On July 15, 2022, the Centers for Medicare & Medicaid Services (CMS) released its proposed rule for the 2023 Medicare Hospital Outpatient Prospective Payment System (OPPS). The Association for Clinical Oncology (ASCO) is assessing the full proposal, but ASCO’s initial analysis is as follows.
In June 2022, the Supreme Court ruled that the Department of Health and Human Services (HHS) may not vary reimbursement rates for drugs and biologicals among groups of hospitals without conducting a survey of hospital acquisition costs. Given the timing of the Supreme Court decision, CMS was unable to adjust its proposed payment rates and budget neutrality calculations to account for the decision before issuing its proposal.
As a result, while CMS is proposing a reimbursement rate of average sales price (ASP) minus 22.5% for drugs and biologicals acquired through the 340B drug pricing program, the agency anticipates finalizing a reimbursement rate of ASP plus 6% for such drugs and biologicals in the 2023 final rule.
While changes to the OPPS payment rates and the conversion factor that reflect the Supreme Court decision are anticipated to be reflected in the language of the final rule, in the interim, CMS will make relevant impact tables and other supporting data associated with the alternative policy available.
CMS is continuing to advance its Prior Authorization program in Medicare; however, new additions to the list of items or services requiring prior authorization are not directly related to cancer care. Specifically, CMS is proposing to add facet joint interventions as a category of services to the prior authorization process for hospital outpatient departments beginning March 1, 2023.
Stay tuned to ASCO in Action for more analysis of the 2023 OPPS proposal as well as news, advocacy and analysis on cancer policy.