The US Centers for Medicare & Medicaid Services (CMS) has released an online tool that enables consumers to compare Medicare payments and copayments for 114 procedures that are performed in both hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs).
Required by the 21st Century Cures Act, the Procedure Price Lookup tool displays national averages of the amounts Medicare pays hospitals and ASCs and the national average copayment a Medicare beneficiary with no Medigap insurance would pay.
For example, a Medicare patient might want to know how much CMS would pay a hospital and an ASC and what part of that he'd have to pay, on average, for electroremoval of the prostate through bladder canal (urethra) with control of bleeding using an endoscope. The person would enter "prostate" into the tool, select this procedure from a drop-down list, and see the average Medicare cost and the average patient cost in both care settings. For this particular procedure, the patient would pay $351 in an ASC and $741 in an HOPD. The cost to Medicare would be more than twice as high in the HOPD as in the ASC.
In a blog post, CMS Administrator Seema Verma said, "Procedure Price Lookup will help patients with Medicare consider potential cost differences when choosing among safe and clinically appropriate settings to get the care that best meets their needs."
The Procedure Price Lookup is needed, she said, because the CMS is required by law to pay HOPDs differently than it pays ASCs. As a result, the CMS and Medicare beneficiaries pay "vastly different amounts for the same service, depending on the site of care." She noted that although it would take Congress to change the law, CMS can now provide some transparency to patients under the 21st Century Cures Act.
Impact on Physicians
Depending on how many consumers use Procedure Price Lookup and whether the price differential prompts more of them to select ASCs, this new online tool could affect physicians in at least two ways. First, patients might ask about the price comparison when they discuss elective surgery with their physicians. Second, physicians who co-own ACSs might benefit if more patients choose to have their procedures performed in ASCs.
A few years ago, hospitals had an incentive to acquire surgical practices in order to capture the higher payments for procedures in HOPDs. But in 2016, CMS stopped classifying certain employed physicians with off-campus ambulatory practices as part of an HOPD. At the same time, it began requiring "site-neutral" Medicare payments to ambulatory care practices owned by hospitals. As a result, hospitals received lower payments for those doctors' services than before, because the physicians were paid under the Medicare fee schedule.
Procedure Price Lookup is the latest in a series of patient-oriented transparency tools from CMS. For example, CMS recently overhauled its drug pricing and spending dashboards, vastly increasing the number of medications that patients can look up. The agency has also enhanced its interactive online decision support feature to help people better understand and evaluate their Medicare coverage options. And CMS now offers a mobile-optimized out-of-pocket cost calculator to provide beneficiaries with information on overall plan and drug costs.