Last week, the U.S. Department of Health & Human Services (HHS) released a draft framework for an initiative that aims to ensure every person in America has access to comprehensive, evidence-based treatment.  The framework is organized around six goals that range from increasing awareness of the benefits of smoking cessation to finding the best measures for the success of the effort.  Research released last year showed that, in 2020, smoking prevalence was higher in rural (19.2 percent) than in urban areas (14.4 percent). From 2010 to 2020, the odds of quitting were lower in rural versus urban areas. HHS invites all potentially interested parties—individuals, associations, governmental and non-governmental organizations, academic institutions, and private sector entities—to respond by July 30.

 This proposed rule describes the actions that the Centers for Medicare & Medicaid Services (CMS) proposes to take to comply with the United States Supreme Court’s decision about the adjustment of Medicare payment rates for drugs acquired under the 340B Program from calendar year (CY) 2018 through September 27th of CY 2022.  As background, in 2018, CMS decreased the Medicare payment rate for 340B drugs from average sales price (ASP) plus 6 percent to ASP minus 22.5 percent.  They also made a corresponding increase to payments to all hospitals (340B hospitals and non-340B hospitals) for outpatient non-drug items and services, so the policy change was budget neutral.  The Supreme Court unanimously ruled that the differential payment rates for 340B-acquired drugs were unlawful because, prior to implementing the rates, HHS failed to conduct a survey of hospitals’ acquisition costs under the relevant statute.  To comply with the ruling, CMS proposes to pay affected 340B providers an estimated $7.8 billion in lump sum payments and to reduce future outpatient non-drug item and service payments to all hospitals starting in CY 2025. CMS would continue to adjust the OPPS payments until the full $7.8 billion is offset, estimated to be 16 years. The proposed actions in this rule would affect all hospitals. Comments are by September 5, 2023.

Proposed policies will expand behavioral health services, support the President’s Cancer Moonshot, promote innovation, and grow value-based care

The Centers for Medicare & Medicaid Services (CMS) issued the calendar year (CY) 2024 Medicare Physician Fee Schedule (PFS) proposed rule to announce rate updates, advance health equity, and expand access to critical medical services — including behavioral health care and certain oral health services. Notably, the proposed rule supports the Biden-Harris Administration’s Cancer Moonshot mission to accelerate the fight against cancer.

“At CMS, our mission is to expand access to health care and ensure that health coverage is meaningful to the people we serve,” said CMS Administrator Chiquita Brooks-LaSure. “CMS’ proposals in the proposed physician payment rule would help people with Medicare navigate cancer treatment and have access to more types of behavioral health providers, strengthen primary care, and for the first time, allow Medicare payment for services performed by community health workers.”

“CMS continues to demonstrate commitment to advancing health equity and building a stronger Medicare program,” said Meena Seshamani, MD, CMS Deputy Administrator and Director of the Center for Medicare. “If finalized, the proposals in this rule ensure the people we serve experience coordinated care focused on treating the whole person, considering each person’s unique story and individualized needs — physical health, behavioral health, oral health, social determinants of health, and are inclusive of caregivers, which are all so important to providing the care that people with Medicare deserve.”

Proposed Payment Rate

The CY 2024 PFS proposed rule includes updates to PFS payments for clinicians as required by law. Overall proposed payment amounts under the PFS would be reduced by 1.25% compared to CY 2023, in accordance with factors specified by law. CMS is also proposing increases in payment for many visit services, such as primary care, and these proposed increases require offsetting and budget neutrality adjustments to all other services paid under the PFS, by law. The proposed CY 2024 PFS conversion factor is $32.75, a decrease of $1.14, or 3.34%, from CY 2023.

Advancing Health Equity and Caregiver Support

Building on the agency’s commitment to health equity, and the Biden-Harris Administration’s Executive Order to support caregivers, CMS is proposing coding and payment for several new services to help underserved populations, including addressing unmet health related social needs that can potentially interfere with the diagnosis and treatment of medical problems. First, CMS is proposing to pay for certain caregiver training services in specified circumstances, so that practitioners are appropriately paid for engaging with caregivers to support people with Medicare in carrying out their treatment plans.

CMS is also proposing separate coding and payment for community health integration services, which would include person-centered planning, health system coordination, promoting patient self-advocacy, and facilitating access to community-based resources to address unmet social needs that interfere with the practitioner’s diagnosis and treatment of the patient. These are the first Physician Fee Schedule services designed to include care involving community health workers, who link underserved communities with critical health care and social services in the community and expand equitable access to care, improving outcomes for the Medicare population.

