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AHA fights site-neutral payments for HOPDs with new study

The American Hospital Association is challenging CMS's 2019 payment reductions to off-campus hospital outpatient clinic visits, and the move toward site-neutral payments, with a new study that claims patients at hospital outpatient departments are poorer and sicker than ASC patients.


Seven things to know:

1. When CMS released the final rule in November 2018, ASCA applauded their movement toward site-neutral payments. The new policy could save Medicare $380 million this year by dropping reimbursement by around 60 percent.

2. KNG Health Consulting conducted a study for the AHA comparing patient populations at HOPDs with ASCs. The study found HOPD patients are more likely non-white, dual eligible, from lower-income areas, have more severe chronic conditions and reported previous hospitalization than the ASC's patient population.

3. The study found around 47.4 percent of Medicare patients at HOPDs are between the ages of 65 and 74 years old, compared to 56 percent of ASC patients. However, 8.2 percent of the Medicare patients at HOPDs were 85 years old or older, compared to 6 percent of ASC patients.

4. ASCs reported 52.8 percent of their patients had at least one chronic condition, compared with 66.6 percent of HOPDs. Patients at HOPDs were also more likely to have at least one major chronic condition, with 23 percent reporting a major chronic condition, compared with 13 percent of ASCs.

5. The study authors concluded, "Due to their higher medical complexity, HOPD patients may require a greater level of care than ASC patients."

6. CMS reduced payments for off-campus HOPD clinic visits under the 2019 outpatient prospective payment system final rule, which led to the AHA and Association of American Medical Colleges to join three hospitals in filing a lawsuit against the agency. The AHA alleges Medicare already reimbursed HOPDs less than the cost of care; Medicare's margins for outpatient services in the 2017 fiscal year were -12.8 percent.

"Physicians tend to refer more complex patients to hospital outpatient departments for safety reasons, as hospitals are better equipped to handle complications and emergencies," said AHA President and CEO Rick Pollack. "Proposals that treat hospital outpatient departments the same as ambulatory surgical centers and other sites of care are misguided, and ignore the healthcare needs of the patients and communities we serve."

7. AHA and KNG Health have also worked together on studies that show similar outcomes between hospitals and independent physician offices to argue against lowering payments for similar services in the hospital setting.

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