CMS Proposes 340B Payment Cuts and Site-Neutral Imaging Payments in 2027 OPPS Rule
核心洞察
CMS proposes a 2.4% increase to OPPS payment rates for 2027, reflecting a 3.2% market basket update reduced by a 0.8% productivity adjustment.
The rule would slash 340B drug payments to ASP minus 33.4%, aiming to reduce total drug spending by $5.7 billion in 2027.
Site-neutral payments would expand to imaging without contrast at off-campus provider-based departments, saving Medicare approximately $260 million in the first year.
The Centers for Medicare and Medicaid Services (CMS) issued the 2027 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule on July 2, introducing sweeping changes to drug reimbursement, site-neutral payment policies, and the inpatient-only list. The proposed rule includes a 2.4% increase to OPPS payment rates, reflecting a market basket update of 3.2% reduced by a productivity adjustment of 0.8%.
"This proposed rule focuses squarely on patient affordability by strengthening our utilization management tools, aligning drug payments with actual acquisition costs, and removing site-of-care disparities that have unnecessarily driven up costs for millions of seniors," said CMS Administrator Dr. Mehmet Oz in a press release.
340B Drug Payment Overhaul
The most consequential proposal involves the 340B drug discount program (搜索). CMS proposes to reimburse hospitals for 340B-acquired drugs at the drug's Average Sales Price (ASP) minus 33.4% for 2027. This represents a significant departure from the traditional Medicare Part B payment rate of ASP plus 6%.
CMS noted that studies show vast disparities between drugs acquired through the 340B program and those outside the program. In some instances, the agency found that beneficiary cost sharing was greater than the total price hospitals paid for drugs through 340B. The proposal is projected to reduce total drug spending by $5.7 billion in 2027 alone, including $1.15 billion in beneficiary drug payments during the first year.
Because the policy is required to be budget neutral, regulators are proposing to increase outpatient payments for non-drug services by an equivalent amount. According to a TD Cowen (搜索) research note, for-profit hospitals that do not participate in the drug discount program would be "major beneficiaries" of this redistribution.
This marks the second time the Trump administration has attempted to reduce Medicare payments for 340B drugs. In 2017, CMS finalized a policy reimbursing 340B drugs at ASP minus 22.5%, but the Supreme Court struck it down in 2022, determining it was unlawful because the government had not conducted a study of relevant hospitals' drug acquisition costs. CMS now states it has conducted such a survey and "likely feels they're in better standing now," according to TD Cowen (搜索) analysts, though legal challenges are still anticipated.
Provider groups swiftly condemned the proposal. "The proposed OPPS rule from CMS takes an axe to critical funding that supports essential hospitals without concern for how it will affect the patients they serve," said Jennifer DeCubellis, president and CEO of America's Essential Hospitals (搜索).
Site-Neutral Payment Expansion
CMS proposes to broaden site-neutral payments by applying the Physician Fee Schedule (PFS) equivalent payment rate for any HCPCS codes assigned to imaging without contrast APCs when provided at an off-campus provider-based department. Rural Sole Community Hospitals would be exempt from this policy.
"Medicare and patients should not be charged more for an imaging test solely because it is done in a hospital setting rather than a standalone clinic," CMS stated. If finalized, the rule would reduce Medicare Part B expenditures by approximately $260 million in the first year.
Inpatient-Only List Phase-Out
CMS proposes to remove approximately half of the remaining inpatient-only (IPO) services. Due to their clinical complexity, the agency plans to remove the cardiovascular family of services from the IPO list in 2028. In 2027, the second of three years of the phase-out, Medicare proposes removing 638 services across a variety of clinical areas.
Cardiovascular-Specific APC and CPL Changes
The proposed rule includes several provisions of note to cardiology. CMS proposes initial or revised APC assignments for multiple cardiovascular services, including Cardiac PET/CT, C-Codes describing PCI with drug-eluting stents, Cardiac Contractility Modulation Systems, endovenous femoral-popliteal arterial revascularization with placement of stent graft, and the WiSE (Wireless Stimulation of the Endocardium Technology) CRT System.
Additionally, the agency proposes adding 618 procedures to the ASC Covered Procedures List (CPL).
Software-Based Medical Services
CMS proposes a new interim payment methodology for software-based medical services with algorithmic analyses (formerly known as software as a service), which will temporarily place these services in New Technology APCs.
Quality Reporting and Other Provisions
Hospital outpatient departments and ASCs that fail to report required quality data will receive a 2% payment reduction to their annual payment update. CMS expands the OPPS data validation program to include electronic quality measures, requiring hospitals to demonstrate that reported quality measure data accurately match the medical record.
The rule also proposes adding prior authorization for outpatient botulinum toxin injection procedures, as CMS states the volume of injections is increasing without "any explanations to justify it." Eight additional botulinum toxin injection codes would require prior authorization.
CMS is also issuing a request for information concerning hospital price transparency, seeking input on how to standardize and strengthen data reporting requirements. Additionally, the agency proposes permitting certain hospital accrediting organizations to assess compliance with the Emergency Medical Treatment and Labor Act (EMTALA).
ACC Advocacy staff will continue to review the proposals and submit formal comments by the August 31 deadline.