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  • Washington Highlights

    CMS Releases CY 2019 OPPS Final Rule

    Mary Mullaney, Director, Hospital Payment Policies
    Phoebe Ramsey, Director, Physician Payment & Quality
    Andrew Amari, Hospital Policy and Regulatory Specialist

    The Centers for Medicare and Medicaid Services (CMS) Nov. 2 released the calendar year (CY) 2019 Medicare Outpatient Prospective Payment System (OPPS) final rule. Among other policy issues, the final rule addresses site-neutral payment reductions for off-campus outpatient clinics, expands payment reductions for certain drugs acquired under the 340B program, and makes changes to the Medicare hospital quality reporting program. The AAMC previously submitted comments on the proposed rule [see Washington Highlights, Sept. 28]. 

    CMS is finalizing its site neutral payment policy that will decrease reimbursement for clinic visits (HCPCS code G0463) furnished at off-campus provider-based departments (PBDs) paid under the OPPS. As part of a two-year phase-in, beginning Jan. 1, 2019, clinic visits provided at these sites will be paid at 70% of the OPPS full payment rate. Beginning Jan. 1, 2020, reimbursements will be reduced further to 40% of the OPPS full payment rate. CMS estimates that the payment cuts’ implementation will save $380 million in CY 2019. The proposal will not be implemented in a budget neutral manner.

    CMS also finalized its proposal to expand payment reductions for drugs acquired under the 340B Drug Pricing Program and furnished in nonexcepted off-campus PBDs. CMS will pay the average sales price minus 22.5% for 340B-acquired drugs that are furnished by nonexcepted off-campus PBDs beginning Jan. 1, 2019.Additionally, drugs acquired under the 340B program and reimbursed at the wholesale acquisition cost (WAC) will be paid at WAC minus 22.5%.

    The final rule included a 1.35% increase to the OPPS payment for CY 2019. Reimbursements for drugs with WAC pricing will be reduced from WAC plus 6% to WAC plus 3%. As recommended in the AAMC’s comment letter, CMS did not finalize its proposal to define clinical families of services.

    Additionally, the final rule included changes to the hospital quality reporting program. CMS updated and refined the requirements for quality reporting and removed quality measures that are duplicative, “topped out,” or the costs to report are greater than the benefits of reporting. The agency also removed eight of the 10 quality measures that had been proposed for removal from the hospital outpatient quality reporting program. CMS did not finalize the removal of the Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients (OP-29) and the Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery (OP-31) measures.

    The rule modified the Hospital Consumer Assessment of Healthcare Providers and Systems survey measure under the hospital inpatient quality reporting program by removing the “communication about pain” questions effective with fiscal year 2022 payment determination. CMS will not report publicly the three revised “communication about pain” questions in the interim when they remain included in the survey.

    A fact sheet on the final rule is available on the CMS website.