Image by Jan from PixabayFor years, ambulatory surgery center (ASC) operators have faced a basic reimbursement dilemma in post-surgical pain care.
Opioids are cheap and easy to use, while some non-opioid alternatives are harder to justify from a payment perspective. The Non-Opioids Prevent Addiction in the Nation (NOPAIN) Act is meant to address that conundrum.
The law, enacted in late 2022 and effective Jan. 1, 2025, temporarily allows separate Medicare payment for qualifying non-opioid drugs, biologics and devices used for pain management in ASCs and hospital outpatient departments (HOPDs). For the ASC industry, the policy is aimed at removing a financial barrier that advocates say has long made it harder for facilities to use some non-opioid options, even as pressure has grown to reduce unnecessary opioid exposure after surgery.
“As a physician managing opioid use disorder (OUD) treatment, I know the most effective way to address OUD is preventing avoidable opioid exposure in the first place,” Dr. Ayesha Appa, SVP and head of medical affairs at Boulder Care, told ASC News. “Surgery is one of the most common first exposures to opioids, and for some patients, that health care experience can become the start of long-term use or addiction.”
Portland, Oregon-based Boulder offers digital outpatient care for OUD and alcohol use disorder (AUD), including prescriptions for medications for addiction treatment (MAT).
With Americans continuing to struggle with OUD and the U.S. health care system overall looking to better address behavioral health conditions (in theory, minimizing costs in the process), The NOPAIN Act is increasingly relevant for ASCs. That’s partly why the topic was spotlighted on a recent Advancing Surgical Care Podcast from the Ambulatory Surgery Center Association (ASCA).
In the past, under traditional ASC payment structures, facilities often had to absorb the cost of certain non-opioid products, making opioids the straightforward economic choice even when clinicians and patients might have preferred alternatives.
That dynamic had already begun to shift in the ASC setting before Congress stepped in with The NOPAIN Act, according to Chris Fox, executive director of Voices for Non-Opioid Choices. Speaking on the recent ASCA podcast, Fox pointed to an earlier U.S. Centers for Medicare & Medicaid Services (CMS) policy change.
“In 2019, for the first time, a separate payment was made available for procedures performed in an ASC for qualifying non-opioid products,” Fox explained.
CMS later measured the impact of that move and found that from 2019 to 2020, there was a 120% increase in qualifying non-opioid product utilization attributed to the policy change, he noted on the podcast.
Fox’s organization – Voices – is a non-partisan coalition dedicated to preventing opioid addiction and abuse by advocating for increased patient and provider access to non-opioid pain management therapies.
For The NOPAIN Act, that earlier increase is a critical proof point. The law largely builds on the same premise that if Medicare pays separately for qualifying non-opioid pain treatments, providers – including ASCs – may be more likely to offer them. It also extended similar reimbursement treatment to the hospital setting.
“I feel like we have a fairly large pilot program that’s been conducted in the ASC setting, and if past is prologue, we expect utilization of non-opioids to increase in the hospital setting in the same way that they did in the ASC,” Fox said.
Bob Poznanovich, founder and principal advisor of Poznanovich Behavioral Health Advisory Group and a long-time executive working within the substance use disorder (SUD) treatment space, told ASC News that he has seen the impacts of opioid prescribing firsthand.
“One of the hardest truths in our field is that many people did not start out looking for drugs – they started out as patients,” Poznanovich said. “I have seen it too many times over the years. Someone has a routine surgery, the procedure goes well, but the pain medication that follows starts a very different and much longer problem.”
Indeed, that first opioid exposure can trigger a chain of consequences that include dependence, treatment, relapse risk, recovery, and very real human and financial costs that can last for years, he said.
“That is why the NOPAIN Act matters,” Poznanovich continued. “It gives ASCs and outpatient providers more support to use qualifying non-opioid pain options, helping reduce unnecessary first exposure to opioids in the first place.”
Dr. Ming Wang, medical director for Caron Pennsylvania, echoed those sentiments.
“By reducing financial barriers, the legislation may encourage broader use of multimodal pain strategies – including regional and local anesthesia, non-opioid medications such as NSAIDs and acetaminophen and non-pharmacologic approaches like physical therapy or acupuncture when appropriate,” Wang told ASC News. “These approaches can help manage pain while minimizing the need for opioids and avoiding common opioid-related side effects.”
Founded in 1957, Caron Treatment Centers is one of the largest nonprofit providers of inpatient and outpatient SUD treatment services in the U.S.
Additionally, while The NOPAIN Act is focused on Medicare, it likely has implications across payer categories.
“Because the NOPAIN Act is tied to Medicare, it also has the potential to influence national standards of care and shift the broader culture of perioperative pain management toward safer, evidence-based alternatives,” Wang said.
For ASC operators, these conversations are becoming more frequent.
The law does not solve every issue tied to pain management, and not every non-opioid approach falls within its separate payment structure. Even so, it is an attempt to change the economics that have historically favored opioids in some outpatient settings.
Still, there are unresolved questions about how far the policy goes and how long it will last.
Fox noted on the ASCA podcast that the law is temporary and that its future will depend in part on how CMS evaluates further results.
“When Congress enacted this law at the end of 2022, which went into effect on Jan. 1, 2025, it’s a three-year policy, and CMS is tasked with evaluating the impact of this law,” Fox said.
That timeline gives providers, advocates and policymakers a limited window to show the law made a difference.
For ASCs, that means the NOPAIN Act is both a current payment change and a test of what comes next. If ASCs use its benefits, if CMS sees measurable impact and if Congress decides to extend the policy beyond 2027, the law could become more than a temporary reimbursement adjustment.
“… [Safer], non-opioid pain care needs to be just as easy for providers to offer and reimburse as opioids,” Appa emphasized.
ASCA was also an early supporter of The NOPAIN Act, ASCA Chief Advocacy Officer Kara Newbury said on the podcast.
As Voices and ASCA support the continuation of The NOPAIN Act, ASCA also plans on advocating for streaming and improving the reimbursement process, Newbury said.
“We have heard from some of our members that they don’t fully understand how to achieve reimbursement for the codes, they are contractor price, but it’s a little convoluted what you can bill,” she said on the ASCA podcast.
