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Kara Newbury - Acting on CMS' 2023 Final Medicare Rule
179 Plays1 year ago
It's officially 2023! Kara Newbury, ASCA’s Director of Government Affairs and Regulatory Counsel, is here today to share what ASCs need to do to start Acting on CMS’ 2023 Final Medicare Rule. As the industry's expert, Kara walks us through reimbursement rates, the covered procedures list, the complexity adjustment policy, and more.
In our news recap, we’ll cover five trends ASCs need to know in 2023, how a hospital recovered $35,000 worth of lost instruments in 9 months, tips for adopting new tech, and of course, end the news segment with a positive story about a doctor who saved two lives during a half marathon.
Articles Mentioned:
5 trends ASCs need know in 2023
Finding a Needle (or Microsurgical Instrument) in a Haystack
7 Rules Hospitals Should Follow When Adopting New Tech
Doctor saves 2 lives during half-marathon
Brought to you by HST Pathways.
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Transcript
Podcast Introduction
00:00:01
Speaker
Welcome to This Week in Surgery Centers. If you're in the ASC industry, then you're in the right place. Every week, we'll start the episode off by sharing an interesting conversation we had with our featured guests, and then we'll close the episode by recapping the latest news impacting surgery centers. We're excited to share with you what we have, so let's get started and see what the industry's been up to.
Kara Newberry on CMS's 2023 Medicare Rule
00:00:27
Speaker
Hi, everyone. Here's what you can expect on today's episode. This week's guest needs no introduction. Kara Newberry, ASCA's Director of Government Affairs and Regulatory Council, is here today to share what ASCs need to do to start acting on CMS's 2023 final Medicare rule. Kara walks us through reimbursement rates, the covered procedures list, the complexity adjustment policy, and more.
ASC Trends and a Heroic Doctor
00:00:55
Speaker
In our news recap, we'll cover five trends ASCs need to know in 2023, how a hospital recovered $35,000 worth of lost instrument in nine months, tips for adopting new tech in 2023, and of course, end the new segment with a positive story about a doctor who saved two lives during a half marathon. Hope everyone enjoys the episode and here's what's going on this week in Surgery Centers.
00:01:26
Speaker
Tara, welcome to the show. Thanks. Thanks for having me. Appreciate you joining us today. And I know that many of our listeners are going to be familiar with you and your name, given the work that you do in this industry and advocating for this industry. But for those that may not know you, can you give us a little bit of an overview on yourself and the work that you do?
00:01:49
Speaker
Sure, absolutely. So Kara Newberry, I work for the Ambulatory Surgery Center Association. I've been with ASCA for more than 11 years now. And my current role is regulatory counsel and director of government affairs. So I'm basically spearheading all of the advocacy work that ASCA does. Fantastic. And we're excited to have you on in general, but super excited with this timing.
00:02:17
Speaker
with CMS publishing their final ruling just a couple of weeks ago, I believe, and wanted to ask you a couple of questions about that. There's folks that we talked to trying to interpret and understand different pieces. And so if it's okay, I wanted to ask you a couple of kind of clarifying questions as it relates to the ruling.
Medicare Reimbursement Rate Increase
00:02:37
Speaker
So to start, can you give our listeners a quick overview of the increases to Medicare reimbursement rates for 23?
00:02:46
Speaker
Sure. So I'll just start out by saying, you know, because usually I'm called a Debbie Downer when I give some of these updates. So, you know, it was slightly more positive than was in the proposed role. So I have to start out, I guess, with a little bit of a positive. So the effective update for ASCs is 3.8.
00:03:08
Speaker
percent. Obviously, 3.8% is nowhere near what we know our facilities are facing in terms of increased costs, staffing costs, supplies, overhead. So we were disappointed that it wasn't higher, but it was, like I said, at least a little better than the 2.7% effective update that had been in the proposed rule.
00:03:34
Speaker
Got it. And can you tell us a little bit about the changes to the ASC covered procedure list?
