logo
Medicare proposes $8.1B boost for hospital outpatient care

Medicare proposes $8.1B boost for hospital outpatient care

Axios16-07-2025
The Trump administration wants to boost Medicare payments for hospital outpatient services by $8.1 billion next year — while simultaneously decreasing hospitals' reimbursement for services like chemotherapy.
Why it matters: The payment proposal reveals that the administration is pushing hard for site-neutral reimbursements, or paying the same rate for services regardless of whether they're delivered in hospital outpatient facilities or doctors' offices. Hospitals typically bill Medicare more for the same services.
Health systems have successfully lobbied against similar proposals in Congress in recent years.
State of play: Hospital outpatient departments overall could expect a 2.4% increase in their Medicare payments, mostly due to an increase in the index that the Centers for Medicare and Medicaid Services uses to measure changes in prices.
But Medicare administrators want to decrease what they pay hospitals to administer outpatient drugs at off-campus facilities, including chemotherapy, to make the sums equal to what is paid to physicians in private practices.
This year, Medicare pays physician offices around $119 for a chemotherapy infusion, while off-site hospital outpatient facilities collected about $341, per the proposal.
What it says: "We believe that financial incentives have driven volume from the office setting to the higher paying [outpatient department] setting, creating unnecessary increases in the volume of OPD services," the proposed rule states.
CMS expects the change to decrease Medicare patients' cost-sharing by $70 million in 2026, and to reduce Medicare spending on hospital outpatient services by $210 million.
The American Hospital Association called the proposal "inadequate."
"We oppose the proposal to expand 'site-neutral' cuts and eliminate the inpatient-only list, as both policies fail to account for the real and crucial differences between hospital outpatient departments and other sites of care," Ashley Thompson, senior vice president of public policy analysis and development, said in a statement.
CMS also wants to phase out over three years the list of services Medicare will only pay for when delivered in an inpatient setting.
Medicare created the list in 2000 on the premise that some procedures could only be safely delivered at an inpatient hospital. The list currently includes 1,731 procedures.
CMS proposed eliminating the list in 2021 but ultimately decided not to. Now, the agency says it's decided that innovations in medicine have made outpatient procedures much safer.
"We agree with past commenters that the physician should use clinical knowledge and judgment, together with consideration of the beneficiary's specific needs, to determine whether a procedure can be performed appropriately in a hospital outpatient setting or whether inpatient care is required for the beneficiary," the proposal says.
Orange background

Try Our AI Features

Explore what Daily8 AI can do for you:

Comments

No comments yet...

Related Articles

Imaging Boom Drives Cancer Detection and Healthcare Growth
Imaging Boom Drives Cancer Detection and Healthcare Growth

