Sending Office: Honorable Peter J. Roskam
Sent By:

        Request for Signature(s)

Dear Colleague:

In its calendar year 2019 outpatient prospective payment system (OPPS) proposed rule, the Centers for Medicare & Medicaid Services (CMS) incorporates changes to outpatient service payment rates that may impact the ability of hospitals across the country to
deliver care to vulnerable patients.

The rule proposes to reduce payment rates for outpatient services billed under “evaluation and management” codes in an effort to curb utilization of these services. We are concerned that by cutting critical services delivered in the lower-cost outpatient
setting, the proposal will undermine CMS’ efforts to reward value over volume.

According to MedPAC’s most recent data, hospital outpatient departments have a negative 14.8 percent Medicare margin. This is concerning and the proposed rule would further lower payments significantly. This could then make it more difficult for our constituents
on Medicare to access care.

Because of these concerns, we have written the attached letter to CMS and we are seeking co-signers to this letter. Please contact or to sign onto the letter. 


Peter J. Roskam

Mike Thompson


October XX, 2018

Seema Verma
Centers for Medicare and Medicaid Services
U.S. Department of Health and Human Services
7500 Security Boulevard
Baltimore, MD  21244

Dear Administrator Verma:

We are writing regarding the Centers for Medicare & Medicaid Services (CMS) calendar year (CY) 2019 outpatient prospective payment system (OPPS) proposed rule. The proposed rule incorporates changes to hospital outpatient services payment rates that we are
concerned may affect efforts to move to value-based care.

Specifically, the CY2019 OPPS proposed rule would implement a significant reduction in the payment of evaluation and management (E/M) services delivered at off-campus hospital outpatient departments (HOPDs), which may run contrary to actions by Congress
under Section 603 of the Bipartisan Budget Act of 2015 (BBA of 2015).

CMS cites Section 1833(t)(2)(F) of the Social Security Act as the authority under which the agency proposes to make this change. This provision gives the agency ability in “controlling unnecessary increases in the volume of covered OPD services.”  It is
unclear how CMS has deemed all of the OPD services at the grandfathered off-campus HOPDs as cause of an
unnecessary increase in volume of OPD services, and we ask that you provide clarity on this when making these payment changes.  We want to ensure that the payment cuts in the proposed rule are targeting services that the agency has deemed unnecessary.
It is not clear that the increase in total expenditures for such services outlined by CMS is reflective of an increase that was unnecessary, nor that the proposed payment reduction will drive a reduction in utilization moving forward.

The agency has also proposed cutting payment to 40 percent of the current HOPD rate for grandfathered off-campus HOPDs that begin to furnish a new service from a clinical facility not offered prior to November 1, 2015 which could unfairly penalize grandfathered
off-campus HOPDs that expand or diversify the critical services they offer to meet the changing needs of their patients.

We share the agency’s objectives of increasing efficiency, limiting costs incurred by beneficiaries, and paying for value within the Medicare program. We will continue to serve as partners in those efforts. However, we believe that these changes should not
diminish progress made in the shift to value over volume in today’s health care system. As providers enter into different, value-based payment arrangements it is important that rate changes do not undercut these arrangements – potentially diminishing provider
desire to invest in these positive changes.

The facilities impacted by this rule provide care to some of the most vulnerable patient populations in difficult to serve areas. We believe it is critically important for these patients to be able to access care and services in the appropriate setting in
their communities.

We appreciate your consideration of these concerns.



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