
The Centers for Medicare & Medicaid Services (CMS) on Wednesday released its proposed rule for the Calendar Year (CY) 2025 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System.
This annual proposed rule, which includes a 60-day comment period ending on September 9, 2024, will be finalized in early November. The proposed updates and policies outlined in the rule are designed to impact approximately 3,500 hospitals and 6,100 ASCs working within the Medicare program.
“In addition to proposing payment rates, this year’s rule includes proposed policies that align with several key goals of the Administration, including addressing health disparities, expanding access to behavioral health care, improving transparency in the health system, and promoting safe, effective, and patient-centered care,” CMS wrote in a fact sheet on the proposed rule.
For CY 2025, CMS proposes a 2.6% increase in ASC payment rates, consistent with the productivity-adjusted hospital market basket update. This proposal extends the interim period for applying the hospital market basket update to ASC payment system rates through CY 2025.
ASCs that meet the relevant quality reporting requirements will be eligible for this update, which is based on a proposed hospital market basket percentage increase of 3%, adjusted down by 0.4 percentage points for productivity.
“The update applies to ASCs meeting relevant quality reporting requirements,” CMS wrote.
CMS also proposed updating OPPS payment rates for hospitals that meet applicable quality reporting requirements by 2.6%.
Broadly, these proposed rate updates are in line with industry expectations.
“The proposed net rate update of +2.6% for both OPPS/ASCs reads as in line with our modeling expectations for our outpatient hospital/ASC providers coverage (HCA, THC, UHS and UNH),” Stephens analysts wrote in a Wednesday note. “The proposed OPPS and ASC rate update proposals are each somewhat above their L-T historical preliminary reimbursement trends of +2.4% and +1.7%, respectively.”
In its 984-page proposed rule, CMS projected that 2025 Medicare payments to OPPS providers and ASCs will total about $88.2 billion and about $7.4 billion, respectively, when factoring in estimated changes in enrollment, utilization and case-mix.
Health disparities and behavioral health
The proposed rule also includes several policies aimed at addressing health disparities, expanding access to behavioral health care, improving system transparency, and promoting safe, effective and patient-centered care.
Those changes include strengthening reimbursement for intensive outpatient programs (IOPs) and partial hospitalization programs (PHPs) for mental health and substance use disorder (SUD) treatment.
CMS additionally proposed implementing Section 4135 of the Consolidated Appropriations Act (CAA) of 2023, which allows for temporary additional payments for certain non-opioid treatments for pain relief in the hospital outpatient department and ASC settings from Jan. 1, 2025, through Dec. 31, 2027.
“We are proposing that seven drugs and one device qualify as non-opioid treatments for pain relief, and we propose these products be paid separately in both the HOPD and ASC settings starting in CY 2025,” CMS wrote. “We are soliciting comment and supporting documentation from interested parties on additional products that may qualify for separate payment under this provision starting in CY 2025.”
ASC Quality Reporting Program
The Ambulatory Surgical Center Quality Reporting (ASCQR) Program continues to be a focal point in the proposed rule.
Participating ASCs must report on specified quality measures to avoid a 2-percentage-point reduction in their annual payment rate update.
Key proposed measures for the CY 2025 reporting period include:
- Facility Commitment to Health Equity (FCHE): Starting CY 2025, ASCs will report on their commitment to health equity, impacting the CY 2027 program determination.
- Screening for Social Drivers of Health (SDOH): This measure begins with voluntary reporting in CY 2025, followed by mandatory reporting from CY 2026.
- Screen Positive Rate for SDOH: Similar to the screening measure, this will also shift from voluntary to mandatory reporting between CY 2025 and CY 2026.
Additionally, CMS proposes modifying the immediate measure removal policy to an immediate measure suspension policy to better align with other quality reporting programs and enhance transparency in decision-making.
“In the event of an immediate suspension, CMS would address the suspension and propose to retain, modify, or remove the measure in the next feasible rulemaking cycle,” CMS wrote. “CMS is proposing this change to align measure suspension policies across the REH, HOPD, and ASC quality reporting programs. Additionally, our goal is to increase transparency and the public’s voice in decision-making through the rulemaking process before potentially removing a measure.”
CMS is also proposing to remove the “MRI Lumbar Spine for Low Back Pain” measure starting with the CY 2025 reporting period and CY 2027 payment determination, citing that recent studies have shown that performance or improvement on this measure did not result in better patient outcomes.
Additionally, the “Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac, Low-Risk Surgery” measure is also proposed for removal in the same timeframe.
“The wide range of cases per hospital outpatient department and lack of statistically distinguishable variation in performance indicates the measure does not provide sufficiently meaningful data to result in better patient outcomes,” CMS wrote.
Furthermore, CMS proposes that Electronic Health Record (EHR) technology be certified for all electronic Clinical Quality Measures (eCQMs) available for reporting in the Hospital OQR Program. This requirement ensures that hospitals can accurately capture and report data for all eCQMs in the measure set.
The final rule will solidify these proposals and set the stage for ASC operations and Medicare payments in CY 2025.
This is a developing story. Please return to ASCNews.com later for more information and updates.