David Shapiro, M.D. Texas Ambulatory Surgery Center Society 2013 Annual Meeting Houston

Regulatory Effects on ASC Paymentor

Surgery Centers and Quality Measuresor

Everything You Didn’t Want To Know About ASC Federal Legislation & Regulation

David Shapiro, M.D.Texas Ambulatory Surgery Center Society

2013 Annual MeetingHouston

2014 Proposed Medicare Payment Rule

CMS Proposed and Final Rule for ASCs and Hospital Outpatient Departments (HOPD)

Contains information regarding Payment and Quality Reporting for both sites of service.

Timeframe:July 8, 2013 Proposed Rule Release DateSeptember 6, 2013 Comments DueNovember 1, 2013 Original Final Rule release dateMid to Late November Current Final Rule release date

2014 Proposed RuleASC HOPD

Inflation Update Factor 1.4% 2.5%

Productivity Reduction (Mandated by PPACA)

0.5 percentage points 0.4 percentage points

Additional Reduction(Mandated by PPACA)

N/A 0.3 percentage points

Effective Update 0.9% 1.8%

Conversion Factor $43.321 $72.728

2014 Proposed Rule

Under the proposal, ASC rates will receive an across-the-board increase of 0.9 percent based on the Consumer Price Index for All Urban Consumers (CPI-U) while hospital outpatient departments (HOPDs) will receive an across-the-board increase of 1.8 percent based on the hospital market basket. The agency chose to continue to use the CPI-U, an inappropriate measure of inflation in the cost of providing health care, to update the ASC rates ASCA and TASCS will continue to work both with CMS officials and in Congress to halt the growing disparity in the ASC and HOPD rates.

2014 Proposed Rule

Outpatient Prospective Payment System: Hospital payments: projected to increase next year by

nearly $4.4 billion, or 9.5 percent over 2013,Ambulatory Surgical Center payments: projected to

increase by about $133 million, or 3.5 percent over 2013

It would also “make the payment system more of a predetermined one that packages more services together” by “adding seven more categories of services.”

2014 Proposed RuleNo new procedures proposedThe agency has not proposed to add any procedures to the ASC list

of payable procedures for 2014.

ASCA is gathering information to determine which procedures should be added to the list of ASC payable procedures for 2014. This information will help ASCA advocate for the expansion of the list of procedures that CMS considers clinically appropriate for ASCs to provide to Medicare beneficiaries.

Participants must complete one form for each procedure they would like added. For example, someone who would like to see three procedures added would need to complete three documents.

2014 Proposed RuleFour additional quality measures proposed. CMS is proposing the following

measures, which will affect payment in CY 2016, with data collection beginning in CY 2014:

1. Complications within 30 Days following Cataract Surgery Requiring Additional Surgical Procedures

2. Endoscopy/Polyp Surveillance: Appropriate follow-up interval for normal colonoscopy in average risk patients

3. Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use

4. Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery.

2014 Proposed Rule

Proposed small facility quality reporting exemptionCMS has proposed a minimum case threshold to

exempt smaller facilities where program implementation can be overly burdensome. They have selected 240 Medicare claims per year because 10 percent of ASCs have fewer than 240 Medicare claims per year so this policy would exempt only those ASCs with the fewest number of Medicare claims.

Maintain Minimum Reporting Threshold at 50%

CMS Interpretive Guidelines Proposed and Enacted Revisions

416.50 Patient Rights 416.44 (c) Emergency Equipment 416.44 (a) Physical Environment (Temperature and Humidity) 416.49 (b) Radiologic Services416.50 (c) Advance Directives

CMS CfC Reversal

October, 2011 CMS issued a Final Rule which will allow ASCs to notify patients of their rights on the day of the procedure without qualification

The policy change effective date was December 23, 2011

Reverses the policy that required ASCs, except in very limited circumstances, to provide patient notifications prior to the day of surgery.

CMS CfC Reversal

The change in the timing of the notification applies to all the information an ASC previously had to communicate with a patient prior to the date of the surgery:

Patient RightsPhysician OwnershipAdvance Directive Policy

Revised CfCEmergency Equipment Requirement

Effective July 16, 2012, the Centers for Medicare & Medicaid Services (CMS) announced

that it will no longer mandate that ASCs have a specific list of emergency equipment.

