Navigating healthcare's future: CMS CY 2025 OPPS released

CMS proposes updates to CBSAs, which are crucial for determining hospital wage indexes. This change aims to align payment structures with evolving regional economic distributions, ensuring fair compensation for healthcare institutions. 

3. New status indicators for pain management 

Two new status indicators, H1 and K1, are proposed to represent separately payable, non-opioid post-surgical pain management products. This initiative supports the use of alternative pain management options, aligning with broader efforts to combat opioid dependency. 

4. Changes in obstetrical services conditions of participation 

CMS is revisiting the conditions of participation for obstetrical services, introducing updated protocols to enhance maternal care. These changes reflect a growing emphasis on ensuring safe and effective care for pregnant, birthing, and postpartum patients. 

New OB services conditions 

For example, CMS plans to introduce conditions of participation for OB services, emphasizing organized and standardized care for pregnant, birthing, and postpartum patients. This proposal aims to improve maternal health outcomes and ensure consistent service delivery. 

QAPI program enhancement 

The quality assessment and performance improvement (QAPI) program focuses on OB services, striving to reduce disparities and enhance care quality. These updates align with broader efforts to improve patient experiences across healthcare settings. 

5. Enhancements to OQR quality reporting program 

CMS proposes adding three new health equity measures to the hospital OQR program and removing two existing measures.  These modifications aim to improve data collection and analysis, ultimately driving quality improvements in healthcare delivery, reflecting an essential shift towards more inclusive healthcare policies. 

Additional OPPS CY 2025 updates 

1. OPPS Payment Rate 

CMS is proposing to use CY 2023 claims data and CY 2022 Healthcare Cost Report Information System (HCRIS) data for CY 2025 OPPS rate setting, resulting in a proposed 2.29% increase to the OPPS rate.  

2. Excluding payment for cell and gene therapies 

For CY 2025, CMS proposes excluding payment for cell and gene therapies from comprehensive ambulatory payment classification (C-APC) packaging. This decision aims to better capture the unique therapeutic value of these treatments. 

3. Addressing diagnostic radiopharmaceuticals 

In response to stakeholder feedback, CMS proposes a per-diem packaging threshold of $630 for diagnostic radiopharmaceuticals. This approach intends to ensure access to clinically appropriate, high-cost, low-utilization diagnostics. 

4. Virtual direct supervision extension 

To maintain alignment with the CY 2025 physician fee schedule (PFS) proposed rule, CMS suggests extending virtual direct supervision for therapeutic and diagnostic services through Dec. 31, 2025. This extension supports flexible healthcare delivery, crucial in our digital age. 

5. Indian Health Service (IHS) and tribal facilities 

Starting Jan. 1, 2025, CMS plans to pay IHS and tribal hospitals separately for high-cost drugs in outpatient departments. This change recognizes the unique challenges faced by these facilities and aims to enhance their financial sustainability. 

6. New payment approach for HIV prep 

CMS proposes including HIV pre-exposure prophylaxis (PrEP) drugs and services as additional preventive services under OPPS, pending coverage by the pending issuance of the final National Coverage Determination (NCD). This proactive stance aligns with public health goals to curtail the spread of HIV. 

7. Methodology for clinical trials 

CMS proposes a new payment methodology for drugs and devices covered under an NCD, like the one developed for category B IDE clinical trials. This emphasizes the importance of evidence development in drug and device evaluations. This approach seeks to maintain the integrity of clinical research while ensuring fair compensation. 

8. Addressing clinic services in IHS/tribal clinics 

CMS proposes additional exceptions to the four walls requirement for clinic services in specific settings, including IHS/tribal clinics and rural areas. This initiative addresses access challenges and supports the unique needs of diverse patient populations. 

9. Emergency services readiness 

CMS proposes new requirements for hospitals and critical access hospitals (CAHs) offering emergency services to ensure readiness for diverse patient needs. This proposal reflects an evolving healthcare landscape where adaptability is paramount. 

10. Transfer protocols refinement 

CMS proposes mandating written transfer protocols for hospitals, with the aim of enhancing patient safety and continuity of care. 

11. Modifications to hybrid measures 

CMS recognizes the need for further preparation before mandating hybrid hospital-wide all-cause readmission and risk standardized mortality measures. Voluntary reporting is proposed to continue for FFY 2026, providing hospitals with additional time to meet reporting thresholds. 

12. Exploring safety of care measure group 

CMS seeks public input on modifying the safety of care measure group within the overall hospital quality star rating. 

Conclusion navigating healthcare's evolving landscape 

By understanding the changes in CMS OPPS CY 2025 proposed rule, healthcare providers and administrators can proactively adapt to ensure compliance and the delivery of high-quality care. 

For those looking to understand these changes further, explore DataGen’s Medicare Fee-For-Service Policy Analytics. Stay informed, stay ahead, and together, let's shape the future of healthcare. 

This content is for informational purposes only. It has been partially generated from an AI language model, which may not always be exhaustive or tailored to individual circumstances. We encourage you to contact one of our experts for more information.  We assume no liability arising from any use of this content.