35 hours ago · OPPS Payment Update. For CY 2017, CMS is updating OPPS rates by 1.65 percent. The change is based on the projected hospital market basket increase of 2.7 percent minus … >> Go To The Portal
Today, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2017 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System policy changes, quality provisions, and payment rates final rule with comment period (CMS-1656-FC).
The CMS Annual Financial Reports can be obtained at: www.cms.gov/CFOReport AT A GLANCE Original Publication Date: November 3, 2017 Publication Number: 909418 Inventory Control Number: 952017 CMS Financial Report 2017 i 123 $ in billions AT A GLANCE
Calculated as the count of inpatient admissions, outpatient facility visits, outpatient facility procedures, and professional services, divided by the number of people with ESI coverage, and weighted by intensity of services provided.
After considering all other policy changes finalized under the OPPS, including estimated spending for pass-through payments, CMS estimates a 1.7 percent payment increase (before taking into account changes in volume and case mix) for hospitals paid under the OPPS in CY 2017.
CMS believes that a basic tenet of a prospective payment system is the packaging of all integral, ancillary, supportive, dependent, or adjunctive services into primary services. Under current policy, many ancillary services are conditionally packaged.
114-74) in the final rule with comment period and is establishing interim final payment rates under the Medicare Physician Fee Schedule (MPFS) in an IFC described in more detail below. As required by the statute, the final rule with comment period provides that certain items and services furnished by certain off-campus PBDs shall not be considered covered outpatient department services for purposes of OPPS payment and shall instead be paid “under the applicable payment system” beginning January 1, 2017. CMS is finalizing several policies relating to which off-campus PBDs and which items and services are “excepted” from application of the payment changes under this provision and thus will continue to be paid under the OPPS.
Applicable Payment System – For CY 2017, CMS is finalizing the MPFS to be the “applicable payment system” for non-excepted items and services furnished in a nonexcepted off-campus PBD. In light of public comment on the proposals regarding hospital billing and payment, CMS is issuing an IFC to establish new interim final MPFS rates so that hospitals may be paid for these nonexcepted items and services in CY 2017.
In the CY 2017 OPPS/ASC final rule, CMS is finalizing the addition of seven measures to the Hospital OQR Program for the CY 2020 payment determination and subsequent years: two claims-based measures, and five Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey-based measures. The seven measures are:
CMS-1656-IFC— Establishment of Payment Rates under the MPFS for Nonexcepted Items and Services Furnished by an Off-Campus Provider-Based Department of a Hospital
New Payment Policy for Low Volume Device-Intensive Procedures: CMS is also finalizing a proposal that the payment rate for any device-intensive procedure that is assigned to an APC with fewer than 100 total claims for all procedures in the APC be based on the median cost instead of the geometric mean cost. CMS believes that this approach will mitigate significant year-to-year payment rate fluctuations while preserving accurate claims-data-based payment rates for low volume device-intensive procedures.
The EHR reporting period will be any continuous 90-day period between January 1 st and December 31 st in CY 2016 and CY 2017.
CMS Office of Minority Health Data Highlights present national and regional data on health care service utilization, spending, and quality indicators for the Medicare population. The information products include an overview of the specific public health issue, provide a brief quantitative and/or qualitative analysis of the data, and explain how the findings support or relate to CMS or HHS policy or initiatives. These data products are valuable to the work of researchers, policy makers, and health care professionals.
This report uses data from the 2013 Medicare Current Beneficiary Survey to examine differences in self-reported receipt of preventive care by type of disability for community-dwelling Medicare beneficiaries ages 65 and older.
This data highlight examines the physical and mental health outcomes of Medicare Advantage beneficiaries by race and ethnicity. It is one of the few analyses that compares granular racial and ethnic groups in the same study, is based on a nationally representative sample, and focuses on mental health in older adults.
