What is ASCA’s overall reaction to Medicare’s proposed 2020 payment rule?

We view this rule as another positive sign that CMS is paying careful attention to the results that ASCs are having on controlling Medicare costs without diminishing quality or safety, and we remain optimistic about our working relationship with CMS going forward. We were pleased to see that CMS is proposing to continue to align the ASC update factor with the factor used to update HOPD payments. Under this proposal, CMS will continue to use the hospital market basket to update ASC payments for calendar year (CY) 2020 through CY 2023 as it assesses the impact on volume migration.

As a result, if the rule is finalized as written, ASCs will see, on average over all covered procedures, an effective update of 2.7 percent—a combination of a 3.2 percent inflation update based on the hospital market basket and a productivity reduction of .5 percent mandated by the Affordable Care Act.

It is important to remember that the 2.7 percent increase is an average that will not apply equally to every procedure ASCs perform, so updates might vary significantly by code and specialty. Also, this proposed update does not take into consideration sequestration, which reduces ASC payments by 2 percent each year until at least 2024 unless Congress acts.

ASCA has updated its Medicare rate calculator so members of the association can see what payments they would receive if the rates were to be finalized as proposed. There are always significant changes to most of the rates between the proposed and final rules, however, so we are also advising members who use the calculator to make sure to download the rate calculator once the rule is finalized in November to see the actual payments their facility will receive.

This proposed rule would add total knee arthroplasty and several cardiac procedures to the ASC payable list. It would also move total hip arthroplasty off the inpatient-only list, making it payable in HOPDs. Please discuss the impact of those changes.

After years of encouraging Medicare to give its beneficiaries access to the cost savings and high-quality outcomes that ASCs offer commercially-insured total joint replacement patients, ASCA is extremely pleased to see CMS proposing to reimburse ASCs for providing total knee arthroplasties in 2020. That said, we have some concern about the rates ASCs will be paid for providing those procedures, so we encourage facilities that are performing this procedure to provide comments to CMS on a fair payment that will encourage migration of appropriate patients from the hospital to the ASC.

We are also pleased to see CMS proposing to move total hips off the inpatient-only list and into the HOPD setting next year. Although ASCs will not be reimbursed for performing those procedures for Medicare beneficiaries in 2020, given the excellent outcomes privately insured patients are already experiencing with those procedures in the outpatient setting and how quickly Medicare moved total knees from the HOPD setting into ASCs, we are hopeful that total hips will be approved for ASCs in the near future.

We also commend CMS for its proposal to move six cardiac codes onto the ASC-payable list for the first time. These, too, are codes that ASCA has been asking CMS to allow ASCs to provide to Medicare patients.

If this rule is enacted as proposed, what changes can ASCs expect to see in Medicare’s ASC quality reporting program?

CMS is proposing to adopt one new quality measure in 2020: ASC-19, a measure that looks at hospital visits within 7 days after general surgery performed in an ASC. Data on comparable measures related to colonoscopies and orthopedic and urology procedures is already being collected, and adoption of this measure would continue a trend toward more specialty-specific data collection that ASCA supports. Because CMS collects this data from hospital claims forms, if this measure is adopted as we expect it to be, ASCs will not have to do anything beyond what they are already doing to submit this information. If adopted, this measure would affect payment determinations for ASCs for 2024 and beyond.

Of note, CMS did not propose to make the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey (OAS CAHPS) survey mandatory. We were not surprised at this decision since CMS is currently conducting comprehensive tests of an electronic version of this survey.

One element of this proposed rule that has already generated controversy in the hospital community is a requirement that hospitals post their negotiated rates in an accessible, patient-friendly format. Does that proposal have an impact on ASCs?

If approved, the requirement that hospitals post their negotiated prices will likely spur CMS to expand that requirement to other providers over time. We will be paying close attention as this proposal moves forward and will keep our members apprised of all developments.

When will the proposals contained in the rule become final?

There is no guarantee that any of the actions suggested in this proposed rule will become final, and ASCs and others have until September 27, 2019, to submit comments that could influence CMS’ final decisions that will be reflected in the final rule. ASCA encourages interested members to submit comments. Please contact Kara Newbury at knewbury@ascassociation.org with any questions. Once the comment period closes, CMS will review the comments it receives and issue a final rule. That rule is required by statute to be released no later than November 2, 2019.