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MedPAC Discusses Tracking Opioid Use in the Hospital Setting, Non-Urgent Care and Upcoding in Hospital Emergency Departments, and Other Topics

October 5, 2018—The Medicare Payment Advisory Commission (MedPAC) met Oct. 4-5 to discuss several issues, including the use of opioids in the hospital setting and analysis regarding the care and coding practices for services delivered in hospital emergency departments (ED). The commission also held a discussion on how to address the primary care physician shortage [see related story].

Opioids in Hospital Settings

The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Community Act (SUPPORT Act, H.R. 6) calls on MedPAC to report to Congress by March 15, 2019, on how Medicare pays for opioids and non-opioid alternatives in inpatient and outpatient hospital settings, the incentives under prospective payment systems for prescribing opioids and non-opioid alternatives, and how the Centers for Medicare and Medicaid (CMS) tracks opioid use.

Committee staff presented its initial research on these items, noting that both the Medicare inpatient prospective payment system (IPPS) and outpatient prospective payment system (OPPS) bundle payments and financially incentivize hospitals to select the lowest-cost goods and services possible. This incentive is balanced with providers’ clinical expertise and the Medicare program’s quality measurement and reporting programs. In regard to monitoring, CMS currently monitors opioid use only through data available in the Part D program; it does not operate tracking programs through Parts A and B. To track opioid use in hospital settings, CMS would need to operationalize program changes, in part because Parts A and B claims data currently do not include information on pain management drugs.

Commissioners provided ideas on how Medicare should track opioid use in the hospital setting. One prominent idea from commissioners was to research whether opioid addition could be measured as a hospital-acquired condition (HAC) through the HAC Reduction Program. Other ideas considered hospital monitoring through state-run prescription drug monitoring programs or through the Food and Drug Administration’s voluntary national Sentinel System.

The commission will discuss the topic again at its January 2019 meeting and will include a chapter on the subject in its March 2019 report to Congress.

Medicare Policy Issues Related to Non-Urgent and Emergency Care

Following two MedPAC recommendations from earlier this year relating to urgent care centers (UCCs) and stand-alone, off-campus emergency departments [see Washington Highlights, April 13], commission staff presented additional analysis and observations related to care delivered at UCCs and coding for services in hospital EDs.

First, staff identified overlap in the most common conditions treated at both UCCs and EDs and that a significant portion of the claims at both are for non-urgent, principal diagnoses like urinary tract infections, bronchitis, sprains, and back pain. Considering the greater cost for services delivered in the ED versus the UCC, commission staff analysis showed that beneficiaries with claims for non-urgent care at EDs appeared more complex on average than the beneficiaries with claims for non-urgent care at UCCs. However, a subset of the non-urgent care claims for beneficiaries treated at EDs may be delivered more appropriately at a UCC, which they said could save the Medicare program an estimated $1 billion to $2 billion annually. Commissioners agreed a softer approach to addressing non-urgent care provided in EDs should consider patient education campaigns, greater availability of primary care services, and evaluating how commercial payers have implemented solutions.

The second discussion focused on the observation that hospital coding of ED visits has shifted in the last ten years to an increase of Level 4 and 5 visits and a decrease of Level 1 and 2 visits. Staff analysis found it unlikely that the shift was caused by patient severity changes or by the growth in UCC visits alone, suggesting upcoding may have occurred. Commissioners discussed and ultimately opposed consideration of collapsing codes for ED visits and instead would like to look into implementing national guidelines for coding.

Other topics covered included a discussion about managing prescription opioid use in Medicare Part D, evaluating Medicare payment policies for advanced practice registered nurses and physician assistants, assessing Medicare payment for services provided in inpatient psychiatric facilities, and episode-based payments and outcome measures under a unified prospective payment system for post-acute care.

Contact:

Andrew Amari
Hospital Policy and Regulatory Specialist
Telephone: 202-828-0554
Email: aamari@aamc.org

Phoebe Ramsey, J.D.
Sr. Regulatory Analyst - Quality & Payment Policy
Telephone: 202-448-6636
Email: pramsey@aamc.org

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Washington Highlights, a weekly electronic newsletter, features brief updates on the latest legislative and regulatory activities affecting medical schools and teaching hospitals.


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For More Information

Jason Kleinman
Sr. Legislative Analyst, Govt. Relations
Telephone: 202-903-0806
Email: jkleinman@aamc.org