Instead, an ASC’s governing body, working in conjunction with the ASC’s medical staff, will have flexibility in determining which emergency equipment is necessary to best safeguard the safety of the patients the ASC serves. The decision about which equipment is necessary must be based on accepted standards of practice.

In making the change, CMS echoed the concerns ASCA had previously expressed to the agency. CMS also noted that it had “learned from the ASC community that some of these equipment requirements are outdated, while other equipment requirements would not be applicable to the emergency needs of all ASCs.”

Allows ASCs to tailor their list of equipment to suit their needs and remove the cost and burden of having to maintain unnecessary equipment

§416.44 (a) Physical Environment Q-0101 (Temperature and Humidity)

Humidity- An example of an acceptable humidity standard for ORs is the American Society for Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) Standard 170, Ventilation of Health Care Facilities. Addendum D of the ASHRAE standard requires RH in ORs to be maintained between 20 - 60 percent. In addition, this ASHRAE standard has been incorporated into the Facility Guidelines Institute (FGI) 2010 Guidelines for Design and Construction of Health Care Facilities, and has been approved by the American Society for Healthcare Engineering of the American Hospital Association and the American National Standards Institute.

§416.49 (b) Radiologic Services Current Requirement

b) Standard: Radiologic services.

(1) The ASC must have procedures for obtaining radiological services from a Medicare approved facility to meet the needs of patients.

(2) Radiologic services must meet the hospital conditions of participation for radiologic services specified in § 482.26 of this chapter.

Proposed Change (Wrong Answer)

Remove (b)(1) and replace it with the requirement that radiologic services may only be provided when integral to procedures offered by the ASC and must meet the requirements specified in § 482.26(b), (c)(2), and (d)(2).

Remove (b)(2) and replace with the requirement that an MD/DO who is qualified by education and experience in accordance with State law and ASC policy must supervise the provision of radiologic services

ASCA Comment Letter (Right Answer)

Option A: 416.49(b)(2) The ASC’s governing body must oversee the provision of radiologic services in keeping with state law and in accordance with approved policies and procedures of the ASC.

Option B: Supervision of the provision of radiologic services shall be performed by a physician or other credentialed practitioner, in accordance with State law and the individual ASC’s radiology policies.

Advance Directives

The CMS state surveyor guidelines have been recently updated to provide additional instruction on how to survey ASCs regarding their policy on honoring advance directives. ASCs should review their advance directive policy to make sure that it takes into consideration the new surveyor guidelines.

Advance Directives

The new guidelines (416.50(c)) indicate that an ASC should “to the maximum extent practicable” honor a patient’s advance directives. This means that a blanket statement that an ASC does not honor any advance directives is no longer permissibleThe new guidelines permit an ambulatory surgery center to refuse to honor certain advance directives due to moral or ethical beliefs (reason of conscience) so long as it is in compliance with state law.

Advance DirectivesIf the ambulatory surgery center was not willing to comply with this directive, the guidelines require that it will communicate this to the patient through a statement of limitation rather than by providing a blanket statement that advance directives are not honored. If, after the physician explains the ASC’s statement of limitation and the patient refuses to accept the limitation; the law requires that the patient be transferred to a facility that will honor the patient’s advance directive. The statement of limitation should be communicated before the start of surgery and meet three criteria specifically set out in the surveyor guidelines. The surveyor guidelines also provides an example of a sample statement of limitation.

Advance Directives

Statement of Limitation (Recommendations) -Delete blanket statement refusing to honor. -Check state regulations for limitations. -Include legal language from Florida law stating your center will: always attempt to resuscitate a patient and transfer that patient to a hospital in the event of deterioration. -Have governing board approve new statement of limitations, if allowed by state. -Document the new policy in meeting minutes. -Change center policies after governing board approval, and educate employees on changes.

Advance DirectivesASCA submitted a letter to CMS Administrator Marilyn Tavenner raising

concerns with recent changes to the advance directive requirements in the recently revised interpretive guidelines.

The new advance directive language, adding more procedural requirements for ASCs who refuse to honor all aspects of an advance directive, is not appropriate for patients who receive care at ASCs.

