2025 OPPS Proposed Rule

CMS is set to introduce a series of transformative changes for Hospitals, Critical Access Hospitals (CAHs) and Ambulatory Surgical Centers (ASCs). In the 2025 Outpatient Prospective Payment System (OPPS) Proposed Rule, CMS reflected its ongoing commitment to enhancing healthcare quality, accessibility, and equity.

They proposed updates across four regulatory programs, OQR (outpatient), ASCQR (ASC), REHQR (Rural Emergency Hospital), and IQR (inpatient). You read that right. IQR is not a typo.

In addition, CMS proposed big changes to the Conditions of Participation for any Hospitals or CAHs offering OB services and even some changes for those who only offer emergency services. They also outline their considerations for a series of different methodologies to calculate the Hospital Quality Star Rating.

There was quite a bit in this proposed rule. This article will provide you with the highlights.

In addition, CMS proposed big changes to the Conditions of Participation for any Hospitals or CAHs offering OB services and even some changes for those who only offer emergency services. They also proposed a series of different methodologies to calculate the Hospital Quality Star Rating.

There was quite a bit in this proposed rule. This article will provide you with the highlights.

Payment Rate Increase

CMS proposed a 2.6% increase in payment rates for 2025, which translates to an Outpatient Department (OPD) fee schedule of $89.379 for applicable services. Hospitals that fail to comply with the OQR program’s reporting requirements will face a 2% reduction in their payment rate updates, which equals an $87.636 OPD fee.

Also see: How does the OQR penalty work?

2025 Proposed Changes: OQR Program

The biggest news in the OQR Program is that CMS proposed a new required PRO-PM. They are calling it the Information Transfer PRO-PM. Voluntary reporting starts January 1, 2026. Mandatory reporting start January 1, 2027.

Maybe equally as newsworthy, CMS is proposing to require the health equity measures across every program listed in this proposed rule. These measures are already required in the IQR and IPFQR programs.

Summary of OQR Updates:

1. Introduction of New Measures

   1. PRO-PM: There is a new proposed PRO-PM called the Information Transfer PRO-PM. The measure is calculated using patient-reported outcome (PRO) data collected by Hospital Outpatient Departments (HOPDs) either directly or through authorized third-party vendors via a web-based survey. This survey is administered between two to seven days post-procedure or surgery. The measure’s denominator includes patients aged 18 or older who underwent a procedure or surgery in an HOPD and left the HOPD alive. The numerator is the sum of all individual scores received from eligible respondents, using a top-box approach. Only fully completed surveys are considered in the measure calculation. Hospitals must sample and submit 300 completed surveys. If the hospital doesn’t have 300 eligible cases, they must submit everything they’ve got.

      1. Information Transfer PRO-PM: voluntary CY 2026 (starts January 1st, 2026); required CY 2027 (starts January 1st, 2027).

   2. Health Equity Measures. All that work you did setting up your screening process for inpatients will need to be set up for your outpatients as well. These measures will be submitted separately from the same measures submitted to IQR. To avoid redundant screenings for patients, your organization can use information from a previous screening to fulfill the requirements, if such information has already been collected during the same reporting period in a different care setting. They can simply verify and utilize the existing data.

      1. Hospital Commitment to Health Equity: required 2025

      2. SDOH-01 & SDOH-02: voluntary 2025, required 2026
2. Measure Removal
   1. The MRI Lumbar Spine for Low Back Pain and Cardiac Imaging for Preoperative Risk Assessment measures are being removed starting in 2025.
3. EHR Certification Requirement
   1. Starting in 2025, there’s a new mandate for certified Electronic Health Record (EHR) technology (CEHRT) to be certified to all available OQR eCQMs.
4. Public Reporting Enhancement
   1. The Median Time from ED Arrival to Departure for Discharged ED Patients measure will now be publicly reported with a specific focus on Psychiatric/Mental Health Patients starting in 2025.

2025 Proposed Changes: IQR Program

Headline: Hybrid measure submissions aren’t going well. In fact, CMS indicated that they would expect ¾ of the submissions this year to fail, which would result in the majority of hospitals taking an APU penalty. Yikes!

CMS is proposing that this hybrid reporting cycle (July 1, 2023 – June 30, 2024, Reporting Year 2024) remains voluntary instead of mandatory, as is the current status. Here’s the kicker; you won’t know if this proposal is finalized until after the submission window closes (October 1, 2024). Which means everyone still must submit their hybrid measures this year or risk the proposal not being finalized.

2025 Proposed Changes: Conditions of Participation (CoP)

CMS is concerned about Maternal Health in our country. They point to 2022 data on maternal deaths in the U.S., which has a rate of 22 maternal deaths for every 100,000 live births. Compare that to Canada, France, Japan, and the UK, which had a rate of 8.6 deaths for every 100,000 live births. CMS is proposing a series of baseline OB requirements for hospitals and CAHs who offer OB services to adhere to or lose their Medicare contract. And they ask in this rule if these same requirements should apply to Rural Emergency Hospitals as well.

