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  • Washington Highlights

    CMS Releases CY 2019 OPPS Proposed Rule and Request for Information

    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) July 25 released the calendar year (CY) 2019 Outpatient Prospective Payment System (OPPS) proposed rule, which seeks public comment on multiple policy changes significant to academic medicine, in particular two proposals to reduce substantially Medicare payment rates for services in hospitals’ offsite outpatient departments.

    CMS proposes to expand the agency’s payment reductions for drugs purchased under the 340B Drug Pricing Program implemented last January 1. If this proposal were implemented, CMS would pay the average sales price (ASP) minus 22.5 percent for 340B-acquired drugs that are furnished by non-excepted off-campus provider-based departments.

    CMS also proposes to apply the Physician Fee Schedule (PFS)-equivalent payment rate for clinic visits provided at an off-campus provider-based department (PBD) in place of the current OPPS rate to control for “unnecessary increases in utilization of outpatient services.” CMS estimates Medicare savings to be $760 million for 2019. Additionally, CMS is proposing to pay for services for new clinical families of services that are specifically furnished at off-campus provider-based departments under the PFS, instead of the OPPS.

    AAMC President and CEO Darrell G. Kirch, MD, issued a July 25 statement opposing these proposals. He stated, “CMS should rescind the 340B policy and not finalize the cuts to off-campus outpatient department clinic visits. Otherwise, these misguided and unjustifiable policies will harm teaching hospitals and the patients and communities they serve.”

    The AAMC is still reviewing the proposed rule; below are descriptions of other major policy proposals included in the rule.

    Reimbursement Proposals

    • Increase OPPS payment rates by 1.25 percent.
    • Pay for services under the PFS, instead of OPPS, for new clinical families of services that are specifically furnished at off-campus provider-based departments.
    • Pay separately at ASP plus 6 percent for non-opioid pain management drugs that function as a supply when used in covered surgical procedure performed in an ambulatory surgical center (ASC). CMS is also soliciting feedback on whether other non-opioid alternatives for acute and chronic pain are shown to decrease opioid prescriptions and addiction that may warrant separate payment under the OPPS and ASC payment systems.

    Quality Proposals

    • Update and refine the requirements for quality reporting and remove quality measures that are duplicative, “topped out,” or the costs to report are greater than the benefits in reporting
    • Remove 10 quality measures from the Hospital Outpatient Quality Reporting (OQR) Program and 8 measures from the Ambulatory Surgical Center Quality Reporting (ASCQR) Program
    • Modify the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey measure under the Hospital Inpatient Quality Reporting (IQR) Program by removing the Communication about Pain questions.

    Requests for Information

    • Require providers to inform patients of the out-of-network costs they may incur.
    • Develop solutions to better achieve interoperability or the sharing of healthcare data between providers, specifically on the possibility of revising Conditions of Participation (CoPs) related to interoperability to increase electronic sharing of data by providers.
    • Leverage the Competitive Acquisition Program (CAP) under Part B to reduce drug and biologic expenditures while maintaining access or improve quality of care.

    Comments on the proposed rule are due September 24, 2018. The AAMC will be providing members with additional information and will be seeking feedback as the association prepares its comment letter. Information about the OPPS webinars will be forthcoming.