Time Business News

time22 minutes ago

  • Time Business News

Imaging Boom Drives Cancer Detection and Healthcare Growth

Cancer is a condition where cells in a specific part of the body start multiplying out of control, often clumping together to form tumors. Doctors can identify cancer using different kinds of tests, including imaging scans, endoscopy, tumor marker tests, biopsies, complete blood counts, and MRI scans. Major growth factor consist of large number of clinics have adopted tools for cancer detection like MRI, CT-scans and other. This has led to growth in healthcare sector and global economy. It is also a milestone for healthcare services. Key Growth Drivers and Opportunities Growing Incidence of Cancer: The increasing prevalence and incidences of various types of cancer like lung cancer and breast cancer, help the cancer diagnostics market to grow significantly during the forecast period. According to estimates, 1 in 100 (or 1% yearly) of those 70 years of age or over lost their lives to cancer in 2019. Overall death toll is rising in tandem with the world's population growth. From roughly 46 million in 1990 to 56 million in 2019, there have been more fatalities. Most cancer deaths occur in elderly adults. Rising Expenditure of Healthcare: The cost estimates cover both prescription medications taken by mouth and medical treatments for cancer. The most expensive medical services nationally were linked to non-Hodgkin lymphomas, as well as cancers of the prostate, lung, colon, and female breast. Medical services care costs, which comprise Medicare payments as well as patient obligations for all billed medical services, such as hospitalizations, outpatient hospital services, physician/supplier services, infusion or injectable drug, durable medical equipment, and hospice care, were estimated from Medicare Parts A and B claims. Challenges The implementing cancer diagnostics can require significant upfront investment, including the cost of the software itself, customization, and integration with existing systems. This can be a barrier for smaller hospitals with limited budgets. The regulatory landscape for cancer diagnostics is constantly evolving, with new guidelines and requirements emerging regularly. Keeping up with these changes and adjusting reporting practices accordingly can be a daunting task for companies Innovation and Expansion Guardant, Boehringer Team Up on HER2 NSCLC Liquid Biopsy In December 2024, the Guardant Health, Inc. announced a partnership with Boehringer Ingelheim aimed at obtaining regulatory approval and advancing the commercialization of the Guardant360 CDx liquid biopsy. This partnership is all about using liquid biopsy as a companion diagnostic (CDx) for zongertinib. Zongertinib is a new type of drug called a covalent tyrosine kinase inhibitor (TKI) designed to specifically target HER2 in non-small cell lung cancer (NSCLC), while minimizing the impct on the epidermal growth factor receptor (EGFR). GE, GenesisCare Partner to Tackle Cancer and Heart Disease In November 2020, GE Healthcare entered into partnership with GenesisCare to improve patient outcomes for the two biggest health burdens globally, cancer and heart disease. GE Healthcare will provide CT, MRI, PET/CT, SPECT, digital mammography, and ultrasound equipment to GenesisCare's 440+ cancer and cardiovascular disease treatment centers across Australia, the US, the UK, and Spain This partnership is all about boosting how accurately we can diagnose conditions and making treatment plans smoother, all thanks to state-of-the-art imaging tech. With GE Healthcare's innovative tools, GenesisCare can really speed up spotting issues early on and providing tailored care for folks dealing with cancer or heart-related conditions. Inventive Sparks, Expanding Markets The Key players in the global cancer diagnostics market includes, Thermo Fisher Scientific Inc., Hoffmann-La Roche Ltd., Abbott Laboratories, Becton, Dickinson and Company among others. As major key players, they're effectively striving in innovation to make sure consumers globally can benefit from modern healthcare tech and to really elevate the overall experience for patients everywhere. About Author: Prophecy is a specialized market research, analytics, marketing and business strategy, and solutions company that offer strategic and tactical support to clients for making well-informed business decisions and to identify and achieve high value opportunities in the target business area. Also, we help our client to address business challenges and provide best possible solutions to overcome them and transform their business. TIME BUSINESS NEWS

BerryDunn Announces the National Healthcare at Home 2025 Best Practices Study
BerryDunn Announces the National Healthcare at Home 2025 Best Practices Study

Business Wire

timean hour ago

  • Business Wire

BerryDunn Announces the National Healthcare at Home 2025 Best Practices Study

PORTLAND, Maine--(BUSINESS WIRE)--BerryDunn, a full-service accounting, tax, and consulting firm, is pleased to announce the National Healthcare at Home 2025 Best Practices Study. The study is conducted in partnership with the National Alliance for Care at Home, LeadingAge, and the Council of State Home Care and Hospice Associations. First conducted in 2022, this important national research effort returns in 2025 to assess how home-based care providers are responding to the changing healthcare landscape. This year's study will focus on critical issues facing the industry today, including: Healthcare and payment reform Medicare payment cuts The rise of Artificial Intelligence (AI) in clinical and operational workflows Medicare Advantage saturation rates and their impact on agency operations Increasing regulatory scrutiny 'We are thrilled to bring this national study back to the industry in 2025,' said study co-chair Lindsay Doak, Director of Healthcare Research and Education at BerryDunn. 'Home-based care remains a vital part of the healthcare system, and it's essential that we continue to identify and share best practices that support agency success and improve patient care outcomes.' The 2025 study will follow a three-phased approach. The first phase, currently underway, invites providers to suggest topics and priorities to guide the study design. Phase two will entail a comprehensive survey of nearly 1,000 agency leaders, followed by the phase three distribution of the resulting data and analysis. Providers interested in registering for the study and providing input on the study's themes can complete this form. Working with a National Steering Committee of industry leaders, the 2025 study will address the topics that matter most to agencies today. Doak added, 'This study is designed to unite providers and industry leaders in a collective effort to strengthen home-based care. By learning from each other, we can drive real change that improves care delivery and patient outcomes nationwide.' BerryDunn, a firm with broad expertise in healthcare research, education, and training, recognizes the significant scope of this national effort and is inviting some of the industry's most innovative vendors and partners to join in supporting the study. Their collaboration will help expand the study's reach, deepen its impact, and deliver meaningful insights to the healthcare-at-home community. About BerryDunn BerryDunn is the brand name under which Berry, Dunn, McNeil & Parker, LLC and BDMP Assurance, LLP, independently owned entities, provide services. Since 1974, BerryDunn has helped businesses, nonprofits, and government agencies throughout the US and its territories solve their greatest challenges. The firm's tax, advisory, and consulting services are provided by Berry, Dunn, McNeil & Parker, LLC, and its attest services are provided by BDMP Assurance, LLP, a licensed CPA firm. BerryDunn is a client-centered, people-first professional services firm with a mission to empower the meaningful growth of our people, clients, and communities. Led by CEO Sarah Belliveau, the firm has been recognized for its efforts in creating a diverse and inclusive workplace culture, and for its focus on learning, development, and well-being. Learn more at

