Overall, what is ASCA’s view of CMS’ final 2019 ASC payment rule?

The changes included in this year’s rule are among the most significant I have seen in my eight years with ASCA. Overall, I would say they demonstrate greater recognition of the quality and value ASCs provide than we have seen in any previous rulemaking. For example, foremost among the changes is a decision to update ASC payments using the hospital market basket inflation factor, a much more realistic indicator of rising costs in the ASC space than what CMS has been using. We have fought for this change over the last decade and appreciate that it has been adopted.

Other new policies in the rule encourage the migration of device intensive procedures to ASCs, allow for several new cardiac procedures in the ASC setting and introduce changes to the ASC Quality Reporting program.

These changes are positive and beneficial for ASCs and the patients they serve, and we are encouraged to see CMS adopting these policies. The credit for achieving these goals belongs to every ASC supporter who has helped ASCA advocate for these changes over so many years.

How does the 2019 payment rule change the annual inflationary adjustment for ASCs?

Under the 2019 payment rule, CMS will use the hospital market basket to update ASC payments for the five-year period of calendar year (CY) 2019 through CY 2023. During those five years, as a way of controlling costs in the Medicare program, CMS intends to examine whether this adjustment reduces the Medicare program’s expenses by leading to a migration of services from other more expensive settings into ASCs.

Historically, ASCs have been shortchanged by a requirement that our adjustments be based on the Consumer Price Index for All Urban Consumers, or the CPI-U, (which focuses on broad consumer price changes) rather than the hospital market basket. But since ASCs use the same staff, services and supplies as HOPDs, it only makes sense to apply the same inflation rate for our yearly updates.

Under the final rule, ASCs will see, on average over all covered procedures, an effective update of 2.1 percent—a combination of a 2.9 percent inflation update based on the hospital market basket and a productivity reduction mandated by the Affordable Care Act of 0.8 percentage points. It is important to note that this adjustment is an average and that updates vary significantly by code and specialty.

Because CMS will be evaluating whether Medicare and its beneficiaries are able to reduce the cost of care using this new payment methodology over the next five years, ASCs will need to begin in 2019 to collect data that demonstrates the migration of Medicare patients into the ASC setting. ASCA will be helping to coordinate these efforts and looking to individual ASCs for help.

What changes occurred regarding device intensive procedures performed in ASCs?

CMS reduced the threshold definition of device intensive procedures in ASCs from 40 percent to 30 percent—a policy change that we have been advocating for over the past several years to encourage migration of these procedures into ASCs.

This means that if the device portion of the overall procedure equals 30 percent or more of the total cost of the procedure in the HOPD setting, the total device cost will be included in the reimbursement rate when the procedure is performed in an ASC. This decision results in a net increase of 124 new device intensive procedures that ASCs can now afford to provide for Medicare beneficiaries for the first time, effectively growing the approved list from 153 device intensive procedures to 277 in 2019.

What procedures were added to Medicare’s ASC payable list for the first time?

In the rule, CMS revised its definition of “surgery” to account for certain “surgery-like” procedures that are assigned codes outside the Current Procedural Terminology (CPT) surgical range. This change allowed it to add the 12 cardiac catheterization procedures that were included in the proposed rule to the ASC covered procedures list.

Based on feedback from stakeholders, CMS also added five additional procedures that are often performed alongside those codes.

Last year CMS allowed HOPDs to perform total joint replacement procedures. Did this rule make any changes regarding those procedures in ASCs?

No, and we didn’t expect any total joint replacement codes to be added this year. We say this even though we know that many ASCs around the country are safely and effectively performing these procedures on non-Medicare patients. One issue is that the reimbursement CMS applied to the procedures it moved into HOPDs last year seems to be too low to encourage migration from the inpatient space for Medicare beneficiaries.

Speaking of procedures, CMS proposed reviewing procedures added to its ASC list in the last three years to ensure those procedures can be performed safely on Medicare beneficiaries. Did the final rule address that process?

Yes. CMS completed its review and concluded that all 38 procedures it added in 2015, 2016 and 2017, which includes some spine, vascular and gynecologic procedures, can be performed safely on Medicare patients in ASCs.

We agree that there can be clinical differences between the Medicare and non-Medicare populations, so this kind of review of newly added procedures to a site of service—whether from hospital inpatient to outpatient, HOPD to ASC or ASC to the physician office—makes sense, and we support this oversight.

