CMS' Outpatient Prospective Payment System and ASC Payment System final rule for 2021, which was finalized Dec. 2, shows the agency's willingness to trust clinical judgement but lacks necessary changes to site-of-service reimbursement differentials, according to Bill Prentice, CEO of the Ambulatory Surgery Center Association.
Mr. Prentice spoke to Becker's ASC Review on Dec. 9 about CMS' final rule for 2021 and the implications for ASCs.
Note: Responses were lightly edited for style and length.
Question: Which elements of the CMS final rule are most exciting for ASCs, and why?
Bill Prentice: Over the 10 years I've been at ASCA, I think there's been a growing trend of moving more and more procedures to the ASC-payable list. Obviously, this year was the culmination of that with [the addition of] 267 procedures — the most, to my knowledge, ever moved into our space in one fell swoop. I think that's a really promising trend because it's showing the medical directors at CMS see the value and quality of care that's being provided in the ASC space and are trusting the clinical judgment of clinicians in making the right decisions about which patients can be safely seen in the ASC versus the hospital.
Q: You've expressed disappointment that CMS didn't address budget policies that negatively affect ASC payments. Could you expand on that?
BP: One of the things we find concerning, and a big barrier to migration of more cases from the more expensive hospital setting to the ASC setting, is reimbursement — the fact that ASCs are reimbursed roughly 50 percent of what the hospital outpatient department is for the same code. We think that really needs to be addressed if we're really going to try and migrate more volume, which is going to save the Medicare program billions of dollars and save Medicare beneficiaries money in terms of copays and deductibles.
Q: Why do you think there hasn't been more progress toward reducing that payment differential?
BP: I think it's the way the federal government shortsightedly views budgets in silos. They look at increases in reimbursement for the ASC space as adding cost to the system, not recognizing the fact that that migrates cases from a more expensive setting to ours. They're just going to say, 'Look, we've [already] increased [ASCs'] budget in 2021,' and not recognize that in 2022, 2023 and on, as more cases move over to the ASC space, we're going to save money because that hospital budget is going to go down. So, looking at these things in silos is preventing decision making that's going to save the overall system billions of dollars over time.
Q: Are there other parts of the final rule were you disappointed in or that may have harmful implications for the future of ASCs?
BP: For the past couple of years, they haven't made any significant changes to our quality reporting program. That's an area that needs more attention. We want to be able to continue to show the safety and high quality of care we provide, so I'm hoping that in future years they'll add quality measures to our program. We have the ASC Quality Collaboration working to try and generate quality measures, and I'm hoping some of those will be added. It's going to be of high value to patients and help them make decisions to go to the right setting for their care.
We've offered a couple [measures] up that haven't been accepted — a normothermia measure, different cataract measures, we have a measure for surgical site infection in breast surgeries. I'm hoping that over the next year or so we're going to finally develop a broad infection measure that we can offer up to CMS and eventually report on.
Q: What was your reaction to CMS' decision to gradually eliminate the inpatient-only list? Was it surprising?
BP: Bit of a surprise, but when you look at what they've done in our space — moving all those procedures, changing the process used to determine which procedures are appropriate for our setting — I think it all speaks to an acknowledgment that they trust the clinical judgment of the physician community and will let them make the decisions about which patients go to which setting for care. The important thing to realize is just because you're moving procedures off of the inpatient-only list or moving procedures to the ASC list, it doesn't mean all those cases are going to shift. There's still clinical judgment involved in determining whether any specific patient belongs in one setting versus the another. For example, the fact that we're going to be reimbursed for performing total hip procedures in 2021 doesn't mean there's going to be a huge migration of cases to the ASC setting because in each individual case, the surgeon's going to look at the patient, their health history, their comorbidities, and determine which is the best site of service for them.
Q: What kind of changes will ASCA be lobbying for in future rulemaking?
BP: We have our ASC Quality and Access Act that we introduced to Congress and have been successful getting different pieces of that enacted into law over time. We'll be reintroducing a new version of that in this Congress. We're still working on bill sponsors for that, trying to determine exactly what provisions will be in it, but we would love to see some of these reimbursement-related policies be changed. Again, that's going to be dependent on sponsors.
There is currently a cap on the copays for some procedures in the hospital space that doesn't exist in our space because when that cap was put in place, it wasn't contemplated that ASCs would perform those types of procedures. We're hoping to get that addressed because right now, there's this irrational thing where the total cost of the procedure in the ASC space is far lower than in the hospital space, but the patient would have to pay more out of their own pocket to get care done in an ASC than in a hospital. The cap is based upon the price of the procedure in the HOPD, so it's the higher-cost procedures like total knees and total hips that are most dramatically affected by that.