The Centers for Medicare & Medicaid Services (CMS) finalized the 2023 Outpatient Prospective Payment System (OPPS) Final Rule. The Final Rule continues the agency’s focus on Medicare and uses lessons learned from the pandemic to inform its approach to quality measurement, focusing on changes that may help to close the health equity gap.
Updates to OPPS and Ambulatory Surgical Center Payment Rates
In the Final Rule, CMS is updating OPPS payment rates for hospitals that meet certain quality reporting requirements by 3.8%, based on the projected hospital market basket percentage increase of 4.1% and reduced by 0.3% for a productivity adjustment. The productivity-adjusted hospital market basked update has been applied since 2019 and 2023 Is the final year in the interim period of five years.
OPPS Payment for 340B Drugs
In the CY 2018 OPPS/ASC final rule, CMS reexamined whether it should pay the average sales price (ASP) plus 6% for drugs acquired through the 340B Program, as 340B hospitals acquire the drugs at steep discounts. Therefore, starting on January 1, 2018, CMS adopted a policy to pay an adjusted amount (generally ASP minus 22.5%) for certain drugs or biologics acquired through the 340B Program. CMS continued this policy in CYs 2019 through 2022.
Additionally, as required by statue, CMS is implementing a 3.09% reduction to the payment rates for non-drug services to achieve budget neutrality for the 340B drug payment rate change for CY 2023.
However, the Final Rule does not address any remedies for payment cuts from 2018 to 2022, nor does it clearly indicate whether CMS plans to restore payments for 340B drugs dispensed to hospital outpatients at certain off-campus locations to the ASP plus 6% payment rate. CMS does plan to address the remedy for 340B drug payments from 2018-2022 in future rulemaking (prior to the CY 2024 OPPS/ASC proposed rule).
Payment for Non-Opioid Pain Management Drugs and Biologics
CMS also finalized that it will separately pay for five qualifying non-opioid pain management drugs when administered in an ambulatory care center in 2023. This will help ensure Medicare beneficiaries have access to non-opioid pain management drugs and encourage providers to use non-opioids in pain management settings.
Rural Sole Community Hospital Exemption
CMS has historically paid the Physician Fee Schedule (PFS) equivalent payment rate for a clinic visit when provided at an excepted off-campus provider-based department paid under the OPPS to control the unnecessary increases in volume observed by CMS. The PFS-equivalent rate is roughly 40% of the OPPS payment rate and the clinic visit is the most frequently billed service under the OPPS.
Therefore, to maintain access to care in rural areas, CMS finalized its proposal to exempt Rural Sole Community Hospitals (SCHs) from this policy and pay for clinic visits furnished in excepted off-campus PBDs of these hospitals at the full OPPS rate.
“CMS is committed to expanding access to care in rural communities and ensuring people with Medicare get the high-quality care they need,” said CMS Administrator Chiquita Brooks-LaSure. “Through the establishment of Rural Emergency Hospitals, supporting clinic visits at rural sole community hospitals and enabling people with Medicare to remotely access behavioral health services in their homes, today’s actions promote patient safety, equity, and quality for these underserved communities. We received broad support for the role Rural Emergency Hospitals can play in advancing health equity and thank stakeholders for their thoughtful input during the public comment period.”