By Matthew Brengman, MD, FASMBS
In April 2015, CMS released its annual Inpatient Prospective Payment System (IPPS) Proposed Rule (The proposed rule and corrections can be found here: http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/AcuteInpatientPPS/FY2016-IPPS-Proposed-Rule-Home-Page- Items/FY2016-IPPS-Proposed-Rule- Regulations.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending )
CMS estimates that the proposed rule will increase the average FY 2016 IPPS operating payment rate by 1.1% for hospitals that successfully participate in the Hospital Inpatient Quality Reporting Program (IQR) and are meaningful electronic health record (EHR) users. Hospitals that do not comply with the quality data submission requirements and also are not meaningful electronic health records users would receive an update of -0.125 percent. After accounting for this range of updates and other policy changes from FY 2015 to FY 2016, CMS projects that total IPPS payments for operating and capital costs will increase by 0.3%, approximately a $120 million increase in FY 2016.
For Bariatric Surgery: FY 2016 payments decrease by -11.1% for MS-DRG 619 (with MCC), increase by 0.9% for MS-DRG 620 (with CC); and increase by 1.6% for MS-DRG 621 (without CC or MCC). Procedure volume increased from 15,177 to 18,316.
The Insurance committee pulled the DRG weights for 2014, 2015 and the proposed rule for 2016. The case weight (which are intended to represent the resourced required for each MS-DRG) for primary uncomplicated Bariatric Surgery, MS-DRG 621, is essentially unchanged over the 3 years. For MS-DRG 620 there is a 7.5% reduction in the LOS but only a 5% reduction in the case weight. For MS-DRG 621 (less than 10% of Medicare cases) there was a 20.8% in LOS and a corresponding 20.4% reduction in the case weight.
It would appear CMS is largely basing resources on length of stay. At some point the LOS based case weight will no longer represent the intense resources utilized to achieve the shortened length of stay. As surgeons and programs continue to push our LOS lower for primary bariatric procedures some published data on resource utilization. Below is the response from ASMBS leadership to CMS:
“The American Society for Metabolic and Bariatric Surgery (ASMBS) is the world’s largest medical society devoted to care for patients who are affected by severe and morbid obesity, representing over 4000 surgeons and health care professionals. ASMBS has been instrumental in the establishment and refinement of multidisciplinary care and education of the bariatric patient. The effectiveness of this comprehensive care is evident through a ten-fold reduction in 30-day mortality in less than a decade (Nguyen SOARD 2012) and continues through the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program
Currently, bariatric comprehensive care encompasses education and preparation at the hospital prior to admission to the hospital, high intensity care during admission, coordination of resources for the post-operative period and finally important care during the post-operative period. This integrated, coordinated approach for the bariatric surgical episode has brought unprecedented improvements in both operative morbidity and mortality, and resulted in decreased readmissions (Flum Ann Surg 2011). Coincident to the safety improvements, many comprehensive bariatric programs have been able to deliver some of these essential services in the pre-operative period and increased the intensity of the delivery of care during the inpatient episode. It is common for a program to have a post-operative patient ambulating with assistance within 4 hours of the operation and then every 4 hours afterward. In addition, dietary, education and coordination services are delivered in a similarly efficient manner.
The global Medicare Severity Diagnostic Related Group (MS-DRG) reimbursement supports these comprehensive services, whether they are delivered in the pre- operative period or during the inpatient episode. These essential services become even more important in the Medicare population who are at even higher risk for readmission following major
In CMS-1632, CMS FY2016 Inpatient Prospective Payment System (IPPS) Proposed Rule, there is a proposed reduction in MS-DRG 619 of 11.1%. This MS-DRG represents bariatric procedure with major complication or comorbidity. While this category represents a small percentage of the total bariatric procedures performed on Medicare beneficiaries, patients in this MS-DRG are at the greatest risk for readmission and require the greatest support and coordination of post-operative resources to ensure a safe and efficient recovery. Even more intensive coordination of care is now being provided to decrease readmissions through the DROP initiative for MBSAQIP hospitals (Morton SOARD 2014).
ASMBS strongly supports the comprehensive care of Medicare beneficiaries. ASMBS continues to support innovative care to decrease morbidity, mortality and readmission following Bariatric surgery. However, our impressive gains in safety and decreased costs through decreased readmission and morbidity are only achieved through the use of additional supportive resources during the primary inpatient admission. ASMBS is concerned that CMS certified facilities will be unable provide the above comprehensive resources if reimbursement is so drastically reduced. The ASMBS requests CMS to reconsider the 11.1% reduction in MS-DRG 619. We ask that CMS consider an increase of 1.1% for MS-DRG 619 in keeping with Hospital Inpatient Quality Reporting Program (IQR) and meaningful electronic health record users (MEHR) incentives. For hospitals not participating in IQR or MEHR, we ask that MS-DRG 619 be kept neutral. We are also requesting an opportunity to meet with CMS to further discuss bariatric surgery in hopes of an ongoing dialogue."
John Magaña Morton, MD, MPH, FACS, FASMBS President, American Society for Metabolic and Bariatric Surgery
Matthew Brengman, MD, FASMBS Chair, American Society for Metabolic and Bariatric Surgery Insurance Committee