CMS Outpatient Final Rule Expands Surgical Options and Lowers 340B Drug Costs, With $5.45 Billion in Estimated 2027 Savings
The Centers for Medicare & Medicaid Services (CMS) announced on November 4 that it has finalized an outpatient final rule that will expand outpatient surgery options, lower out-of-pocket costs for imaging services and 340B drugs, and strengthen oversight of select services. The rule also updates 2027 payment rates for hospital outpatient departments and ambulatory surgical centers (ASCs).
At the center of the rule is payment for drugs purchased under the 340B Drug Pricing Program. A CMS survey found that hospitals acquire 340B drugs at an average cost significantly below the Average Sales Price (ASP), consistent with findings from the Medicare Payment Advisory Commission (MedPAC) and industry reports. By better aligning payments with documented acquisition costs, CMS estimates the policy will save people with Original Medicare an estimated $1.1 billion in drug costs and save taxpayers an additional estimated $4.35 billion in drug expenditures, reducing total drug spending by approximately $5.45 billion in 2027 alone. Beneficiaries who receive a qualifying drug in the hospital outpatient department are expected to save an average of $900 in drug costs in CY 2027.
On imaging, CMS is extending its policy of paying the lower Physician Fee Schedule equivalent rate, rather than the Outpatient Prospective Payment System (OPPS) rate, for imaging without contrast services, including certain bone density scans, x-rays, ultrasounds, CT scans, and MRIs, performed at off-campus provider-based departments. The policy already applies to clinic visits and drug administration services at those locations. CMS estimates the change would save beneficiaries and taxpayers a total of $260 million in CY 2027 and over $9 billion from CY 2027 to CY 2036.
The rule also continues to phase out the "Inpatient Only" procedure list, allowing more services to be delivered in outpatient settings, and continues to expand the ASC covered procedures list by several hundred surgical procedures. CMS said the changes give physicians more flexibility to choose an appropriate care setting and give patients more outpatient surgical options while maintaining patient safety, and that the expanded policies will often lower beneficiaries' cost-sharing obligations.
The rule also allows hospital accrediting organizations with CMS-approved "deeming authority" to assess hospital compliance with certain Emergency Medical Treatment and Labor Act (EMTALA) administrative requirements as part of routine accreditation and reaccreditation surveys. To address unnecessary increases in certain botulinum toxin-related services, CMS will add eight additional botulinum toxin injection codes to the list of hospital outpatient services requiring prior authorization. Hospital outpatient department claims for these eight codes rose 42.8% from 2017 to 2024, while overall hospital outpatient service volume fell 8.3%, and CMS found no clinical or coding explanation for the increase. Medicare will continue to cover medically necessary injections, including treatment for chronic migraines, when a physician documents the need.
"CMS is committed to spending taxpayer funds wisely and efficiently, so America's seniors can continue getting the care they need," said CMS Administrator Dr. Mehmet Oz. "By right-sizing payments and rooting out waste, today's reforms will drive affordability in Medicare for current beneficiaries while ensuring it will still be there to serve their children and grandchildren."
(Source: Centers for Medicare & Medicaid Services)
Source: Centers for Medicare & Medicaid Services
Published by GSM · USA (original Chinese edition)
Photo: 图：西弗吉尼亚州 Charleston Area Medical Center 门诊手术中心。SuperDalio 摄，CC BY-SA 4.0，经 Wikimedia Commons。 / Photo: The CAMC Outpatient Surgery Center in Charleston, West Virginia. By SuperDalio, CC BY-SA 4.0, via Wikimedia Commons.
