The United States Department of Health and Human Services (HHS) and Centers for Medicare and Medicaid Services (CMS) recently issued the 2025 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) proposed rule. In that proposed rule, CMS also proposed policies to increase access to care and advance health equity.
Hospital and ASC Payment Rates
CMS proposed to update OPPS payment rates for hospitals that meet applicable quality reporting requirements by 2.6%, based on the projected hospital market basket percentage increase of 3% (and reduced by a 0.4 percentage point productivity adjustment). CMS also proposed an update factor to the ASC rates for CY 2025 of 2.6%, applicable to ASCs that meet certain quality reporting requirements and based on the proposed IPPS market basket percentage increase of 3% and reduced by a 0.4 percentage point for the productivity adjustment.
Access to Non-Opioid Treatments for Pain Relief
CMS is proposing to implement Section 4135 of the Consolidated Appropriations Act 2023, which provides temporary additional payments for certain non-opioid treatments for pain relief in the hospital outpatient department and ASC settings from January 1, 2025, through December 31, 2027. This would implement several statutory provisions, including evidence requirements for medical devices and the FDA-approved indications that meet the statutory requirements.
CMS is also proposing to initially assign a payment offset of zero dollars for the qualifying non-opioid products. CMS believes that maintaining the non-opioid portion of the procedure payment rate better aligns with the overall intent of the non-opioid policy to ensure access is not hindered by Medicare payment policies.
Additional Proposals
Included in the proposed policies is an add-on payment to the All-Inclusive Rate (AIR) for certain Indian Health Services (IHS) and tribal facilities to increase access to certain high-cost drugs; expanding the hospital outpatient, ASC and rural emergency hospital quality program measure sets to include equity measures consistent with other provider types; and supporting individuals returning to the community from incarceration through the elimination of barriers for these individuals to enroll in and maintain their Medicare coverage.
The proposed rules would, for the first time ever, enable IHS and Tribal facilities to receive separate payment for high-cost drugs for people with Medicare, allowing clinics to provide certain health care services, like cancer treatment, in Tribal communities.
Conclusion
The proposed payment policies outlined in the rule would impact roughly 3,500 hospitals and 6,100 ASCs.
Dr. Danielle Carnival, Deputy Assistant to the President for the Cancer Moonshot and Deputy Director for Health Outcomes of the Office of Science and Technology Policy, issued a statement in support of the proposal. “The President and First Lady have been clear that cancer patients deserve access to quality care, regardless of their zip code. Today, the Biden-Harris Administration is taking significant steps to reduce barriers for IHS and Tribal facilities so they can expand the breadth of health care services they provide to their communities. The proposed CMS rule for Medicare to pay separately for high-cost drugs and biologics will provide critical reimbursements to IHS and Tribal facilities providing specialty care today, and will establish a pathway for Tribal facilities seeking to bring specialty care-including oncology-to their communities in the future. Today’s proposal is just one of the many ways the Biden Cancer Moonshot is delivering on the President and First Lady’s goal to equitably improve the experience and outcomes of those touched by cancer.”
“With this proposed rule, we are helping make sure that all people can access care more equitably,” said Dr. Meena Seshamani, CMS Deputy Administrator and Director of the Center for Medicare. “The Medicare program is meant to work for everyone – including those transitioning from incarceration and those accessing care at IHS and tribal hospitals and the policies in this proposed rule represent a significant step forward in doing just that.”
Comments
Comments are accepted through September 9, 2024, and the final rule will be issued in early November 2024.