CMS Releases Medicare 2025 Outpatient Prospective Payment System Proposed Rule

The Centers for Medicare & Medicaid Services (CMS) recently released a proposed rule to update the Medicare fee-for-service outpatient prospective payment system (OPPS) effective Jan. 1,  2025.

The proposed rule:

  • Provides a net 2.3% increase to the OPPS conversion factor from $87.38 to $89.38 for hospitals that report quality measure data.
  • Increases the outlier fixed-dollar threshold by 3.2% from the current $7,750 to $8,000.
  • Modifies the timeframe for standard review of prior authorization requests for hospital outpatient department services from 10 business days to seven calendar days.
  • Uses 2023 claims data and the most updated cost report data from the healthcare cost report information system, primarily from 2022, to set payment rates.
  • Adds three services (CPT codes 0894T, 0895T and 0896T) for liver allograft-related procedures to the 2025 Inpatient-Only List.
  • Updates the core based statistical areas used to determine a hospital’s wage index, consistent with other 2025 proposed rules.
  • Adds two new status indicators (H1 and K1) to identify healthcare common procedure coding system/current procedural terminology (HCPCS/CPT) codes representing separately payable, non-opioid post-surgical pain management products as authorized by the Consolidated Appropriations Act of 2023.
  • Establishes separate payment for diagnostic radiopharmaceuticals with a per-day cost exceeding $630.
  • Excludes qualifying cell and gene therapies from comprehensive ambulatory payment classification packaging.
  • Adopts three measures related to health equity for the Outpatient, ambulatory surgical center (ASC) and rural emergency hospital quality reporting programs, and extending voluntary data reporting for two hybrid measures in the inpatient quality reporting program.
  • Establishes new conditions of participation for hospitals and critical access hospitals focused on obstetrical services and maternal care.
  • Extends the virtual direct supervision of therapeutic and diagnostic services under the physician fee schedule (PFS) through Dec. 31, 2025. The CMS also proposes to extend virtual direct supervision under the OPPS through Dec. 31, 2025, to maintain alignment between the PFS and OPPS.
  • Adds 20 medical and dental procedures to the ASC covered procedures list.
  • Updates the hospital outpatient quality reporting program requirements.
  • Updates requirements for the rural emergency hospital quality reporting program.

The MHA will provide a hospital-specific impact analysis within the next few weeks and encourages members contact Vickie Kunz by Aug. 30 regarding issues identified. Hospitals are encouraged to review the proposed rule and its impact on operations and submit comments to the CMS by Sept. 9.  The CMS is expected to release a final rule around Nov. 1 for the Jan. 1, 2025, effective date.

Members with questions may contact Vickie Kunz at the MHA.

MHA Webinar Reviews CMS Medication Administration and Management Requirement Updates

The MHA is hosting the webinar CMS Medication Administration and Management: IV Medication, Blood Administration and Safe Opioid Use from 10 a.m. to noon ET Aug. 27.

Knowing medication is involved in 80% of treatment plans, hospitals and healthcare organizations are closely monitored by the Centers for Medicare & Medicaid Services (CMS) on how they are administered. Healthcare teams looking to assess and strengthen their medication dispensing protocol and ensure CMS compliance are encouraged to attend the webinar, which will cover:

  • Updated CMS guidelines on medication administration and safe opioid use.
  • Specific time frames that medications must be administered.
  • CMS policy and education requirements on medication administration and safe opioid use.
  • CMS requirements to ensure staff are competent when performing IV medications or blood transfusions.

MHA members can register for a $195 connection fee. Those interested in attending are encouraged to register by noon Aug. 26. Members with questions should contact Brenda Carr at the MHA.

Introducing New Infection Prevention Education

The MHA Keystone Center, in partnership with the Michigan Department of Health and Human Services (MDHHS), created a series of online learning modules for infection control and prevention education. The modules cater to the needs of Michigan hospitals and are available at no cost.

Niki McGuire, the manager of the multidrug resistant organisms containment unit at MDHHS, and Josh Suire, a senior manager of safety and quality at the MHA Keystone Center, share the purpose of the series and how healthcare providers in Michigan can use the resource to improve infection prevention practices.

What is Project Firstline?