In alignment with the goal of the Biden-Harris Administration’s Cancer Moonshot for everyone with cancer to have access to covered patient navigation services, CMS is proposing payment for Principal Illness Navigation services to help patients navigate cancer treatment and treatment for other serious illnesses. These services are also designed to include care involving other peer support specialists, such as peer recovery coaches for individuals with substance use disorder.

This rule also proposes coding and payment for social determinants of health risk assessments, which could be furnished as an add-on to an annual wellness visit or in conjunction with an evaluation and management visit.

Payment for Dental Services prior to Certain Cancer Treatments

Access to oral and dental health services that promote health and wellness allows people with Medicare to achieve the best health possible. In this proposed rule, CMS is supporting the Biden-Harris Administration’s Cancer Moonshot initiative by proposing that payment can be made for certain dental services prior to and during several different cancer treatments, including, but not limited to, chemotherapy.

Supporting Whole-Person Care

The CMS Behavioral Health Strategy strives to support a person’s emotional and mental well-being through their behavioral health care. This rule contains some of the most important changes to improve access to behavioral health in Medicare in the program’s history. The rule proposes to allow marriage and family therapists and mental health counselors, including addiction counselors, to enroll in Medicare and bill for their services for the first time. The rule also proposes increased payment for crisis care, substance use disorder treatment, and psychotherapy.

Primary care is instrumental in the delivery of high-quality, whole-person care. CMS is recognizing the value and inherent complexity in primary and longitudinal care by proposing to implement new payment and coding to accurately and appropriately pay for these services, which aligns with the goals articulated in the HHS Initiative to Strengthen Primary Care.

CMS is also continuing to promote whole-person care in the Medicare Shared Savings Program, the largest Accountable Care Organization (ACO) program in the country. CMS is proposing changes to the assignment methodology that would better promote access to accountable care for individuals who see nurse practitioners, physician assistants, and clinical nurse specialists for their primary care services. CMS is also proposing changes to the financial benchmarking methodology to better encourage participation by ACOs serving complex populations. In total, these proposals are expected to increase participation in the Shared Savings Program by roughly 10% to 20%, which will provide additional opportunities for beneficiaries to receive coordinated care from ACOs.

CMS is further driving quality care by proposing to increase the performance threshold in the Quality Payment Program from 75 to 82 points for the CY 2024 Merit-Based Incentive Payment System (MIPS) performance period/2026 MIPS payment year. This statutorily required increase aligns with our goal to provide practices with a greater return on their investment in MIPS participation by giving an opportunity to achieve a higher positive payment adjustment while also encouraging participation in Advanced Alternative Payment Models. CMS is also proposing changes to align the Quality Payment Program with the Universal Foundation, a core set of quality metrics across CMS programs to more effectively drive change.

There are also proposed changes to promote care for individuals with diabetes, by enhancing the Medicare Diabetes Prevention Program (MDPP) Expanded Model to further increase participation and access in underserved communities. This rule proposes to extend the MDPP Expanded Model’s Public Health Emergency Flexibilities for four years, which would allow all MDPP suppliers to continue to offer MDPP services virtually using distance learning delivery through December 31, 2027, as long as they maintain an in-person Centers for Disease Control and Prevention organization code.

For a fact sheet on the CY 2024 Physician Fee Schedule proposed rule, please visit: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-proposed-rule

For a fact sheet on the CY 2024 Quality Payment Program proposed changes, please visit: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/2483/2024%20QPP%20Proposed%20Rule%20Fact%20Sheet%20and%20Policy%20Comparison%20Table.pdf

For a fact sheet on the proposed Medicare Shared Savings Program changes, please visit: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-proposed-rule-medicare-shared-savings-program

To view the CY 2024 Physician Fee Schedule and Quality Payment Program proposed rule, please visit: https://www.federalregister.gov/public-inspection/2023-14624/medicare-and-medicaid-programs-cy-2024-payment-policies-under-the-physician-fee-schedule-and-other

The Centers for Medicare & Medicaid Services (CMS) is proposing to expand access to behavioral health services through coverage of intensive outpatient services — an intermediate level of behavioral health care. To support practices to help curtail shortages of essential medicines, CMS is seeking comment in this rule on potential payment adjustments to hospitals for the additional costs of establishing and maintaining a buffer stock of essential medicines. CMS is also taking steps to increase hospital compliance with the requirements, to improve automated access to standard charge information, to further strengthen enforcement, and to improve the ability of the public to understand and meaningfully use hospital charges for items and services. Additionally, CMS is proposing actions to promote health equity for tribal communities. These proposals are included in the calendar year (CY) 2024 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) proposed rule released today.