This brief uses 2012 Medicare Current Beneficiary Survey (MCBS) data to examine racial and ethnic differences in self-reported measures on access to care, propensity to seek care, self-care knowledge and behaviors, diabetes management, and complications among Medicare beneficiaries ages 65 and older.
Rural hospital bypass may occur for a number of reasons, including patient choice and the complexity of care a patient needs. When patients bypass their local rural hospital for services that are available locally, it can further threaten the sustainability of their local rural hospital. This data highlight seeks to understand the extent to which rural Medicare beneficiaries bypass their nearest rural hospital and to learn what hospital services rural Medicare beneficiaries most often seek locally and at distant hospitals.
Findings show chronic kidney disease is under recognized in Medicare populations across all stages and that provider recognition of CKD varies by disease stage. Later stages are more likely to be recognized.
The volume displayed is the number of Medicare patient discharges for the selected MS-DRGs.
In March, 2008, the Centers for Medicare & Medicaid Services (CMS) began posting information on Hospital Compare about selected inpatient hospital stays of Medicare patients. The new information shows how often Medicare patients were admitted to the hospital for these conditions (volume) and what Medicare pays for those services (payment). This information gives consumers even more insight into the quality of the health care that is available at their local hospitals and what Medicare pays for those services.
The payment and volume information reflects inpatient hospital services provided by many hospitals to Medicare beneficiaries. CMS has posted this information for the public to see the cost to the Medicare program of treating beneficiaries with certain illnesses in their community. A better understanding of the cost of care leads to more informed decision making, one more way beneficiaries can help improve the longer term financial health of the Medicare program. Payment and volume information can provide users with a general overview of hospitals' experience with Medicare Severity Diagnosis Related Groups (MS-DRGs).
The median payment refers to the midpoint of all payments to the hospital for a particular MS-DRG, that is, half the payments were lower and half the payments were higher than the median payment. The median hospital payments for the same MS-DRG can vary.
It pays its employees more compared to the national average because the hospital is in a high-cost area. Note: A hospital's Medicare payments are adjusted based on the wage rates paid by area hospitals based on their payroll records, contracts and other wage related documentation.
MS-DRGs are payment groups of patients who have similar clinical characteristics and similar costs. Each MS-DRG is associated with a fixed payment amount based on the average cost of patients in the group. MS-DRGs for which Medicare payment and volume data are available include common inpatient stays such as hospitalizations for heart failure and heart bypass surgery.
Correct coding of claims is important for hospitals to avoid improper payments, which can lead to recoveries of overpayments. CMS encourages hospital billing and coding personnel to review the OIG reports and take steps to avoid the problems identified in those reports. It is important that you support claims submitted by documentation in the patient's medical records.
The OIG reports referenced in this article focused on claims for Right Heart Catheterizations (RHCs) with heart biopsies that used modifier -59 and claims for 96 or more continuous hours of mechanical ventilation.
determine if hospitals were correctly reporting modifier -59 for RHCs and heart biopsies. The OIG found that in billing for outpatient RHCs with heart biopsies, hospitals often use modifier -59 inappropriately. This leads to significant overpayments and overpayment recoveries on claims for these services.
hospitals often use incorrect procedure codes when billing for mechanical ventilation . In their study of mechanical ventilation billings, the OIG looked at the relation between Medicare Severity - Diagnosis Related Groups (MS-DRGs) billed to the procedures coded for those
74 percent of healthcare providers reported an increase in patient financial responsibility in 2015
68% of patients failed to fully pay off medical bill balances in 2016, up from 53 percent in 2015, and 49 percent in 2014. This number is expected to climb to 95% by 2020
Omnichannel payments are impacting healthcare. 68% of consumers prefer electronic payment methods to pay their medical bills. 80% of consumers prefer online payment channels to pay their health plan premiums. 20% of online healthcare payments are made on a mobile device. Paper is hurting all healthcare stakeholders.
