Comment period open for Hospital Outpatient Prospective Payment System (OPPS) & Ambulatory Surgical Center (ASC) proposed rule for Calendar Year 2022

The Centers for Medicare & Medicaid Services (CMS) is proposing actions to address the health equity gap, ensure consumers have the information they need to make fully informed decisions regarding their health care, improve emergency care access in rural communities, and use lessons learned from the COVID-19 pandemic to inform patient care and quality measurements.

In accordance with President Biden’s Competition Executive Order, CMS is further strengthening its efforts to increase price transparency, holding hospitals accountable and ensuring consumers have the information they need to make fully informed decisions regarding their health care.

“As President Biden made clear in his executive order promoting competition, a key to price fairness is price transparency,” said HHS Secretary Xavier Becerra. “No medical entity should be able to throttle competition at the expense of patients. I have fought anti-competitive practices before, and strongly believe health care must be in reach for everyone. With today’s proposed rule, we are simply showing hospitals through stiffer penalties: concealing the costs of services and procedures will not be tolerated by this Administration.”

“CMS is committed to addressing significant and persistent inequities in health outcomes in the United States and today’s proposed rule helps us achieve that by improving data collection to better measure and analyze disparities across programs and policies,” said CMS Administrator Chiquita Brooks-LaSure. “We are committed to finding opportunities to meet the health needs of patients and consumers where they are, whether it’s by expanding access to onsite care in their communities, ensuring they have access to clear information about health care costs, or enhancing patient safety.”

The proposed rule includes the following actions:

Price Transparency
Hospital price transparency helps Americans know what a hospital charges for the items and services they provide. CMS takes seriously concerns it has heard from consumers that hospitals are not making clear, accessible pricing information available online, as they have been required to do since January 1, 2021.

CMS proposes to increase the penalty for some hospitals that do not comply with Hospital Price Transparency final rule. Specifically, CMS is proposing to set a minimum civil monetary penalty of $300/day that would apply to smaller hospitals with a bed count of 30 or fewer and apply a penalty of $10/bed/day for hospitals with a bed count greater than 30, not to exceed a maximum daily dollar amount of $5,500. Under this proposed approach, for a full calendar year of noncompliance, the minimum total penalty amount would be $109,500 per hospital, and the maximum total penalty amount would be $2,007,500 per hospital.

Based on information that hospitals have made public this year, there is wide variation in prices – even within the same hospital or the same system, depending on what each insurance plan has negotiated with that hospital. CMS is committed to ensuring consumers have the information they need to make fully informed decisions regarding their health care, since health care prices can cause significant financial burdens for consumers.

Health Equity
CMS is seeking input on ways to make reporting of health disparities based on social risk factors and race and ethnicity more comprehensive and actionable. This includes soliciting comments on potential collection of data, and analysis and reporting of quality measure results by a variety of demographic data points including, but not limited to, race, Medicare/Medicaid dual eligible status, disability status, LGBTQ+, and socioeconomic status.

Access to Emergency Care in Rural Areas
Since 2010, 138 rural hospitals have closed – disproportionately within communities with a higher proportion of people of color and communities with higher poverty rates. Rural communities experience shorter life expectancy, higher mortality, and have fewer local providers, leading to worse health outcomes than in other communities.

Rural hospital closures deprive people living in rural areas of crucial services, including access to emergency care. To address these concerns, Congress enacted Section 125 of the Consolidated Appropriations Act of 2021 (CAA), which establishes a new provider type for Rural Emergency Hospitals (REHs). REHs will be required to furnish emergency department services and observation care and may provide other outpatient medical and health services as specified by the Secretary through rulemaking. In this proposed rule, CMS is requesting information to inform the development of requirements that would apply to Rural Emergency Hospitals (REHs). This new provider designation will apply to items and services furnished on or after January 1, 2023.

