2009 OPPS rule is good news for EDs

Trauma response, critical care receive pay boost

Every year at about this time, the Centers for Medicare & Medicaid Services (CMS) publishes its final Out-patient Prospective Payment System (OPPS) payment rule for the following calendar year, and every year emergency medicine experts express their dissatisfaction with one aspect or another of what CMS has wrought. This year, however, might prove to be an exception.

"The changes that are significant are basically good, which makes this one of the rare years," says Barbara Tomar, MBA, director of federal affairs for the American College of Emergency Physicians.

Mike Williams, MPA/HAS, president of The Abaris Group, a Walnut Creek, CA-based health care consulting firm specializing in emergency services, says, "These changes are not as big as those we saw last year. They've adopted most what they proposed. This year looks very modest."

The biggest and most positive change of all came under the classification "Trauma Response with Critical Care." While the payment rate for 2008 was $330.28, the rate for 2009 is a whopping $935.12. "That's huge," says Tomar.

In the final OPPS rule for 2009, CMS includes a 3.6% annual inflation update for hospital outpatient departments. The final rule, which at press time was scheduled to appear in the Nov. 18 Federal Register, says hospitals reporting seven outpatient quality measures in 2009, including measures of ED care, will receive a 3.6% inflation update. Hospitals not submitting data will receive a 1.6% update.

Five of the measures that relate to cardiac care/intervention in the ED are:

  • median time to fibrinolysis;
  • fibrinolytic therapy received within 30 minutes;
  • median time to transfer to another facility for acute coronary intervention;
  • aspirin at arrival;
  • median time to EKG. (Editor's note: You can access the rule on the CMS web site. Go to www.cms.gov/HospitalOutpatientPPS. Then, on the left side of the page, select "Hospital Outpatient Regulations and Notices." Then select "Final Changes to the Hospital Outpatient Prospective Payment System and CY 2009.")

Here is a comparison between the 2009 payment rates and the 2008 payment rates:

  • The payment rate for a Level 1 Type A emergency visit for 2009 is $52.66, compared with a rate of $50.76 in 2008, or a 4.1% increase.
  • The payment rate for a Level 2 Type A emergency visit for 2009 is $86.14, compared with a rate of $83.67 in 2008, or a 2.9% increase.
  • The payment rate for a Level 3 Type A emergency visit for 2009 is $136.70, compared with a rate of $132.17 in 2008, or a 3.4% increase.
  • The payment rate for a Level 4 Type A emergency visit for 2009 is $217.96, compared with a rate of $212.59 in 2008, or a 2.5% increase.
  • The payment rate for a Level 5 emergency visit for 2009 is $323.90, compared with a rate of $315.51 in 2008, or a 2.6% increase.

For the first time this year, CMS distinguished between Type A emergency visits and Type B emergency visits, the latter referring to care received at an ED that is not open 24/7. The rates for Type B visits were: Level 1, $45.18; Level 2, $61.45; Level 3, $88.64; and Level 4, $159.16. No payment distinction was made between Type A and Type B Level 5 visits.

Tomar says, "While we do not conceptually agree with the idea of Type A and Type B visits, the payments they set up for Type B visits were fairly reasonable."