If your hospital or CAH offers OB services

1. Adhere to These Organization, Staffing, and Delivery of Services Requirements
   1. Ensure obstetrical services are well-organized and provided in accordance with nationally recognized acceptable standards of practice for both physical and behavioral health care of pregnant, birthing, and postpartum patients.
   2. Ensure outpatient obstetrical services are consistent in quality with inpatient care based on the complexity of services offered.
   3. Organize obstetric services appropriately to the scope of services offered and integrate them with other departments of the facility.
   4. Supervise obstetrical patient care units by an individual with the necessary education and training, such as an experienced registered nurse, certified nurse midwife, nurse practitioner, physician assistant, or a doctor of medicine or osteopathy.
   5. Delineate obstetrical privileges for all practitioners providing obstetrical care and maintain a roster of practitioners specifying their privileges.
   6. Establish policies governing obstetrical care to ensure high standards of medical practice and patient care and safety.
   7. Equip labor and delivery room suites with basic resuscitation equipment readily available.
   8. Implement protocols consistent with evidence-based, nationally recognized guidelines for obstetrical emergencies, complications, immediate post-delivery care, and other patient health and safety events, with necessary supplies and equipment readily accessible.
   9. Follow nationally recognized acceptable standards of practice for physical and behavioral health care of pregnant, birthing, and postpartum patients, based on medical professional society and/or accrediting organization standards.
   10. Articulate your standards, the sources of these standards, and demonstrate that they are based on evidence and nationally recognized sources.
2. Train Staff Using Evidence-Based Best Practices: Hospitals and CAHs must develop policies to ensure that obstetrical services staff are trained annually on evidence-based best practices. Training must be documented and tailored to staff roles.
   1. Develop policies and procedures that ensure obstetrical services staff are trained on evidence-based best practices and protocols to enhance maternal care.
   2. Training Topics: Training should encompass trauma-informed care, cultural competency, and person-centered care. These topics should align with the scope and complexity of services provided and be informed by the facilities’ Quality Assurance and Performance Improvement (QAPI) programs. Participation in local or regional perinatal quality collaboratives (PQCs) and the implementation of patient safety bundles are also encouraged.
   3. Annual Training and Documentation: The governing body must identify staff required to complete annual training and document in the personnel records that the training was successfully completed.
   4. Demonstration of Staff Knowledge: Facilities must demonstrate that staff have knowledge of the training topics, although the method of demonstration is not specified.
   5. Continuous Improvement: Training needs and updates should be informed by findings from the facility’s QAPI programs.
3. Use data to drive improvements to maternal health outcomes
   1. Data Analysis: Hospitals are already required to engage in quality activities to improve patient care and outcomes under the Quality Assessment and Performance Improvement (QAPI) program standards. Existing QAPI standards do not require that facilities analyze or stratify QAPI data by patient subpopulations such as race, gender, or payer. This proposal would modify the existing QAPI standards and require hospitals to use its QAIP program to assess and improve health outcomes and disparities among OB patients on an ongoing basis. Specifically, you must:
      1. Analyze data and quality indicators collected for the QAPI program by diverse subpopulations among OB patients.
      2. Measure, analyze, and track data, measures, and quality indicators related to patient outcomes and disparities in processes of care, services, operations, and outcomes among OB patients.
      3. Analyze and prioritize patient health outcomes and disparities. You must develop and implement actions to improve these outcomes and disparities, measure the results, and track performance to ensure that improvements are sustained when disparities exist among OB patients.
      4. Conduct at least one performance improvement project annually that focuses on improving health outcomes and disparities among the hospital’s population(s) of OB patients.
      5. Leadership at your organization must be engaged in the facility’s QAPI activities.
      6. If an MMRC (Maternal Mortality Review Commission) is available at your facility in the State or local jurisdiction, your hospital must have a process for incorporating MMRC data and recommendations into the facility’s QAPI program.

Note: CMS said you can use the PC-02 and PC-07 eCQMs to meet the data analysis portion of these requirements. And you can use the inpatient SDOH-01 and SDOH-02 measures as well. Learn more about Medisolv’s Hospital Quality Reporting Package, which includes all of these measures as eCQMs and includes the ability to stratify performance by race, gender, ethnicity, and payer.