The letter questions the survey and certification office’s authority to require ASCs to comply with regulatory language that is almost identical to requirements for hospitals and other providers outlined in 42 CFR 489.102(a), despite the fact that ASCs are excluded from that language.

Current CMS Quality Reporting Program

Measure Reporting Period Payments Affected

Reporting Method

Patient Burn October 1, 2012 2014 G Codes

Patient Fall October 1, 2012 2014 G Codes

Wrong Site, Patient, Procedure, etc. October 1, 2012 2014 G Codes

Hospital Transfer/ Admission October 1, 2012 2014 G Codes

Prophylactic IV Antibiotic Timing October 1, 2012 2014 G Codes

Safe Surgery Checklist Use in 2012 July 1-Aug 15 2013 2015 Quality Net

Volume of Selected Procedures 2012 July 1-Aug 15 2013 2015 Quality Net

Influenza Vaccination Rate Oct 1, 2014-Mar 31, 2015 2016 NHSN

Submission of Web-based Measure data for ASC Measures 6 and 7

Web based submission (Quality Net) of data regarding:• Safe Surgery Checklist Use in 2012• Volume of Selected Procedures 2012(Original) Reporting Period July 1-Aug 15 2013Affects Payment Determination for 2015

Quality Net

To submit web-based measure data and access reports, the ASC must have an active Security Administrator registered with QualityNet

Download>Complete>Approval (another individual)>Notarize>Mail In

Upon completion, the form must be submitted to the ASCQR Program Support Contractor for processing.

QualityNet User Guide

New User Enrollment Process - Prerequisite for Secure Portal Usage Before you log in to the Secure QualityNet Portal for the first time, you must complete the New User Enrollment Process. The prerequisites for this process are:

• A completed QualityNet Registration that in turn has allowed your organization’s Security Administrator to provide you with a QualityNet user ID and password.

• A Symantec VIP multifactor credential application downloaded to your PC, tablet, or smartphone.

To download the multifactor authentication application to your PC or tablet, access the Verisign ID Protection Center web site: https://idprotect.verisign.com/desktop/download.v

To download the multifactor authentication application directly to your smartphone, type the following into your default mobile browser: m.verisign.com

QualityNet User Guide

Important: You will only complete this new user enrollment process once; you will not do this every time you log into the Secure QualityNet Portal. This one-time process is a six-step procedure that should take you no longer than five minutes to complete if you have all of your prerequisites in hand. Some users will find they cannot complete the proofing part of the new user enrollment process as they will experience errors. Here are some explanations of why this might happen: The identity proofing steps of this process include identity verification by Experian, an external service that CMS has engaged to verify user identities. Experian uses your credit history within their extensive financial databases to confirm that you are who you say you are. If you do not have much credit history or if you have had problems with credit in the past, the online steps of the process may not work for you. If this happens, there are alternative options. If you find you cannot complete the proofing process online, you may be given the option to complete the proofing process with Experian via a phone call. This option will be offered if you have some credit history. If you have little or no credit history, you will be offered the option to prove your identity directly, in-person, with your Security Administrator.

While you are on the Identity Proofing screen during the enrollment process (see Figure 5-4), please review the Remote Proofing FAQ link for more details and Q&A about the proofing process. You may also visit Experian’s PreciseID web site, http://www.experian.com/whitepapers/precise_id_whitepaper.pdf, for more details about the proofing process.

Additional QualityNet Requirements

As of May 31, 2013, the Centers for Medicare & Medicaid Services (CMS) is now requiring QualityNet users for the ASC Quality Reporting Program to complete an additional user enrollment process to ensure access to the Secure QualityNet Portal.

After receiving a user ID and password, the security administrator will now be required to download the Symantec VIP Access application (Symantec VIP multifactor credential application).