McGuire: Project Firstline is a Centers for Disease Control and Prevention (CDC) training collaborative that aims to provide more accessible infection control education for frontline healthcare workers. MDHHS partnered with the MHA Keystone Center to develop CDC-based education materials for Michigan’s healthcare workers. With a shared goal of creating accessible and applicable content, the MDHHS and MHA Keystone Center worked together to create six online courses. Three courses in the series are geared toward infection preventionists, with an emphasis on quality improvement best practices. The series also offers courses geared toward frontline workers that serve as a great training resource for staff to interact with at their convenience.

Suire: The Project Firstline modules were created with healthcare workers’ needs and preferences at the forefront. As a nurse with bedside experience myself, I understand healthcare providers are stretched thin. We intentionally built all the courses in an online system that allows participants to check in and out of the classroom around their schedule. Each module is also designed to take less than 45 minutes to complete.

What is the commitment associated with participating?

Suire: These resources were created to meet healthcare workers where they are. The courses are available to Michigan healthcare workers at no cost. We encourage participants to engage with the courses at their convenience. While the courses were created to be completed as a series, healthcare workers are welcome to take courses specific to their training needs.

What are the main takeaways a participant will obtain after taking the courses?

McGuire: MDHHS offers the assessment portion of the CDC’s Infection Control Assessment and Response (ICAR) tool to all acute- and long-term care facilities in Michigan.  We are non-regulatory. The first two modules in this series are great for infection preventionists looking to begin the ICAR process – providing background information about the entire process and how to engage with MDHHS Healthcare Associated Infections team. The clinical modules will provide frontline workers with the competencies needed to engage in on-the-spot critical thinking about infection prevention – sharing best practices for hand-hygiene, transmission-based precautions and more.

Suire: The MHA Keystone Center aims to deliver frontline healthcare workers fun, interactive learning modules with basic infection prevention practices that should be implemented in day-to-day patient/resident care activities. It is our hope facilities across the state use these modules as part of their infection control and prevention program. We encourage all Michigan acute- and long-term care facilities to take advantage of this free resource to reduce the preventable spread of infections.

To learn more about the Project Firstline series, visit the module series webpage or contact the MHA Keystone Center.

Media Recap: State of Healthcare, State Budget & Public Health Partnerships

MHA CEO Brian Peters
MHA CEO Brian Peters

The MHA received media coverage the week of July 15 on healthcare priorities in Michigan, the state budget and the intersection between public health and healthcare.

Hillsdale Hospital published an episode of the Rural Health Rising podcast July 18 featuring an interview with MHA CEO Brian Peters discussing the state of healthcare in Michigan and efforts underway to support rural hospitals.

“We have to really focus on the right strategies – the right tactics – to make sure we can continue providing access to care for all rural Michiganders,” said Peters. “It’s really an honor to be a part of that journey.”

Laura Appel, Executive Vice President, Government Relations and Public Policy, MHA, was also featured as a guest on Hillsdale’s podcast July 11 discussing the fiscal year 2025 state budget.

“The passage [of the state budget] is a culmination of many months,” said Appel. “The big thing we got is direct funding for hospitals to have peer recovery coaches to help people who have substance use issues that come to the ED or into the hospital for any reason.”

Lauren LaPine, Senior Director, Legislative and Public Policy, MHA, was featured July 16 in a story from Model D and Flintside exploring how collaboration between hospitals and public health partners benefits Michigan communities.

“Public health and hospitals working in tandem really protects and promotes community health,” said LaPine. “Public health focuses on prevention while hospitals focus on health intervention.”

Members with any questions regarding media requests should contact John Karasinski at the MHA.

News to Know – July 15, 2024

  • July 22 is the deadline to register by mail or online to be eligible to vote in the Primary Election on Aug. 6. To check registration status, find polling locations or view a sample ballot, visit the Michigan Voter Information webpage. Voters can register in-person through Election Day at a local clerk’s office. For key dates and additional election resources, visit the MHA Elections webpage.
  • The MHA recently submitted comments on the Michigan Department of Licensing and Regulatory Affair’s Psychology proposed rules. Members with questions may contact Kelsey Ostergren at the MHA.

MHA Service Corporation Board Highlights Solutions and Mission

The MHA Service Corporation (MHASC) board held its final meeting of the 2023-2024 program year June 26 focused on supporting the MHA Strategic Action Plan priorities of workforce support and innovation, viability, behavioral health and health equity. The Board explored strategies to invest and diversify products and services, as well as how the MHA could approach “mission-focused” partnerships.

