By Bill Prentice
ASCA is ringing in the New Year with optimism that changes in the Centers for Medicare & Medicaid Services’ (CMS) final 2024 ASC and hospital outpatient department (HOPD) payment rule will lead to increased Medicare beneficiary access to surgery centers. To keep the momentum going, we need all members of the ASC community to join us as we continue to advocate for surgery centers and their patients.
What Happened?
CMS finalized many of the policies contained in the proposed rule circulated last July and several others the proposed rule did not address but for which ASCA had been long advocating. Among the latter were the addition of 11 significant procedures to Medicare’s ASC Covered Procedures List (ASC CPL), including total shoulder arthroplasty, total ankle replacement and a thyroid procedure.
Combined with 26 dental codes that CMS included in its proposed rule, the agency’s decision means that, as of January 1, 2024, ASCs can now provide a total of 37 procedures to Medicare beneficiaries that they couldn’t offer these patients before. (You can learn more about all the procedures added and the other changes the rule puts in place online in ASC Focus magazine’s Digital Debut column “ASCA Advocacy Achieves Victories in 2024 Final Payment Rule.” ASCA members can learn more about the impact of the new rule on their facility under the Medicare Resources tab on ASCA’s home page.
Physicians have been performing total shoulder and total ankle procedures on an outpatient basis for private pay patients and seeing outstanding results in HOPDs and ASCs for many years. Multiple studies demonstrate the high level of patient satisfaction and low level of complications physicians see when they perform these procedures in the outpatient setting, especially in surgery centers.
CMS Decision Supports Patients, Providers, Medicare and Others
For patients, CMS’ decision to add these new codes will mean improved access to care and to the many benefits ASCs offer, including high-quality outcomes, a patient friendly experience and often significant cost savings. For the Medicare program and taxpayers, as these procedures continue to migrate from the more costly inpatient setting into surgery centers, CMS’ decision could quickly translate into millions of dollars of savings each year in addition to the billions of dollars ASCs already provide to Medicare annually.
Physicians, too, will benefit. By allowing physicians to perform these procedures on appropriate Medicare beneficiaries in surgery centers, surgeons will be able to bring more of their patients to the site of service they prefer – the ASC, providing greater control over scheduling.
Since private insurance providers often build their policies on Medicare’s, private insurers and their beneficiaries can also expect to benefit from expanded access to these procedures in surgery centers and the high-quality, lower-cost care provided there.
Other Good News
The new codes added to the ASC-CPL aren’t the only piece of good news for surgery centers in CMS’ final rule. CMS also moved total shoulder surgeries into a different Ambulatory Payment Classification (APC) category with a higher reimbursement, ensuring that more ASCs can afford to provide these procedures to Medicare patients. It also finalized its plan to extend the use of the hospital market basket as the inflation update factor for ASCs for an additional two years. ASCA advocated for that extension, seeing it as an important step toward more closely aligning ASC and HOPD payment policy and eliminating the growing disparity between ASC and HOPD payments that has occurred in the past.
Two changes CMS adopted to its quality reporting program also reflected requests from ASCA and its members. First, CMS decided not to finalize its proposal to readopt ASC-7: ASC Facility Volume Data on Selected ASC Surgical Procedures, a quality measure ASCA expressed concerns about in comments it submitted on the proposed rule. CMS also agreed to push back mandatory reporting for a year on a new measure it introduced in the final rule: ASC-21: Risk-Standardized Patient Reported Outcome-Based Performance Measure (PRO-PM) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) in the ASC Setting (THA/TKA PRO-PM).
Next Up
Although surgery centers are celebrating several of the decisions CMS made in its 2024 final rule, now is not the time to let up.
As many of you reading this column already know, significant changes in CMS’ payment policies don’t come easily or happen overnight. ASCA has spent years working with our members compiling data, meeting with CMS officials, talking with members of Congress and working with the media to build support for expanding Medicare’s ASC-CPL to include total shoulders, total ankles and many of the other procedures the agency decided to add in 2024. ASCA has also been working with CMS over many years to try to make its ASC quality reporting program meaningful, useful to patients and less burdensome for surgery centers.
Meanwhile, conversations and hearings in several key health care committees in Congress this past year have focused on issues that could negatively impact surgery centers. Some of the topics raised include cost reporting, site-neutral payments, the elimination of facility fees and price transparency. The ASC community, with leadership from ASCA and our members, needs to be involved in these conversations to make certain that any policy recommendations that result take the needs and specialized interests of surgery centers into account.
If you work in a surgery center, one of the most important things you can do to be involved in ASC advocacy is to make sure your facility is a member of ASCA. Please get in touch with ASCA Government Affairs Manager Maia Kunkel at mkunkel@ascassociation.org to find out about other ways you can participate.
