Kara Newbury – Acting on CMS’ 2024 Final Payment Rule

Here’s what to expect on this week’s episode. 🎙️

CMS’ 2024 Final Payment Rule was released last month. We sat down with Kara Newbury, the Director of Government Affairs and Regulatory Counsel at the Ambulatory Surgery Center Association, to talk through the most important aspects of the 1,672-page document that every ASC should be aware of.

Here’s a brief summary of the key points:

🔢 Medicare Reimbursement Rates: For 2024, there’s an approximate 3.1% increase across all procedures, aligning with HOPDs. This varies by specialty and code, with the top 100 codes by volume in the ASC setting seeing around a 6% update, and the top 10 codes witnessing a 7% increase in some scenarios.

🎉 Expansion of ASC Covered Procedures List: There are 11 new surgical procedures added for 2024 that were not part of the proposed rule, including total shoulder and total ankle surgeries. This expansion is a big win for Medicare beneficiaries, offering them more options for lower-cost, high-quality care in ASCs.

📝 Quality Reporting Updates: The new Patient Reported Outcome-Based Performance Measure for total knee and hip arthroplasties will be mandatory from 2028, requiring pre-op and post-op surveys. It’s critical for ASCs to start preparing early for this significant change.

Find the full episode on Apple Podcasts, Spotify, or YouTube to hear all the details.

Episode Transcript

00:04.42
Erica Palmer / HST Pathways
Hi Kara Welcome back to the podcast. So I’m sure all of our listeners are familiar with you but can you please share a little bit about yourself.

00:07.20
Kara Newbury
Thanks for having me how look. Sure Kara Newberry I work for the ambulatory surgery center association I’ve been with ASCA now for more than 12 years and I handle regulatory affairs for the association and serve as director of government affairs.

00:34.18
Erica Palmer / HST Pathways
Great. So we really wanted to have you on because as everyone knows CMS officially published their 2024 final payment rule last month and we wanted to make sure that our listeners understood exactly what it contains and what their next steps might be.

00:37.58
Kara Newbury
Man Ah, black.

00:51.70
Kara Newbury
Let’s.

00:52.60
Erica Palmer / HST Pathways
So to start could you give us a quick overview of the increASCs to the Medicare reimbursement rates for 2024

00:59.40
Kara Newbury
Absolutely and just to I want to first highlight the fact that our update is the same as the hospital outpatient department update and that is because for. As long as I’ve been with ASCA we’ve been pushing for better alignment with the hospital outpatient department’s update which is the hospital market basket because our payment system is tied to the hospital outpatient department. So it makes sense so our effective update is approximately three point 1 across all procedures which like I said is the same as hospital outpatient departments. It will vary by specialty and by code so make sure that you are looking at specific procedures if you have questions I do want to note that. We do kind of a quick analysis of how it impacts like the top hundred codes by volume in the ASC setting the top 10 codes and although it’s a 3.1% overall for the top hundred codes. We’re seeing. It’s approximately a 6.68% update for those. And a 7.22 update for our top 10 codes and of course our top 10 codes are some opphthhoic codes including cataract a few gi codes and pain management codes. So for the highest codes by volume in the ASC setting. We’re seeing a better.

02:29.38
Kara Newbury
Update Then the average across all codes which I think is a positive sign.

02:34.21
Erica Palmer / HST Pathways
That’s awesome is that a record high or I don’t remember ever seeing those numbers.

02:36.70
Kara Newbury
I know it’s yeah so I’d have to go back and check. But for like the top 10 and top hundred codes. It is definitely much higher than. We normally see you know we’re seeing like cataracts 6 6 9 8 4 is almost to 7% increase over to 2023 some of the standard colonoscopy screening codes are you know, seven point Nine Eight point seven poor four. So. Much ah much higher than like I said that 3% update overall so you know that’s a positive sign especially as a lot of our physicians are dealing with the cuts of course that are coming under the physician fee schedule. So it’s important that. We’re seeing that that growth and that increase with a lot of our higher volume codes on the facility side.

03:34.79
Erica Palmer / HST Pathways
Yeah, that’s awesome. So when it comes to the ASC covered procedures list I feel like we’re typically used to being a little disappointed in this arena but this year feels different. So let’s talk about the changes to the list. What has been added.