Could you speak to the provision in the final rule that addresses payment for non-opioid pain management therapy?

As you know, President Trump has made responding to the opioid epidemic in America a priority. This provision is a result of that endeavor and an idea we brought to the Administration’s attention.

Past payment policy served as an impediment to using non-opioids for post-surgical pain. This provision addresses our concerns by allowing ASCs to get paid for non-opioid pain relief drugs when used in a surgical procedure. Currently, Exparel is the only drug that CMS has identified in the rule that qualifies. We continue to look to the ASC community for information about whether there are other alternatives being used for which CMS should apply this new policy.

Did the final payment rule incorporate all the changes to Medicare’s ASC Quality Reporting (ASCQR) Program that CMS proposed?

No. In the end, CMS did finalize the removal of ASC-8 and ASC-10. However, the Agency did not finalize its proposal to remove quality measures ASC-1 through ASC-4, ASC-9 or ASC-11. For ASC-9 and ASC-11, measures tied to endoscopy and cataract surgery, it determined that these measures still provide important information for consumers.

For ASC-1 through ASC-4, quality measures tied to adverse events, CMS recognized that even though ASC performance on these measures is so impressive that little additional improvement would be possible, it agrees with ASCA that there is still value to the public in reporting on these types of measures. As a result, CMS suspended data collection on these four measures beginning in 2019 while it explores ways of making them more valuable in the future. ASCA looks forward to working with CMS staff to develop these measures and others that will provide more actionable data about outpatient surgery to patients, providers and regulators.

What do ASCs need to do now to make sure they are in compliance with the changes to Medicare’s quality reporting program this rule defines?

Because the devil is in the details when it comes to Medicare quality reporting compliance and ASCs that don’t comply are subject to payment reductions, ASCA’s Director of Education and Clinical Affairs Gina Throneberry and ASC Quality Collaboration Executive Director Donna Slosburg presented a free webinar that answers common questions on this issue. That is now available for viewing on demand. I recommend that all ASCs review that program, “CMS Quality Reporting for ASCs,” to make sure they are doing everything needed to comply.

In short, ASCs can stop reporting anything on Medicare claims beginning January 1, 2019. They can also stop reporting ASC-8 immediately and stop collecting data on ASC-10 on January 1, 2019. To qualify for their full payment update in 2020, however, facilities still need to report the data they collect this year on measures ASC-9 and 10 in 2019. Reporting on ASC-11 is already voluntary, so there are no additional reporting requirements tied to that measure.

Beginning in 2019, ASCs will also need to report information they began collecting this year on two new measures—ASC-13: Normothermia and ASC-14: Unplanned Anterior Vitrectomy. These reporting requirements were not changed in the final rule.

A few years ago, CMS proposed instituting a lengthy patient experience of care survey in ASCs and HOPDS that it called the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey (OAS CAHPS). Based on comments it received on the complexity of the reporting process, CMS decided last year to delay implementation of the survey until further notice. Does this rule reveal when that survey might begin?

In this rule, CMS indicates that the OAS CAHPS survey remains on hold but makes clear that it continues to plan to require ASCs and HOPDs to use a version of that survey in the future. ASCA continues to have strong concerns about the length of the survey and the lack of an email option, but we remain hopeful that those concerns will be addressed before CMS begins to require use of that survey.

Does ASCA provide any resources that can help ASCs calculate the effect of this payment rule on their bottom line?

ASCA makes several resources available to its members to help them determine the financial impact Medicare’s payment rule will have on their facility, including our rate calculator. These resources, however, are available only to ASCA members, so I recommend that anyone who is not a member that would like to use these tools join ASCA today. If you have questions about how to do that, please contact Mykal Cox, ASCA’s assistant director, membership & business development, at mcox@ascassociation.org.

Of course, as I mentioned earlier, ASCA has an on-demand webinar available that can help ASCs comply with Medicare’s 2019 quality reporting requirements. That program is available free to all ASCs, and I recommend that every ASC review it. ASCA will also be talking about Medicare compliance in our 2019 webinar series, at our 2019 Winter Seminar and at ASCA 2019, our annual conference and expo in Nashville, Tennessee, this May. We encourage every ASC to participate in those events.