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CENTERS FOR MEDICARE &
MEDICAID SERVICES (CMS)
Special
Edition – Wednesday, December 2, 2020
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Trump Administration Finalizes Policies to Give Medicare
Beneficiaries More Choices around Surgery
Outpatient Prospective Payment System and
Ambulatory Surgical Center final rule empowers beneficiary choices and
unleashes competition to lower costs and improve innovation On December 2, CMS finalized policy changes
that will give Medicare patients and their doctors greater choices to get
care at a lower cost in an outpatient setting. The Outpatient Prospective
Payment System (OPPS) and Ambulatory Surgical Center (ASC) final rules will
increase value for Medicare beneficiaries and reflect the agency’s efforts to
transform the health care delivery system through competition and innovation.
These changes implement the Trump Administration’s Executive Order on
Protecting and Improving Medicare for Our Nation’s Seniors, and will take
effect on January 1, 2021. “President Trump’s term in office has been
marked by an unrelenting drive to level the playing field and boost
competition at every turn,” said CMS Administrator Seema Verma. “Today’s rule
is no different. It allows doctors and patients to make decisions about the
most appropriate site of care, based on what makes the most sense for the
course of treatment and the patient without micromanagement from Washington.” In this final rule, CMS will begin
eliminating the Inpatient Only (IPO) list of 1,700 procedures for which
Medicare will only pay when performed in the hospital inpatient setting over
a three-year transitional period, beginning with some 300 primarily
musculoskeletal-related services. The IPO list will be completely phased out
by CY 2024. This will make these procedures eligible to be paid by Medicare
when furnished in the hospital outpatient setting when outpatient care is
appropriate, as well as continuing to be payable when furnished in the
hospital inpatient setting when inpatient care is appropriate, as determined
by the physician. In the short term, as hospitals face surges in patients
with complications from COVID-19, being able to provide treatment in outpatient
settings will allow non-COVID-19 patients to get the care they need. In addition to putting decisions on the best
site of care in the hands of physicians, allowing more procedures to be done
in an outpatient setting also provides for lower-cost options that benefit
the patient. For example, thromboendarterectomy (HCPCS
code 35372) is a surgical procedure that removes chronic blood clots from the
arteries in the lung. If this procedure is performed in an inpatient setting,
a patient who has not had other health care expenses that year would have a
deductible of about $1500. In contrast, the copayment for this procedure for
the same patient in the outpatient setting would be about $1150. Patient
safety and quality of care will be safeguarded by the doctor’s assessment of
the risk of a procedure or service to the individual beneficiary and their
selection of the most appropriate setting of care based on this risk. This is
in addition to state and local licensure requirements, accreditation
requirements, hospital conditions of participation, medical malpractice laws,
and CMS quality and monitoring initiatives and programs. Beginning January 1, 2021, we are adding
eleven procedures to the ASC Covered Procedures List (CPL), including total
hip arthroplasty (CPT 27130), under our standard review process.
Additionally, we are revising the criteria we use to add surgical procedures
to the ASC CPL, providing that certain criteria we used to add surgical
procedures to the ASC CPL in the past will now be factors for physicians to
consider in deciding whether a specific beneficiary should receive a covered
surgical procedure in an ASC. Using our revised criteria, we are adding an
additional 267 surgical procedures to the ASC CPL beginning January 1, 2021.
Finally, we are adopting a notification process for surgical procedures the
public believes can be added to the ASC CPL under the criteria we are
retaining. CMS is announcing that it will continue its
policy of paying for 340B-acquired drugs at average sales price minus 22.5%
after the July 31, 2020, decision of the Court of Appeals for the D.C.
Circuit upholding the current policy. This policy lowers out-of-pocket drug
costs for Medicare beneficiaries by letting them share in the discount that
hospitals receive under the 340B program. Since this policy went into effect
in 2018, Medicare beneficiaries have saved nearly $1 billion on drug costs,
with expected Medicare beneficiary drug cost savings of over $300 million in
CY 2021. As part of the agency’s Patients Over
Paperwork Initiative, which is aimed at reducing burden for health care
providers, CMS is establishing a simple updated methodology to calculate the
Overall Hospital Quality Star Rating (Overall Star Rating). The Overall Star
Rating summarizes a variety of quality measures published on the Medicare.gov
Care Compare tool (the successor to Hospital Compare) for common conditions
that hospitals treat, such as heart attacks or pneumonia. Along with publicly
reported data on Care Compare, the Overall Star Rating helps patients make
better-informed health care decisions. Veterans Health Administration
hospitals will be added to CMS’ Care Compare, which will help veterans
understand hospital quality within the VA system. Overall, these changes will
reduce provider burden, improve the predictability of the star ratings, and
make it easier for patients to compare ratings between similar hospitals. In response to stakeholder feedback about the
current methodology used to calculate the Overall Star Rating, CMS is not
finalizing its proposal to stratify readmission measures under the new
methodology based on dually eligible patients, but will continue to study the
issue to find the best way to convey quality of care for this vulnerable
population. Finally, in order to address the ongoing
public health emergency, CMS is finalizing a new requirement for the nation’s
6,200 hospitals and critical access hospitals to report information about
their inventory of therapeutics to treat COVID-19. This reporting will
provide the information needed to track and accurately allocate therapeutics
to the hospitals that need additional inventory to care for patients and meet
surge needs. For More Information: Like our newsletter? Have
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