Regulatory Affairs: Another Year, More Disappointment for ASCs

The CMS proposed plan for 2025 is short on reimbursements.

Is the Center for Medicare & Medicaid Services (CMS) spineless, heartless or both?

That depends on whom you ask, of course, but ASC advocates are certainly not happy with CMS’s 2025 proposed rule that doesn’t include any of the 18 heart and spine codes proposed for inclusion by the Ambulatory Surgery Center Association (ASCA).

‘Supposedly more transparent process’

That obviously didn’t sit well with ASCA CEO Bill Prentice.

“It is disheartening that CMS established a new, supposedly more transparent process for submitting procedure codes that could be added to the ASC-Covered Procedures List, yet proceeds in this proposed rule to ignore the 18 cardiac and spine codes we submitted,” he says. “Medicare beneficiaries would have more access to the care they need if the agency simply relied on the clinical expertise of surgeons who safely perform these procedures and are best positioned to know where they can be performed.”

The fact that the 18 new codes ASCA proposed were not even mentioned anywhere in the 984-page rule, which CMS released in July, is problematic. Public comments are accepted until Sept. 9. The final rule is scheduled to be released in November and goes into effect on Jan. 1.

David Shapiro, MD, CASC, an anesthesiologist who practices in Florida and a board member of the ASC Quality Collaboration, a nonprofit advocacy group, echoed Mr. Prentice’s dissatisfaction with the contents of the proposed rule.

“Our requests were based on really thoughtful scientific and clinical analyses of things that we could do to expand our services that would be absolutely suitable for the Medicare population,” says Dr. Shapiro. “The fact that they just ignored them all is incredibly discouraging. This was a snoozer of a proposal in which they essentially gave us nothing.”

The 18 codes suggested by ASCA are for procedures that have been safely performed in ASCs for years on non-Medicare patients, including on patients old enough to be eligible for Medicare but who have private insurance, notes Dr. Shapiro.

If the events of a year ago repeat themselves, however, there’s reason for hope. Thanks to 2023 lobbying efforts from ASCA leaders, its members and others, CMS reversed course from its initial proposal for 2024 and approved two codes for total shoulder replacements and other procedures to the ASC-Covered Procedures List for 2024 that were not initially included in the agency’s proposed rule it released in July 2023.

For 2025, CMS has proposed 20 new surgical and dental codes in its proposed rule, including two cardiac and two rotator cuff codes Dr. Shapiro characterized as “non-earth-shattering.” The codes can be found on pages 574 and 575 of the document.

The proposal also includes an effective 2.6% increase in reimbursements for procedures that are already covered in ASCs and HOPDs. Dr. Shapiro says the fact that HOPDs are slated to receive the same percentage increase maintains the inequity that exists for ASCs when it comes to Medicare reimbursements. “This proposal doesn’t bend the curve at all,” he says.

The American Hospital Association (AHA) also opposes the 2.6% increase, saying it’s not fair to HOPDs. “CMS has yet again proposed an inadequate update to hospital payments. This proposed increase for outpatient hospital services of only 2.6% comes despite the fact that many hospitals across the country continue to operate on negative or very thin margins that make providing care and investing in their workforce very challenging,” says Ashley Thompson, AHA’s senior vice president for public policy analysis and development. “Hospitals’ and health systems’ ability to continue caring for patients and providing essential services for their communities may be in jeopardy, and we urge CMS to provide additional support in the final rule.”

Even though CMS announced last year that it would no longer mandate COVID-19 vaccinations for healthcare personnel, surgery centers are still required to report this data under the agency’s ASC Quality Reporting Program (ASCQR). The proposed rule for 2025 calls for the reporting requirement about vaccination data to remain. ASCA says the measure is burdensome and will lobby to remove it.

Under the ASCQR, CMS says in its proposed rule that it wants to adopt three reporting measures: the Facility Commitment to Health Equity; the Screening for Social Drivers of Health; and the Screen Positive Rate for Social Drivers of Health. Failure to submit and publicly display data collected could eventually result in ASCs being assessed a two-percentage-point payment penalty to their annual payment rate updates, CMS says.

“These quality measures reflect CMS priorities, including safety and readmissions,” says CMS.

Dr. Shapiro opposed the measures, saying it’s unrealistic to expect ASCs to have the ability to collect such data from their patients, many of whom they see only once and only for a few hours.

“Health equity, social determinants and social drivers of health are important issues, but the idea of us in an ASC environment really having an impact on any of them is beyond ludicrous,” he says. “This would turn the ASCQR program into something it was never intended to be, and these measures would wind up as unfunded, inappropriate and unactionable mandates shoved down our throats and wouldn’t improve patient care, which is my main focus as a clinician and an advocate for the ambulatory surgery community.” OSM