CMS inpatient only policy threatens patient access to appropriate surgical setting

CMS inpatient only policy threatens patient access to appropriate surgical setting

Editor’s note: Joseph Bosco is president of the American Academy of Orthopaedic Surgeons. He is also professor and vice chair for clinical affairs in the department of orthopaedic surgery at NYU Langone Health, where he specializes in sports medicine and knee surgery.

The continued surge of COVID-19 cases has forced more than 100 hospitals to postpone elective surgeries.
Patients are suffering as a result. Arthritis patients in need of joint replacements have been inactive for months. Patients with severe back pain — which could be alleviated with minimally invasive spinal surgeries — have temporarily lost their mobility. A few have waited almost a year for their operations, since hospitals canceled surgeries en masse last spring and summer due to the pandemic.
Unfortunately, a well-intentioned federal reform could soon make patients’ lives even harder.

Late last year, CMS finalized a significant policy change to eliminate the Medicare “Inpatient Only” (IPO) list. The resource identifies over 1,700 procedures that are only eligible for Medicare reimbursement if they are performed on an inpatient basis in hospitals, rather than in outpatient clinics.
The IPO elimination occurs gradually over three years — and has already started taking effect. As of Jan. 1,  CMS dropped all 266 musculoskeletal-related procedures, including amputations and other high-risk surgeries and services, from the list.
In theory, eliminating the list enables patients — and their doctors — to choose whether to perform a surgery at an outpatient clinic or an inpatient, full-service hospital. More freedom to account for individual circumstance is a good thing.
But in practice, the rule could have dangerous, unintended consequences.
Contrary to popular belief, dropping services from the IPO list does not necessitate that they be performed in an outpatient setting. But it could nevertheless impede patients’ access to hospital operating rooms and threaten the physician-patient relationship. That is because many private insurers will follow the government’s supposed lead — and then go further, refusing to pay for certain procedures unless they are performed in outpatient clinics, or unless physicians waste considerable time arguing with insurers why a procedure should take place in the inpatient setting.
This has already happened in recent years, after the government removed total hip and knee replacements from the IPO list.
Such changes pose a risk to patients who need the highly coordinated care that only full-service hospitals can provide. Consider a woman living in a three-story walkup in New York City without any family nearby. That patient cannot go home the same day of a joint replacement surgery without risking serious complications — yet that is exactly what insurers have required with total knee arthroplasty.
That would cause more pain for the millions of Americans whose conditions have worsened over the past year due to surgery postponements.
Eliminating the IPO list is not a bad idea, in and of itself. But regulators need to safeguard patients by offering clearer guidance to insurers about the reform. Otherwise, it will be too easy for insurers to effectively kick patients to the curb, forcing them to return home mere hours after serious surgeries.
Regulators could also relieve patients by abandoning plans to slash Medicare reimbursements for many orthopaedic services by 4%. Those cuts were originally set to take effect on Jan. 1, but fortunately Congress intervened in late December to mitigate these cuts by one year. However, orthopaedic services will continue to see reduction in Medicare reimbursement due to other policy changes.
Moreover, Medicare patients may have a higher out-of-pocket payment responsibility if they have a surgery in the outpatient setting (covered by Medicare Part B) as compared to hospital inpatient (covered by Part A).
Across the country, orthopaedic surgeons are taking on debt and reducing staff to keep their lights on. Still, one in three private surgical practices is facing permanent closure. The planned reimbursement cuts would put more doctors out of business — and thus limit patients’ ability to get high-quality, convenient care in their own communities.
Patients have been through a lot over the past 12 months. Regulators can deliver at least some relief — by providing clearer guidance on the drastic policy change and nixing reimbursement cuts that would force many small practices to shutter their doors, adding to the burden that patients could face.

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