03:42.79
Kara Newbury
Yeah, at a disappointed even this one.

03:54.12
Kara Newbury
Sure Absolutely and we were very disappointed with the proposed rule. Um, even though it had ah you know a few dozen codes they were all dental and with a lot of restrictions attached. So. There was a dental procedure but you had to do other ancillary codes in conjunction with it in order to get paid and we’re still kind of sorting out some of um the you know the dental code side of things because those procedures were finalized in the final rule.

04:27.27
Kara Newbury
But in the proposed rule. There were no other codes proposed outside of the dental. Um, even though Asa had submitted a list of 63 procedures that we would like to see added included including total shoulder total ankle and other procedures that were requested by our membership. And so we were obviously very pleasantly surprised to see that total shoulder total ankle a thyroid procedure that we have been promoting and several others were included in the final rule. So there were 11 surgical procedures that were not included. In the proposed rule that were finalized that will be payable in the ASC setting beginning January One twenty twenty four which is fantastic and it’s really, um, you know most fantastic obviously for the Medicare beneficiaries who now have access to the site of service. You know that in the. Care and the efficiency and you know the quality of care the ASCs provide so we were very excited to see that um and you know, looking forward to hopefully maybe this has turned over a new leaf and you know moving forward CMS is going to listen to us. More closely and and be more inclined to add procedures that ASCA and our clinicians are telling them are safe to be performed on the Medicare population.

05:54.66
Erica Palmer / HST Pathways
Yeah, actually the market agency marketing team was together in person. Um, when the final rule came out and we all you know, kind of stopped to read it and we were blown away. We were project. We were guessing like maybe 1 or 2 like throw us a bone.

05:59.38
Kara Newbury
With what.

06:10.97
Erica Palmer / HST Pathways
Um, and then all just to see the list and especially have total shoulders and total ankle on there was super super exciting. Um with the expansion of those codes Specifically what do you think? the future now could potentially hold with these additions and and look like.

06:21.46
Kara Newbury
Protecting Um, it was.

06:30.24
Kara Newbury
Sure so we were actually nervously promoting the addition of those codes because we were concerned that the rate might be um, you know, just way too low for. Um, ASCs to be able to perform those procedures. But fortunately another big positive in this rule was that excuse me total shoulder and total ankle were moved to a higher Apc group meaning that they were bumped up to kind of a. Costlier more complex. It could be 1 or the other or both bumping it up an ortho ambulatory payment classification group meaning ultimately that the reimbursement is better. Um, for hospital occupation apartments and now it’s going to be better for ASCs than it would have been under the 2023 payment classifications and where it it it currently stands in 2023 so what we’re looking at for 2024 at the national level is approximately. Like a $14000 um, reimbursement rate for shoulder a little higher for ankle. Um, which of course is significantly higher than what we see for like knee and hip. For example, other total joint replacement procedures and we do know that the.

07:58.87
Kara Newbury
Implant costs the device costs for shoulder and ankle are more significant so it was critical. It was very important to get that higher now we know that our facilities would obviously still love to see a higher reimbursement rate and we can certainly you know work on that in and the future. But. Ah, we have been hearing from facilities that hopefully this should allow them. You know if they’re going back and maybe negotiating with some of the device manufacturers but should hopefully allow them to do some fee for service medicare volume for shoulders and ankles in 2024.

08:35.28
Erica Palmer / HST Pathways
Yeah, it’s really exciting and um, we had just crunched some numbers on our end for a kind of state of the industry report and we did average net revenue per case and this was um, not just total joints just ortho in general but it was obviously the highest. Um.

08:37.57
Kara Newbury
A much.

08:52.64
Erica Palmer / HST Pathways
Specialty for reimbursement. So when we saw this I was like you know, Obviously we’re always talking about cost savings and and all these you know low reimbursement rates like this could be really exciting for not only profitability, but the patients and just increasing Physician interest in the outpatient space as Well. So. Very cool to see.

09:12.65
Kara Newbury
So yeah in ah, in addition to getting several emails that night from folks who are kind of in disbelief they’re like now what does this really mean you know because I think I’ve trained I think I think I’ve trained people over the years to know that.