CMS is seeking feedback on a wide-range of issues to help inform policy proposals for the CY 2023 rulemaking cycle, including feedback on the potential services to be provided by REHs; health and safety standards and quality measures to be established for REHs; and payment provisions for this provider type.

COVID-19 Lessons
To incorporate lessons learned from the COVID-19 pandemic, CMS is seeking comment on the extent to which hospitals are using flexibilities offered during the COVID-19 public health emergency (PHE) to provide mental health services remotely and whether CMS should consider changes to account for shifting practice patterns. In addition, CMS is proposing changes to measure how many of our nation’s front-line healthcare workers in hospital outpatient departments and ASCs are vaccinated against COVID-19, and to make this information available to the public so consumers know how many workers are vaccinated in different health care settings.

Improving Patient Experience and Outcomes
The Radiation Oncology (RO) Model aims to improve the quality of care for cancer patients receiving radiotherapy and move toward a simplified and predictable payment system. The RO Model tests whether prospective, site neutral, modality agnostic, episode-based payments to physician group practices, hospital outpatient departments, and freestanding radiation therapy centers for radiotherapy episodes of care reduces Medicare expenditures while preserving or enhancing the quality of care for Medicare beneficiaries.

CMS is proposing changes to the RO Model, which aim to improve the experience of patients receiving radiation treatment, while incorporating evidence-based best practices to help providers improve patient outcomes.

Patient Safety
CMS is increasing Medicare beneficiary safety by reversing changes made for 2021 regarding the care setting for which Medicare will pay for surgical procedures that may pose risk to patients.

Specifically, the agency is proposing to halt the phased elimination of the Inpatient-Only (IPO) list—procedures that Medicare will only make payment for when provided in the inpatient setting. There are some services designated as inpatient only that, given their clinical intensity, would not be expected to be performed in the outpatient setting. CMS adopted a policy for 2021 to eliminate this list over a phased period and removed musculoskeletal procedures from the list in 2021.

This change happened without individually evaluating whether the procedures met the long-standing criteria previously used to determine if a procedure could be safely removed. Some of the musculoskeletal services removed includes services like limb amputations and invasive spinal procedures.

CMS reviewed each procedure code of services that were removed and found none met criteria for removal, with insufficient supporting evidence that the service can be safely performed on the Medicare population in the outpatient setting.

CMS is proposing to add them back on to the list in 2022, and is seeking comment on whether to maintain the longer-term objective of eliminating the IPO list, maintaining the IPO list, or maintaining the list but continue to streamline the list of services. The latter would continue systematic scaling of the list back to ensure inpatient-only designations are consistent with current standards of practice.

CMS is also proposing to reinstate the patient safety criteria it uses to evaluate whether a procedure should be payable in the Ambulatory Surgery Center setting that were removed in 2021. CMS is proposing to adopt a nomination process whereby the publicly can formally nominate procedures it believes are safe to perform for the Medicare population in the ASC setting.

For a fact sheet on the Calendar Year (CY) 2022 OPPS/ASC Payment System proposed rule (CMS-1753-P), please visit: https://www.cms.gov/newsroom/fact-sheets/cy-2022-medicare-hospital-outpatient-prospective payment-system-and-ambulatory-surgical-center.

The OPPS/ASC Payment System proposed rule is displayed at the Federal Register, with a 60-day comment period. The proposed rule can be downloaded from the Federal Register at: https://www.federalregister.gov/documents/current.

The Pennsylvania Commission on Crime and Delinquency (PCCD), in partnership with the Departments of Drug and Alcohol Programs (DDAP) and Education (PDE), announced the availability of $1 million in federal State Opioid Response (SOR) funding designed to increase availability of universal prevention programs addressing substance use initiation among youth, especially in areas of the Commonwealth hardest hit by the opioid epidemic. Funding will support collaborative planning, capacity building, and implementation of new school-based prevention programs focused on youth in grades 6 through 12.