ASC Procedure List Decisions for 2023
00:03:42
Speaker
Sure. So every year, CMS, primarily led by their medical officers, is looking at and evaluating procedures that may be eligible for addition to the ASC cover procedure list for the coming year. And unfortunately, once again, playing Debbie Downer role, I guess, but they had only proposed one procedure to be added to the list.
00:04:10
Speaker
And ASCA had submitted, I think, 37 codes for their consideration. We had gone to our members and done a survey to ask what procedures our members were doing on, you know, private pay market that they thought would be safe for Medicare beneficiaries. And in the proposed rule, they only added one. In the final rule,
00:04:34
Speaker
They did increase that to four. So there were four procedures that were added to the ASC cover procedure list for 2023. Probably most significant to the listeners and at least our members would be CPT code 19307. That's a radical mastectomy code.
00:04:58
Speaker
that we have been requesting for some time now. But all the procedures that we had asked CMS for are done primarily in the outpatient space. So although we were disappointed that there were only four procedures added, we're excited that in the future, CMS is going to start a new nomination process.
00:05:21
Speaker
where, you know, any interested stakeholders, so all the listeners for this podcast, hopefully you'll submit codes in the future that you think should be payable in the Medicare space.
Future ASC Advocacy Plans
00:05:36
Speaker
Unfortunately, that process has been delayed. And so that won't start until January 1, 2024, which would be effective for 2025 rulemaking. So we have a little bit of time before that and goes into place. So ASCA is planning on being
00:05:51
Speaker
very proactive in 2023. We're scheduling a meeting to go speak with Medicare medical officers in January or early February to present codes that we would like to see added. One of the primary codes that we're pushing hard for in future rulemaking, so it wouldn't be 2024 at the earliest, but one of the codes we're pushing for is total shoulder.
00:06:16
Speaker
Arthroplasty, it's far and away the procedure lately that's been getting the most traction and had the most requests from our members. So more to come on that, but I will just put in a quick plug to anyone listening. If you have any outcomes data from your facility, specifically on Total Shoulder, we would welcome that information.
00:06:41
Speaker
CMS is very interested in, you know, seeing actual data. And like I said, you know, how the procedures, how many procedures are being performed, we can typically pull that kind of information. We have access to volume data, but they are looking at outcomes data, you know, so they can show that they'll be safe procedures to be performed in ASC. So any help we can get, we would welcome that.
00:07:09
Speaker
Very helpful.
CMS's Nomination Process for Procedures
00:07:11
Speaker
And just, you know, there's a couple of follow-up questions there. From a context perspective, you said there was four procedures in the final rule. How does that compare to previous years?
00:07:22
Speaker
So it's fairly consistent, unfortunately. And that's part of the reason that we wanted this new, more formal nomination process where you can eventually go on the CMS website, submit codes through a portal, and then CMS will have to respond to those codes. Because in the past, you know, we've, you know, gone and presented to CMS. And it's kind of like,
00:07:44
Speaker
you know, you don't hear back and then it's either in the proposed rule or it's not. And anywhere from zero procedures added to, we did have, you know, a couple of years where we got like 17 codes. Those were typically in years where we had like certain specialties that were focused on. So, you know, you may remember that a few years ago we had some cardiovascular codes added to our list. So we got 17 codes, I think,
00:08:12
Speaker
at that time, but they were all within the same specialty. But it's typically between, I'd say four to six codes a year. So slow movement, unfortunately, but we are, like I said, planning on being more proactive in 2023. We kind of took a little bit of a hiatus taking surgeons to meet with CMS medical officers during the pandemic.
00:08:41
Speaker
But we are picking that up and resuming that in 2023. So slow but steady progress. And it sounds like, hey, at least there's line of sight into a new, more structured, hopefully, more visibility nomination process.
ASCA's CPT Code Recommendations
00:09:02
Speaker
Until then, you mentioned that ASCA is continuing to help us fill that gap.
