On July 10, 2024, the Centers for Medicare & Medicaid Services (CMS) released the proposed rule for the Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System for calendar year (CY) 2025.¹ The agency proposes increased payments to all outpatient providers, updates to current programs, and a new standard to address the ongoing maternal health crisis.

For CY 2025, CMS proposes to increase OPPS payment rates to hospital outpatient departments (HOPDs) that meet specific quality reporting criteria by 2.6% – calculated from the proposed hospital inpatient market basket percentage increase of 3.0% minus the proposed productivity adjustment of 0.4%.² This calculation results in a proposed OPPS conversion factor of $89.379.³ ASCs that meet the required quality criteria will also receive proposed payment rate increases of 2.6%, by way of the same calculation described above for OPPS payment rates.⁴ Consequently, the proposed ASC conversion factor for 2025 is $54.675.⁵ For both HOPDs and ASCs, the CY 2025 proposed payment rate increase is 0.2% less than the CY 2024 OPPS/ASC payment rate increase of 2.8%.⁶

In the CY 2019 OPPS/ASC final rule, CMS began applying productivity-adjusted hospital market basket updates (i.e., the updates used for HOPD payment rate updates) to ASC payment rates for a test period of five years,⁷ in order to assess changes in the migration of services and determine if the data trends were consistent.⁸ Because of abnormal healthcare utilization in 2020 due to the COVID-19 public health emergency (PHE), CMS proposes to extend the five-year period for an additional two years, until CY 2025.⁹ This will allow CMS to gather data unrelated to the COVID-19 PHE to determine if utilizing the hospital market basket update achieved one of its goals of shifting services from the hospital to the ASC setting.¹⁰

Citing the growing maternal health crisis, which “has not only led to a maternal mortality rate that is among the highest in high-income countries but also disproportionately affects racial and ethnic minorities,” CMS proposes new Conditions of Participation (CoPs) for critical access hospitals (CAHs) and regular hospitals for obstetrical services.¹¹ The proposed CoPs include requirements for maternal quality assessment and performance improvement (QAPI), annual staff training on evidence-based maternal health practices, and baseline standards for the staffing, organization, and delivery of care in obstetrical units.¹² Starting in 2025, hospitals or CAHs that provide obstetric services will be required to utilize CMS’s QAPI program to improve and assess health disparities and outcomes among obstetrics patients on a consistent basis.¹³ The new staff training standard would require the hospitals and CAHs to develop policies to ensure the appropriate staff members have some baseline training.¹⁴ Training materials would reflect the complexity of services offered by each respective hospital, including, but not limited to, evidence-based best practices and protocols to improve maternal care delivery.¹⁵ The new organization and staffing standard would require the hospitals and CAHs adhere to national acceptable standards of practice.¹⁶ To ensure better delivery of care, the standards also include requirements that obstetrics services remain consistent with the resources and needs of their respective facilities.¹⁷

Other proposals CMS suggested for 2025 include, but are not limited to:

1. Helping tribal and Indian Health Services (IHS) facilities afford high-cost pharmaceuticals;
2. Authorizing federal reimbursement for certain Medicaid clinic services delivered outside of a tribal clinic or freestanding IHS facility;
3. Increasing accessibility to healthcare for recently-incarcerated individuals;
4. Expanding and adjusting quality reporting programs for inpatient and outpatient hospitals, rural emergency hospitals, and ASCs; and
5. Potentially modifying the Overall Hospital Quality Star Rating methodology for the Safety of Care measure group.¹⁸

CMS will receive comments and information on the OPPS/ASC proposed rule until September 9, 2024, and the final rule is expected to be released in November 2024.¹⁹