的 Centers for Medicare and Medicaid Services is walking back its push to pay for more complex services without inpatient stays, a move that will dent revenues for health systems that have boosted investment in outpatient facilities.
的 agency announced during the Trump administration that it would phase out its list of around 1,700 services Medicare would only pay for on an inpatient basis due to the complexity of the procedure, the underlying physical condition of the patient or the need for at least 24 hours of postoperative recovery time. CMS于2021年开始逐步淘汰，从清单中删除了298项服务.
但在医院和医生协会就安全问题进行了大量游说之后, the Biden administration’s CMS said it would pause the phase-out plans and add back almost all the services it removed from the inpatient-only list last year. CMS also removed most of the more than 260 procedures that had been added to a separate ambulatory surgical center-covered procedures list in the 2021 rule.
延误，如概述 门诊预期支付系统最终规则 与CMS的典型信息传递方式截然不同. 的 agency has largely been proposing regulations that would move care from high-cost inpatient treatment to ambulatory surgery centers and other outpatient facilities.
CMS said in the 2022 final rule that it realized the three-year timeframe for phasing out the list was too short and that it needs more time to evaluate whether the services removed in 2021 should actually be taken off the list.
“这似乎是一个180度的大转弯,苏珊·莫平说, 医疗咨询公司Advis的副总裁. “但只要供应商表达了安全问题, CMS should rightfully take a step back and reevaluate if there are any legitimate concerns.”
That earlier push to move away from inpatient care, in part, has prompted health systems to 增加对门诊设施的投资. But those new surgery centers will likely take a financial hit as CMS reworks its approach.
“Business plans for those trying to build an ASC will be blown out of the water for a little bit of time, 但我不认为这将是一个永久的改变,莫妮卡·汉说, Advis的副总裁, 谁支持监管机构退一步.
而流动外科中心协会 强烈反对 CMS在2021年删除了asc覆盖程序列表中添加的大多数服务, 该组织赞同该机构宣布的暂停行动. 在对拟议规则的评论中, 该组织对彻底改变政策路线表示担忧. Although ASCs can’t always immediately perform procedures removed from the inpatient-only list, allowing a service to be performed at a hospital outpatient department could be a precursor to adding it to the ASC list.
ASCA asked CMS to keep three services that have been performed in ASCs on other patient groups off the inpatient-only list in 2022, 机构在最终规则中同意做什么.
But CMS also said 131 of the 298 services taken off the inpatient-only list in 2021 appeared in one or no OPPS claims through May 21, 2021, 这表明前一年的政策并没有改变临床实践.
“One of the barriers is that if you don’t incent care to be done in an outpatient setting, 没有动力把它变成一个高质量的地方,”医生说。. 阿勒格尼健康网络首席医疗运营官斯里查兰·查利康达说.
阿勒格尼健康公司 保持计划 将更多的手术纳入其不断壮大的门诊手术中心网络. Surgeries were up around 10% in 2020 at the Pittsburgh-based integrated health system’s 11 ASCs, Chalikonda说.
“Every market maybe isn’t ready to move to outpatient, but we can only speak to what we’re doing. 我们如何设计明升体育app下载asc, 如果我们把更多的东西搬到住院部，那就退一步了,他说. “如果说有什么影响的话，我认为对质量影响最大的是数量.”
许多卫生系统, 类似于阿勒格尼, 尽管CMS暂停，他们在门诊护理方面的投资不会放缓吗. 不管医疗保险报销, 商业保险公司仍将尝试鼓励医院外的医疗服务, 在适当的地方, 行业观察人士表示.
“很多手术仍将在门诊进行, 尤其是骨科服务,” 琳恩·柯林斯咨询公司LBMC的高级经理. “It will just move at a slower pace now, which will be a challenge initially for newer ASCs.”
联邦监管机构已经将目标瞄准了医院和医院门诊部 设备费用, which they charge Medicare for certain emergency department overhead and staffing costs. 他们有 与美国医院协会对簿公堂 通过联邦网站中立政策, which eliminates the payment differential for evaluation and management services provided at hospital-owned outpatient departments and independent physician offices.
而将更多的护理转移到医院之外会降低医疗成本, hospitals’ and medical associations’ warnings that quality would suffer seemed to trump cost concerns.
Eliminating the inpatient-only list would create “inappropriate safety risks for Medicare beneficiaries, 对医生和医院施加行政负担, 增加了受益人的经济负担，侵蚀了A部分保险的价值,德克萨斯州医院协会去年在给CMS的评论中写道.
而达特茅斯-希区柯克健康中心则普遍支持取消住院病人名单, it told CMS it would be confusing to have a surgery off the inpatient-only list while having anesthesia for the same procedure on the list.
的 New Hampshire-based provider noted payment differentials between inpatient DRG and outpatient codes can vary by at least $10,000. 也, the bundled payment programs that will move from inpatient to outpatient surgery will upset physicians who have honed treatment protocol and stand to lose their shared savings, 它在给该机构的评论中写道.
但除了行政上的模棱两可, 安全的论点站不住脚, 行业观察人士表示. 的 COVID-19大流行 reinforced that ambulatory and home-based care can be a safe substitute for many inpatient procedures, 他们说.
“我不理解安全的说法,杰夫·戈德史密斯说, 医疗保健咨询公司Health Futures的创始人兼总裁. “的re is a further downward lurch in inpatient utilization and people are trying to postpone the inevitable. 作为一名病人，我并不认为门诊治疗不安全.”
Allegheny Health has been improving its preoperative and postoperative care to shorten inpatient stays or avoid hospitalization altogether. Rehabilitation starts immediately in the post-anesthesia care unit and clinicians regularly check in with patients at home via virtual visits, Chalikonda说.
“我们认为这对病人来说是最好的. 只要你通过虚拟健康和其他资源提供良好的支持系统, 我认为这就是未来,他说. “如果COVID-19有什么影响的话, we found that transitioning from extended inpatient recovery to ambulatory care didn’t change quality.”