Highlights of CMS's 2018 ASC Payment Rule
JOINT EFFORT ASCs could soon begin receiving Medicare payments for joint-replacement procedures.

From paying surgery centers for total joints to delaying mandatory participation with a patient satisfaction survey, there are several positive developments in the 2018 proposed payment rule for ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs), which the Centers for Medicare & Medicaid Services (CMS) released the last week.

Here's a breakdown of the key provisions of the 664-page proposed rule, which would be effective Jan. 1, 2018:

  • ASCs paid for total joints. ASCs could start receiving Medicare payments for 3 joint-replacement procedures: total knee arthroplasty; partial hip arthroplasty; and total hip arthroplasty. CMS is proposing to remove total knee arthroplasty from the inpatient-only list for 2018. In addition, CMS is soliciting comments on whether partial and total hip should also be removed from the inpatient-only list and added to the ASC Covered Surgical Procedures List.
  • Delay OAS CAHPS. CMS would delay requiring that facilities participate in the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey, also known as OAS CAHPS, "until further action in future rulemaking." For years, many in the ASC community have raised concerns about the size and intrusive nature of the survey, as well as the administrative and financial burdens associated with it. Under this proposal, ASCs that would like to continue to administer the 37-question survey voluntarily may do so, but there will be no mandatory adoption based on 2018 reporting.
  • Payment rate updates. ASCs would, on average, receive a 1.9% inflation update in 2018. HOPDs would receive a 1.75% update. CMS estimates the rate increases would generate an additional $5.7 billion for HOPDs and an additional $155 million for ASCs, based on estimated 2017 Medicare payments.
  • ASC quality reporting. CMS has proposed removing 3 measures under the ASC Quality Reporting Program, starting with the 2019 payment determination and subsequent years — ASC-5: Prophylactic Intravenous Antibiotic Timing; ASC-6: Safe Surgery Checklist Use; and ASC-7: ASC Facility Volume Data on Selected Procedures — and adopting 3 new measures, including ASC-16: Toxic Anterior Segment Syndrome, which would be collected via a web-based tool for 2021 payment determination and subsequent years, and ASC-17: Hospital Visits after Orthopedic Ambulatory Surgical Center Procedures and ASC-18: Hospital Visits after Urology Ambulatory Surgical Center Procedures, which would be collected via claims for 2022 and beyond.
  • 3 new procedures proposed. CMS has proposed to add 3 new procedures to the ASC list of payable procedures for 2018: 22856 (Cerv artific diskectomy), 22858 (Second level cer diskectomy), and 58572 (Tlh uterus over 250 g).

CMS has not proposed further action regarding the establishment of a facility fee for office-based cataract surgery.

CMS will accept comments on the proposed rule until Sept. 11, 2017.

Bill Donahue

Nurse's Drug Theft Leads to Infection Outbreak, Patient Death
NUMEROUS VICTIMS Six people, including the nurse's father, were infected.
Note: Photo is for illustration only. The person depicted is a model.

A drug-pilfering nurse was responsible for a 2014 outbreak of Serratia marcescens that led to one patient death and sickened 5 others at a Wisconsin hospital, according to a study recently published in Infection Control & Hospital Epidemiology.

The outbreak, which occurred over a period of 6 weeks, attracted attention at the University of Wisconsin Hospital, because the facility usually has fewer than 10 such infections per year. Hospital staff discovered that 4 hydromorphone and 6 morphine patient-controlled analgesia syringes in an automated medication dispensing cabinet had been tampered with. Eventually, another 32 syringes were linked to evidence of drug diversion. All had been filled with saline or other solutions instead of medication. The nurse, who worked in the PACU, was eventually identified and immediately fired.

One of the affected patients was the nurse's father, who lived with her before he was hospitalized with the infection. Four of the others were exposed in the PACU, shortly after the nurse accessed cabinets with contaminated syringes. All but one of the patients ultimately recovered.

Serratia marcescens, which can lead to infections in the urinary and respiratory tracts and the eye, has also been linked to heart and bone infections, pneumonia and meningitis. It's resistant to several antibiotics.