00:09:08
Speaker
How does Aska go about determining what you guys put on your recommendation list from a CPT code perspective?
00:09:15
Speaker
Absolutely. So we do a survey of our members every year, and we ask for them to submit codes to us that they would like to be considered. And then we always ask for all of those procedures. We also go to look at the claims data that we have access to for private payer claims, and we look to see
00:09:43
Speaker
how often those codes are being done in the outpatient setting, both ASCs and hospital outpatient departments. I would argue, hopefully most in our space would argue that in terms of safety and quality, ASCs and hospital outpatient departments are pretty much one and the same. So we argue consistently to CMS that anything that
00:10:05
Speaker
is allowed to be performed in a hospital outpatient department should also be allowed on the ASC cover procedure list. But it's all based on member recommendations. And then in addition to that, we will include other procedures that we see that are being done in high volume in case, you know, we just didn't hear from
00:10:26
Speaker
those folks, those doctors who are performing other procedures. So it's usually high volume and anything that is requested from membership.
Challenges with CMS Outcomes Data Requirements
00:10:38
Speaker
Great. And another piece I want to touch on that you mentioned was the outcomes data that seems to be pretty important in the CMS decisioning.
00:10:50
Speaker
What type of outcome data or outcome tracking have you seemed to be most effective? Because this outcome term can mean different things to different folks. And it can be hard in terms of, hey, what really is going to hold up under the scrutiny?
00:11:06
Speaker
It's tough too because I think sometimes CMS doesn't even know what it's looking for. We provided them with a couple of research studies in the past two years of rulemaking specific to total shoulder, total ankle, and a spine fusion code. And it was successful two years ago keeping those codes off of going back on the inpatient only list.
00:11:31
Speaker
Some listeners may remember that there were huge sweeping changes made during the final year of the Trump administration and then the Biden administration in its first year kind of pulled back a lot on those changes. And so they were planning on adding like total shoulder.
00:11:46
Speaker
total ankle and some spine codes back to the inpatient only list. We are successful keeping those off and thought that you know the research that we shared was probably compelling and helpful with that but then when we shared similar research and information you know this year or last year for
00:12:05
Speaker
2023 rulemaking, you know, it wasn't as compelling. Part of the reason that we need to go meet with CMS is because we want further guidance in terms of what is going to move the needle. In the final rule, they said that the data wasn't compelling because I guess it wasn't
00:12:25
Speaker
enough volume to look at. And then they also made this weird argument about, you know, is it transferable across all surgery centers? And I didn't exactly understand what that meant. Like, you know, an eye center is not going to all of a sudden start doing total shoulder surgery. But anybody who's already doing total joint replacements, you know, I have full confidence
00:12:45
Speaker
in our facilities that those who are doing total joint replacements are safe and effective and could add total shoulder Medicare volume to that mix. So like I said, it's kind of unclear what exactly they want. And of course, you know, the outcomes data for each type of procedure varies. You know, so for
00:13:05
Speaker
A lot of these joint replacements, they're looking to see, you know, infections. They're looking to see, you know, was there a follow-up depending on the surgery? Was there a follow-up required? So, you know, really any data that we get our hands on, we share with CMS because
00:13:26
Speaker
Anything is better than nothing. And like I said, it's still kind of unclear to us based on the responses that we've gotten from them in previous meetings, what exactly they're looking for.
00:13:36
Speaker
Sure. Okay.
Complexity Adjustment Policy Benefits
00:13:38
Speaker
We'll shift gears on you a little bit on maybe more of a kind of positive glasses half full perspective. The ruling from my understanding does include some complexity adjustments for certain code combinations, I believe. Can you explain what the policy does and talk about the benefit of that for the industry?