The board was joined by Dr. John Crongeyer, CEO, ModusOne Health, for an overview of the only physician-founded and physician-run Clinical Diagnosis Improvement (CDxI®) company that delivers robust monthly leaderboard-style reporting of provider accuracy in diagnosing patients on the conditions that most directly affect quality metrics and the financial bottom line. The MHASC is planning to launch new endorsed business partnerships in the coming months.

The MHASC board made several appointments and reappointments, adding depth and breadth of expertise by welcoming new board members Brian Brown, regional vice president of marketing & business development, McLaren Health Care, Grand Blanc; Ane McNeil, senior vice president of human resources, Trinity Health, Livonia; and Andrea Poulopoulos, senior vice president of supply chain, Corewell, Grand Rapids. The board affirmed the reappointments of Saju George, regional CEO, Prime Healthcare, Garden City, and vice chair Bill Manns, CEO, Bronson Healthcare, Kalamazoo. The board also recognized outgoing board members for their service, including inaugural chair Gwen MacKenzie, senior advisor, McKinsey and Company; Deloris Hunt, retired chief human resources officer, Michigan Medicine; Scott McLean, former managing director, Corewell Health Ventures; and Brian Connolly, Connolly Associates.

The MHASC mission is to deliver innovative solutions that help improve value and performance through its Unemployment Compensation Program, Data Services and Endorsed Business Partner program. Visit the MHA Business Services webpage to learn more about resources available.

Members with questions regarding the MHASC Board may contact Ruthanne Sudderth at the MHA.

2025 Medicare Fee-for-Service Home Health Proposed Rule Released

The Centers for Medicare & Medicaid Services (CMS) recently released a proposed rule to update the home health (HH) prospective payment system (PPS) for calendar year (CY) 2025. The rule includes updates to the Medicare fee-for-service HH PPS payment rates based on changes by the CMS and those previously adopted by Congress.

Highlights of the proposed rule, which takes effect Jan. 1, 2025, include:

  • A negative 4% adjustment to base payment rates to achieve budget neutrality following the transition to the Patient-driven Groupings Model (PDGM).
  • A 30-day standard payment rate of $2,008.12 ,down 1.5% from the current $2,038.13, for HH agencies that submit the required quality data.
  • Updating core-based statistical areas for wage index purposes, consistent with recent fiscal year 2025 proposed rules.
  • Recalibrating the PDGM case-mix weights, low utilization payment adjustment thresholds, functional levels and comorbidity adjustment subgroups.
  • Revising the fixed dollar loss ratio from 0.27 to 0.38, reducing outlier payments.
  • Requiring HH agencies to report four new patient assessment items in the HH agency Outcome and Assessment Information Set under the social determinants of health category, beginning CY 2027.
  • Adding a new standard within the Medicare Conditions of Participation requiring HH agencies to develop, implement and maintain a patient acceptance to service policy that is applied consistently to each prospective patient referred for HH care.
  • Requiring long-term care facilities to report respiratory illness data as part of their infection prevention and control programs. The CMS proposes that facilities would electronically report weekly data on COVID-19, influenza and RSV in a standardized format through the National Healthcare Safety Network.
  • Requesting information on:
    • HH quality reporting program measure concepts under consideration for future years.
    • Future performance measure concepts for the expanded HH value-based purchasing model.
    • Rehabilitative therapists conducting the initial and comprehensive assessment.
    • Plan of care development and scope of services HH patient receive.

Members are encouraged to review the proposed rule and contact Vickie Kunz by Aug. 19 regarding issues. Comments are due to the CMS Aug. 26, 2024, and can be submitted electronically. The MHA will provide an estimated impact analysis in the near future.

Members with questions should contact Vickie Kunz at the MHA.

MHA Webinar Tying Person and Family Engagement to Culture and Performance

The MHA is hosting the webinar Tying Person and Family Engagement (PFE) to Culture and Performance from noon to 1 p.m. Aug. 20. The webinar will outline a process for structuring value-based employee competencies that are foundational to delivering patient-centered care, programs that uniformly train and support knowledge and application of PFE principles across the system and examples of how to establish clear expectations of behaviors and actions that support a patient-centered culture.