To download the multifactor authentication application to your PC or tablet, access the Verisign ID Protection Center web site: https://idprotect.verisign.com/desktop/download.v

When logging in to the portal for the first time, security administrators will be guided through a six-step New User Enrollment Process that includes personal identity verification conducted by Experian, an external service enlisted by CMS. Name, Home Address, Financial Data (Mortgage, Credit Cards)Social Security Number

Additional QualityNet IssuesAdministrators uncomfortable with the requirement to enter personal data such as home address and social security number to comply with the regulationsThe new ASC Portal was not communicated and appeared very late in the process. Many administrators had already registered and this was not built yet so they were not aware they needed to complete this phase of the process.The instruction manual is very difficult to follow and not user friendly – the portal portion was added to this but late and many had already registeredASCA and FSASC have significant concerns with personal data being required from our members in order to comply with quality reporting regulations, and is reaching out to CMS to determine the rationale behind this requirement. Possible modification involving

Masking SS#No query regarding specific mortgage amount

QualityNet ReportingAs announced to QualityNet users in an email blast on June 28, the reporting period for the Web-based measures for the ASC Quality Reporting Program (ASCQR), scheduled to begin on July 1, 2013, was delayed due to the need for continued software testing. In this communication, the Florida Medical Quality Assurance, Inc. (FMQAI), the national support contractor for the reporting program, stated that it anticipated that access to measures ASC-6 (Safe Surgery Checklist Use) and ASC-7 (ASC Facility Volume Data on Selected ASC Surgical Procedures) would be enabled by July 9th FMQAI also indicated that ASCs would be alerted to the new start date for reporting through the ASCQR ListServe as soon as the Web-based tool becomes available (Eventually resolved July 10th)

QualityNet ReportingAccess to measures ASC-6 (Safe Surgery Checklist Use) and ASC-7 (ASC Facility Volume Data on Selected ASC Surgical Procedures) have been enabled through the web-based tool.

If you encounter one of the following issues listed below, please contact the QualityNet Help Desk at 866-288-8912 for assistance. You see a "Run Report" link but not a "Measures" link on the task page. You receive an error message once logged into the portal at any part during the process. You can enter data, but the system will not save the data.

Posted July 16:Document addressing known issues associated with Ambulatory Surgical Center Quality Reporting (ASCQR) Now updated with newly identified issues and resolutions

QualityNet UpdatesPrivacy Issues

CMS worked with Experian to establish a set of questions that would be less invasive and yet still maintain the integrity of the identity proofing process

Outdated Versions of Java Resolved so that centers may use a version of Java that is compatible with Internet Explorer 8

Application BacklogAll applications received have been processed

Reporting DelaysCMS extended the reporting deadline to August 23

QualityNet Contact Information

Florida Medical Quality Assurance, Inc. Ambulatory Surgical Center Support Contractor Team

Florida Medical Quality Assurance, Inc. (FMQAI): Information for Healthcare Improvement

5201 W. Kennedy Blvd. Suite 900 Tampa, FL 33609

Phone: 866-800-8756

Agency for Healthcare Research and Quality (AHRQ)

AHRQ Surgical Unit-based Safety Program for ambulatory (SUSP-AS) named “AHRQ’s Safety Program for Ambulatory Surgery”, is focused on developing the optimal use of a safe surgical checklist to improve outcomes in ambulatory settings and developing a culture of safety. Data reporting for the first cohort began July 1, 2013

Consumer Assessment of Healthcare Providers and Systems (CAHPS)

The CMS contract for the development of an outpatient surgical CAHPS survey was awarded to Research Triangle Institute (RTI). RTI still plans to recruit patients from 36 sites for the field test. RTI would like a mix of demographics as well as different surgery/procedures. Volunteer facility participants are being sought.

Additional Item to Worry AboutHIPAA Omnibus Rule

Ten years have passed since the HIPAA Security Rule came out, and much changed when the HIPAA Omnibus Rule became effective on September 23th, 2013

ASCs must be compliant with far-reaching changes to the Health Insurance Portability and Accountability Act’s (HIPAA) privacy, security and breach notification requirements

HIPAA Omnibus Rule

Compliance involves consideration of issues related to:Notice of Privacy Practices Changes to privacy policies Risk analysis for Breaches New contract requirements for Business Associate Agreements (BAA) Enforcement

Fines range from $100 - $50,000/violation. Maximum fines of $1.5 million for all violations.

Currently, a Covered Entity is not liable for the acts of its Business Associates who meet the federal common law definition of an “agent” –If HIPAA-compliant Business Associate agreement is in place –Covered Entity did not know of a pattern or practice of violations and fail to act.

The Final Rule eliminates this exception, essentially making a Covered Entity or Business Associate strictly/vicariously liable for violations by its agent.