A new TransUnion Healthcare (NYSE:) analysis revealed that patients experienced an 11% increase in average out-of-pocket costs during 2017, rising from $1,630 in Q4 2016 to $1,813 in Q4 2017. The analysis also revealed that in 2017, on average, 49% of patient out-of-pocket costs per healthcare visit were below $500; 39% were $501-$1,000; and 12% were more than $1,000. Total hospital revenue attributable to patient financial responsibility after insurance increased 88 percent between 2012 and 2017
Patient healthcare costs – including both deductibles and out-of-pocket maximum payments – have increased by almost 30% percent since 2015.
COVID-19 in-patient hospitalizations may cost the U.S. healthcare system up to $16.9 billion in 2020
The average annual premiums for employer-sponsored health insurance in 2019 are $7,188 for single coverage and $20,576 for family coverage. The average single premium increased 4% and the average family premium increased 5% over the past year. Workers’ wages increased 3.4% and inflation increased 2%.
The 2017 Health Care Cost and Utilization Report examines medical and prescription drug spending, utilization, and average prices, and is based on health care claims data from 2013 through 2017 for Americans under the age of 65 who were covered by employer-sponsored insurance (ESI). The keyfindings are:
In 2017, per-person spending reached $5,641, a new all-time high for this population. This total includes amounts paid for medical and pharmacy claims. While it reflects discounts negotiated from wholesale or list prices for prescription drugs, it does not account for manufacturer rebates provided in separate transactions, because these data are not available. Average prices increased 3.6% in 2017. Year-over-year price growth decelerated throughout the five- year period, rising 4.8% between 2013 and 2014 and slowing to 3.6% in 2016 and 2017. That trend reflects a slowing in the year-over-year changes in average point-of-sale prescription drug prices. Spending per-person grew at a rate above 4% for the second year in a row, rising 4.2% from 2016 to 2017. This year’s spending growth wasslower than the 4.9% growth from 2015 to 2016 (2016 spending estimate revised up from previous report). The overall use of health care services changed very little over the 2013 to 2017 period, declining 0.2%. In 2017, utilization grew 0.5% compared to 2016. Out-of-pocket spending per-person increased 2.6% in 2017. The growth was slower than the rise in total spending, resulting in out-of-pocket costs comprising a smaller share of spending by 2017.
Spending on outpatient visits and procedures grew faster than other service categories. Per-person spending on outpatient visits and procedures rose 5.1% in 2017. That rate of growth was the highest of any of the four service categories for the second year in a row. Outpatient spending also increased faster than spending on inpatient admissions or professional procedures between 2013 and 2015. Outpatient surgery and emergency room (ER) visits accounted for the majority of outpatient spending, 36% and 24% respectively [Figure 20]. These subcategories also saw the largest growth, both year-over-year and cumulatively throughout the five-year period [Figures 21 and 22]. Outpatient surgery and ER visits represented 60% of outpatient spending in 2017 and 66% of the increase in per- person spending between 2013 and 2017. Among outpatient procedures, radiology spending grew faster than other subcategories of procedures throughout the entire period; the cumulative rise between 2013 and 2017 was 10% [Figure 26 on page 15].
The health care claims in the underlying data were categorized into four service categories: inpatient facility, outpatient facility, professional services, and prescription drugs. This classification reflects the way claims were processed and paid, and not necessarily how patients interacted with health care providers. In many cases, a single episode of care can have claims in multiple categories. It is also possible that the classification of claims for similar types of episodes vary by provider, or groups of providers, depending on how claims were submitted. Such variation can also occur across years within the same provider. See the accompanying methodology document for further detail. Year-to-year changes in spending, use, and average price for each service category can reflect changes in the site of service for certain procedures. For example, if mammograms that had previously been performed in a physician’s office, and therefore classified as a professional service, are shifted to an outpatient facility, the trends in spending, use, and price for the radiology subcategory in outpatient facility and professional services categories will be affected. These service-level shifts were not examined, but their possibility should be noted when interpreting the findings presented in the remainder of this report. As stated before, prescription drug spending includes the amount paid for pharmacy claims. These point-of-sale prices reflect discounts from the wholesale or list prices of prescription drugs, but do not account for manufacturer rebates that occur in separate transactions.