09:23.68
Erica Palmer / HST Pathways
Um.

09:29.48
Kara Newbury
Ah, you know, just because something’s on the hospital payable in the hospital outation. Departments doesn’t mean it’s payable in ascs and you know that it often takes a long time to get procedures moved to the Ac cover procedure list and if it’s not proposed. It’s typically not. You know, put in the final rule. So I think people are like is this real is this true and I said yes and then some of the follow-up was you know a surgeon emailing their administrator saying hey now I’m going to be able to do a full day you know Mondays or what or what have you tuesdays can be dedicated to total shoulder in the Asc which should help um, you know make the surgeons happier the facility happier I think one of the questions now we’re looking at is you know, making sure that that they the surgeons have the. Um, the operating room time you know to to do these procedures but I guess that’s a better problem to have than not being able to not being allowed to do them. Um and having to take all of those cASCs to the hospital setting which of course is great and needed in certain circumstances. But.

10:35.83
Kara Newbury
You know if at all possible. We think that people should be given the opportunity for the more convenient often less expensive site of service that ASCs provide.

10:47.27
Erica Palmer / HST Pathways
Yep I totally agree. Um all right switching gears a little bit. Um, let’s talk about the quality reporting updates. Um, what’s going on there. What what do we need to know for 2024

10:51.44
Kara Newbury
Ah.

11:02.30
Kara Newbury
Sure and you know I might just touch upon something that you know we’d like folks to know for 2024 that wasn’t in the rule. Um first. Um, so just a reminder that oscaps. Um, which is the patient experience. Survey is going into effect for hospital outpatient departments in 2024 I think there were some thinking that some people were hoping that it might be delayed again. You know we’ve been trying to tell people. It’s not going to be delayed. But so it’s. Going full effect for hospital off departments in 2024 so we really would like ascs to start at least looking at vendors. You know the first and second quarters of the year so that they are geared up and ready to go for 2025 when it becomes mandatory for ASCs because there’s no indication. It’s going to be delayed anymore. Going into effect for ASCs in 2025 and we just know from previous experience with other ASCs who’ve already started with the survey that it can take time to get up and running and so that’s my just kind of quick plug that if you have not already started looking at vendors. For the oscap survey which will be part of the asquity reporting program requirements in 2025, you know, please do start doing that. But so quick quick plug for that and then in terms of the final rule.

12:24.83
Kara Newbury
Um, you know it was kind of a mixed bag. But ultimately we’ll say it was positive for ASCs so CMS had proposed to add back in a volume measure ASC 7 with some modifications to how it was run previously when it was in our quality reporting program. Um, you know ASCA just kind of had some concerns and questions about you know why? this particular measure. How is it really benefiting the patient. Um, you know while there are a couple of studies that show that and there are studies that show that higher volume can of course indicate. Um, positive performance because the surgeons and the staff and everyone is is doing these on a regular basis and they’re efficient There’s really not a lot of data or evidence saying that. If you’re not doing quite as high a volume that you’re unsafe and we’re fearful that that’s where kind of CMS was looking to maybe take that measure or or the way what they were thinking and so CMS is going to continue to evaluate that measure and look for more data and information and we’re going to. Happy to help them with that but we were happy to see that the measure was not finalized for now while we kind of all talk through and and work through what might you know make that measure better if it’s going to be implemented.

13:46.98
Kara Newbury
And then there was another measure a new measure that was finalized for addition to the asc quality reporting program but we are given ah a 1 year um Delay I guess from what it was supposed when it’ was supposed to be implemented and that is a patient reported outcome performance measure. For total knee and total hip hip arthroplastys and it is quite a measure. It is quite going to be time consuming for our facilities. It’s going to require a preop survey a postop survey a mental health survey in there.

14:21.32
Erica Palmer / HST Pathways
Wow.

14:23.55
Kara Newbury
Um, all sorts of information. Yeah, and the postop is up to four hundred days post operaatively. So you know it’s not necessarily common as you know, right now for ASCs to still be in touch with their patients four hundred day at four hundred days after the procedure. So we’re trying to work through that.

14:28.28
Erica Palmer / HST Pathways
Yeah.

