With site-neutral payments, the devil is in the details


Physician groups are pushing back against a proposal to implement site-neutral payments, despite the fact that they generally support the concept of it.


In the proposed update to the Hospital Outpatient Prospective Payment System (OPPS) for 2019, the Centers for Medicare & Medicaid Services introduced a physician fee schedule–equivalent payment for clinic visit services when provided at an off-campus, provider-based department that is paid under the OPPS.

The American Medical Association said in a letter to the CMS that, while it “generally supports site-neutral payments, we do not believe that it is possible to sustain a high-quality health care system if site neutrality is defined as shrinking all payments to the lowest amount paid in any setting.” The AMA said that the current proposed rule is “complex, confusing, and is not truly site neutral because the policies do not apply equally to all hospital outpatient clinics,” adding that a contributor to the differential between private practice and hospital outpatient departments (HOPD) stems from physicians being underpaid in the physician fee schedule.

In a letter signed by the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy, they wrote that, “while ambulatory surgical centers (ASCs) are a more efficient and lower-cost alternative to the HOPD for a number of gastroenterology procedures, it does not mean, however, that reimbursement rates for services provided in both the ASC and the HOPD should be the same. Our societies support payment rates appropriate for each site of service and using appropriate policy and payment levers that result in patients receiving care in the most cost-efficient site of service.”

The American Academy of Family Physicians stated in a letter to Seema Verma, current administrator of the CMS, that, while it supports the idea of site-neutral payments, “we note that the payment methodology for 2019 will not assure equal payments for the same service, regardless of site of service.” The AAFP noted that the goal of curbing hospital acquisition of independent physician practices may not come to fruition and that “hospitals may still be incentivized to buy physician practices based on the mix of services they provide and bill them as PBDs [provider-based departments] at Medicare rates higher than would have been paid had the practice not been bought by the hospital.”

The American College of Cardiology offered support for site-neutral payments and, while it did not come out against the CMS’s proposal, it did offer a series of recommendations to consider, including determining that payments reflect “the resources required to provide patient care in each setting” and that “payment differences across sites should be related to documented differences in the resources needed to ensure patient access and high-quality care.”

The American Academy of Dermatology Association voiced its support for the proposal to the agency.

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