To ensure that Medicare beneficiaries have prompt access to improvements in outpatient care, the Centers for Medicare & Medicaid Services has authorized hospitals to receive special payments under the Outpatient Prospective Payment System (OPPS) for three additional drugs. In addition, CMS has identified four additional services for payment as new technologies in the outpatient setting. Both types of payments are temporary until there is sufficient cost data from outpatient services to develop an appropriate price within the OPPS.
“The decisions we are announcing today are intended to ensure that Medicare beneficiaries are able to get state-of-the-art health care, by making it financially feasible for hospitals to incorporate medical advances as soon as possible,” said CMS Administrator Mark B. McClellan, Ph.D., M.D.
The drugs for which the special add-on payments (called pass-through payments) include: daptomycin, an injectible antibiotic for serious staph infections, for which hospitals will receive payment of $0.31 per 1 mg; risperidone, an injectible antipsychotic, $131.86 per 12.5 mg; and rasburicase, an injectible treatment for high uric acid levels that may result from certain cancer treatments, $105.54 per 0.5 mg. These pass-through payments became effective April 1, 2004.
The new technologies include:
- The insertion of a special device for measuring and monitoring acid levels associated with gastroesophageal reflux disease (GERD), which will be paid at $450;
- A procedure using a laser device that vaporizes the prostate and controls bleeding before and after the procedure, which will be paid at $3,750;
- The concurrent or immediate placement of a balloon catheter in the breast for interstitial radiation therapy following a partial mastectomy, which will be paid at $2,750; and
The delayed placement of a balloon catheter into the breast for interstitial radiation therapy following a partial mastectomy; which will be paid at $3,250.
The new payment rates were included in a quarterly update to the outpatient payment system. Under this system, hospitals are paid for outpatient services based on groupings, called ambulatory payment classifications, or APCs, that are clinically similar and require similar resources. The system was required by the Balanced Budget Act of 1997, and was implemented in August of 2000. Since then, Congress has made a series of significant changes to the system that are intended to remove any financial barrier to hospitals using new drugs and technologies in treating Medicare beneficiaries.
The update also clarifies billing and payment issues affecting intensity modulated radiation therapy and brachytherapy devices used in cancer treatment.
The complete update document can be found at: http://www.cms.hhs.gov/manuals/pm_trans/R132CP.pdf.