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What CMS' decision to pay separately for Exparel use means for ASCs — 5 insights

CMS' 2019 final payment rule for ASCs and hospital outpatient surgery departments included a new code allowing separate payments to ASCs that use Pacira Pharmaceuticals' non-opioid pain management drug, Exparel.

During a Dec. 4 webinar sponsored by Pacira and hosted by Becker's ASC Review, ECG Management Consultants Principal Naya Kehayes explained what CMS' new rule entails, where it could benefit ASCs and how centers should prepare for the policy.

Five panelists weighed in during the webinar:

  • Alan Barber, MD, surgeon owner, Plano (Texas) Orthopedic Sports Medicine & Spine Center
  • Gregory DeConciliis, administrator, Boston Out-Patient Surgical Suites
  • Lisa Rock, president, National Medical Billing Services
  • Brent Miller, DO, general surgeon, Rochester, N.Y.-based Westside Surgical Associates
  • Matt Pate, physician strategy group senior vice president, Addison, Texas-based United Surgical Partners International

Here are five topics the experts covered:

1. Details of CMS' new rule. The non-opioid Exparel bupivacaine liposome injectable suspension will be eligible for separate payment exclusively in the ASC setting beginning Jan. 1, 2019, when billed with HCPCS code C9290. Exparel is indicated for single-dose infiltration in adults to produce postsurgical local analgesia, as well as for interscalene brachial plexus nerve block to produce postsurgical regional analgesia. It comes in 133 milligram and 266 milligram doses.

2. The value for ASCs. Incorporating Exparel into his practice enabled Dr. Barber to control his patients' pain with an opioid-sparing, multimodal pain management protocol. The approach particularly appeals to patients in recovery for drug or alcohol use, he said.

"I found a remarkable decline in the amount of opioid requirement for patients," Dr. Barber said. "Many of them will have significant surgical procedures and not require any opioids for breakthrough pain. I think that's healthier for the patients and reduces the risk for everyone concerned."

Access to Exparel or non-opioid pain management medications "without a doubt" encourages the migration of surgical cases from hospitals to ASCs, according to Mr. Pate. While Enhanced Recovery After Surgery protocols have accelerated the shift, USPI has also seen physicians become frustrated with hospitals that wouldn't allow non-opioid treatments like Exparel on their formulary.

"As a result, some of those cases came over to our facilities simply because we were willing to allow it to be on the formulary," he said. "This [CMS rule] makes it even more beneficial."

3. Clinical applications. Dr. Barber began using Exparel for anterior cruciate ligament reconstruction and rotator cuff repairs. As his experience grew, he became confident expanding the use to cases ranging from shoulder instability to simple knee scopes.

Physicians at Westside Surgical Associates find the drug particularly useful for procedures that could cause patients significant pain, such as incisional hernia cases. Dr. Miller's aim is to set patients up for success after they leave his care.

"Gone are the days where we say [to patients], 'just go home and get your rest,'" Dr. Miller said. "I want my patients up, I want them walking around, I want them active. I don't want them coming back with blood clots, pneumonia or any of those other issues — but in order for them to do that, I have to make sure they're comfortable.

4. Commercial payers will likely follow. Along with improving outcomes, CMS' new rule paves the way for commercial payers, according to Ms. Kehayes. Ms. Kehayes noted major players have already taken action: Aetna launched a pilot program to reimburse select ASCs in Florida and New Jersey for using Exparel. Ms. Rock added that some local Blue Cross Blue Shield plans have it on their fee schedule.

To encourage commercial payers to follow Medicare's lead, Boston Out-Patient Surgical Suites leaders meet with high-level personnel at insurance companies and provide information about procedures they'd like to see reimbursed.

"We'll meet with the highest-level person we can and say, 'You followed CMS before. This is obviously good patient care and something we'd like you to follow again.' That's usually the tactic we take: a face-to-face meeting and providing good information [to] the right people," Mr. DeConciliis said.

5. Preparing for 2019. Looking ahead, ASCs should review the "laundry list" of case types that may benefit from Exparel use, including shoulder repairs, knee cases, hernias and breast reconstruction, Ms. Kehayes said. It's also crucial to contact commercial payers — especially those with Medicare Advantage plans — to determine if and when they'll allow for reimbursement in light of the CMS rule.

When practices begin billing Medicare for Exparel after Jan. 1, "documenting the use and dosage is going to be critical," Ms. Rock said. In the meantime, she advised ASCs seeking Exparel reimbursement from commercial payers to start working with payer representatives.

"You need to have your complete commercial contracts in hand and then check your specific payer fee schedules online to see if there's already a fee loaded. In some cases, there is fee loaded for this drug," she said. "Next, you're going to call your payer rep and establish that dialogue with them to discuss what the plans are for getting this reimbursed in the near future."

Mr. Pate said he's optimistic about the opportunities separate payment for Exparel creates for ASCs.

"I'm not expecting sweeping changes, but this should certainly allow us to improve reimbursement on the Medicare cases being done," he said. "It'll also allow us to capture a few more cases that have historically not been done. … Equally important, I think this will definitely help improve patient satisfaction and outcomes by the use of this type of drug."

To view the webinar, click here. To access the webinar slides, click here.

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