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Tony Mira, Chairman and Chief Executive Officer of MiraMed

Inside information for anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs) on the most current best practices during changing times.

CMS’s 2019 Anesthesia-Related Payment Proposals for Outpatient and Ambulatory Services

The proposed rule for the Outpatient Prospective Payment System and the Ambulatory Surgery Center Payment System for 2019 includes proposals to change payment policy for non-opioid postsurgical pain management drugs, expand reimbursement for anesthesia services for some knee surgeries to outpatient settings and remove questions about pain communication from patient surveys.

Non-opioid pain management, anesthesia for knee procedures and patient surveys of pain communication are among the anesthesia-related topics covered in the Centers for Medicare and Medicaid Services' (CMS's) 2019 proposed rule for the Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) Payment System, published July 25, 2018. CMS is taking comments on the proposal until September 14, 2018. Publication of the final rule is expected in early November.

Non-Opioid Alternatives

In response to recommendations from the President's Commission on Combating Drug Addiction and the Opioid Crisis, CMS is considering revising how it pays for non-opioid pain medications that are currently packaged as surgical supplies. The purpose of the proposal is to incentivize the use of non-opioid medications in postoperative pain management to support the government's multi-pronged effort to curb opioid over-prescribing, support pain management research and address the opioid epidemic. The agency proposes to pay separately for the medications at the average sales price (ASP) plus six percent for covered procedures performed in an ASC while keeping the current packaging policy for surgeries in hospital outpatient settings.

In its 2017 report, the Commission asked CMS to review and modify policies that might discourage the use of non-opioid pain treatments, including certain bundled payments that might make these alternative medications cost prohibitive for hospitals and physicians. "The current CMS payment policy for 'supplies' related to surgical procedures creates unintended incentives to prescribe opioid medications to patients for postsurgical pain instead of administering non-opioid pain medications," the report states.

CMS currently provides one all-inclusive bundled payment to hospitals for all "surgical supplies," which includes hospital-administered drugs for postsurgical pain—a policy that results in hospitals receiving the same fixed fee from Medicare whether an opioid or non-opioid drug is given.

A CMS evaluation of packaging policies under the OPPS/ASC payment system showed decreased utilization of certain non-opioid alternatives in ASCs, but not in hospital outpatient department settings. In light of these findings, CMS proposes unpackaging and paying separately for the cost of these drugs in ASCs to encourage their use.

CMS cites the example of Exparel (approved by the Food and Drug Administration in April 2018 for a new indication as an interscalene brachial plexus nerve block for postsurgical analgesia). After having pass-through payment status for three years (2012-2014), the drug was packaged as a supply beginning in 2015.

CMS's analysis indicates the policy change did not discourage use of the drug in hospital outpatient settings. In fact, utilization increased 229 percent, with claims reporting Exparel between 2013-2017 increasing 222 percent—increases that persisted even after the pass-through period ended at the end of 2014. "If the packaging policy discouraged the use of drugs that function as a supply or impeded access to these products, we would expect to see a significant decline in utilization of these drugs over time," CMS observes in the proposal. "In fact, under the OPPS, we observed the opposite effect for several drugs that function as a supply, including Exparel."

The agency found a different scenario in ASCs. During the same five-year period, 2013-2017, claims reporting Exparel decreased overall by 16 percent in ambulatory settings. After the pass-through payment status ended at the end of 2014, claims dropped 62 percent. However, during 2013-2014, when the drug had pass-through status, claims rose 192 percent, which suggests that separate payment could help incentivize increased use of the drug in ambulatory settings, CMS reports.

Though CMS proposes changing payment for these drugs in ASCs but not in outpatient hospital settings, the agency is interested in comments and peer-reviewed evidence showing whether separate payment in outpatient hospital settings could incentivize further use of non-opioids such as Exparel and decrease opioid use and addiction among beneficiaries.

