联邦医保中心定版门诊最终规则：340B药品对齐成本价，2027年预计省54.5亿美元
联邦医疗保险与医疗补助服务中心（CMS）11月4日宣布定版一项门诊最终规则：扩大门诊手术选择、降低影像服务与340B药品的自付费用，并更新2027年医院门诊部与门诊手术中心（ASC）的支付费率。
规则的核心是340B药品定价计划的支付对齐。CMS调查发现，医院购入340B药品的平均成本显著低于平均销售价格（ASP），与医保支付咨询委员会（MedPAC）及行业报告「医保付款大幅高于340B购药成本」的结论一致。新规让支付更贴近有据可查的购药成本，CMS估算，仅此一项2027年可为原始医保（Original Medicare）参保人节省约11亿美元药费、为纳税人再省约43.5亿美元，2027年药品总支出减少约54.5亿美元。在医院门诊部接受符合条件药品的受益人，2027年度平均可省约900美元药费。
影像服务方面，患者在不同地点接受同一检查的共付额历来不同。新规把按较低的医师费表等值费率（而非门诊预付系统费率）支付的政策，扩展到在院外附属门诊部进行的无对比剂影像服务，包括部分骨密度扫描、X光、超声、CT与MRI；该政策此前已适用于这些地点的门诊就诊与给药服务。CMS估算，这一改变2027年可为受益人与纳税人合计节省2.6亿美元，2027至2036年节省逾90亿美元。
规则还继续逐步淘汰「仅限住院」手术清单，让更多手术可以在门诊环境进行，并把门诊手术中心可开展的手术清单再扩大数百项。CMS表示，这给医生选择合适治疗场所更多灵活性、给患者更多门诊手术选择，同时维持患者安全，扩展政策也往往会降低受益人的费用分担。
监督方面，规则允许经CMS批准、具有「视同授权」的医院认证组织，在例行认证与再认证调查中一并评估医院对《紧急医疗与分娩法》（EMTALA）某些行政要求的遵守情况。针对肉毒毒素相关服务的不必要增长，新规再把8个肉毒毒素注射编码加入需事先授权的医院门诊服务清单——这些编码的医院门诊申报量2017至2024年上升42.8%（年均4.6%），同期门诊服务总量下降8.3%，CMS未发现临床或编码上的解释；有医学必要的注射（包括慢性偏头痛等治疗）在医生记录需求后仍由医保承保。
CMS局长 Dr. Mehmet Oz 表示：「CMS致力于明智、高效地使用纳税人的钱，让美国的老年人继续得到他们需要的护理。通过让支付回归合理规模、清除浪费，今天的改革将为当下的受益人带来医保可负担性，同时确保医保还能服务他们的子孙后代。」
（来源：联邦医疗保险与医疗补助服务中心）
CMS Outpatient Final Rule Expands Surgical Options and Lowers 340B Drug Costs, With $5.45 Billion in Estimated 2027 Savings
The Centers for Medicare & Medicaid Services (CMS) announced on November 4 that it has finalized an outpatient final rule that will expand outpatient surgery options, lower out-of-pocket costs for imaging services and 340B drugs, and strengthen oversight of select services. The rule also updates 2027 payment rates for hospital outpatient departments and ambulatory surgical centers (ASCs).
At the center of the rule is payment for drugs purchased under the 340B Drug Pricing Program. A CMS survey found that hospitals acquire 340B drugs at an average cost significantly below the Average Sales Price (ASP), consistent with findings from the Medicare Payment Advisory Commission (MedPAC) and industry reports. By better aligning payments with documented acquisition costs, CMS estimates the policy will save people with Original Medicare an estimated $1.1 billion in drug costs and save taxpayers an additional estimated $4.35 billion in drug expenditures, reducing total drug spending by approximately $5.45 billion in 2027 alone. Beneficiaries who receive a qualifying drug in the hospital outpatient department are expected to save an average of $900 in drug costs in CY 2027.
On imaging, CMS is extending its policy of paying the lower Physician Fee Schedule equivalent rate, rather than the Outpatient Prospective Payment System (OPPS) rate, for imaging without contrast services, including certain bone density scans, x-rays, ultrasounds, CT scans, and MRIs, performed at off-campus provider-based departments. The policy already applies to clinic visits and drug administration services at those locations. CMS estimates the change would save beneficiaries and taxpayers a total of $260 million in CY 2027 and over $9 billion from CY 2027 to CY 2036.
The rule also continues to phase out the "Inpatient Only" procedure list, allowing more services to be delivered in outpatient settings, and continues to expand the ASC covered procedures list by several hundred surgical procedures. CMS said the changes give physicians more flexibility to choose an appropriate care setting and give patients more outpatient surgical options while maintaining patient safety, and that the expanded policies will often lower beneficiaries' cost-sharing obligations.
The rule also allows hospital accrediting organizations with CMS-approved "deeming authority" to assess hospital compliance with certain Emergency Medical Treatment and Labor Act (EMTALA) administrative requirements as part of routine accreditation and reaccreditation surveys. To address unnecessary increases in certain botulinum toxin-related services, CMS will add eight additional botulinum toxin injection codes to the list of hospital outpatient services requiring prior authorization. Hospital outpatient department claims for these eight codes rose 42.8% from 2017 to 2024, while overall hospital outpatient service volume fell 8.3%, and CMS found no clinical or coding explanation for the increase. Medicare will continue to cover medically necessary injections, including treatment for chronic migraines, when a physician documents the need.
"CMS is committed to spending taxpayer funds wisely and efficiently, so America's seniors can continue getting the care they need," said CMS Administrator Dr. Mehmet Oz. "By right-sizing payments and rooting out waste, today's reforms will drive affordability in Medicare for current beneficiaries while ensuring it will still be there to serve their children and grandchildren."
(Source: Centers for Medicare & Medicaid Services)
来源：联邦医疗保险与医疗补助服务中心
发布：GSM·美国（发布链接）
图片来源：图：西弗吉尼亚州 Charleston Area Medical Center 门诊手术中心。SuperDalio 摄，CC BY-SA 4.0，经 Wikimedia Commons。 / Photo: The CAMC Outpatient Surgery Center in Charleston, West Virginia. By SuperDalio, CC BY-SA 4.0, via Wikimedia Commons.
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