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AAMC Raises Concerns About Major OPPS Proposals

September 13, 2013—AAMC President and CEO Darrell G. Kirch, M.D., submitted Sept. 6 comments on the calendar year (CY) 2014 hospital outpatient prospective payment system (OPPS) proposed rule. CMS will implement finalized changes to the OPPS by Jan. 1, 2014.

The AAMC comment letter  expresses concerns with CMS’s proposals to implement “major changes to the way hospitals are currently reimbursed for their outpatient services” without providing accurate data or enough information to assess the individual impact of each proposal.  The association’s comment letter explains that the AAMC cannot support these proposals, because the agency calculated payment rates using faulty data and only made partial corrections to this data nine days before the original comment period closed, denying the public a meaningful opportunity to comment as required by law.

One day before the comment period deadline, CMS issued a correction notice and limited comment period extension, providing an additional ten days to comment on technical data corrections CMS released on Aug. 28.  This limited extension still did not provide stakeholders a meaningful opportunity to comment, because not all data errors were addressed, and because it remains impossible to determine the unique impact of several complex and interconnected proposals.

The association opposes CMS’s proposal to eliminate the five levels of evaluation and management (E/M) visit codes and replace them with a single outpatient hospital visit code that would be paid under a newly created ambulatory payment classification (APC).  While the association is not opposed to the concept of reducing the number of E/M clinic visit codes to fewer than five, the letter explains that AAMC has no choice but to oppose this proposal because of the significant data errors in the rule, and because it is impossible to understand the interaction between this policy and proposed packaging policies.

The AAMC also strongly opposes CMS’s proposal to collapse all five levels of Type A Emergency Department (ED) visit codes into a single code and all five levels of Type B ED visit codes into a single code, because this proposal would have a disproportionately negative impact on hospitals with trauma centers that treat higher acuity patients.

While the AAMC is generally supportive of CMS’s attempt to improve payment accuracy through increased bundling of services, the association could not support CMS’s proposal to expand packaging to seven additional categories of items and services due to substantial concerns with the agency’s methodology in determining payment rates, and the interactive effect with several other policy changes.  Concerns related to data inaccuracies, unknowns about the combined effect with other policies, and the inability to determine the individual impact also led the AAMC to oppose CMS’s proposal to create 29 comprehensive APCs to replace the existing device-dependent APCs.

Among other OPPS payment proposals, CMS proposed to collect data on the frequency, type, and payment for services furnished in off-campus provider based departments.  Given the differing opinions surrounding how this data should be collected, the AAMC urged CMS to convene a group of CMS staff and hospital stakeholders to identify the most accurate and least burdensome way of collecting this data.  Additionally, the association encouraged CMS to engage the hospital and physician stakeholder community to help put any such data in context. 

In response to CMS’s proposal to use new cost-to-charge ratios (CCRs) for cardiac catheterization, CT scan, and MRI for the first time in CY 2014 to calculate relative payment rates, the AAMC urged CMS not to finalize the proposal to use the two new radiology CCRs.  Capital costs for CT and MRI are not applied consistently, which could distort the relative value of advanced imaging services.

The AAMC supported CMS’s proposals to continue to pay separately payable drugs and biologicals at a rate of Average Sales Price (ASP) plus six percent, to continue the policy of providing the cancer hospital payment adjustment, and to clarify supervision requirements for outpatient observation services.

For the outpatient quality reporting (OQR) program, CMS proposed two cataract surgery measures, two endoscopy surveillance measures, and a measure assessing health care personnel’s influenza vaccination status starting CY 2016. The AAMC expressed serious concerns with the cataract surgery and endoscopy measures for use in the OQR program, because these measures were designed for clinician offices and have not been properly tested for use in the outpatient setting.

While the AAMC supports greater alignment between the physician and hospital settings, the association believes that CMS must select measures that recognize there are differences in how facilities and physicians collect information, report quality measures, and interact with patients.   Additionally, the AAMC stated that all measures should be fully endorsed by the National Quality Forum (NQF) and reviewed by the Measure Applications Partnership (MAP) before being considered for the OQR program. 

Last, the AAMC urged CMS to remove seven measures from being publicly reported, because these measures were no longer NQF-endorsed and had been recommended for removal from the OQR program by the MAP.  CMS also proposed the same cataract surgery and endoscopy measures for the Ambulatory Surgery Center Quality Reporting (ASCQR) program; the AAMC reiterated that measures should be specified correctly and fully endorsed by the NQF before being proposed for a quality reporting program.


Scott Wetzel, M.P.P.
Lead, Quality Reporting
Telephone: 202-828-0495



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