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2010 OPPS Proposed Rule Does Not Include Higher Separately Payable Drug Reimbursements

Michelle Leppert, July 2, 2009

Outpatient facilities and pharmacies hoping to see an increase in reimbursement for separately payable drugs in CMS' 2010 OPPS proposed rule didn't get their wish, but they did see additional proposed guidance on physician supervision rules.

CMS also proposes to allow hospitals to bill Medicare for pulmonary and intensive cardiac rehabilitation services.

"My sense when I first looked at the proposed rule this year was that it seemed much shorter," says Jugna Shah, MPH, president of Nimitt Consulting in Washington, DC. One reason for that, Shah says, might be because CMS chose not to add any additional composite APCs or additional outpatient quality indicators.

That doesn't mean CMS is abandoning its commitment to "value-based" purchasing principles, Shah says, but it does seem like CMS is taking some time to assess the impact of its current composite APCs before adding additional ones.

Reimbursement for separately payable drugs

Providers and various stakeholders have repeatedly weighed in to CMS over the past four years that charge compression has a huge negative impact on how it computes payment rates for separately payable drugs. CMS acknowledges this as an issue, and in its discussion on how it calculated payment rates for 2010, CMS referred to the pharmacy stakeholders' proposal.

Although CMS analyzed the pharmacy stakeholders' proposal, the agency elected not to use that methodology nor did it follow the APC Advisory Panel's recommendations. Instead, CMS introduced a new calculation method: the result is that CMS' proposed payment for 2010 for all separately payable drugs of average sales price (ASP) plus 4% came as a total surprise, says Shah.

"The fact that the 2010 proposed payment rates for separately payable drugs remains the same as what we have today, despite the CMS' new calculation methodology, is truly disheartening," says Shah.

CMS' new methodology does shift some packaged drug costs to separately payable drugs, but falls quite short of covering what providers would consider their drug acquisition costs and pharmacy overhead/handling costs, says Shah.

Shah cautions that an in-depth reading of the information is required to analyze how CMS arrived at the payment rate.

"To the end user–hospitals paid under OPPS–if the proposed payment rate of ASP plus 4% is made final for 2010, then nothing will look different," Shah says. She is hopeful that hospitals will weigh in on this and other CMS proposed changes.

 

"CMS' proposal is far from what providers have been telling CMS they need for separately payable drug reimbursement to cover both acquisition and pharmacy overhead/handling costs," Shah says.

 

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