CMS’ Proposed CY 2019 OPPS Rule: Top-Line Takeaways

On July 25, 2018, the Centers for Medicare & Medicaid Services (CMS) released the CY 2019 Outpatient Prospective Payment System (OPPS) proposed rule, and we are seeing several efforts to continue the push towards “site neutral” payments in off-campus provider-based departments (PBDs). This rule was issued weeks after the CY 2019 Physician Fee Schedule (PFS) proposed rule, and the atypical lag time between the two rules' release had stakeholders wondering how impactful these policies would be.

As important background to this year’s proposed OPPS rule, in 2015, Congress passed a provision that started to distinguish off-campus PBDs: those that were billing under OPPS prior to November 2015 (“excepted” or old PBDs) and those that began billing under OPPS after November 2015 (“non-excepted” or new PBDs). Currently, CMS is reimbursing “non-excepted” PBDs at 40 percent of the OPPS rate as a part of a longer-term effort by the agency to equalize payments between the outpatient and physician office settings. For 2019, CMS is proposing several policies that will bring payment rates for excepted (old) PBDs in line with the lower rates at non-excepted (new) PBDs.

While ACCC staff continues to analyze the CY 2019 proposed OPPS rule, below are top-line takeaways that we think are most important for ACCC members and their patients:

• For 340B participating entities, reduce payment for Part B drugs at non-excepted (new) off-campus PBDs. Last year, CMS finalized a proposal to reimburse 340B hospitals who were billing under OPPS for Part B drugs at Average Sales Price (ASP) minus 22.5 percent. This reduction was limited to the excepted PBDs. The non-excepted PBDs were billing for services under a special PFS rate of 40 percent of OPPS. As the non-excepted PBDs were billing under the PFS, they did not experience the reduction in 340B drug reimbursement. In response to some concerns that there may be shifting of patients to the non-excepted (new) PBDs to avoid the 340B cut, for CY 2019 CMS is proposing to extend the payment rate of ASP minus 22.5 percent for Part B drugs to include non-excepted off-campus PBDs at 340B hospitals. This may have a minimal impact on ACCC members, depending on how many have opened non-excepted HOPDs since November 2015.
• Reduce payment for clinic visits at excepted (old), off-campus PBDs. CMS is proposing to pay for a clinic visit at excepted (old) off-campus PBDs at the special PFS rate of 40 percent of the OPPS rate. The agency is proposing to not do this in a budget neutral way, and the impact will be an overall decrease of 1.2 percent in payments to hospitals, with $760 million in savings ($610 million accruing to Medicare and $150 million saved by beneficiaries in the form of reduced copays). This has the potential to significantly impact ACCC members, and signals CMS’ goal to ultimately transition reimbursement at all off-campus PBDs to rates they deem closer to the PFS.
• Reduce payment for service line expansions in excepted PBDs. CMS proposes to reduce payment for service line expansions in excepted (old) off-campus departments. If a department added services in new clinical families since November 2015, those services would be paid at 40 percent of the OPPS rate. Clinical families include drug administration and clinical oncology, radiation oncology, and imaging services. For example, if a department added a radiation oncology service line after November 2015, it would be paid at the reduced rate starting on January 1, 2019, instead of the full OPPS rate. CMS has proposed this policy twice before during the annual rule-making process, including in 2017, but it has not yet been finalized.
• Request for Information (RFI) for how CMS can implement a Competitive Acquisition Program (CAP) for Part B drugs. CMS is issuing an RFI for a CAP-like program (i.e., private vendors negotiating drug prices) for Part B drugs. This is a more detailed version of the concept outlined in the recent drug pricing blueprint RFI.

ACCC is continuing to analyze both the CY 2019 OPPS and PFS proposed rules for how they will impact ACCC cancer programs and their patients.

ACCC will host a webinar for members on the proposed rules on Wednesday, August 8, 2018, from 4:00 -5:00 PM EDT. For more information and to register click here. ACCC will be submitting comments on the proposed rules and encourages our members to do the same.

Public comments are due on Monday, September 10 for the CY 2019 PFS Proposed Rule, and on Monday, September 24 for the CY 2019 OPPS Proposed Rule. ACCC members are encouraged to contact the ACCC policy team with any questions or concerns.