00:13:58
Speaker
Sure, absolutely. So this was a big win for ASCs and a good starting point for this policy. So for hospital outpatient departments, for some time, they've had this complexity adjustment. So CMS takes the primary surgical code that's being done and then an add-on code that's done in conjunction with that. And they bump up the reimbursement rate because they're saying that the add-on code
00:14:26
Speaker
changes the complexity and the cost of performing that procedure. So typically for every run of the mill case, add-on codes are not separately payable. They're N1 payment indicator and there's no additional
00:14:42
Speaker
reimbursement available, but CMS has found, like I said, these code combinations for 2023, there are 55 of them in the ASC setting for which the add-on is going to increase that reimbursement for ASCs.
00:15:00
Speaker
it's it's a start there certainly other code combinations were looking to get added there's not really a ton of spine on there and we know for a fact that there are a lot of spying code combinations with an ad on that you know certainly are more complex and costlier.
00:15:16
Speaker
So 1 example I've been giving is removal of thyroid. So the primary code is 60240 and there's often an add on with that 60512 that would typically not be reimbursed under under the 2022 and prior Medicare policies.
00:15:36
Speaker
But CMS has found that when those codes are done in combination, it's costlier and more complex. And so now this new C code that CMS has established is C7555, and it has a reimbursement rate of around 4,200. So basically an increase of, you know, 17, $1,800 because of, you know, those codes being done in combination.
00:16:02
Speaker
Aska is going to put out more resources. We also have some already available on our website so you can see which code combinations are already going to get this new complexity adjustment. But as I said, we're really going to be pushing for a lot more code combinations in the future, specifically in the spine area.
00:16:25
Speaker
Great. Sounds like something we can build on.
Quality Reporting and Medicare Payments
00:16:29
Speaker
Can you tell me a little bit about quality reporting? And I understand there's a linkage between Medicare's quality reporting and payments. And can you tell me a little bit about how that linkage works and what the implications are?
00:16:42
Speaker
Sure, so I don't know if everybody who's listening realizes this, but updates to our quality reporting program are always found in our payment rule. Because there could be a 2% penalty if you fail to report under the quality reporting program. So.
00:17:01
Speaker
And this year's final rule, there weren't a ton of significant changes. We did kind of push back ASC11, which is this cataract improvement in patient's visual function within 90 days measure. It's one that we've been
00:17:19
Speaker
push advocating against, I guess you would say, for almost a decade now because it's really a physician measure. It's not a facility level measure. And so we'll continue to push back on that. But I did just want to let everyone know as a reminder that we have a few outcomes measures that are back in our quality reporting program as of
00:17:41
Speaker
2023 data collection. So ASC one through four, they were, you know, the first measures that were added to our program back in 2012 when it was first initiated. So burns, falls, wrong events and hospital transfers. Just a reminder that you have to collect data for those again.
00:18:03
Speaker
And I know we've been getting a lot of questions that ask us, so you might get a lot of questions too. It is not claims-based anymore, so you used to submit those on your fee-for-service Medicare claims. That's no longer the case. Now you're collecting that data for all of your patients and then you'll be submitting it
00:18:22
Speaker
through the web-based portal that CMS has next May. So just wanted to remind everyone on that. I know we've been getting a lot of questions, so I'm guessing that you might be getting some questions as well. Absolutely. Fantastic. Anything else from a final ruling perspective, from a kind of macro topic perspective that our listeners should be aware of or keep an eye on?
Potential Medicare Overhauls
00:18:48
Speaker
I think it's just always important to know that, you know, we are a small cog in, you know, this larger machine and, you know, really, there's a lot of discussions and rumblings happening right now about a complete overhaul and more significant changes to the Medicare program.
00:19:07
Speaker
I've talked with a lot of folks at CMS about this, and I would love to be part of those discussions because I think that there are definitely improvements that could be made. But, you know, I was just listening to the med pack meeting a few weeks ago, and I think that they said that we are 0.5% of the Medicare spend ASCs are. So, you know, although we think, you know, obviously there are six
00:19:33
Speaker
6,100 CMS-certified ASCs, and we're saving Medicare billions of dollars a year, but we're still a very small piece of the puzzle. But I think that we do a good job at ASCA, even though we're a small piece of the Medicare puzzle kind of hitting above our weight or getting a lot of positives for our industry.