"Our experience highlights the importance of active monitoring systems to prevent hospital-related drug diversion," hospital epidemiologist Nasia Safdar, MD, PhD, says in a press release, adding that drug diversion should be considered as a "potential mechanism of infection when investigating health care-associated outbreaks related to gram-negative bacteria."

Jim Burger

Post-op Opioids Overprescribed at Mayo Clinic
SUPPLY AND DEMAND Standardized prescribing guidelines can leave patients in pain or at risk of addiction.

Physicians at the Mayo Clinic in Rochester, Minn., have called themselves out for overusing opioids to manage post-op pain and say a lack of evidence-based prescribing guidelines is to blame.

Mayo researchers reviewed about 5,750 opioid prescriptions written across the health system to patients who did not take the painkillers at least 90 days before surgery. The findings, published in the Annals of Surgery, showed 4 out of 5 prescriptions written at the health system exceeded the amount currently outlined in Minnesota state prescribing guidelines. The median prescription was equivalent to 50 pills of 5 mg oxycodone — or nearly twice the amount of the state guideline maximum dose. Surgeons at the Minnesota campus prescribed a median of 40 pills, while their colleagues at the health system's campuses in Florida and Arizona prescribed the equivalent of 50 and 60 pills, respectively.

The researchers concede there is room for improvement in opioid prescribing within the health system, but they also point out there are no evidence-based guidelines that focus on the prescribing opioids after surgery. "That's the fundamental issue," says study coauthor Robert Cima, MD, chair of surgical quality at the Mayo Clinic. "And because pain is very subjective, it makes it challenging."

Issues also arise when standardized prescribing guidelines aren't appropriate for surgeries associated with varying levels of post-op pain. For example, the statewide guidelines in Minnesota might not be appropriate for all orthopedic procedures, some of which can cause a significant amount of post-op discomfort. For that reason, the Mayo Clinic's department of orthopedic surgery is developing a tiered approach for prescribing opioids based on the surgical procedure that's performed.

Dr. Cima also points to the importance of partnering with patients to set realistic expectations about the pain they'll experience after surgery. "We actively support patients, but they also need to be educated that some discomfort is part of the process," he says. "We want patients to be comfortable enough to function, but taking away all the pain isn't an appropriate part of recovery."

Daniel Cook

InstaPoll: Text, Talk or Email?

Tell us in this week's InstaPoll how you prefer to communicate at work: texting, talking on the phone or in person, or email?

Nearly two-thirds (65%) of the 328 respondents to last week's InstaPoll say their first cases of the day start of time "always" (8%) or "very often" (57%). When the first case of the day starts late, as it does for more than one-third (35%) of our resondents, it can upset the entire day's surgical schedule, delaying subsequent cases, causing bottlenecks, and frustrating patients, surgeons and staff. The results:

Our first case of the day starts on-time __________ .

  • always 8%
  • very often 57%
  • sometimes 22%
  • rarely 11%
  • never 2%

Dan O'Connor

News & Notes
  • Joint Commission updates medication standards The Joint Commission has revised its medication management standards to include, among other things, policies that require facilities to have emergency backup for both medication-dispensing equipment and for refrigeration of medications that require it. The update also adds "wasting" of medications to the policy that addresses control of medication between the time a health care provider receives it and the time that it's administered.
  • Ups and downs of prostate cancer surgery Surgery may not be the best option for treating men who have localized prostate cancer, according to a nearly 20-year-long study of more than 730 men. During 19.5 years of follow-up, death occurred in 223 of 364 men — 61.3% — who had surgery and in 245 of 367 — 66.8% — whose cancer was merely observed. Men who had the surgery were slightly more likely to live longer, but they were also more likely to be forced to live with the side effects of surgery, such as urinary incontinence and erectile dysfunction.
  • Laparoscopic total pancreatectomy feasible Researchers at Johns Hopkins University in Baltimore, Md., have shown that using laparoscopic total pancreatectomy to treat chronic pancreas disease reduces risk of post-op infections and results in faster recovery and better pain management. The procedure is far from being considered outpatient, but Martin Makary, MD, MPH, a professor of surgery at the Johns Hopkins University School of Medicine and the study's lead author, says performing a major operation through a minimally invasive technique can mean less pain for patients and reduce the need for opioids and related complications.