Proposed payment rule may help CMS transform healthcare through competition and innovation

May 12, 2020

A CMS proposed rule would update Medicare payment policies for hospitals paid under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) for fiscal year 2021, reports the Centers for Medicare & Medicaid Services (CMS).

“The CMS Hospital Without Walls initiative empowers local hospitals and healthcare systems to expand their physical spaces, telehealth capabilities and staff to care for people with Coronavirus,” said CMS Administrator Seema Verma. “Today’s payment rate announcement focuses on what matters most to help hospitals conduct their business and receive stable and consistent payment.”

CMS is proposing a separate new hospital payment category for Chimeric Antigen Receptor (CAR) T-cell therapy. CAR-T is the first-ever gene therapy and uses a patient’s own genetically modified immune cells to treat people with certain types of cancer, instead of additional chemotherapy or other types of treatment paid for under the IPPS. Currently, CAR-T hospital cases are paid at the same rate as bone marrow transplants and qualify for additional payments through the temporary new technology add-on payment for high cost cases that’s set to expire this year. The new inpatient hospital payment category, or the Medicare Severity Diagnostic Related Group (MS-DRG), for CAR-T will provide a predictable payment rate for hospitals administering the therapy. This is another example of CMS’ commitment to ensuring that beneficiaries have access to the latest medical innovation and to removing barriers to medical innovation across our healthcare system.

The rule includes proposals to remove barriers to new antimicrobials, which are antibiotics to treat drug-resistant infections. Medicare beneficiaries account for the majority of new diagnoses and resulting deaths due to drug-resistant infections, which also remains a public health concern. To support access to these critical antibiotics for Medicare beneficiaries, CMS is proposing changes for the new technology add-on payment (NTAP) which is an additional payment to hospitals for cases using eligible high cost technologies. CMS is proposing that drugs that are approved by the Food and Drug Administration (FDA) under the Limited Population Pathway for Antibacterial and Antifungal Drugs (LPAD pathway) can seek an NTAP through an alternative NTAP pathway for certain antimicrobial products, which is the same streamlined pathway we made available last year for drugs designated by the FDA as Qualified Infectious Disease Products (QIDPs). This provides more predictability for these products with respect to new technology add-on payments.

CMS is proposing to collect a summary of certain data already required to be disclosed by CMS’ 2019 price transparency rule, specifically hospitals’ median payer-specific negotiated inpatient services charges for Medicare Advantage organizations and third-party payers. In addition, the agency is requesting information regarding the potential use of these data to set relative Medicare payment rates for hospital procedures.

CMS has the story.

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