(Legislation that ties in with this proposal has been passed in the House. HR 5804, the Post-Surgical Injections as an Opioid Alternative Act, would incentivize post-surgical injections as a pain treatment alternative to opioids by reversing the reimbursement cut for these treatments in the ASC setting and collect data on a subset of related codes. ABC is following this bill, which could have significant implications for anesthesia practitioners. The bill is part of HR 6, the Support for Patients and Communities Act, a comprehensive bipartisan bill passed by the House Energy and Commerce Committee to combat the opioid crisis that includes several additional Medicaid, Medicare and public health reforms.)

Anesthesia for Knee Procedures

Also of interest to anesthesia practitioners in the proposed rule is the recommendation to remove CPT Code 01402 (Anesthesia for open or surgical arthroscopic procedures on knee joint; total knee arthroplasty) from the inpatient only (IPO) list, which consists of procedures and services CMS has identified as typically only provided in inpatient settings and which, therefore, are not paid under OPPS. If finalized, this rule would reimburse anesthesia practitioners for anesthesia services for these surgeries in outpatient settings. (Please note: this is a national proposal. Some anesthesia providers may already be receiving Medicare reimbursement for these services in some locations.)

The effective management of non-Medicare patients in outpatient settings has led to the removal of many services from the IPO list. CMS believes CPT 01402 merits removal because it is closely related to CPT Code 27447 (Arthroplasty, knee, condyle and plateau; medical and lateral compartments with or without patella resurfacing (total knee arthroplasty)), which was removed from the IPO list in 2018, and because the service is already being performed in many hospitals on an outpatient basis.

HCAHPS Pain Questions

CMS also proposes some changes to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey that would take effect in 2022. The agency suggests removing the three Communication About Pain questions that were added to the HCAHPS survey in 2018 for the 2020 payment determination under the Quality Payment Program. These questions were added in place of the previously adopted pain management questions, which were removed to reduce pressure among physicians to prescribe opioids in an attempt to boost their HCAHPS scores. The current Communication About Pain questions are as follows:

  • ​  ​During this hospital stay, did you have any pain? 
        Yes No

  • ​  During this hospital stay, how often did hospital staff talk with you about how much pain you had?
        Never Sometimes Usually Always

  • ​ During this hospital stay, how often did hospital staff talk with you about how to treat your pain?
        Never Sometimes Usually Always

Though CMS notes that there is no known connection between scores on these questions and opioid prescribing practices, the agency proposes removing the questions in 2022 because some stakeholders remain concerned that the questions could continue to pressure clinicians to prescribe more opioids in order to achieve higher HCAHPS scores.

Site Neutrality Expansion, 340B

In proposals that more broadly affect providers in outpatient hospital departments and ASCs, CMS is also calling for expansion of the site-neutral payment policy mandated by the Bipartisan Budget Act of 2015 (BBA). That policy reduced payments to off-campus provider-based hospital departments for outpatient services to the amounts paid to physician clinics, except for sites that were already billing under the hospital outpatient rate when the BBA went into effect, as well as emergency services provided by off-campus emergency departments.

In 2019, CMS wants to expand the site-neutrality policy to reduce payments for certain services to these initially-exempted sites as well. The goal, according to the agency, is to temper the impact of the shift among providers away from physician offices to costlier hospital outpatient settings in the delivery of many services. The proposal would save approximately $760 million. A portion of those savings would be passed on to patients in the form of reduced cost-sharing, according to CMS.

In addition, CMS proposes extending reimbursement cuts for outpatient drugs under the 340B program to the off-campus hospital departments that have already experienced payment reductions under the site neutrality policy. In 2018, CMS finalized a policy to pay for outpatient drugs purchased by hospitals under the 340B program at the ASP minus 22.5 percent—considerably less than the ASP plus six percent that is typical under the payment system. Those 340B reductions did not apply to these off-campus departments; however, CMS is calling for a reversal of that policy (with exemption for children's hospitals, some cancer hospitals and some rural hospitals).

With best wishes,

Tony Mira
President and CEO