policies and requirements for the REHQR.</p><p>For the ASC QRP, CMS proposes to adopt a patient-reported outcome measure on Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery. If finalized, ASCs could voluntarily report the measure in CYs 2027 and 2028, with mandatory reporting beginning in CY 2029.</p><p>Finally, CMS proposes a two-phase change to the methodology for calculating the Overall Hospital Star Rating to emphasize hospital performance in the Safety of Care measure group. For the 2026 ratings, CMS would implement a cap at four stars for hospitals in the lowest-performing quartile in this measure group and then replace the cap starting in 2027 with a blanket one-star reduction for hospitals in that quartile.</p><h3>Proposed Changes to the Inpatient-only List</h3><p>Currently, there are 1,731 procedures/services included on the IPO list. For CY 2026, CMS proposes to phase out the IPO list over three years. This would begin in CY 2026 with the removal of 285 mostly musculoskeletal type services, but also includes 16 non-musculoskeletal services (cardiovascular, lymphatic, digestive, gynecological and endovascular),  and completing the elimination of the IPO list by Jan. 1, 2029. With this proposal, CMS further proposes to establish a 7-level Musculoskeletal Procedures APC series, allowing for the assignment of musculoskeletal procedures removed from the IPO list to an APC with an applicable range of estimated costs. Given the proposal to eliminate the IPO list in its entirety over three years, the agency further proposes to eliminate the criteria used to determine whether procedures should be removed from the IPO list.</p><h3>Two-midnight Rule Medical Review Activities Exemptions</h3><p>For CY 2026, CMS proposes to continue the existing policy that exempts procedures removed from the IPO list under the OPPS from certain medical review activities related to the two-midnight policy. Per this policy, procedures removed from the IPO list are exempted from site-of service claim denials, Beneficiary and Family-Centered Care Quality Improvement Organization referrals to Recovery Audit Contractor (RAC) for persistent noncompliance with the two-midnight rule, and RAC reviews for “patient status” (i.e. site-of-service) until claims data demonstrates that the procedures are more commonly billed in the outpatient setting than the inpatient setting.</p><h3>Access to Non-opioid Treatments for Pain Relief</h3><p>CMS proposes continuing its current policies to provide temporary additional payments for certain non-opioid treatments for pain relief in the HOPD and ASC settings from Jan. 1, 2025, through Dec. 31, 2027, consistent with statute.</p><p>CMS proposes that five drugs and six devices would qualify as non-opioid treatments for pain relief, and that these products be paid separately in both the HOPD and ASC settings, starting in CY 2026. CMS requests comments and supporting documentation from interested parties on additional products that may qualify for separate payment under this provision for CY 2026.</p><h3>Payment for Skin Substitute Products under the OPPS</h3><p>CMS proposes to pay separately for certain groups of skin substitute products as supplies when they are used during a covered application procedure paid under the Physician Fee Schedule in the non-facility setting or under the OPPS. This proposal includes grouping skin substitutes that are not drugs or biologicals using three Food and Drug Administration (FDA) regulatory categories (PMAs, 510(k)s, and 361 HCT/Ps) to set payment rates. To accomplish this categorization and incorporation into OPPS payment policy, CMS proposes to create three new APCs for HCPCS codes describing skin substitute products organized by clinical and resource similarity and by their FDA regulatory pathway. The proposed APCs include APC 6000 (PMA Skin Substitute Products), APC 6001 (510(k) Skin Substitute Products), and APC 6002 (361 HCT/P Skin Substitute Products) with an initial payment rate of $125.38 for each of the new proposed APCs.</p><h2>CY 2025 ASC PROPOSED 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. In light of the impact of the COVID-19 public health emergency on health care utilization, the agency extended this policy through CYs 2024 and 2025. In this proposed rule, the agency proposes extending the utilization of the hospital market basket update as the update factor for the ASC payment system for one additional year, through CY 2026. As such, CMS proposes to increase payment rates by 2.4% for ASCs that meet the quality reporting requirements under the ASC QRP.</p><h3>Proposed Changes to the List of ASC-covered Surgical Procedures</h3><p>CMS proposes revising the regulatory criteria used to evaluate potential additions to the ASC-covered procedures list (CPL). This would include modifying the general standard criteria and eliminating five of the general exclusion criteria, and instead moving them into a new section as nonbinding physician considerations for patient safety.</p><p>Utilizing these revised patient safety criteria, CMS proposes adding, beginning in CY 2026, 276 procedure codes (spanning the musculoskeletal, respiratory, cardiovascular, digestive, genitourinary, endocrine and nervous systems) to the ASC CPL based on the revised criteria and adding an additional 271 procedure codes to the ASC CPL that are proposed for removal from the IPO list for CY 2026.</p><h2>OTHER PROPOSALS</h2><h3>Method to Control “Unnecessary Increases in the Volume of Outpatient Services” Furnished in Grandfathered Off-Campus Provider-Based Departments</h3><p>In the CY 2019 OPPS/ASC final rule, CMS applied a previously unused authority in the Social Security Act to develop a “method to control for unnecessary increases in the volume of outpatient services” by imposing a site-neutral payment reduction on clinic visit services furnished in off-campus provider-based departments (PBDs) that had previously been protected from site-neutral provisions under the Bipartisan Budget Act of 2015. The “physician-equivalent” rate applied to grandfathered clinic visit services was ultimately finalized to be 40% of the OPPS payment rate.