“CMS is taking action to help shape a resilient, equitable, and high-value health care system,” said CMS Administrator Chiquita Brooks-LaSure. “This proposed rule expands access to behavioral health care and supports the Biden-Harris Administration’s priority to remove barriers that limit price transparency with a goal of increasing competition to bring down health care costs.”

Every year, CMS reviews and updates payment rates and policies for the OPPS and the ASC payment system. CMS is proposing to update OPPS payment rates for CY 2024 for hospitals that meet applicable quality reporting requirements by 2.8%. This update is based on the projected hospital market basket percentage increase of 3%, reduced by 0.2 percentage point for the productivity adjustment. Using the proposed hospital market basket update, CMS is also proposing to update the ASC rates for CY 2024 by 2.8% for ASCs that meet relevant quality reporting requirements.

Currently, Medicare covers and pays for various of behavioral health services, including inpatient psychiatric hospitalizations, partial hospitalizations services, and outpatient therapeutic services. However, there is a current gap in coverage when people with Medicare require levels of services more frequent than individual outpatient therapy visits, but less intensive than a partial hospitalization program. The CY 2024 OPPS and ASC Payment System Proposed Rule includes proposals to implement provisions of the Consolidated Appropriations Act, 2023 that created a new benefit category for Intensive Outpatient Program services. CMS is proposing to establish payment and program requirements for the benefit across various settings, including hospital outpatient departments, Community Mental Health Centers, Federally Qualified Health Centers, and Rural Health Clinics effective January 1, 2024. CMS is also proposing to establish payment for intensive outpatient program services provided by Opioid Treatment Programs (OTPs) effective January 1, 2024, and is clarifying that these intensive behavioral health services are available for individuals with mental health conditions and for individuals with substance use disorders.

“This proposed rule reflects CMS’ commitment to ensure Medicare is comprehensive in its ability to address patient needs, filling gaps in the health care system including behavioral health,” said Dr. Meena Seshamani, Deputy Administrator and Director for CMS’ Center for Medicare. “Through these proposals, we will ensure people get timely access to quality care in their communities, leading to improved outcomes and better health.”

Over the past several years, CMS has implemented or is in the process of implementing complementary groundbreaking policies to promote transparency across the health care system. In this rule, CMS proposes to strengthen the hospital price transparency regulations, which require each hospital operating in the United States to make its standard charges public. CMS proposes to make it easier for the public to learn what a hospital charges for items and services and to further enhance the hospital price transparency enforcement process, building on actions taken to streamline enforcement earlier this year. These proposals include new requirements to standardize the hospital’s display of standard charge information in their machine-readable file and new requirements governing how hospitals must publicly post those files on their websites.

Additionally, CMS is proposing new policies to improve and streamline its enforcement capabilities, including certification by hospital officials as to the accuracy and completeness of data, requiring hospital acknowledgement of warning notices, reserving the right for CMS to communicate directly with health system leadership about all of its hospitals, not just one hospital at a time, and publishing other enforcement activities, in addition to civil monetary penalties, on a CMS website.

Furthermore, the Biden–Harris Administration has developed the National Strategy for a Resilient Public Health Supply Chain, which is a roadmap to support reliable access to products for public health in the future, including through prevention and mitigation of medical product shortages. CMS is taking concrete steps to help achieve this goal by seeking comment on a separate payment to hospitals for establishing and maintaining access to a buffer stock of essential medicines to foster a more reliable, resilient supply of these medicines. This builds on similar supply chain resiliency actions in last year’s OPPS rulemaking to create a separate hospital payment for domestic surgical N95 respirators.

In this proposed rule, CMS is also promoting equity and taking actions to support Indian Health Service (IHS) and tribal facilities. CMS is proposing that IHS and tribal facilities that convert to the new Rural Emergency Hospital (REH) provider type may continue to be paid per visit rate, in addition to receiving the monthly facility payment that applies to all REHs.

REHs are a new provider type that started in January 2023 to provide a more sustainable option for rural hospitals facing closure and support access to care in rural and underserved communities. This aligns with CMS’ work to advance health equity to make sure our programs support health for all people we serve, particularly those who are underserved. In addition, CMS is seeking comment on how to pay for high-cost drugs and services, such as oncology drugs, outside of the per visit rate that these facilities receive to provide equitable payment for high-cost drugs and services provided by IHS and tribal facilities.

For a fact sheet on the CY 2024 OPPS/ASC Payment System proposed rule, please visit: https://www.cms.gov/newsroom/fact-sheets/cy-2024-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center

For a fact sheet on hospital price transparency, please visit: https://www.cms.gov/newsroom/fact-sheets/cy-2024-hospital-outpatient-prospective-payment-system-opps-policy-changes-hospital-price