University of Minnesota, Minneapolis, MN, USA.
Inquiry. 2024 Jan-Dec;61:469580241275758. doi: 10.1177/00469580241275758.
Site-neutral payment is a policy created by federal rule making and implemented by the Centers for Medicare and Medicaid Services (CMS) that aims to reduce healthcare costs by aligning payment rates for certain services provided in multiple care settings. Site-neutral payments are intended to eliminate the incentive for providers to acquire facilities, such as physician offices or ambulatory surgical centers (ASCs), that Medicare reimburses at the lower non-facility rate and convert those settings into hospital outpatient departments (HOPDs), where Medicare reimburses at the higher facility rate. Although initiated by Congress to address payment disparities in Medicare, similar payment discrepancies can be seen in the commercial market where individual and employer-sponsored health plans often pay more for certain outpatient services depending on their location. This analysis presents a simulation of the impact of applying site-neutral payments to the commercial market with respect to overall potential savings for consumers, health plans and the federal government. To conduct the analysis, we use an all-payer claims data base generalizable to the United States. The analysis focused on a select group of outpatient services identified by the Medicare Payment Advisory Commission (MedPAC). We mapped the MedPAC identified 68 Ambulatory Payment Classifications (APCs), the codes Medicare uses to reimburse facilities for outpatient services, to the relevant CPT4/HCPCS codes, which the commercial market uses for billing. The potential cost savings of applying the site-neutral payment policy to the commercial insurance market to be $58 billion for year 2022. We estimate the 10-year total (2024-2033) employer market premium reduction ranges from 5.35% to 5.0% and found that those premium reductions would result in employer-sponsored insurance (ESI) tax subsidy savings of $140 billion to the federal government over a 10-year period (2024-2033).
按项目付费是联邦规则制定的一项政策，并由医疗保险和医疗补助服务中心（CMS）实施，旨在通过调整在多种护理环境中提供的某些服务的支付率来降低医疗成本。按项目付费旨在消除提供者收购设施（例如，医疗保险按较低的非设施费率报销的医生办公室或门诊手术中心（ASC））并将这些设施转换为医疗保险按较高的设施费率报销的医院门诊部门（HOPD）的激励。尽管这一政策是由国会发起的，旨在解决医疗保险中的支付差异，但在商业市场中也可以看到类似的支付差异，在商业市场中，个人和雇主赞助的健康计划通常根据服务地点支付更高的某些门诊服务费用。本分析针对将按项目付费应用于商业市场对消费者、健康计划和联邦政府的总体潜在节省进行了模拟。为了进行分析，我们使用了一个可推广到美国的所有付款人索赔数据库。该分析侧重于医疗保险支付咨询委员会（MedPAC）确定的一组选定的门诊服务。我们将 MedPAC 确定的 68 个门诊支付分类（APC），即医疗保险用于为门诊服务报销设施的代码，映射到商业市场用于计费的相关 CPT4/HCPCS 代码。在 2022 年，将按项目付费政策应用于商业保险市场的潜在成本节约预计为 580 亿美元。我们估计，在未来十年（2024-2033 年），雇主市场保费降低幅度在 5.35%至 5.0%之间，发现这些保费降低将使联邦政府在未来十年（2024-2033 年）的雇主赞助保险（ESI）税收补贴节省 1400 亿美元。
