Providers want CMS to proceed cautiously in its attempt to phase out paying for some services only in inpatient settings, according to comments on CMS' proposed outpatient payment rule due Monday.
CMS in August proposed to phase out the inpatient-only list over three years. The agency claimed the list wasn't necessary, saying physicians should use their knowledge, judgment and assess patient needs to determine the right care site. Under the proposal, Medicare would start paying for nearly 270 musculoskeletal-related services delivered in outpatient departments in 2021.
Providers asked CMS to stop or slow the payment shift, citing safety and quality concerns. The American Hospital Association and the American Medical Association said CMS should continue its current policy of removing services from the list on a case-by-case basis. AHA said, "it would be premature and myopic" to end the inpatient-only list because many of the services are high-risk. Independent experts warned CMS was too optimistic about how providers decide where to deliver care.
"There is no guarantee that physicians will always select the most appropriate setting. Factors other than clinical knowledge and judgment, such as financial considerations, can affect these decisions," the Medicare Payment Advisory Commission said.
Hospitals worried the changes would hurt their finances by shifting more care from higher-cost inpatient settings to lower-cost outpatient settings.
"It would be unconscionable to finalize this policy when the financial impact of the COVID-19 public health emergency … has already been devastating for hospitals — and there still remains an uncertain future as to the path of the pandemic," AHA said.
Physicians worried it would require clinicians to do more paperwork.
"Hospitals, as well as private payors, often influence determinations regarding the appropriate site-of-service for procedures and services. The burden then falls on the physician to convince a hospital or payor that a particular patient should receive a given procedure in an inpatient setting due to patient safety concerns," AMA said.
The American Association of Orthopaedic Surgeons said it was concerned the two-midnight rule would stay in effect during the phase-out "in light of the ongoing confusion surrounding the (rule) and the subsequent decisions by hospitals and private payers to require that some procedures … default to the outpatient setting."
Several commenters recommended CMS phase out the inpatient-only list over a longer period and study each change's effects before removing more services from the list. They also said CMS should give stakeholders more opportunities to weigh-in on any proposed changes.
Hospital groups had mixed opinions about CMS' proposed changes to how it decides which surgical procedures to reimburse under the ambulatory surgical center payment system. The agency had asked providers to comment on whether it should use a nomination process to decide which procedures to cover or change the regulations it currently uses to make those determinations. Some hospital groups opposed making any changes, while others supported a nomination process.
"The nomination alternative should include a requirement that any individual or group that nominates a procedure or procedures for inclusion in the ASC (covered procedures list) should not be involved in the process of approving the nominated procedure or procedures to the list," MedPAC said.
Hospital groups were especially concerned about CMS' proposal to end the agency's current exclusion criteria, which bans Medicare from reimbursing ASCs for procedures with high-risk characteristics, including those that generally result in extensive blood loss or are life-threatening.
The Ambulatory Surgery Center Association supported all of CMS' proposed changes to the ASC covered procedures list, saying it "encourages further policy changes to ensure that the appropriate site of care is determined by healthcare providers."
Hospitals groups and MedPAC cautioned CMS' proposal to require prior authorization for complex services like cervical fusion with disc removal and implant of spinal neurostimulators could lower Medicare beneficiaries' access to care.
"As CMS expands prior authorization requirements based solely on increases in services, then it is possible that more services will be subject to prior authorization requirements, particularly in light of CMS' proposal to eliminate the (inpatient only) list," the Association of American Medical Colleges said.
Hospitals continued to oppose CMS' planned cuts to the 340B drug discount program, site-neutral payment policy and changes to support physician-owned hospital expansion. They generally supported changes to the agency's hospital quality star ratings.