00:19:59
Speaker
We love it and appreciate all that you do and all ASCA does on behalf of the industry. Kira, final question for you.
ASCA's National Advocacy Day
00:20:08
Speaker
And we ask this for all of our guests every week. What's one thing our listeners can do this week over the near term to improve their surgery centers?
00:20:18
Speaker
Okay, it's a little self-serving, but ASCA is hosting our first fly-in in three years. And I would say, if at all possible, if you can come and participate in our fly-in, also known as our National Advocacy Day,
00:20:36
Speaker
You know, really, that's how you're going to help make an impact, not only for your facility, but the industry as a whole is getting in front of your elected officials and telling them your story and how great you are. That's how we really get through to them. If that's not feasible, I would say, you know, host a facility tour and bring folks in, you know.
00:20:56
Speaker
I'm not a clinical person and I could never give advice on how to run your surgery center. I'm also not a business person in that sense, but what we do hear from elected officials who go to bat for us in Congress or in your states,
00:21:12
Speaker
is that really hearing your story, what you're doing, and all of the great care you're providing is really what resonates with them and gets them to either sign on to our legislation or help push different wins for the industry. So that's my plug. I'd love for you all to bring people into your facilities or come to DC if you have the ability. And for folks that are interested in learning more about the flying day and what that entails, where can they get some information on that?
00:21:39
Speaker
Sure, you can reach out to me. You can go to our website, askassociation.org. And you can, like I said, feel free to reach out to me. Follow us on all the social media platforms. We have more information there as well. Fantastic. Cara, thanks so much for joining us today. Yep, thank you.
00:22:05
Speaker
As always, it has been a busy week in healthcare, so let's jump right in.
Becker's ASC Trends for 2023
00:22:10
Speaker
Our first story of the new year comes from Becker's ASC review. With the end of the year comes a bunch of articles recapping 2022 and looking ahead to the new year, and this article is the latter. Becker has published a write-up titled 5 Trends ASCs Need to Know in 2023, and here's the scoop.
00:22:29
Speaker
Trend number one is value-based care. With low-cost, high-quality procedures, ASCs are set up for success as healthcare transitions to this payment model. ASCs have always offered high quality results, so this payment model will bode well for the industry.
00:22:45
Speaker
And minutes from Optum's investor meeting in October, they shared that their revenue per consumer has grown 31%, and they attribute that success to the increasing number of patients served under value-based care relationships. And if you do look at their minutes and you do a quick search for value-based care, you'll see that that term comes up over a dozen times, which is very telling.
00:23:10
Speaker
Trend number two is physician pay cuts. Medicare's physician fee schedule final rule will reduce the conversion factor by 4.48%, which is down to $33.06. There have been concerns that the cut will push physicians away from ASEs into larger health systems and will also lead to declining availability of physician services.
00:23:36
Speaker
Trend number three is staff shortages. Now, this is not news to anybody. This is one of the largest concerns for ASCs right now. We've talked about it a couple times. There's unfortunately no secret solution here as you can't cut corners with higher and qualified staff.
00:23:53
Speaker
And VMG Health shared that many ASCs will have to spend a quarter or more of their net operating revenue on employees alone as we look to next year. So focus on satisfaction and retention and recruitment as much as you can.
00:24:10
Speaker
Trend number four is physician ownership. If there are employed physicians at your ASC that are not currently stakeholders, you might want to consider including them. This will incentivize all physicians who work with you to not only strive for their own day-to-day satisfaction and good pay, but to also strive for the longevity and success of the ASC. And obviously with more cases comes more revenue and more stability.
00:24:37
Speaker
Trend number five, last but not least, is stagnant reimbursement rates. ASCs are paid much lower rates than hospital outpatient departments for the same exact procedures. So you need to keep a close eye on payer behavior and really build one-on-one relationships with your payers as much as you can. And there you have it. Those are the five trends from Becker's to keep an eye on as we are officially now in the new year.