If your hospital or CAH offers emergency services

4. Protocols: Hospitals must have adequate protocols to meet the emergency needs of patients, tailored to the complexity and scope of services they offer. Protocols must align with nationally recognized, evidence-based guidelines for emergency patient care. Hospitals are required to articulate these standards and identify the sources of these guidelines. For example, facilities may utilize a national medical professional society, accrediting organization, credentialling body, or other national guidelines.
5. Training: It is mandatory for applicable emergency services personnel to be trained annually on these protocols and provisions.
6. Provisions: Hospitals are required to keep stocked certain provisions, including equipment, supplies, and medication used in treating emergency cases. Hospitals can determine the appropriate type and quantity of these provisions. The available provisions must include:
   1. Drugs, blood and blood products, and biologicals commonly used in life-saving procedures
   2. Equipment and supplies commonly used in life-saving procedures
   3. A call-in-system for each patient in each emergency services treatment area

For all hospitals and CAHs

7. Document Transfer Protocols: Hospitals must have written policies and procedures for transferring patients, including transfers from the emergency department to inpatient admission, between inpatient units, and between different hospitals.
8. Protocol Training: It is mandatory that relevant staff be trained on these protocols.

2025 Proposed Changes: REHQR Program

There weren’t too many changes to the Rural Emergency Hospital Quality Reporting (REHQR) Program.

1. Health equity measures. The same information from above applies here. The health equity measures are added to the program’s requirements.
   1. Hospital Commitment to Health Equity: required 2025
   2. SDOH-01 & SDOH-02: voluntary 2025, required 2026
2. Modifying measures. CMS is extending the reporting period for the Risk-Standardized Hospital Visits Within 7 Days After Hospital Outpatient Surgery measure from one year to two years.

3. Data Submission Policy Modification. CMS proposed that an REH must begin submitting data to the REHQR program on the first day of the quarter following the date that a hospital has been designated as an REH.

2025 Proposed Changes: ASCQR Program

CMS proposed updates to the Ambulatory Surgical Center Quality Reporting (ASCQR) Program, parallel to the OQR and REHQR programs.

1. Adding measures. CMS has added the health equity measures to the program. The same information from above applies here.
   1. Facility Commitment to Health Equity: required 2025
      1. This measure is slightly different from the HCHE measure because it does not require that all EHRs are CEHRT.
   2. SDOH-01 & SDOH-02: voluntary 2025, required 2026
2. “Specialty-Select” Framework RFI. CMS didn’t propose anything specifically but asked for comments on a new framework they are considering for ASCs, which would ask for reporting based on the ASCs specific specialty. Right now, they are considering Ophthalmology, Surgical, Gastroenterology, and Urology. The framework includes both mandatory claims-based measures and optional non-claims-based measures. ASCs must report all claims-based measures as they are required. For non-claims-based measures, ASCs need to meet a minimum number of cases to be eligible to report. If an ASC qualifies for all measures, they can choose which to report. If they qualify only for certain measures, they must report those. If they don’t qualify for any, they can choose to report voluntarily. There is no need for ASCs to confirm that they have zero cases for any measure. Among the non-claims measures, they list – what else – the THA/TKA PRO-PM.

2025 Proposed Changes: Hospital Quality Star Rating Calculation

CMS is considering changing the way the Hospital Quality Star Rating methodology is calculated. In the current system, a hospital could be a terrible performer in safety and still achieve a 5-star rating. They are asking for comments on how they could adjust it in the future. They outline a few options:

1. Reweighting the Safety of Care Measure Group: Increase the weight of the Safety of Care measure group from 22 percent to 30 percent. This change aims to increase the emphasis on patient safety in the overall rating by proportionally reducing the weights assigned to the other measure groups.
2. Policy-Based Adjustment: Implement a policy-based adjustment that reduces the Star Rating of any hospital in the lowest quartile of Safety of Care (based on at least three measure scores) by one star. This adjustment is intended to penalize hospitals with poor safety performance.
3. Combination of Reweighting and Policy-Based Cap: This suggestion combines the reweighting of the Safety of Care measure group with a policy-based cap that limits hospitals in the lowest quartile of Safety of Care (based on at least three measure scores) to a maximum of four stars out of five. This approach aims to both increase the emphasis on patient safety and prevent hospitals with poor safety performance from receiving the highest rating.

Note: They specifically mention adding new eCQMs to the Hospital Star Rating. So, if your performance isn’t great on these measures, it’s time to start working on them.

“Similarly, any measures that are added to the CMS programs and displayed on Medicare.gov may be included in the Overall Hospital Quality Star Rating; for example, upcoming measures such as the Severe Obstetric Complication (87 FR 48780), Failure-to-Rescue (89 FR 35934), Hospital Harm-Severe Hypoglycemia (89 FR 35934) and Hospital Harm-Opioid-related Adverse Events (87 FR 48780) measures may be considered for inclusion in the Safety of Care measure group.”

Through these comprehensive updates, CMS continues to emphasize health equity, safety and a digital-first approach to measurement. To learn more about Medisolv’s Hospital Quality Reporting Package, which can help your hospital track and report your quality measures to CMS, schedule a 1:1 call today.