OPPS Proposed Rule Aims to Improve Healthcare

Today, I’d like to discuss the recently proposed policies by the Centers for Medicare & Medicaid Services (CMS) under the U.S. Department of Health and Human Services (HHS).

These proposals are part of the Calendar Year (CY) 2025 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) proposed rule and touch on a range of important updates aimed at improving healthcare delivery and addressing significant issues within our healthcare system.

1. Payment Rate Updates: CMS proposes a 2.6 percent increase in OPPS payment rates for hospitals that meet quality reporting requirements. This adjustment is based on a projected hospital market basket percentage increase of 3.0 percent, reduced by a 0.4 percentage point productivity adjustment. The same update factor is proposed for ASC rates for an additional two years, ensuring these facilities also see a necessary increase in funding.

2. Behavioral Health and Substance Use Disorder Services: To address the ongoing mental health crisis, CMS plans to maintain the current rate structure for Intensive Outpatient Program (IOP) services and Partial Hospitalization Program (PHP) services. These programs offer structured outpatient psychiatric care as an alternative to inpatient treatment, crucial for individuals with acute mental illness or substance use disorders.

3. Access to Non-Opioid Pain Treatments: In a bid to combat the opioid crisis, CMS proposes additional payments for certain non-opioid treatments for pain relief in hospital outpatient and ASC settings from Jan. 1, 2025, through Dec. 31, 2027.
   This measure aims to provide safer pain management options for patients, reducing reliance on opioids.

4. Payment for Remote Services: Recognizing the importance of telehealth, CMS is clarifying OPPS payment for services provided remotely by hospital staff. This includes aligning these requirements with Medicare telehealth services, which have become essential during the pandemic and continue to offer significant benefits in improving access to care.

5. Support for Indian Health Services (IHS) and Tribal Facilities:To better support healthcare delivery in underserved areas, CMS proposes an add-on payment for high-cost drugs provided by IHS and tribal hospitals. This initiative aims to address the unique financial challenges faced by these facilities and improve service delivery to these communities.

6. Specialized Diagnostic Radiopharmaceuticals: CMS plans to refine payment policies for high-cost diagnostic radiopharmaceuticals. The goal is to ensure accurate payment and access to essential nuclear medicine tests, thereby improving diagnostic capabilities and patient outcomes.

7. Health Equity Measures: A significant focus of the proposed rule is advancing health equity. CMS is introducing new measures for hospitals, rural emergency hospitals, and ASCs to screen for social determinants of health (SDOH). Hospitals and ASCs that do not meet these health equity standards, which include screening for SDOH, will face a 2 percent reduction in annual payment updates.

8. Maternal Health Initiatives: Addressing the maternal health crisis in the United States, CMS proposes baseline health and safety requirements for hospitals and critical access hospitals for obstetrical services. These standards cover organization, staffing, delivery of care within obstetrical units, emergency services readiness, transfer protocols for obstetrical patients, and annual staff training on evidence-based maternal health practices and cultural competencies. These measures are crucial for reducing maternal mortality and morbidity, which disproportionately affect underserved communities.

9. Medicare Physician Fee Schedule (PFS) Changes: The proposed CY 2025 Medicare Physician Fee Schedule (PFS) includes a 2.8 percent reduction in the conversion factor, impacting reimbursement rates. CMS also proposes measures to improve payment for and access to behavioral health services, extend certain telehealth waivers, and introduce new Merit-based Incentive Payment System (MIPS) Value Pathways.

These proposed changes are part of a broader effort by the Biden Administration to address healthcare disparities, expand access to care, and improve health outcomes across the country. The rule is currently open for public comment until Sept. 9, 2024. Your input and feedback are crucial during this period, as they will help ensure these policies are effective and equitable.

Programming note:

Listen to Angela Comfort report this story live today on Talk Ten Tuesday, 10 Eastern, with Chuck Buck and Dr. Erica Remer.