Against strenuous objection from hospital trade groups, ambulatory surgery centers can start receiving reimbursement for fee-for-service Medicare beneficiaries undergoing total knee replacement and mosaicplasty procedures, coronary angioplasties, and placements of stents starting Jan. 1.
"We have determined these procedures would not be expected to pose a significant risk to beneficiary safety when performed in an ASC," the Centers for Medicare & Medicaid Services said in its released Friday. The agency added its belief that "standard medical practice would not dictate that the beneficiary would typically be expected to require active medical monitoring and care at midnight following the procedure."
The American Hospital Association, which on multiple grounds, said Friday the agency's policy shift could harm beneficiaries. "It is very disappointed that CMS chose to finalize this policy and we continue to believe that it is not clinically appropriate. We are concerned that this decision will pose serious risks and have negative quality of care implications for vulnerable Medicare patients," said Roslyne Schulman, director of AHA policy.
Hospital officials asserted that, should a complication develop in an ASC patient, appropriate backup expertise is not as readily available in an ASC as it is in a hospital outpatient department or inpatient setting. The ASC must summon an ambulance and get that patient to an appropriate higher level of care setting, which may be many miles away. (ASCs, on the other hand, that many hospital-affiliated clinics are no less remote and also would require ambulance transport in the event of serious complications.)
"Nearly half of all Medicare beneficiaries live with four or more chronic conditions, and one-third have one or more limitations in activities of daily living (ADL) that limit their ability to function independently ... (and) make even simple procedures more complicated," the AHA said.
CMS also declined to require that ASCs "have a certain amount of experience in performing a procedure before being eligible for payment for performing the procedure under Medicare," as hospital groups had sought.
And the agency was not persuaded by the AHA's argument that the policy change would hurt beneficiaries financially, costing them more out-of-pocket. Because outpatient department procedures have a Medicare-imposed deductible cap, total costs are lower for procedures performed there than in an ASC.
But CMS noted that its new rules requiring price transparency, through a searchable website offering an tool, allows beneficiaries to "compare their potential cost-sharing liability for procedures performed in the hospital outpatient setting versus the ASC setting ... (which) therefore mitigates the commenters' concern."
Besides, the agency said in this final rule, "despite the higher cost-sharing, some beneficiaries, especially those with supplemental insurance, may still choose to have their procedure performed in the ASC setting."
CMS said in its final rule that it did not expect many fee-for-service beneficiaries would undergo a total knee arthroplasty in an ASC as opposed to a hospital outpatient or inpatient setting, because few would be "suitable candidates" on account of age, comorbidities, or body mass index putting them at higher risk for complications. It noted that, for beneficiaries enrolled in Medicare Advantage plans in 2016, "over 800" underwent a TKA in an ASC.
But, the agency said, "We believe that beneficiaries not enrolled in an MA plan should also have the option of choosing to receive the TKA procedure in an ASC setting based on their physicians' determinations."
The agency said physicians should exercise their clinical judgment when choosing an appropriate setting for each patient undergoing these outpatient procedures. Hospital officials, in their comments on the proposed rule, worried about conflicts of interest among physicians who own ASCs.
For its part, the Ambulatory Surgery Center Association, representing many of the nation's nearly 6,000 ASCs, that it is grateful for CMS's new policy.
"Proposing to add total knee arthroplasty to our procedures list so soon after moving it from the inpatient only list, as well as a number of cardiac codes, speaks well to the confidence that CMS has in the ability of physicians to use well-established patient selection criteria to move appropriate patients to the lower-cost ASC setting," said ASCA CEO Bill Prentice in an emailed release.
San Diego-based health consultant Nathan Kaufman said that the new rule could ricochet financially throughout the hospital industry, which will have a new and large competitor for common knee and coronary procedures in the enormous Medicare fee-for-service market.
"While many in the industry have been focusing on dramatic headline catching changes, e.g., CVS-Aetna, Amazon, etc., these incremental changes in site of service adopted by CMS will have a far greater impact over the next five years," he said.
For health systems that have collaborated with physician groups that have moved joints and stents to the outpatient setting, the policy change "is not a surprise." He expects more joint ventures between hospitals and ASCs and their independent physician groups "to migrate appropriate interventional cardiology cases to the outpatient setting."
But, Kaufman added, "too many health systems have been distracted by the 'noise' associated with value based care and population health and thus have been caught by surprise." For those latecomers to these changes, he said, "it will be expensive to buy their way into the ambulatory orthopedic business."
Specific codes to be reimbursed to ASCs as of 2020 are listed .