Surgical Instrument Recovery Innovation
00:25:04
Speaker
Our next piece of news comes from outpatient surgery magazine. And I personally think this story is really cool. Um, an airport style security scanner at the university of Iowa hospitals and clinics is saving tens of thousands of dollars worth of valuable instruments from accidentally entering the waste stream. After each surgery bags of trash are removed from the OR.
00:25:27
Speaker
They are run through environmental services placed on a conveyor belt and scanned. Each bag is numbered to identify the room and surgery from which it came from, and if the scan detects an instrument, a nurse is called to identify it and process it correctly through the sterile processing department.
00:25:45
Speaker
This idea alone has recovered $35,000 worth of lost instruments in its first nine months. So as we're constantly thinking about ways to reduce waste and save money, this idea checks both of those boxes. Now, I'm not sure how much the conveyor belt cost, but I'd imagine with an average savings of roughly $3,800 per month, it will pay for itself pretty quickly if it hasn't already.
Technology Adoption Rules for ASCs
00:26:15
Speaker
Our third story comes from MedCity News, and they put together a piece on seven rules hospitals should follow when adopting new tech. And five of those rules really apply to ASCs as well. If your surgery center is considering adopting new technology in 2023, whether it's patient texting or an EHR or a patient estimating tool, keeping these rules in mind will help you significantly in the implementation process.
00:26:43
Speaker
So first, planning should begin during the sales process. Work with your vendor to set clear expectations, timelines, implementation plans, any hidden costs, and everything else. Don't hold back with your questions and don't hold back pushing your vendor for clear answers until you're comfortable with them.
00:27:04
Speaker
Tip number two, clearly define governance structures. So by this, they mean just organize a leadership team for the project and make sure members of the team have clear roles and responsibilities. Now that might seem like a no-brainer, but it shouldn't be something that's just assumed. We want this written down and everyone needs to buy in.
00:27:27
Speaker
Tip number three is always communicate. Everyone involved should have a clear understanding of who's doing what at all times and why they're doing it. And create an actual communication plan and provide regular updates. Tip number four is to prioritize stakeholder alignment. Leaders of both your ASC and the vendor must be transparent with each other, express buy-in, and commit to success. Without that stakeholder alignment,
00:27:55
Speaker
The whole process could fall out of whack. And the last tip here, training is a necessary investment and I couldn't agree more. This is a huge one. We just did an episode on nursing informatics, which kind of ties in exactly to what this tip is saying. Without proper training, end users usually don't feel comfortable adopting a new technology or won't be satisfied with it.
00:28:20
Speaker
So early on in the tech adoption process, you should designate who is responsible for creating and delivering training materials and assign power users to each department. Without those power users and without proper training, the care patients are receiving could be impacted and patient safety could be impacted. So make sure you invest in training.
A Doctor's Heroic Marathon Intervention
00:28:47
Speaker
And to end our new segment on a positive note, Dr. Steve Lomé saved two lives during a half marathon recently. Dr. Lomé was running the marathon himself when he saw Gregory Gonzalez, a fellow runner, fall and hit his head. He immediately began CPR until an ambulance arrived.
00:29:07
Speaker
Then at the finish line, another fellow runner, Michael Heilman, also fell in his head and the same chain of events occurred. Dr. Lomain began CPR until an ambulance arrived. Both men ultimately had blockages that led to their cardiac arrest and they received stents in their coronary arteries and are perfectly fine. And the three men plan to run the half marathon together in 2023.
00:29:34
Speaker
And that news story officially wraps up this week's podcast.
Podcast Wrap-up
00:29:38
Speaker
Thank you as always for spending a few minutes of your week with us. Make sure to subscribe or leave a review on whichever platform you're listening from. I hope you have a great day and we'll see you again next week.