–The most important criterion is the right to exercise control over the Business Associate. –In drafting a BAA, consider the tradeoff between the need to control the Business Associate and the liability associated with such control

Electronic Health Records (EHR)

Congress passed the HITECH Act of 2009 to incentivize Medicare providers to adopt and use EHR systems.

Unfortunately, ASCs were not eligible for HITECH funds to develop EHR systems, and no certified EHR is currently available for ASC encounters.

Under the current program, physicians for whom at least half of their patient encounters do not occur in settings with qualified EHR systems will not meet “meaningful use” requirements and will be penalized with reduced payments.

Current regulation may dissuade physicians from using ASCs—often a lower-cost option—because patient encounters in the ASC setting currently count toward the physicians’ total encounters but cannot meet “meaningful use” requirements

Electronic Health Records (EHR)The Electronic Health Records Improvement Act of 2013 introduced

by US Representative Diane Black (R-TN) provides a short-term exemption to the HITECH Act that would allow physicians to provide care in ASCs for three years following its enactment without having the cases they perform there being factored into the “meaningful use” requirements.

This exemption will allow ASCs the time they need to develop standards for EHR that meet the unique needs of the ASC setting.

The legislation also reinstates the “batching” process that allows all physicians who input patient records from an ASC setting into an EHR system at a later time to include those patient encounters in their “meaningful use” requirements.

Electronic Health Records (EHR)

Allowing physicians to perform procedures in ASCs without fear of being penalized encourages them to continue to choose the lowest-cost setting of care. Providing this short-term reprieve will give the ASC community time to explore ways to develop criteria for EHR systems that can be certified for this unique setting, which would benefit both physicians and patients.

Encourage all members of the US House of Representatives to offer their support to H.R. 1331.

Electronic Health Records (EHR)ASCA submitted a letter to Farzad Mostashari, MD, the national

coordinator for Health Information Technology, who is responsible for directing the federal government's development of health information technology (HIT) standards and strategy. The letter was drafted in response to Dr. Mostashari’s request for more information regarding the importance of creating a voluntary certification process for EHRs in the ASC setting.

ASCA staff is also in the process of organizing a group of ASC leaders, vendors and other stakeholders. This group will convene in the Fall to discuss the development of standards for EHRs that would be appropriate for the workflow of ASCs.

ASC Legislation

The ASC Quality and Access Act of 2013 was introduced in early June by Senators Ron Wyden (D-OR) and Mike Crapo (R-ID).

The Senate bill (S. 1137) has 5 additional cosponsors.The ASC Quality and Access Act of 2013 (H.R. 2500) was

introduced in the House of Representatives on June 25th, by Representatives Devin Nunes (R-CA) and John Larson (D-CT). The bill is the companion legislation to (S. 1137)

They have been joined by 37 additional cosponsors

ASC Legislation

Ambulatory Surgery Centers Quality and Access Act of 2013

CMS conversion to Hospital Market BasketValue Based Purchasing ProgramRepresentative to HOP Advisory PanelTransparency in Approved Procedure List

Texas Cosponsors

Michael BurgessKay GrangerRalph HallKenny MarchantPete SessionsMarc Veasey

ASC Quality and Access Act 2013

Requires the Centers for Medicare & Medicaid Services (CMS) to use the hospital market basket as the update factor when determining the update for payments for services performed in ambulatory surgery centers (ASCs). Currently,

ASCs do not have a market basket update and the default update mechanism is the Consumer Price Index for All Urban Consumers (CPI-U), which does not appropriately measure the costs of an ASC.

The provision does not affect the productivity adjusters mandated for all providers by the Patient Protection and Affordable Care Act (PPACA) or the secondary rescaling required for budget neutrality in the ASC pool.

ASC Quality and Access Act 2013Requires the development of a value-based purchasing (VBP) program for

ASCs by January 1, 2015. The system would be established as follows:Each reporting facility would be assigned a score based on its performance on

the quality measurements;Facilities would not be required to report on those measures that were

inappropriate for their facility, i.e. shaving of the surgical site in ASCs that perform ophthalmic procedures;

CMS would develop an estimate of the total amount that Medicare is expected to spend on hospital outpatient department (HOPD) and ASC procedures for the coming year for procedures that are eligible to be performed in an ASC. The estimate would be based on spending in the three prior years and would be adjusted for beneficiary demographics, eligible procedures and other factors, such as changes in the proportion of beneficiaries enrolled in Medicare Advantage plans;


Each year, CMS would compare the actual spending to its estimated spending for procedures eligible to be performed in an ASC that were performed in either an HOPD or an ASC.

