CMS Finalizes Policies to Expand Care Options and Settings

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Key Insights

  • The Centers for Medicare and Medicaid Services (CMS) recently unveiled policy changes to expand care delivery in outpatient settings.
  • The rules “boost competition at every turn,” said CMS Administrator Seema Verma.
  • These changes build on CMS’ recent guidelines to expand at-home care in response to the ongoing COVID-19 pandemic.

CMS Unveils Changes to Outpatient Procedures

The Centers for Medicare and Medicaid Services (CMS) is finalizing policy changes that aim to provide Medicare beneficiaries with more options for outpatient surgery and care. The two final rules — the Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) — will “give Medicare patients and their doctors greater choices to get care at a lower cost in an outpatient setting,” according to a press release by CMS.

The rules will allow “doctors and patients to make decisions about the most appropriate site of care, based on what makes the most sense for the course of treatment and the patient without micromanagement from Washington,” CMS Administrator Seema Verma said.

Over a three-year period beginning January 1, 2021, CMS will gradually reduce the 1,700 inpatient-only (IPO) procedures, reimbursing physicians for delivering care in an outpatient setting as well. The optionality aims to provide for “lower-cost options that benefit the patient” while allowing for physicians to decide whether to conduct the procedure in an inpatient or outpatient environment.

CMS Expands Care Settings in Response to COVID-19 Spike

These changes are in addition to recent efforts by CMS to expand care “outside a traditional hospital setting” as hospitals face volume surges due to the COVID-19 pandemic. “With new areas across the country experiencing significant challenges to the capacity of their health care systems, our job is to make sure that CMS regulations are not standing in the way of patient care for COVID-19 and beyond,” CMS Administrator Verma said.

The comprehensive strategy includes greater flexibility for at-home care and staffing for ambulatory surgical centers (ASCs). Under the new guidelines, participating hospitals can treat patients at home for “more than 60 different acute conditions.” Several safeguards are designed to protect patients. Before transitioning patients from inpatient or emergency settings, a physician must conduct an in-person evaluation. A screening process will evaluate the patient’s home for “medical and non-medical factors,” such as working utilities, physical barriers, and domestic violence. The hospital will then appoint a registered nurse for daily visits.

Janis M. Orlowski, MD, MACP, Chief Healthcare Officer at the Association of American Medical Colleges, applauded the guidelines in a statement. “CMS’ actions offer healthcare providers more regulatory flexibility to provide certain hospital services in patients’ homes and increase patient care via telehealth visits, which will allow our hospitals to better address the pandemic at this crucial time. We appreciate CMS’ continual innovation to help the healthcare system deliver care during the pandemic.”

Dr. Orlowski’s comments were made before CMS finalized its expansion of telehealth services. Deploying telehealth has helped providers and practices stabilize revenue while continuing to care for patients. As Mark Foulke, Executive Vice President of Transformational Value-Based Care at Privia Health, notes: “Care management has one primary goal — to improve the health of the patient — and telehealth has made it possible to deploy new technology to keep patients healthy outside of the doctor’s office with new technology and data.”

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