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Federal Policy Changes Support Patient Access to ASCs

By William Prentice

When it comes to federal health care policy, 2018 is shaping up to be an incredible year for ASCs. This summer, the U.S. Congress and the Centers for Medicare & Medicaid Services (CMS) advanced several significant policies that affect ASCs and respond to years of advocacy efforts involving ASC professionals from across the country.

In May, Congress set in motion substantial reform of the Veterans Administration (VA) health care system when it passed the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018. The VA MISSION Act will directly impact ASCs that offer care to veterans since a major provision in the legislation requires non-VA provider claims to be reimbursed in 30-45 days. ASCA worked hard to raise awareness on Capitol Hill regarding concerns over significant reimbursement delays after ASCA members reported reimbursement delays of 12 months or more for services provided through the Veterans Choice Program. In addition to the new claims reimbursement process, the VA MISSION Act authorizes local provider agreements with the VA that, according to a U.S. Senate bill summary, will “remove bureaucratic red tape and meet veterans’ needs for care in the community.” ASCA will work with the VA as it implements this new law to ensure veterans’ access to ASCs is improved.

Addressing other longstanding ASC concerns, the U.S. House of Representatives passed the ASC Payment Transparency Act of 2018, which comprises two provisions ASCA has promoted for years. First, the bill would add an ASC representative to CMS’ Advisory Panel on Hospital Outpatient Payment (HOP) – a 15-member panel that helps determine payment policies for hospital outpatient departments (HOPD) and ASCs. Current statute requires all HOP members be employed by a hospital or health system. Second, CMS would be required to disclose, for the first time, the specific criteria it uses to exclude procedures from its ASC covered procedures list.

If the ASC Payment Transparency Act of 2018 becomes law, it will help ASCs, specialty societies and other health care stakeholders engage CMS as it considers future changes to the ASC payment system.

On July 25, CMS published its 2019 Hospital Outpatient Prospective Payment System (OPPS)/ASC Payment System Proposed Rule. Although the final rule isn’t due out until early November, ASCA is pleased that the proposed rule addresses several long-standing priorities for ASCs.

In the preliminary rule, CMS proposes to align update factors for ASCs and HOPDs by moving ASCs to the hospital market basket (HMB). The HMB is already used to update HOPD payments, and if this proposal is finalized, will be used to update ASC payments for at least the next five years.

ASCs use the same staff, services and supplies as HOPDs, so it only makes sense to apply the same inflation rate for our annual updates. ASCs have been asking for this for about a decade.

CMS also proposes to define ASC device-intensive procedures as those procedures with a device offset percentage greater than 30 percent based on the standard OPPS ambulatory payment classification rate-setting methodology. The current threshold is 40 percent. Adoption of this new threshold would allow more procedures to be performed in ASCs.

In another proposal, CMS would revise its definition of “surgery” in the ASC payment system to account for certain “surgery-like” procedures that are assigned codes outside the Current Procedural Terminology (CPT) surgical range. Along with this change, CMS proposes to add 12 cardiac catheterization procedures to the ASC covered procedures list.

For 2019, CMS proposes separate payment for non-opioid pain management drugs that function as a supply during a surgical procedure and when the procedure is performed in an ASC. Currently, Exparel is the only therapy that meets the proposed criteria and will receive separate payment when used in an ASC surgical procedure. Health professionals aware of other drugs that could qualify for these payments are encouraged to contact ASCA.

Finally, there are sweeping changes proposed to the ASC Quality Reporting (ASCQR) Program. Most significantly, CMS proposes to remove a total of eight measures from the ASCQR Program over a two-year period. In most cases, the reason CMS cites for removing the measures is that the data collected to date indicate such high performance on those measures that there is little room for improvement.

ASCA is encouraging CMS to finalize the majority of these proposals as written. Our thanks go out to all the members of the ASC community who have worked for many years to support these policy changes that we are seeing proposed and enacted for the first time.

ASCA is optimistic these new and proposed policies signal a recognition of the value ASCs provide to the program and a desire to ensure ASCs have the support they need to continue to serve Medicare patients. ASCs welcome the opportunity these new policies could provide to contribute in new ways to containing the cost of outpatient surgical care, improving the patient experience and providing the high-quality care our aging population needs.



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