If the actual spending for these procedures is less than the estimated spending, the difference would create the shared savings or bonus pool.

This system is similar to the VBP system designed for the home health demonstration mentioned in the

The shared savings pool would be divided, with 50 percent of the pool being retained by CMS and returned as savings to the Medicare program. The other 50 percent of the pool would be used to provide bonuses to high quality ASCs;

The creation of the mechanism to provide bonuses to individual ASCs is left to the discretion of the Secretary with instruction to reward providers for both improvement and attainment; however, the Secretary is required to spend 50 percent of the savings pool on ASC bonuses.


Directs CMS to add a representative from the ASC community to the membership of the Advisory Panel on Hospital

Outpatient Payment since decisions made by the panel affect both HOPD and ASC facility fees and eligible procedures.


The Ambulatory Surgery Center Quality and Access Act requires CMS to disclose which criteria triggers the exclusion and prohibits CMS from excluding procedures reported with unlisted codes from the ASC setting.

The agency is not required to disclose which of the criteria triggers the exclusion.


The Act requires transparency in the Medicare process for approving procedures that are allowed to be performed in the ASC setting. Currently, CMS can exclude a procedure from being performed in an ASC out of a general concern for patient safety, because it is reported using a CPT-unlisted code or for any one of the following criteria:

generally results in excessive blood loss;requires major or prolonged invasion of body cavities;directly involves major blood vessels;is generally emergent or life-threatening in nature;commonly requires systemic thrombolytic therapy; ortypically requires active medical monitoring and care at midnight following the

procedure.

Removing Barriers to Colorectal Cancer Screening Act

The “Removing Barriers to Colorectal Cancer Screening Act,” sponsored by US Representative Charlie Dent (PA), works to correct an oversight in current law that requires Medicare beneficiaries to cover the cost of their copayment for a “free” screening colonoscopy if a polyp is discovered and removed during the procedure.


According to the American Cancer Society, deaths from colorectal cancer have been declining for more than two decades, mostly because of screenings, including colonoscopies and other tests.

The United States Preventive Services Task Force guidelines call for individuals of average risk of colon cancer between the ages of 50 and 75 to be screened, but only about half in the US are screened as recommended.

According to the Centers for Disease Control and Prevention (CDC), colon cancer remains the leading cause of cancer death among nonsmokers. The CDC estimates that if all precancerous polyps were identified and removed before becoming cancerous, the number of new colorectal cancer cases could be reduced by 76 to 90 percent.


Under current law, Medicare waives coinsurance and deductibles for colonoscopies. When a polyp is discovered and removed, however, the procedure is reclassified as therapeutic for Medicare billing purposes and patients are required to pay the coinsurance. H.R. 1070 would eliminate unexpected costs for Medicare beneficiaries when a polyp is discovered and removed, ensuring that unexpected copays do not deter a patient from having the screening performed.

By eliminating financial barriers, this legislation would attain higher screening rates and reduce the incidence of colorectal cancer.


Preventive care services allow medical problems to be discovered and treated earlier, saving the US health care system, insurers and patients money and, more importantly, saving lives. Colorectal cancer is a preventable disease but continues to kill 50,000 Americans each year.

Colonoscopy screenings are essential to combating colorectal cancer. ASCA is pleased to support this legislation and encourages all US Representatives to cosponsor H.R. 1070.

MedPAC June Report

The Medicare Payment Advisory Commission (MedPAC) released its June report to Congress, and it includes a chapter entitled “Medicare Payment Differences Across Ambulatory Settings,” that calls for the equalization of payments between hospital outpatient departments (HOPDs) and ASCs for 12 ambulatory payment classification (APC) groups. These include nine ophthalmic APCs, two pain APCs and one skin APC. We have concerns that the equalization occurs at the APC instead of the CPT level, capturing procedures that are not commonly done in an ASC.