Why So Many Seniors Can't Afford Long-Term Care
Why So Many Seniors Can't Afford Long-Term Care

Time​ Magazine

timean hour ago

  • Time​ Magazine

Why So Many Seniors Can't Afford Long-Term Care

Aisha Adkins' mother Rosetta was adamant that she wanted to age at home. So when Rosetta's dementia started worsening at age 59, Aisha started looking around for options. She quickly found that round-the-clock at-home care was extremely costly, and that her mother didn't qualify for government assistance. Stuck in the middle, Aisha, who was 29 at the time, ended up quitting her job to take of her mother care of her herself. At first, Rosetta just needed help preparing meals and reminders to take her medication. But as her care needs deepened, Aisha had to learn how to bathe and dress and feed her mother. She and her father hired a home health aide for a few hours a week when they could, but most of the care fell to the two of them until her mother finally qualified for Medicaid through a complicated process called spousal impoverishment protection, which allowed her father to keep some assets. 'We faced so many challenges; it was really a struggle,' says Adkins. She ended up caring for her mother for ten years on both a full-time and part-time basis, until her mother passed away in 2023. Many middle-income seniors are unable to afford care As the U.S. population ages, many families are facing the same challenges. Long-term care, which is assistance with the activities of daily living either in a person's home or in a facility, is expensive. Most people pay for it either out of their savings, or by spending down those savings until they qualify for Medicaid, which covers long-term care for indigent seniors. (Medicare does not cover senior housing or long-term care.) But there's a large group of people who are stuck in-between: they are 'too rich' to qualify for the Medicaid benefits that enable them to hire at-home help or put loved ones in a nursing home, but they do not have enough money to pay for the in-home, all-hours care their loved one needs. It then falls to family members to make up the difference. Around two-thirds of caregiving hours for older adults in the U.S. are provided by informal and unpaid caregivers. On one end of the spectrum, there are many expensive communities for seniors with deep pockets who want to start out in apartments and continue on to assisted living or more extensive care. On the other end, there are nursing home spots available for people who qualify for Medicaid, the government payor of last resort, which is strictly for low-income seniors or people who have spent down their savings. Read More: How Health Insurance Monopolies Affect Your Care But 'there aren't a lot of middle-income options on the market, so inevitably people rely on family care and out-of-pocket home care until they end up qualifying for Medicaid,' says David Grabowski, a health care policy professor at Harvard Medical School and one of the authors of a 2019 study about middle-income seniors. His research predicts that as the U.S. ages, many seniors will have insufficient resources for housing and health care needs. People like Rosetta Adkins are often referred to as the 'missing middle' or 'forgotten middle'—the seniors who aren't wealthy but who also aren't poor. There just aren't a lot of options for these seniors in the middle who need care. One 2021 study estimated that a nursing home in the U.S., on average, costs $100,740 per year for a semi-private room, and that home care for six hours a day, five days a week costs $42,120 a year. The costs have only gone up since then. By 2033, researchers at the University of Chicago estimate, there will be 16 million middle-income seniors who can't afford to pay for the health, personal care, and housing services they need. They will have to rely on family members—or on themselves—until they can qualify for Medicaid. There may be even more people in this situation going forward, after the giant cuts to Medicaid in the Trump economic plan recently approved by Congress go into effect. Home and community-based care for low-income seniors is considered an optional program in Medicaid, so states can cut it when their budgets are thin. That may mean that in some states, it will take even longer for people like Rosetta Adkins to qualify for care through Medicaid, putting even more pressure on family members to help out. 'When a state's Medicaid budget is constrained, which is absolutely going to happen because of this bill, there will be limits on some of these home-based services,' says Allison Orris, a senior fellow at the Center on Budget and Policy Priorities, a national research and policy institute. A lack of options puts stress on family members Family members already face intense pressure to provide care for their ailing loved one while still maintaining their careers and taking care of children. One recent report by researchers at Columbia University's Mailman School of Public Health found that nearly half of U.S. states are on the brink of an unpaid family caregiving emergency. That means that in many states, unpaid family caregivers are contributing hundreds of billions of dollars of unpaid labor. The report found that dementia care—like the kind sought by the Adkins family—is driving a lot of the labor. 