Pandemic recovery happened at many levels, but public perception of hospital quality and experience is declining, as shown through research by the Beryl Institute. Now is the time to re-establish programs and policies that place patients and their caregivers at the heart of planning and decision-making, empowering them to actively participate in their care.

The webinar will also highlight the MHA Person & Family Engagement Roadmap, which features research and tools supported by the Centers for Medicare & Medicaid Services and the Institute for Patient- and Family-Centered Care. These resources are proven to re-engage patients and improve PFE.

Registration is free of charge for MHA member organizations. Chief nurse and medical officers, patient experience, safety & quality, social work and human resources professionals are encouraged to register.

Members with questions about the webinar or MHA Person & Family Engagement Roadmap may contact Erin Steward at the MHA.

What I Learned as a Provider Working in Public Policy

Carlie Austin, BSN, RN, shares her journey serving as the maternal infant health policy specialist at the MHA.

As a clinician, what drew you to a role tied to public policy?

If I had to sum it up in two words, I’d say problems and solutions. The challenges I’ve encountered at the clinical level and my quest for generating solutions at the hospital and community level naturally led me to this role. The reality is that the nursing profession is inherently tied to public policy.

One of my favorite documents to read is the Guide to Nursing’s Social Policy Statement. It essentially tells us that it’s our professional duty to address the problems faced by the people we serve, including disparities and inequities. My favorite line says, “In some instances nursing will be in the vanguard of emerging health-related issues. Nursing will participate in the promulgation of healthcare policy at regional, state, national and global levels. Protection of the public through advocacy also includes whistleblowing.”

Although “whistleblowing” may have a negative connotation, I interpret it as meaning that we all should be productive disruptors of the systems, practices and barriers that make it difficult to deliver equitable care to all of our communities. Public policy is about intentionally targeting problems and creating meaningful solutions to support the greater good.

What are some of the things you learned about public policy in your time at MHA?

I learned that public policy truly requires the engagement of issue experts. The saying “people closest to the problem are closest to the solution” has taken on a new meaning during my time at the MHA. I learned that public policy is reliant on relationship and true collaboration among diverse stakeholders in order to foster solutions that best serve Michigan communities.

How did your clinical background inform or influence conversations around public policy? Why should providers and clinicians be involved in public policy?

To quote my supervisor, Lauren LaPine, Senior Director, Legislative and Public Policy, MHA, “having perspective from the bedside helps the MHA create policy and legislative efforts statewide that are directly informed by experience treating patients. Having your insight helps us more deeply focus on public policy that is patient-centered.”

Lauren’s words perfectly capture why clinical providers should be involved in public policy and the strong influence we can have. Before taking this role, fellow bedside nurses questioned my decision. They saw a public narrative that shaped their perceptions of the health policy environment; however, I took the role to challenge that narrative, to inspire systematic change, and to bridge the voice of the bedside with the power of policy.

I was able to show up authentically because I was a part of a team that granted me the space to challenge our system to be better. I’ve worked on efforts to improve maternal regionalization, used my lived experience to advance health equity solutions and regularly engaged with community stakeholders. We’re facing unprecedented times in healthcare, but serving in this role has shown me what we can accomplish by being more intentional about unifying in areas that often divide us.

How can providers get involved in public policy and healthcare advocacy?

Start where you can. It’s our professional duty as providers to seek solutions for the problems we see. Engage with your executive leadership, community advocates, legislators and associations – including the MHA – that will listen and amplify your voice. Most importantly, be open. Never allow a narrative to deter you from writing your own. Public policy requires us all to creatively color outside of the lines.

News to Know – July 1, 2024

  • MHA offices will be closed and no formal meetings will be scheduled July 4 and 5 in honor of Independence Day.
  • Due to the holiday, Monday Report will not be published July 8 and will resume its normal schedule July 15. Member alerts and MHA newsroom articles will continue to be published during that time to provide relevant updates to the MHA membership, as necessary.
  • MHA Endorsed Business Partner ProCredEx will host a free 30-minute webinar for members on July 8 to discuss AI-Assisted Document Transform. AI-Assisted Document Transform turns any document or image into a fully digitized record that includes discrete data points paired with a digital copy of the source document. ProCredEx’s approach is superior to existing OCR or AI document processing tools because it combines large language models with a proprietary data governance engine that quality checks the digitization process to ensure the results meet members’ specific requirements. Members with questions may contact George Bosnjak at ProCredEx or Rob Wood at the MHA.