The political and regulatory landscape for ASCs: 5 key questions with ASCA CEO William Prentice

CMS released the 2019 proposed payment rule for ASCs and hospital outpatient departments (HOPDs) in late July, with the comment period open through Sept. 24. Among the changes, CMS proposed increasing ASC reimbursement by 2 percent and aligning the update factors between ASCs and HOPDs. The update also would:

1. Eliminate reporting requirements for eight quality measures for 2020 and 2021 payment determinations

2. Provide separate payment for non-opioid pain management drugs used during ASC procedures

3. Review the data on 38 procedures placed on the ASC payable list over the past three years

CMS Administrator Seema Verma made comments on July 25 during a speech at the Commonwealth Club of California critical of the variation between payment at different sites of service, and the U.S. House of Representatives passed the ASC Payment Transparency Act in July as well.

Here, ASCA CEO William Prentice discusses these potential changes and expectations for the future.

Question: What do you think CMS' efforts will be to close the reimbursement gap between ASCs and HOPDs?

William Prentice: CMS is just dipping its toes in the water with HOPDs and off-campus physician payments. Where CMS is going to head when it comes to the delta between payment for HOPDs and ASCs is an open question, but in all likelihood, HOPD payment would drop to the ASC rate rather than the reverse.

Q: CMS proposed removing several mandatory quality reporting measures for ASCs in 2019 because the compliance rate was so high. What was your reaction to the news?

WP: The removal of these measures came as a surprise to us. It's nothing we requested. That said, I think the decision by CMS to remove those measures for the reason they provide is laudable. The fact that ASCs were performing at such a high rate on those particular adverse event measures that CMS thought it wasn't worth continuing to measure them speaks to the quality and safety of surgery centers. We know that patients need more and better information about the sites of service they can go to, and we stand ready to work with CMS to develop new measures, particularly outcomes measures, that can be used by patients and providers to improve as well as by state regulators to ensure we are providing the best care possible.

As patients, we would all love to have better information about outcomes by specific procedure. Right now, the trend has been to ask ASCs and hospitals to report on all-cause, seven-day readmissions on various procedures. That's a starting point, but because they are all-cause, they don't provide the necessary information that can truly guide the patient as to whether or not the readmission was an indicator of a bad outcome or if it was bad luck that led the patient to have an unrelated issue.

For example, the patient might have a colonoscopy on Friday, and then run over their foot with the lawnmower on Sunday and go to the ER. That would still be counted as a readmission in the database but isn't particularly helpful. I would love for us to get a better way of discerning the reasons behind readmissions.

Q: The proposed OPPS rule includes a section encouraging additional use of non-opioid pain medications in ASCs. What do you think of this change?

WP: The Trump administration has been looking for ways to deal with the opioid crisis in this country. One suggestion we made—to encourage the use of non-opioid pain relief in ASCs—ended up in this rule. The problem for Medicare has been that it wouldn't pay separately for non-opioid pain relief. If the recommendation is passed, ASCs would receive additional payment when these pain relievers are used. Right now there is only one alternative approved, but we believe there are other non-opioid alternatives that should qualify for those payments, and we are working with CMS to identify those.

Q: What does the emphasis on transparency in healthcare mean for ASCs?

WP: CMS did request comments from the medical community about ways to increase price and quality transparency and asked for guidance about what that might look like. We think patients should have better information about the price and quality of care they will receive. One of those elements we are still waiting for is that CMS is supposed to be developing a website that would allow beneficiaries to go online and see what their copay and deductible would be at different sites of service.

There is a tone throughout the proposed rule that we are very pleased to see. It seems to show a greater appreciation for the quality and cost savings that ASCs offer. Hopefully that's an indicator of greater efforts on the part of the federal government to make the most of ASCs’ ability to provide high-quality, cost-effective care for Medicare beneficiaries.

Q: Finally, CMS proposed retrospectively examining 38 codes on the ASC payable list to determine whether the data supports their remaining in the ASC. Has this happened before?

WP: The expectation has always been that when CMS adds procedures to the ASC payable list, they are going to look at them and see what outcomes result from doing so. If CMS sees there needs to be a change made, we want that to happen to make sure we're doing right by Medicare beneficiaries. It's our expectation that CMS is looking at the procedures in every site of service to make sure the outcomes are right.


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