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Association Comments on CY 2020 OPPS, PFS Proposed Rules

In Sept. 27 letters to the Centers for Medicare & Medicaid Services (CMS), America’s Essential Hospitals commented on the calendar year (CY) 2020 Outpatient Prospective Payment System (OPPS) and Physician Fee Schedule (PFS) proposed rules. The association urged the agency to reverse policies that will result in significant funding cuts to essential hospitals and hinder access to care.

OPPS Comments

As proposed, the OPPS rule would continue to phase in site-neutral payment cuts to hospital provider-based departments (PBDs) and reduce Medicare Part B reimbursement for drugs purchased through the 340B Drug Pricing Program. Additionally, the rule would impose new requirements for hospitals to post charges they negotiate with insurers for a limited set of “shoppable” services.

In its comments on the OPPS rule, America’s Essential Hospitals urged CMS to:

  • pay for drugs administered at 340B hospitals at the statutory default rate of average sales price (ASP) plus six percent, instead of paying at 77.5 percent of ASP, which has already been deemed unlawful by a federal district court;
  • craft a remedy for 340B cuts that would pay hospitals for forgone reimbursement plus interest, and that does not have to be budget-neutral or require beneficiaries to pay copayments on drugs for which payments were reduced in 2018 and 2019;
  • withdraw its policy of reducing payments to excepted provider-based departments, which is unlawful and was recently invalidated by a federal district court;
  • ensure efforts to improve price transparency:
    • are limited to the types of information important and useful to consumers;
    • are within the agency’s legal authority;
    • mitigate the risk of harm to competition and consumers; and
    • do not add administrative burden to providers;
  • withdraw its proposal to require prior authorization for a list of Medicare services; and
  • mitigate concerns about the effect of removing total hip arthroplasty procedures from the inpatient only list on Medicare payment models.

PFS Comments

The PFS rule would:

  • continue the site-neutral payment rate for non-excepted PBDs at 40 percent of the OPPS rate;
  • revise payment and coding for physician evaluation and management (E/M) services;
  • seek to align the Medicare Shared Savings Program (MSSP) quality score with the quality score in the Merit-based Incentive Systems (MIPS); and
  • make year four updates to the Quality Payment Program (QPP) for eligible clinicians.

In its comments, the association:

  • urged CMS to ensure that non-excepted PBDs are adequately reimbursed for the costs of care by being paid no less than 75 percent of the OPPS payment rate;
  • applauded CMS for reversing its previously finalized policy to consolidate the payment rates for physician E/M visits;
  • asked that CMS maintain the current scoring methodology for accountable care organizations in the MSSP and refine existing MSSP measures;
  • provided recommendations on the QPP and a proposed MIPS Value Pathways framework;
  • called on CMS to refine measures in the MIPS by including risk adjustment for sociodemographic factors and delaying implementation of an all-cause unplanned admission measure; and
  • urged the agency to ensure the proposed bundled payments for overall treatment of opioid use disorder account for the complexity of patients essential hospitals serve.

Contact Senior Director of Policy Erin O’Malley at eomalley@essentialhospitals.org or 202.585.0127 with questions.

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About the Author

Shahid Zaman is a senior policy analyst at America's Essential Hospitals.

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