MedPAC June Report

In a separate analysis on reducing payment disparities between HOPDs and physician offices, four pain APCs were identified for potential payment reductions. That analysis was based on the volume of procedures done in HOPDs and physician offices and excluded volume done in ASCs. The report recommended reducing the payments for these and 62 other APCs to either the physician office level or to a new hybrid rate that would account for packaged services provided as part of the procedure. Although ASCs were not part of this analysis, we are concerned that reductions in the HOPD payments for these services would be applied to services provided in the ASC setting.

Chained CPI-UOffice of Management and Budget

ASCA conducted a meeting in July with staff from the Office of Management and Budget (OMB) to discuss the use of CPI-U as our update factor, as well as the proposal being floated to move to chained CPI to update payments in certain government programs.

Supporters argue that the chained CPI-U is a more accurate measure of inflation and there is growing momentum for the idea of using it to update payments in the Social Security and Medicare programs.

Since chained CPI is approximately a quarter point lower than the traditional CPI, this move would save the government billions of dollars, but would exacerbate the gap in payments between ASCs and HOPDs. The OMB is the last stop for the ASC payment rule and the agency has significant input into policies contained in the rule.

Chained CPI-UCongress

Recently, there have been proposals discussed in Congress about changing how the government updates programs such as Medicare, Medicaid and Social Security for inflation. The proposal would change the update factor for these programs from the CPI-U to the Chained CPI-U. The Chained CPI-U is intended to better reflect inflation by not relying on a set basket of goods. Annually, the Chained CPI-U is less than the CPI-U by an average of .25 percent to .3 percent. The letter expressed concern that if ASCs are moved to the Chained CPI-U, annual updates would decrease even further and exacerbate the gap between ASC and HOPD reimbursement rates.

ASCA sent a letter to US Representative Paul Ryan (R-WI), chair of the House Committee on the Budget, expressing concern about transitioning the Medicare reimbursement update factor for ASCs from the Consumer Price Index for All Consumers (CPI-U) to the Chained CPI-U.

Total Joint Demonstration Project

ASCA filed an application with the Centers for Medicare & Medicaid Services’ Innovation Center (CMMI) for a grant to demonstrate the safety and efficacy of performing total joints and spine procedures on Medicare patients in the ASC setting. This is a competitive grant process; last year, CMMI picked 100 grant recipients from more than 3,000 applicants.

Total Joint Demonstration ProjectThe program has three goals:

1. to demonstrate to CMS that performing total joint and spine procedures on Medicare patients in the ASC setting is safe, with patient outcomes that are as good as when the procedures are done in other settings; 2. to establish a learning network among the centers to help develop and refine protocols and best medical practices for these procedures; and 3. to potentially establish a pathway for additional procedures, such as total shoulders and total ankles, to be considered for inclusion in the Medicare approved list in the future.”

Total Joint Demonstration ProjectThe application covered the following procedures: total hips; total knees; anterior cervical disc fusions (ACDF); lumbar discectomies; lumbar laminectomies; 1-level cervical fusion; microdiscectomy; cervical discectomy; and single level posterior lumbar fusion

The program encompasses a transitional payment arrangement for these procedures based upon the hospital diagnosis related groups (DRG). Participating centers will be paid less than the DRG payment that the local hospitals receive for performing these procedures and will work with the post-acute care providers to save additional money by coordinating patient care after the surgery. The ASCs would receive a portion of the savings under the proposal.

ASCA 2014 Annual Meeting

May 14-17Nashville, Tennessee

Gaylord Opryland Resort and Convention Center

In The Meantime…

Continue (or begin) to:Stay connected and informedJoin and participateAdvocate at home and in DCDonate and contributeEducate payers and regulatorsHost facility visits & eventsKeep up your fantastic efforts

Regulatory Effects on ASC Paymentor

Surgery Centers and Quality Measuresor

Everything You Didn’t Want To Know About ASC Federal Legislation & Regulation

David Shapiro, M.D.Texas Ambulatory Surgery Center Society

2013 Annual MeetingHouston

David Shapiro, M.D. Texas Ambulatory Surgery Center Society 2013 Annual Meeting Houston

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Transcript of David Shapiro, M.D. Texas Ambulatory Surgery Center Society 2013 Annual Meeting Houston