AHA criticizes 2.9% increase in CMS' OPPS final rule
The AHA says the final rule only worsens the problem of "sustained and substantial underpayment" of hospitals.
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The American Hospital Association has criticized the Centers for Medicare and Medicaid Services for its Hospital Outpatient Prospective Payment System (OPPS) final rule, saying the increase for outpatient hospital services doesn't go far enough.
CMS issued a 2.9% Medicare payment rate for hospital outpatient and Ambulatory Surgical Center (ASC) services for calendar year 2025, saying it did so in accordance with Medicare law.
Both updates are based on the projected hospital market basket percentage increase of 3.4%, reduced by a 0.5 percentage point productivity adjustment.
Decrying what it sees as "sustained and substantial underpayment" of hospitals, the AMA said the final rule "only worsens this chronic problem."
"The agency's final increase of less than 3% for outpatient hospital services will make the provision of care, investments in the healthcare workforce, and addressing new challenges, such as cybersecurity threats, more difficult," said Ashley Thompson, senior vice president, public policy analysis and development, AHA. "These inadequate payments will have a negative impact on patient access to care, especially in rural and underserved communities nationwide."
She added that, while the AHA appreciates that the rule provides hospitals with additional implementation time and greater flexibility in how they meet certain requirements, concern remains about what the organization called CMS' "excessive use of Conditions of Participation to drive its policy agenda."
Thompson said there's a potential risk that the requirements could inadvertently reduce access to maternal care.
"We believe a less punitive and more collaborative approach would be more effective given that the key drivers of maternal health outcomes are highly complex and involve multiple stakeholders," she said.
WHAT'S THE IMPACT?
As part of the rule, CMS also announced new baseline health and safety requirements for hospitals and Critical Access Hospitals (CAHs) providing obstetrical (OB) services, and removed barriers to expand access to care for those formerly incarcerated and others in underserved communities.
CMS has also finalized new health and safety requirements for hospitals and CAHs providing obstetrical services, which set baseline standards for the organization, staffing and delivery of care within obstetrical units. The requirements also update the quality assessment and performance improvement (QAPI) program, and require staff training on evidence-based maternal health practices.
Premier, however, was not impressed, and joined the AHA in its criticism of the rule.
In a statement, the organization said it was "profoundly disappointed" and said the payment rules would widen the gap between Medicare reimbursements and healthcare providers' actual operational costs.
"Providers are grappling with rising inflation, labor shortages and the demands of an aging population – challenges CMS fails to adequately address," said Soumi Saha, senior vice president, government affairs, Premier. "This update misses the mark, failing to recognize the real cost pressures providers face – particularly labor. It's time CMS adopted more realistic methodologies and data sources to keep up with these escalating challenges."
Saha went as far as to say that if CMS continues to implement payment updates of this nature, "the future of American healthcare will be jeopardized."
THE LARGER TREND
As part of the rule, CMS is also implementing policies meant to reduce the use of opioids and to increase access to high-cost drugs in tribal communities. The agency is finalizing the implementation of a provision from the Consolidated Appropriations Act, 2023 that provides additional payment for certain non-opioid drugs and medical devices for pain relief.
"This policy supports the agency's behavioral health goals of reducing opioid overdoses and helps ensure effective pain management," said CMS.
The rule will also expand the clinic services' benefit for services provided outside the "four walls" of IHS and Tribal clinics, and also gives states the option to cover Medicaid clinic services outside of behavioral health clinics and clinics located in rural areas.
Jeff Lagasse is editor of Healthcare Finance News.
Email: jlagasse@himss.org
Healthcare Finance News is a HIMSS Media publication.
