August 1, 2018

Expansion of the site-neutral payment policy for outpatient services, additional cuts to the 340B drug discount program and separate payments for non-opioid pain medications in ambulatory surgery center (ASC) settings are among the highlights of the Centers for Medicare and Medicaid Services’ (CMS’s) Outpatient Prospective Payment System (OPPS) proposed rule for 2019.

Comments on the proposed rule must be submitted by September 24, 2018.  Publication of the final rule is expected in early November.

One of the most significant proposals calls for extending the site-neutral payment policy mandated by the Bipartisan Budget Act of 2015 (BBA).  That policy reduced payments to off-campus provider-based hospital departments for outpatient services to the amounts paid to physician clinics (except for sites that were already billing under the hospital outpatient rate when the BBA went into effect, as well as emergency services provided by off-campus emergency departments).

In 2019, CMS wants to expand the site-neutrality policy to reduce payments for certain services to these initially-exempted sites as well.  The goal, according to the agency, is to temper the impact of the shift among providers away from physician offices to costlier hospital outpatient settings in the delivery of many services.  The proposal would save approximately $760 million.  A portion of those savings would be passed on to patients in the form of reduced cost-sharing, according to CMS.

In addition, CMS proposes extending reimbursement cuts for outpatient drugs under the 340B program to the off-campus hospital departments that have already experienced payment reductions under the site neutrality policy.  In 2018, CMS finalized a policy to pay for outpatient drugs purchased by hospitals under the 340B program at the average sales price (ASP) minus 22.5 percent—considerably less than the ASP plus six percent that is typical under the payment system.  Those 340B reductions did not apply to these off-campus departments; however, now, CMS calls for a reversal of that policy, with children’s hospitals, some cancer hospitals and some rural hospitals remaining exempt from the reductions.

CMS also proposes removing three measures regarding pain communication from the patient experience questionnaires of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey.  The agency previously removed questions regarding pain management from the questionnaires, but notes that the remaining pain communication questions may continue to pressure physicians to prescribe opioids in order to avoid negative reports from patients that they disregarded their needs and preferences.

The agency also proposes a new separate payment for non-opioid pain medications used in nerve blocks for postoperative pain, citing support for the goals and recommendations of the President’s Opioid Commission.  CMS invites additional feedback on other non-opioid medications for acute and chronic pain that may help decrease opioid prescribing and substance use disorder and that may also warrant separate payment under the OPPS and ASC systems.

CMS also proposes to remove 10 measures from the Hospital Outpatient Quality Reporting (OQR) Program and eight measures from the Ambulatory Surgical Center Quality Reporting (ASCQR) Program that are redundant, “topped out,” or whose costs of reporting outweigh their benefits.

The complete 2019 proposed rule is available here.