</p><p>For CY 2026, CMS proposes to expand this authority to impose a site-neutral payment reduction to drug administration procedures furnished in grandfathered off-campus PBDs. The drug administration ambulatory payment classifications (APCs) to which this policy would apply are APCs 5691, 5692, 5693 and 5694. There are currently 61 HCPCS codes describing various drug administration procedures that map to the four drug administration APCs. Once again, the site-neutral payment rate proposed by CMS would be 40% of the OPPS payment rate. The agency proposes to exempt rural sole community hospitals from this site-neutral payment cut for drug administration services.</p><p>As it did in CY 2019, CMS again proposes to implement this payment reduction in a non-budget-neutral manner. For CY 2026, the agency estimates savings of $280 million, with $210 million of the savings accruing to Medicare and $70 million in reduced beneficiary coinsurance.</p><p>In addition, CMS is seeking input on how to create a systematic process to identify other services to which site-neutral payment reductions should be applied to control for “unnecessary increases in the volume of services.” The agency is also requesting information on expanding its volume control method to on-campus clinic visits, which were previously exempted from the CY 2019 site-neutral clinic visit payment policy.</p><h3>Hospital Price Transparency Updates</h3><p>CMS proposes several changes to the hospital price transparency requirements. First, CMS proposes requiring several new data elements in instances when payer-specific negotiated charges are based on a percentage or algorithm. The new data elements are:</p><ul><li>Tenth percentile allowed amount.</li><li>Median allowed amount.</li><li>Ninetieth percentile allowed amount.</li><li>Count of all allowed amounts (excluding zero-dollar claims).</li></ul><p>CMS proposes requiring a specific methodology, including a set lookback period, and the use of electronic data interchange 835 electronic remittance advice transaction data to calculate these values. These values would replace the “estimated allowed amount” value that was added in the final CY 2024 OPPS/ASC rule.</p><p>CMS proposes requiring two new data elements for all hospital machine-readable files:</p><ul><li>The name of the hospital chief executive officer, president or senior official who is responsible for overseeing the machine-readable file creation and attesting to the file’s completeness and accuracy.</li><li>The hospital’s National Provider Identifier(s).</li></ul><p>CMS also proposes updating the required affirmation statement that hospitals must attest to in their machine-readable files. The new attestation would state, “The hospital has included all applicable standard charge information in accordance with the requirements of § 180.50, and the information encoded is true, accurate, and complete as of the date in the file. The hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.”</p><p>Finally, CMS proposes to reduce the civil monetary penalty amount by 35% in instances when hospitals admit to hospital price transparency violations and waive their right to an administrative law judge hearing.</p><p>If finalized, the new data elements and attestation requirements would go into effect on Jan. 1, 2026.</p><p><strong>Request for Information on Adjusting Payment under the OPPS for Services Predominately Performed in the ASC or Physician Office Settings</strong></p><p>For CY 2026, CMS is requesting information for future rulemaking to develop a systematic process for identifying additional ambulatory services at high risk of “shifting to the hospital setting based on financial incentives rather than medical necessity,” to which it should apply a site-neutral payment policy.</p><h2>FURTHER QUESTIONS</h2><p>CMS will accept comments on the proposed rule for 60 days following publication in the Federal Register. The final rule will be published around Nov. 1, and the policies and payment rates will take effect Jan. 1, 2026.</p><p>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"><a href="/system/files/media/file/2025/07/cms-issues-hospital-outpatient-ambulatory-surgical-center-proposed-rule-for-cy-2026-advisory-7-16-2025.pdf" target="_blank" title="Click here to download the Regulatory Advisory: CMS Issues Hospital Outpatient, Ambulatory Surgical Center Proposed Rule for CY 2026 PDF."><img src="/sites/default/files/2025-07/cover-cms-issues-hospital-outpatient-ambulatory-surgical-center-proposed-rule-for-cy-2026-advisory-7-16-2025-f.png" data-entity-uuid data-entity-type="file" alt="Regulatory Advisory: CMS Issues Hospital Outpatient, Ambulatory Surgical Center Proposed Rule for CY 2026" width="NaN" height="NaN"></a></div></div></div> Wed, 16 Jul 2025 17:10:18 -0500 Ambulatory and Outpatient Care /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 /advisory/2024-11-21-hospital-outpatient-ambulatory-surgical-center-final-rule-cy-2025 <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 /special-bulletin/2024-11-04-special-bulletin-cms-outpatient-pps-and-asc-final-rule-cy-2025 <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 /advisory/2024-07-23-hospital-outpatient-ambulatory-surgical-center-proposed-rule-cy-2025 <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 /advisory/2023-11-17-hospital-outpatient-ambulatory-surgical-center-final-rule-cy-2024 <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