We must represent ourselves and patients to move forward with value-based care
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To provide care associated with the lowest cost to achieve high-quality outcomes, patient care should be optimized to connect patients with the best providers in the best location.
This process is challenging due to the complexity of the health care system and conflicts of interest that can distort the ideal pathway. The key to the best approach is to remain patient-centric about outcomes, cost and patient experience.
In line with this concept, CMS has stated its vision is “to become the most energized, efficient, customer-friendly agency in the government,” to strengthen the health care services and information available to beneficiaries and providers. The impact of CMS decisions and regulations is enormous as CMS is directly involved in spending more than $1.5 trillion of the more than $4 trillion National Health Care Expenditure Accounts. Other payers tend to follow their guidelines.
With hospital expenditures increasing more than 6% annually, one area that could have provided significant cost savings while maintaining patient outcomes, combined with better overall patient and physician experiences, was the elimination of the hospital in-patient only (IPO) list, which was scheduled to occur on Jan. 1, 2022. However, in the CMS final rule on the hospital IPO list, the decision was made to eliminate the proposed changes and put back all but three orthopedic services and their corresponding anesthesia codes of the 298 procedures that were planned to be removed from the hospital IPO list as of January 2022.
Conflicting decision
This decision appears to conflict with the vision and goals of CMS. It also seems to conflict with the evidence-based literature that continues to support the movement of more than 75% of all orthopedic procedures off the inpatient-only list. Many private insurers are steering these same CMS-defined hospital IPO orthopedic cases out of the hospital and into ASCs through financial incentives and the pre-approval process.
CMS has instead decided to embark on a 3-year transition and what they have described as a codification of criteria to determine whether a service should be removed from the hospital IPO list. It may not be surprising to know the Advisory Panel on Hospital Outpatient Payment, which makes the formal recommendations to the HHS Secretary, is comprised of hospital and health system representatives, except for one member of the group who is part of an organization that owns specialty hospitals. There is no representation from a committed member of the ASC community.
Political advocacy
Political advocacy is a slow and often frustrating process for orthopedic surgeons. However, not being involved allows non-orthopedic stakeholders to make critical decisions on the practice of musculoskeletal care. The ability to decide the best location with the best outcomes, patient experiences and satisfaction, is essential to provide the highest valued care.
We will be judged by patients, payers, employers and the government on these issues. Allowing others to essentially handicap our ability to make these decisions by not being involved in the process is not the correct answer.
In early 2022, there will be an open period to respond to the CMS decision to return almost 300 procedures on the hospital IPO list. Many have been proven safe, cost-effective and with similar or better outcomes when performed in ASCs.
You can send comments to the Advisory Panel on Hospital Outpatient Payment at APCPanel@cms.hhs.gov. You can also provide recommendations to the ASC Payment system staff at Scott.Talaga@cms.hhs.gov. Furthermore, you can write a letter to members of Congress to encourage their support of the Outpatient Surgery Quality and Access Act of 2021 (H.R. 5818/S. 3132). The bipartisan bill provides correct incentives for the continued movement toward allowing patients and surgeons to decide the best site of care.
We must participate and represent ourselves and patients in moving forward toward a genuinely value-based care system.
- References:
- https://www.cms.gov/medicaremedicare-fee-service-paymenthospitaloutpatientpps/cms-1753-fc.
- https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet.
- https://www.healio.com/news/orthopedics/20210726/cms-proposed-rule-halts-elimi-nation-of-inpatient-only-list.
- For more information:
- Anthony A. Romeo, MD, is the Chief Medical Editor of Orthopedics Today. He can be reached at Healio, 6900 Grove Road, Thorofare, NJ 08086; email: orthopedics@healio.com.
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