'It is repeatedly the family caregiver who shoulders the immense pressures generated by health care shortages and rising dementia cases,' says John McHugh, lead researcher of the study and an adjunct assistant professor of health policy and management at Columbia University's Mailman School of Public Health. Read More: The Surprising Reason Rural Hospitals Are Closing Aisha Adkins, for instance, set aside her career so she could care for her mother. Her life choices for the next decade were determined by what her mother needed: picking a graduate school nearby and then finding a job that would allow her to work remotely. Aisha, who is only 40, is already worried about how she will pay for her own long-term care when she ages because she was out of the workforce so long caring for her mother. This, too, is not uncommon. 'Many times, family members are reducing their own incomes because they're taking time out of the workforce, or they're working less,' says Amber Christ, managing director of health advocacy at Justice in Aging, a nonprofit that advocates on behalf of low-income seniors. 'They're risking their future retirement, which increases the likelihood they'll age into poverty. So it's really a multigenerational impact.' There's a reason there aren't many options for middle-income seniors: companies can't make money providing it. Over the past few decades, many expensive aging facilities have opened as investors put money into options for Baby Boomers who have extensive savings. But those places are out of reach for many seniors. 'The million-dollar model seems to work,' says Grabowski. 'But middle-income models don't seem to thrive.' Though there are options for nursing homes and facilities for seniors on Medicaid, they often provide a relatively low quality of care, with sparse staffing and dilapidated facilities. Options for middle-income seniors are also limited because many people want to age at home, but at-home care is expensive and there are vast staff shortages, especially in rural areas. The industry is plagued by low compensation, unpredictable scheduling, and high turnover. Analysts predict this shortage will only worsen, with an estimated 4.6 million unfilled jobs by 2032. Aisha Adkins says that even when her mother qualified for Medicaid, it was extremely difficult to get aides to consistently come to the house and provide care. Inexperienced caregivers didn't know how to handle her mother's dementia, so Aisha or her father still had to stay in the home even when a caregiver was around. 'It really fell to my father and myself to ensure that she was safe at all times, even sometimes when the caregiver was in the home,' she says. Solutions for middle-income seniors are expensive Adkins says she now advises friends to look into long-term care insurance or think more carefully about putting aside more money for when they age. But even long-term care insurance, which requires people to pay monthly premiums as they age so they can have care when they need it, has proven so inadequate that only about 4% of Americans 50 and older pay for a policy. Though most people spend down their savings to qualify for Medicaid, elder law attorneys can sometimes help people protect their savings from long-term care costs. "It's worth meeting with and listening to an elder law attorney to find out how to protect your resources," says Eric Einhart, president of the National Academy of Elder Law Attorneys. A few states have tried to help people pay for long-term care by establishing state programs. The WA Cares Fund, in Washington State, is a mandatory program that takes a small percentage of the paychecks of working Washingtonians and then allows them to access benefits of up to $36,500 to pay for long-term care services. But that amount of money won't last them very long if they need more than a few months of care. The lack of long-term care planning in the U.S. is a contrast to many other countries. The Netherlands, for instance, has long included long-term care in its universal health care system, and requires that taxpayers contribute a chunk of their income towards insurance premiums. In 2019, Singapore introduced a mandatory long-term care insurance program. Japan has had a mandatory long-term care insurance system since 2000; it requires people 40 and over to contribute. Read More: America's Dental Health Is in Trouble Most experts agree that the U.S. needs some sort of plan to help more seniors pay for long-term care, especially as Baby Boomers age. Otherwise, many people will spend down their savings until they qualify for Medicaid, which is going to get very expensive for the U.S. government. 'We're going to be swamped by just the pure number of individuals in the system who need long-term care going forward,' says Grabowski. 'We're not at a place politically today to talk about this,' he says—because recently so much discussion has been focused on cutting services, rather than adding them—'but in the longer run, it's a discussion we really need to have.' It's something Aisha Adkins knows at her core. Although her mother passed away in 2023, Adkins is gearing up for another struggle. Her father was recently diagnosed with a type of dementia, too. He spent almost all of his savings paying for Rosetta's care. Now, Aisha is starting to look into options for him. She knows, from experience, that they will be limited.

DOWNLOAD THE APP

Get Started Now: Download the App

Ready to dive into a world of global content with local flavor? Download Daily8 app today from your preferred app store and start exploring.
app-storeplay-store