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Dec 6, 2023

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Uploaded by ElderWombatPerson926

Dawn – Thank you so much for the opportunity to read and respond to your discussion thread. You did an amazing job with providing such detailed information about each OPPS and specifically listing the key words for contrast. I would love to dive into further discussion about this topic. Over the last 18 years, the Hospital Outpatient Prospective Payment System has become a complex diagnosis-related group (DRG) like payment system and is more prospective in paying for services that are bundled, packaged, and grouped into episodes of care Kassing & Berry (2020). In your first paragraph relating to HOPPS, you stated a contrast compared to other OPPS was that payments were based off of APCs and associated HCPCS codes. According to Kassing & Berry (2020), within each APC, the high-cost study should not cost more than two times higher than the low-cost study, which is known as the two-times rule and it determines the boundaries of the classifications. As this payment system has grown, CMS has aggressively attempted to bundle payments for services that either occur in the same visit, on the same day, or over a series of days as presented on the claim (Kassing & Berry, 2020). Radiology was one of the first specialties CMS utilized to test the consolidation concept of developing composite APCs, bundled codes, packaging and comprehensive APCs (Kassing & Berry, 2020). As a supervisor in a Cardiovascular/Interventional Radiology department, I am very aware of the CMS “rules” and we often bring patients back to perform additional procedures and we do our best to get patient’s out of the hospital efficiently. In your paragraph regarding Ambulatory Surgery Centers, you spoke about the services that are capable of being performed in ASC’s and evidence has shown that procedures are more cost- effective and efficient when performed at an ASC versus a hospital outpatient department. Originally, before 2008, ACS’s handled specific surgical procedures under Medicare Part B. These types of procedures were usually less than 90 minutes in length and did not require more than 4 hours of recovery time (Harrington, 2021). According to Makanji et al., during 1996-2008, there was a huge growth of ASCs because reimbursement rates were slightly higher when compared to those received by hospitals. However, since the adoption of the Affordable Care Act, reimbursements for ASCs have become 42% less when compared to hospitals for the same procedures, which has halted the use of ASCs (Makanji et al., 2019). After 2008, CMS published updates to the procedure list that an ASC can get paid for each year. Harrington (2021) explains that surgical procedures that are not covered in ASCs may be billed by the rendering provider as Part B services, and the beneficiary is liable for the facility charges. Makanji et al. (2019) states “the distinction between an ASC and hospital outpatient departments (HOPDs) is important due to different payment systems that are used by CMS for reimbursement. The HOPD reimbursement rates are in part determined by the hospital market basket, whereas the ASC reimbursement rates are subject to the consumer price index (CPI). The difference in these payment metrics creates a disparity in the compensation for similar services because the CPI is a poor proxy for the inflation that the healthcare sector experiences” (p. 1). Biblical Integration Outpatient Prospective Payment Systems are a concept that seeks to connect the principles and values found in the Bible with the design and implementation of healthcare payment systems. The Bible emphasizes the importance of responsible stewardship of resources. This principle can be applied to healthcare payment systems by advocating for efficient and effective allocation of resources in a way that benefits the greatest number of people. Luke 16:10 states “whoever can be trusted with very little can also be trusted with much, and whoever is dishonest with very little will also be dishonest with much” (NIV, 2020, p. 609). This bible verse emphasizes responsible management of resources which is a key aspect of healthcare payment systems.

Resources Barker, K. L. (2020). Niv study bible . Zondervan. Harrington, M. K. (2021). Health Care Finance and the mechanics of Insurance and Reimbursement . Jones & Bartlett Learning. Kassing, P., & Berry, C. D. (2020). Hospital outpatient prospective payment system: A maturing prospective payment system. Journal of the American College of Radiology , 17 (4), 534– 541. https://doi.org/10.1016/j.jacr.2019.11.015 Makanji, H. S., Bilolikar, V. K., Goyal, D. K., & Kurd, M. F. (2019). Ambulatory surgery center payment models: Current trends and future directions. Journal of Spine Surgery , 5 (S2). https://doi.org/10.21037/jss.2019.08.07

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