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CMS' new hospital outpatient rule includes 15% proton bump

by Brendon Nafziger, DOTmed News Associate Editor | November 02, 2011
The Centers for Medicare and Medicaid Services' final 2012 hospital outpatient payment rule includes a mildly pleasant surprise for hospitals that offer proton therapy.

The 2012 Hospital Outpatient Prospective Payment System final rule with comment period, released Tuesday, provides a nearly 15 percent increase in reimbursements for proton therapy over last year, and even a slight increase on payments floated by the CMS in an earlier 2012 proposal.

The final rule payments for the "simpler" or Level I proton therapy (Ambulatory Payment Classification 0664), which includes most prostate treatments, is about $1,184, up from 2011 rates of $1,032 and from proposed 2012 rates of $1,028.
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For Level II, intermediate or complex, proton treatments (APC 0667), reimbursement for hospitals is set at around $1,549, up from the 2011 rates of $1,350 and from proposed rates of $1,345.

The current rule only applies to hospital-based proton therapy centers, of which there are only three in the country: Loma Linda University in Loma Linda, Calif., Massachusetts General Hospital in Boston, and University of Pennsylvania's center in Philadelphia.

However, Leonard Arzt, executive director of the National Association for Proton Therapy, said the rates often set a standard that could be followed by regional Medicare carriers, which negotiate local rates for free-standing proton therapy centers, of which there are about six in the U.S., with several more under construction.

"It has some influence," Arzt told DOTmed News.

Several more hospital-based proton therapy centers will be coming online in the near future, Arzt said, including one being built at the Flint, Mich. campus of McLaren Regional Medical Center, set to open later next year. The next U.S. proton opening, however, will likely be a ProCure center in Somerset, N.J., scheduled to start treating patients in April.

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