Applications are due in PCCD’s Egrants System by Tuesday, August 3, 2021. For full application requirements, applicants are encouraged to read and print the Evidence-Based Programs Support for Substance Misuse Prevention narrative funding announcement and use it as a guide to complete their applications in the Egrants System. Questions must be sent via email to: RA-PCCD-OJJDP@pa.gov with “SOR EBP” in the subject line. PCCD Staff will post responses to questions, as they are received, on PCCD’s website.

The Pennsylvania Trauma Systems Foundation (PTSF) announced that Trauma Center accreditation has been granted to four additional hospitals in Pennsylvania, effective September 1, 2021.

Adult Level II Trauma Center Accreditation

• Grand View Health – Grand View Hospital, Sellersville, PA
• Lehigh Valley Health Network – Lehigh Valley Hospital – Muhlenberg, Bethlehem, PA
• St. Luke’s University Health Network – St. Luke’s Hospital Anderson Campus, Easton, PA
• University of Pittsburgh Medical Center – Williamsport, Williamsport, PA

Effective September 1, 2021, this brings the total number of trauma centers in Pennsylvania to 46 as follows:

Combined Adult Level I /Pediatric Level I Trauma Centers 

• Hershey – PennState Health Milton S. Hershey Medical Center/ PennState Health Children’s Hospital

Combined Adult Level I/Pediatric Level II Trauma Centers

• Allentown – Lehigh Valley Health Network – Lehigh Valley Hospital Cedar Crest/ Lehigh Valley Reilly Children’s Hospital
• Danville – Geisinger Medical Center/ Geisinger Janet Weis Children’s Hospital

Adult Level I Trauma Centers

• Bethlehem – St. Luke’s University Health Network – St. Luke’s University Hospital Bethlehem
• Johnstown – Conemaugh Health System – Conemaugh Memorial Medical Center
• Lancaster – Penn Medicine Lancaster General Health – Lancaster General Hospital
• Philadelphia – Einstein Healthcare Network – Einstein Medical Center Philadelphia
• Philadelphia – Temple Health – Temple University Hospital
• Philadelphia – Jefferson Health – Thomas Jefferson University Hospital
• Philadelphia – Penn Medicine – Penn Presbyterian Medical Center
• Pittsburgh – Allegheny Health Network – Allegheny General Hospital
• Pittsburgh – University of Pittsburgh Medical Center – Mercy
• Pittsburgh – University of Pittsburgh Medical Center – Presbyterian
• West Reading – Tower Health – Reading Hospital
• York – WellSpan Health – WellSpan York Hospital

Pediatric Level I Trauma Centers

• Philadelphia – Tower Health – St. Christopher’s Hospital for Children
• Philadelphia – The Children’s Hospital of Philadelphia
• Pittsburgh – University of Pittsburgh Medical Center – Children’s Hospital of Pittsburgh

Adult Level II Trauma Centers

• Abington – Jefferson Health – Abington Hospital
• Altoona – University of Pittsburgh Medical Center – Altoona
• Bethlehem – Lehigh Valley Health Network – Lehigh Valley Hospital – Muhlenberg
• Camp Hill – PennState Health Holy Spirit Medical Center
• Easton – St. Luke’s University Health Network – St. Luke’s Hospital Anderson Campus
• Erie – University of Pittsburgh Medical Center – Hamot
• Langhorne – Trinity Health Mid-Atlantic – St. Mary Medical Center
• Monroeville – Allegheny Health Network – Forbes Hospital
• Paoli – Main Line Health – Paoli Hospital Main Line
• Philadelphia – Jefferson Health – Jefferson Torresdale Hospital
• Sayre – Guthrie Robert Packer Hospital
• Scranton – Geisinger Community Medical Center
• Sellersville – Grand View Health – Grand View Hospital
• Upland – Crozer-Keystone Health System – Crozer-Chester Medical Center
• Wilkes-Barre – Geisinger Wyoming Valley Medical Center
• Wilkes-Barre – Commonwealth Health – Wilkes-Barre General Hospital
• Williamsport – University of Pittsburgh Medical Center – Williamsport
• Wynnewood – Main Line Health – Lankenau Medical Center Main Line

