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CY2017 Medicare Outpatient Prospective Payment System (OPPS) Proposed Rule Contact: Ivy Baer, ibaer@aamc.org Ayeisha Cox, aycox@aamc.org Mary Mullaney, mmullaney@aamc.org Scott Wetzel, swetzel@aamc.org Susan Xu, sxu@aamc.org August 2, 2016
CY 2017 OPPS Proposed Rule Published in the Federal Register on July 14, 2016, at page 45604 Available at: https://www.gpo.gov/fdsys/pkg/fr-2016-07- 14/pdf/2016-16098.pdf Comments due: September 6, 2016 AAMC OPPS Resources: www.aamc.org/hospitalpaymentandquality
TODAY S TOPICS Section 603 Packaging Policies New comprehensive APCs (C-APCs) Transplant & Organ Procurement EHR Meaningful Use Quality Reporting Program
Payment Update Based on IPPS market basket percentage: +2.8% Productivity Adjustment: -0.5% Statutory Reduction: -0.75% Impact on All Hospitals: +1.7% Impact on Major Teaching Hospitals: +1.2% Payment rate increase by conversion factor adjustment of 1.55%
603 of Bipartisan Budget Act of 2015
603 of the Bipartisan Budget Act of 2015 Made significant changes to OPPS payment for remote HOPDs: After 1/1/2017, no OPPS payment for items and services furnished by an off campus outpatient department of a hospital if that OPD had not billed under OPPS prior to November 2, 2015, except if furnished by a dedicated ED Payment to be made under an applicable payment system as of January 1, 2017
603 of the Bipartisan Budget Act Defines excepted items and services as those services furnished on or after January 1, 2017 in: Dedicated Emergency Department (ED) On-Campus Location Within 250 yards of the main campus
When Can No Longer Bill Under OPPS Relocation of Off-Campus PBDs Off-campus PBDs will lose excepted status if move or relocate from physical address that was listed on hospital enrollment form as of November 1, 2015; possible exception to be developed for disaster/extraordinary circumstances. Expansion of Clinical Family of Services at an Off-Campus PBD If add new clinical families of services after November 2, 2015, wont be paid under OPPS Change of Ownership Excepted status transferred to new ownership only if ownership of the main provider is also transferred and the Medicare provider agreement is accepted by the new owner
Clinical Families of Services
What s the Applicable Payment System? If not excepted, no payment under OPPS in 2017 Could qualify as an ASC or a CMHC, but then no 340B and time lag to qualify For 2017: non-facility rate under physician fee schedule Will be paid to physicians no payment to hospitals Hospital can bill for services not paid under OPPS, such as labs that are not packaged
2018 When CMS hopes to be ready to with an applicable payment system
Impact on 340B Under 340B HRSA requires that the clinic be reported as a reimbursable cost center on the hospital s cost report ASCs and CMCHs wouldn t qualify Must ask CMS to confirm that PBDs will still be reported as reimbursable cost centers Remember: legislation only changes payment
If the rule is finalized as proposed What to do: Submit an amended Medicare provider enrollment form for these locations; submit voluntary attestation to MAC that PBDs meet the provider-based requirements Keep track of costs Submit bills (they will not be paid; you want to build the case for the costs you incurred)
603: AAMC Concerns AAMC Concerns Untenable to not pay hospitals for services in PBDs in 2017 Very narrow reading of statute: can t relocate or expand services without losing HOPD status Same outpatient department may be paid under OPPS for some services, alternative payment system for others Impact on 340B Drug Pricing Program
Packaging Policies
Proposed New Packaging Policy CMS continues to expand packaging policy: Lab tests: package all lab tests on the same claim, even when a lab test is ordered for a different purpose by a different practitioner (vs. current policy that allows separate payment for unrelated lab tests) Services with Conditional Packaging Status Indicator Q1 or Q2: expand conditional packaging policy from same date of service to same claim.