14:44.27
Kara Newbury
Um, with CMS part of the reason that we were able to get the 1 year delay on that. So now it um won’t be required for the ASC the ASCs until 2028 reporting period. Um, but we were able to get that delay because initially CMS wanted to make it voluntary beginning with twenty twenty five and we said that’s the first year that OASCAHPS is required so you’re going to require these facilities that are just operationalizing. You know this new burdensome measure. Um, and adding another one to their plate so CMS listened you know to that I guess to cert to a certain extent and pushed back the voluntary period to twenty six twenty seven which ultimately pushed back the mandatory reporting to 2028 I do just want to also note. This measure has not been tested in the asc setting and typically that’s something that CMS would like to see before they’re adding a measure so we were a little surprised about that and on the inpatient side um a similar measure was as just. Started has just gone into effect as um as a mandatory element of their quality reporting program. So you know I think we’re interested to see how that data comes out and what the response rates look like for the hospitals, the inpatient hospitals and that will help but you know, kind of um.

16:14.11
Kara Newbury
Direct our advocacy as we’re working to make that measure less burdensome for ascs.

16:21.44
Erica Palmer / HST Pathways
Yeah I was reading through that one and the four hundred day thing definitely caught my eye. Um I don’t want to give anybody any ideas. But if they’re doing this for total hip and total knee. Do you anticipate total shoulder and total ankle coming at some point as well.

16:35.52
Kara Newbury
Well so so so it was interesting because we actually used the proposal of this quality measure. Um to highlight how kind of ridiculous it is that um. Shoulder and ankle aren’t even allowed in the Ac Setting. We’re like obviously total joints are being Done. You know on fee for service Medicare in such a high volume that you’ve added you know a quality measure specific to those procedures and you’re not even letting us do um, shoulder and ankle so you know.

17:06.94
Erica Palmer / HST Pathways
Yeah, um.

17:11.75
Kara Newbury
I I think that if it does happen. It would take some time because like I said this this measure has come down to us through the inpatient program and so it would probably be required to be added there first and they might test it. Yeah.

17:26.98
Erica Palmer / HST Pathways
The.

17:30.55
Kara Newbury
On the inpatient basis and then maybe added to the Ac in the future who knows I will say um you know obviously knee and hip have more volume um than even shoulder and certainly more volume than ankles. So in 20 21 which was the first year that we had hip. We saw already 9000 fee for service total hips and approximately 20000 actually more than 20000 total knees done in 2021 on fee for service Medicare um, so you know. I don’t think we’re going to reach that kind of volume um with shoulder and definitely not with ankle but it could be it could be you know something they pursue in the future I will say that overall CMS is very interested in specialty specific measure sets. And so they are certainly looking closer at you know, kind of an orthopedic group of measures. Ah oppothalic group of measures gi et cetera which has its pluses and minuses and like I said we will continue to work with. CMS quality reporting staff on that we do have a monthly call with the quality reporting program staff which allows us you know throughout the year to really raise any concerns that we have so we’re not just kind of coming to them in our comment letter and you know.

19:01.51
Kara Newbury
I hate to say complaining but more often than not raising concerns rather that rather than you know, saying good job but it does allow us to kind of work with them throughout the year which is great.

19:13.70
Erica Palmer / HST Pathways
Yeah, that’s really nice build that relationship keep out patient at the forefront I feel like they anyone working for CMS has to be used to complaints unfortunately. But um, yeah.

19:17.66
Kara Newbury
Are.

19:25.67
Kara Newbury
Yeah, and we we we don’t we don’t yell or we try to keep our our criticisms of you know, productive and making sure that we that everybody in the meeting knows that you know we’re all on the same page. We all want you know, high quality care for.

19:39.58
Erica Palmer / HST Pathways
Yeah.

19:44.84
Kara Newbury
Medicare beneficiaries and you know we’re trying to save the Medicare program money. Um, it’s like you know, let us let us help you with this.

19:52.45
Erica Palmer / HST Pathways
Yes, perfect. So is there anything else that our listeners should be ah, a made aware of for next year or keep a close eye on.