Level III Trauma Centers

• East Stroudsburg – Lehigh Valley Health Network – Lehigh Valley Hospital Pocono

Level IV Trauma Centers

• Coaldale – St. Luke’s University Health Network – St. Luke’s Hospital Miners Campus
• Grove City – Allegheny Health Network – Grove City Hospital
• Hastings – Conemaugh Miners Medical Center
• Hazleton – Lehigh Valley Health Network – Lehigh Valley Hospital Hazleton
• Honesdale – Wayne Memorial Hospital
• McConnellsburg – Fulton County Medical Center
• Quakertown – St. Luke’s University Health Network – St. Luke’s Hospital Upper Bucks Campus
• Stroudsburg – St. Luke’s University Health Network – St. Luke’s Hospital Monroe Campus
• Troy – Guthrie Troy Community Hospital

The Pennsylvania Trauma Systems Foundation (PTSF) is a non-profit corporation recognized by the Emergency Medical Services Act (Act 1985-45). The PTSF is the organization responsible for accrediting trauma centers in the Commonwealth of Pennsylvania.

Trauma centers are hospitals with resources immediately available to provide optimal care and reduce the likelihood of death or disability to injured patients. Accredited trauma centers must be continuously prepared to treat the most serious life threatening and disabling injuries. They are not intended to replace the traditional hospital and its emergency department for minor injuries.

In Pennsylvania, there are four levels of trauma centers. Level I trauma centers provide the highest degree of resources with a full spectrum of specialists and must have trauma research and surgical residency programs. Level II trauma centers require the same high level of care but do not require research and residency programs. Level III trauma centers are smaller community hospitals that do not require neurosurgeons and focus on stabilizing severe trauma patients prior to transport to a higher-level trauma center. They may admit patients with mild and moderate injuries. Level IV trauma centers provide enhanced care to injured patients within the emergency department and focus on stabilization and quick transfer to a higher-level trauma center. They may admit mildly injured patients.

Each trauma center regardless of its level is an integral component of the emergency medical services (EMS) system. The EMS system assures appropriate patient care management from the time of injury to treatment at a local hospital or trauma center through the rehabilitative phase of care.

A comprehensive list of the Commonwealth’s trauma centers is located at www.ptsf.org.

The National Football League Foundation is a nonprofit dedicated to improving the lives of those touched by the game of football – from players at all levels to communities across the country. The NFL Foundation and its members, the thirty-two NFL clubs, support athletes’ health, safety, wellness, youth football, and the communities that support the game.

To that end, the foundation is accepting applications for its Digital Divide Grant application. According to the foundation, the ability to access computers and the internet has become increasingly important to completely immerse oneself in the economic, political, and social aspects of America and the world. Since not everyone has access to this technology, the NFL Foundation will award up to $30,000 per NFL Club to earmark work with local nonprofits that help bridge the digital divide in their communities.

NFL Clubs and nonprofits or schools working in the digital divide space in a club market with NFL Club approval are eligible.

For complete program guidelines and application instructions, see the National Football League Foundation website.  The deadline for applications is September 1, 2021.

The Centers for Medicare & Medicaid Services (CMS) announced a funding opportunity, made possible by the American Rescue Plan, to help states strengthen system capacity to provide community-based mobile crisis intervention services for those with Medicaid. The $15 million funding opportunity is available to state Medicaid agencies for planning grants to support developing these programs. This funding opportunity provides financial resources for state Medicaid agencies to assess community needs and develop programs to bring crisis intervention services directly to individuals experiencing a mental health or substance use related crisis outside a hospital or facility setting. These services may include screening and assessment, stabilization and de-escalation, and coordination of referrals after the initial treatment.