Expanded Lab Packaging No separate payment for unrelated lab tests on the same claim Discontinue reporting L1 code Expanded exemptions: All advanced diagnostic lab tests (vs. current policy of excluding all molecular pathology tests and preventive lab tests) TBD as defined in section 1834A(d)(5)(A))
Q1/Q2 Conditional Packaging Services Expand Q1 and Q2 conditional package policy from on the same date of service to on the same claim > 800 codes with status indicator Q1 or Q2 e.g. various X-ray exams, certain ultrasound exams, and various pathology tests Package Q1 services when on the same claim with S, T, or V procedures; Q2 with T procedures For details of codes with status indicator Q1/Q2, please refer to the Addendum B table on the CMS 2017 OPPS website
New Comprehensive APCs
Comprehensive-APCs Package payment for all adjunctive services and procedures into the most costly primary procedure (J1 status indicator code) When more than 1 primary procedure, pay only the most expensive procedure Complexity adjustment for certain pairs of primary procedures Secondary Items Adjunctive services Primary Care Service Secondary Services Adjunctive Procedures
New Comprehensive-APCs 2015 Implemented 25 C- APCs 2016 Finalized 10 additional C- APCs 2017 Proposing 25 additional new C-APCs https://www.gpo.gov/fdsy s/pkg/fr-2016-07- 14/pdf/2016-16098.pdf (p. 45621-45622)
Comprehensive-APCs For 2017, CMS not proposing extensive changes to the already established methodology used for C-APCs C-APC methodology made effective in CY 2015 Defining the services assigned to C-APCs as primary services or a specific combination of services performed in combination with each other Following the C-APC payment policy methodology of packaging all covered OPD services on a hospital outpatient claim reporting a primary service that is assigned to status indicator J1 or reporting the specific combination of services assigned to status indicator J2, excluding services that are not covered OPD services or that cannot by statute be paid under the OPPS No Change No Change No Change
Transplant & Organ Procurement
Organ Transplant CMS proposes to change performance thresholds in order to decrease the number of unused, recovered organs. Increases the observed to expected (O/E) ratio of patient deaths and graft failures to 1.85 (up from 1.5) for solid organ transplant programs CMS may explore other approaches in the future and focus on optimizing effective use of available organs instead of adjusting CMS outcomes thresholds
Organ Procurement CMS makes several proposals in order to ensure more consistent requirements with Organ Procurement Organizations Revises the definition of eligible death to include donors up to age 75 and changes clinical criteria for donors with multi-system organ failure Aligns regulations on aggregate donor yield for OPO outcome performance measures to align with Scientific Registry of Transplant Recipients Reduces the amount of paper documentation that must be sent to a receiving transplant center
EHR Meaningful Use
EHR Meaningful Use 90-Day Reporting Period CMS proposal: In 2016, EHR reporting period is any continuous 90- day period in CY 2016 for EPs, eligible hospitals, and CAHs that have not successfully demonstrated meaningful use in a prior year (new participants) and the full CY 2016 for EPs, eligible hospitals, and CAHs that have successfully demonstrated meaningful use in a prior year (returning participants). EPs and eligible hospitals New Participants Continuous 90-day period in CY2016 and applies for 2017 and 2018 payment adjustment years Returning Participants Reporting period is full CY 2016 and applies for the 2018 adjustment year **Does not apply to state Medicaid EHR Incentive Program
EHR Meaningful Use Reduced Thresholds CMS proposes to reduce a subset of thresholds for eligible hospitals attesting under the Medicare EHR Incentive Program In 2017 for Modified Stage 2 View Download Transmit (VDT): from 5% to at least one patient In 2017 and 2018 for Stage 3 Patient Electronic Access to Health Information Patient Access: from more than 80% to more than 50% Patient-Specific Education: from more than 35% to more than 10% Coordination of Care VDT: from more than 5% to at least one patient Secure Messaging: from more than 25% to more than 5% Health Information Exchange Patient Care Record Exchange: from more than 50% to more than 10% Request/Accept Patient Care Record: from more than 40% to more than 10% Clinical Information Reconciliation: from more than 80% to more than 50% Public Health and Clinical Data Registry Reporting Any combination of six measures to any combination of three measures **Does not apply to state Medicaid EHR Incentive Program
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31 Proposed Quality Metrics for OQR and VBP
Quality Measures/Programs in the CY 2017 Proposed Rule Outpatient Quality Reporting (OQR) Program CY 2020: Seven new measures proposed: Two measures assessing hospital visits following outpatient chemotherapy treatment and surgery 5 Outpatient and Ambulatory Surgery (OAS) Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey questions No measures proposed for removal Hospital Value Based Purchasing (VBP) Program FY 2018 Change to HCAHPS pain management related questions for VBP 32
33 Hospital Outpatient Quality Reporting (OQR) Program
Admissions and ED Visits Following Outpatient Chemotherapy (OP-35) 34 Calculates rates of inpatient admissions and ED visits within 30 days following chemotherapy. Performance period = CY 2018; Payment determination = CY 2020 Claims based measure Includes chemotherapy for all cancers, except Leukemia Patients attributed to HOPD that administered Chemotherapy Not NQF adjusted; Not SES adjusted; MAP conditionally supported (based on NQF endorsement and SES trial period review).