Total health care utilization changed little over the five-year period, but trends varied across service categories. Except for prescription drugs, utilization reflects year-to-year changes in both volume and intensity of the mix of services used (see complete methodology for more information). From 2016 to 2017, total health care utilization increased 0.5% [Figure 5]. However, from 2013 to 2017 total utilization changed little, with increases in 2016 and 2017 offsetting declines between 2013 and 2015 [for cumulative changes see Figure 2 on page 3]. Utilization trends varied across service categories. • Inpatient admissions declined between 2013 and 2015 before leveling off through 2017. • Declines in outpatient facility visits and procedures and professional services in the initial part of the period were offset by increases in later years, resulting in little cumulative change between 2013 and 2017. • The number of filled prescription days was relatively flat from 2013 to 2016 before increasing 3.3% in 2017. Page 5
In 2017, per-person spending reached $5,641, the highest spending for the ESI population since HCCI began publishing annual health care cost and utilization reports. This total includes $1,097 for inpatient admissions, $1,580 for outpatient visits and procedures, $1,898 for professional procedures, and $1,065 for prescription drugs [Figure 1]. Spending on prescription drugs reflects the amount paid on the pharmacy claim, which includes discounts from the wholesale or list price, but does not account for manufacturer rebates that are paid through separate transactions. Total annual per-person spending increased 16.7% over the five-year period [Figure 2], rising from an average of $4,834 in 2013 to $5,641 in 2017. That is an average annual increase of 3.9%, which slightly outpaced the 3.1% average annual rate of growth in per-capita GDP over the same period. The estimate of spending includes the sum of payer spending and out -of pocket payments by individuals. Increases in spending can arise from increases in use, increases in average prices (spending per unit), or a combination of both. The change in the composition of services, which includes use of newly introduced procedures and technologies, as well as the discontinuation of specific practices and treatments, can also affect spending. After adjusting for changes in the mix of services for three of the four categories (the exception being prescription drugs), price increases drove per-person spending growth among the ESI population between 2013 and 2017 [Figure 2]. • Utilization declined 0.2% between 2013 and 2017. • Average prices increased 17.1% between 2013 and 2017.
Per-person spending on prescription drugs, based on payments at point-of-sale, totaled $1,065 in 2017, of which $807 was spent on brand prescriptions and $246 on generics [Figure 31]. In 2017, spending on prescription drugs and medical devices obtained at pharmacies was 29% higher than in 2013 [Figure 32]. The increase in spending includes increases in expenditures for the same drugs, as well as increases in expenditures that result from the adoption of newly approved medications. The trends in per-person spending were not uniform across all subcategories of prescription drugs [Figure 32 on page 19]. • Spending declined for cardiovascular (-34%), central nervous system (CNS) (-11%), gastrointestinal (GI) (-12%), and ears, eyes, nose, and throat (EENT) (-15%) prescription drugs. • Notable spending increases occurred between 2013 and 2017 for hormones (55%), rheumatoid arthritis (156%), skin (70%), and chemotherapy/antineoplastic agents (95%) prescription drugs. Further, these estimates reflect amounts paid at time of purchase, and therefore, do not include manufacturer rebates. Recent analyses by the Department of Health and Human Services Office of the Inspector General and Medicare Trustees of the effect of rebates in the Medicare Part D program found that rebates offset approximately 20% of spending increases from 2011 to 2015 and accounted for between 11.7% (2012) and 19.9% (2016) of total drug costs. The Prescription Drug Cost Transparency Report published by the California Department of Managed Health Care reports that manufacturer rebates totaled just over 10% of prescription drug spending for commercial health plans regulated by the state in both 2016 and 2017.