20:02.91
Kara Newbury
Sure so there was a new portal that’s being established. Um, it will be live in January where you know interested stakeholders can propose procedures to be added to the asc cover procedure list and. The window is kind of small. So I just want to note that you do have to submit codes for consideration by March First of 2024 for consideration in 2025 so asa is already kind of starting to compile our list and what we’d like to see added. But if there are any procedures that you you know out there would want to. Consider please feel free to you know pass those along to us and ask what will be coming out with more information in the coming weeks and months as to how you know individual facilities or other stakeholders can submit their own codes for consideration. Um, so that’s that’s 1 thing and I you know I think. Ultimately, that’s a positive It’s positive to have a more public facing a more transparent process because like I said although we’re happy that we got shoulder and ankle and other procedures added. Um, you know we’re kind of in the dark right? We we go and we have these meetings and we advocate for it. But you never really know.

21:16.96
Erica Palmer / HST Pathways
Has that.

21:17.35
Kara Newbury
Um, what’s coming what’s coming and until it’s It’s actually finalized So that’s one important thing you know with regards to like rulemaking. But if you don’t mind I might hit on just a couple of things that we’re seeing in congress that I just want people to keep an eye on great. Um, so.

21:29.95
Erica Palmer / HST Pathways
Sure.

21:36.44
Kara Newbury
With our legislation, the outpatient surgery quality and access act of 2023. There is a copay cap provision in there that we’re really trying to promote and and push out because we were talking about like the reimbursement rates first shoulder. For example, you know approximately 14000 so when you look at. There is a copay cap on what a beneficiary would pay in a hospital setting including a hospital outpatient apartment and it’s ah currently at $1600 so if you look at the 14000 you take 20% of that you can see. That um, if a fee for service medicare beneficiary if they only have original medicare you know they would be paying more to have their procedure done in the Asc than a hospital office department which makes no sense. Um, so we’re trying to fix that and make sure that there are no you know cost barriers to the beneficiary. Have you know a procedure done in the Asd. So. That’s you know, part of our legislation There’s also kind of for for my first time at ask and I’ve been here like I said over 12 years um a couple of legitimate threats that we’re kind of facing um in terms of like site neutral payments and we could have a whole. Podcast on that at some point I’m sure but you know, ah there are some certain proposals being floated that could potentially you know negatively impact ASCs and so we want to make sure that we’re you know.

23:05.63
Kara Newbury
Advocating for the interest of the asc setting which of course is already the lower cost compared to hospital outvation apartments and making sure that there’s nothing that is enacted that would you know, um, further you know reduce our our reimbursement rates. And just another thing to keep on ah the lookout for and we’ll we’ll make sure to put out more information from asska as this piece of legislation moves but we did work over the summer there is a price transparency bill that is very similar to what has been required of hospitals and there’s an interest. Um, to include ASCs in that and so there’s been legislation that would require some federal price transparency requirements for ases. So like I said it was much more active on on the hill um, regarding. ASCs than we’ve been used to in the past and we’ll keep folks updated on that. But you know, please do pay attention to like information we’re putting out I’m sure if things get enacted you all will help put out some information as well and you know it should be. And interesting and exciting 2024.

24:22.15
Erica Palmer / HST Pathways
Absolutely So if people want more info from ASCA on the payment rule or these other um items you mentioned what resources can they look for what should ah where should they go.

24:34.56
Kara Newbury
Yeah, and we have kind of ah and recently updated website. So if you haven’t already make sure that you take a look at.

24:47.33
Kara Newbury
Um, ah the ASCA website and there’ is an entire section on there for payment resources. We have our legislation on there for askka members. Of course they can get government affairs updates et cetera. But yeah, it’s aseaaociation.org

25:04.50
Kara Newbury
Um, is where you can go for for more information and you you know everybody can feel free to reach out to me as well. If they have questions or are looking for more information.

25:13.77
Erica Palmer / HST Pathways
Perfect. So I will include ASCA’s website link um in our episode notes as well. So people can easily find it and on behalf of everyone. Thank you Kara you guys really do an amazing job for the industry and I know um how hard you advocate for us and.

25:17.76
Kara Newbury
Um, great. Ah.

25:27.67
Kara Newbury
Um, with.

25:33.55
Erica Palmer / HST Pathways
Ah, congrats on all the the wins in this year’s ah, payment rule and thanks for coming on. We appreciate it.

25:40.68
Kara Newbury
Um, yeah, thanks for having me.