Admissions and ED Visits Following Outpatient Chemotherapy (OP-35), Cont. Hospitals will have two separate rates calculated for patient visits following chemotherapy Hospital Score OP-35 Inpatient admissions ED visits* *ED visits involve: anemia, dehydration, diarrhea, emesis, fever, nausea, neutropenia, pain, pneumonia, sepsis 35
Hospital Visits After Outpatient Surgery (OP-36) Calculates single rate of inpatient admissions, ED visits, and observation stays within 7 days of outpatient surgery Performance period = CY 2018; Payment determination = CY 2020 Claims based measure NQF endorsed; Not SES adjusted; MAP approved (but noted that SES should be considered) 36
Hospital Visits After Outpatient Surgery (OP-36), Cont. Hospitals will have a single rate calculated for patient visits following outpatient surgery Hospital Score OP-36 Inpatient admissions ED visits Observation stays 37
Outpatient Patient Experience Survey Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) Survey proposed for CY 2020 OAS CAHPS contains 37 questions 5 of these questions proposed for OQR These 5 include 3 composite measures: Each composite contains at least 6 additional questions, and 2 global rating questions 38
Outpatient Patient Experience Survey, Cont. OAS Question Topics: Pain Related Questions [Communications Domain] HOPD s not scored on this question 39
Outpatient Patient Experience Survey, Cont. Performance period = CY 2018; payment determination = CY 2020 Demographic information is collected on survey Not NQF endorsed OAS CAHPS Survey (and all OQR program measures) are pay-for-reporting CMS requests feedback on pain related questions CMS started voluntary national submission of OAS CAHPS Survey in January, 2016 40
Additional OQR Related Information CMS seeks feedback on ecqm opioid measure (not proposed) Extension of extraordinary circumstances deadline from 45 to 90 days Clarification regarding appeals: hospitals that fail to submit a timely reconsideration request will not be eligible to appeal with Provider Reimbursement Review Board 41
42 Hospital Value Based Purchasing (VBP) Program
Proposed Removal of HCAHPS Pain Management Questions from VBP Starting FY 2018, CMS proposes to exclude three HCAHPS pain management related questions from VBP performance Change is a response to opioid epidemic Pain management questions would remain on HCAHPS and would continue to be publicly reported CMS currently working on alternative pain management question language AAMC previously supported legislation that would achieve this goal 43
AAMC Quality Resources Individual Institution Reports AAMC Hospital Compare Benchmark Report (swetzel@aamc.org) AAMC Quality Report (mbaker@aamc.org) AAMC Impact Report (mbaker@aamc.org) General Resources AAMC IPPS & OPPS Regulatory Page - Contains previous OPPS webinars and comment letters (www.aamc.org/hospitalpaymentandqu ality) AAMC Quality Spreadsheet Updated (https://www.aamc.org/download/41283 8/data/aamcqualitymeasuresspreadshe et.xlsx) 44
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