CMS releases proposal to greatly reduce inpatient-only list
Click Here to Manage Email Alerts
CMS has released a proposal to expand the number of procedures Medicare pays for when performed in the hospital outpatient setting by reducing the number of procedures on the inpatient-only list.
In the proposal, CMS would phase-in the proposal during the course of 3 years and would gradually allow more than 1,700 additional services to be paid when furnished in the hospital outpatient setting. Approximately 300 musculoskeletal services would be newly payable in the hospital outpatient setting under the proposal. For 2021, a total of 11 procedures, including total hip arthroplasty, are proposed to be removed from the in-patient only list.
The proposed change would be the largest one-time reduction to the inpatient-only list, according to the release. From 2017 through 2020, approximately 30 services were removed from the inpatient-only list.
The proposal is part of Protecting and Improving Medicare for Our Nation’s Seniors, an executive order signed by President Donald J. Trump.
CMS also proposed two alternatives to increase access to care at a lower cost. In the first alternative, CMS establishes a process in which the public nominates additional services that could be performed in ASCs based on certain quality and safety parameters. In the second alternative, CMS revises the criteria used to determine the procedures that Medicare would pay for in an ASC, potentially adding approximately 270 procedures that are already payable when performed in the hospital outpatient setting to the ASC list. CMS would solicit comment on whether the ASC conditions for coverage should be revised given the potential for a significant expansion of the services added under this alternative proposal.
The American Association of Orthopaedic Surgeons released a statement stating the setting where patients receive care is best decided by physicians and the AAOS supports policies that give orthopedic surgeons and patients greater choice.
“While we are cautiously optimistic about CMS’ attempt to offer these flexibilities by promoting site neutrality and lifting restrictions on high-value physician-owned hospitals, we are concerned about the potential for unintended consequences associated with eliminating the inpatient-only list,” Joseph A. Bosco III, MD, FAAOS, president of the AAOS, said. “In pushing forward such a drastic change, CMS may exacerbate many of the same unresolved issues that our surgeons continue to face as a result of hip and knee arthroplasty being recently removed from the inpatient-only list.”
Bosco said payers often misinterpret the policy change to mean these procedures must be performed exclusively in the outpatient setting, which can add more delay and paperwork to existing prior authorization requirements and can jeopardize patients’ access to care.
“The AAOS believes that determining the appropriate setting of care should be done through the lens of patient safety and peer-reviewed evidence, and that physicians are best qualified for leading this individualized decision-making process with their patients. We strongly encourage CMS to carefully reassess this aspect of the proposal in light of these concerns, and we look forward to offering our formal comments on behalf of the musculoskeletal community,” he said.
References:
https://www.federalregister.gov/public-inspection/current
Editor’s note: The story was updated on Aug. 7, 2020 to include information as released by the AAOS.
Perspective
Back to Top
Charles A. Bush-Joseph, MD
The Trump administration’s recent announcement to effectively eliminate the “inpatient only list” as defined by CMS is a strong step forward for transparency and evolution of our opaque medical payment system. As proposed over a 3-year implementation, this proposal will allow over 300 musculoskeletal procedures to move into the outpatient environment and allow CMS to “catch up” what is already advancing in the private insurance market. This allows physicians and patients to make the best decision for “site of service” taking into consideration of patient convenience, risk and expense.
There is no doubt that the legacy CMS payment system has served as method to underwrite or subsidize inpatient medical centers for unreimbursed care. This cost shifting has been born by patients, employers and taxpayers. The CMS proposal if implemented, will force legacy inpatient facilities to evolve at a more rapid pace.
I am sure the vast majority of musculoskeletal providers will applaud these recommendations.
Perspective
Back to Top
Jack M. Bert, MD
In 2021, 266 procedures may be removed from the “inpatient-only” list. These include a full array of spine procedures, reimplantation of fingers, various bone grafting procedures, radical tumor resection, total shoulder replacement and revision TKA as examples. In a previous article published in Orthopedics Today, we know that outpatient TKA had been removed from the inpatient-only list but the reimbursement was significantly lower than the outpatient hospital Medicare reimbursement rate and as many ASC owners quickly realized, often their Medicare reimbursement was basically at a “break even” cost for performing the procedure.
The final Medicare ASC base rate without the professional fee for a TKA was reported to be $8,609 not including the professional fee which is significantly lower than the hospital outpatient prospective system rate for 27447 of $11,899. The stated goal by CMS is to afford reduced costs for seniors by lowering their deductibles and “copays" but honestly, the facility fee reimbursement reduction for the physician-owned ASC may result in fewer Medicare cases being performed in these centers as surgeons realize that their costs are equal to or more than what Medicare is going to pay.
I am skeptical that this move by CMS will result in putting the “doctors and patients back in the driver’s seat and in a position to make decisions about their own care.” A desirable result for CMS will clearly be dependent on what the final reimbursements for these procedures are going to be for an outpatient physician-owned ASC.
Read more about
Click Here to Manage Email Alerts