The Center for Medicare and Medicaid Services (CMS) issued a request for information related to Urgent Care reimbursement. The exact text from the 2025 proposed Medicare Physician Fee Schedule is here: https://public-inspection.federalregister.gov/2024-14828.pdf (pages 390 to 391): “We’ve received information from interested parties that there is a similar concern regarding urgent care centers more broadly. These interested parties note that hospital emergency departments are often used by beneficiaries to address non- emergent urgent care needs that could be appropriately served in less acute settings, but where other settings, such as physician offices, urgent care centers or other clinics, are not available or readily accessible. Patients enter EDs to treat common conditions like allergic reactions, lacerations, sprains and fractures, common respiratory illnesses (for example, flu or RSV), and bacterial infections (for example, strep throat, urinary tract infections or foodborne illness). Conditions like these often can be treated in less acute settings. We are interested in system capacity and workforce issues broadly and are interested in hearing more on those issues, including how entities such as urgent care centers can play a role in addressing some of the capacity issues in emergency departments. In particular, we are interested in feedback on the following questions, as well as any other relevant feedback:
- What types of services would alternative settings to EDs need to offer to meet beneficiaries’ non-emergent, urgent care needs?
- Does the current “Urgent Care Facility” Place of Service code (POS 20) adequately identify and define the scope of services furnished in such settings? Is this place of service code sufficiently distinct from others such as “Walk-in Retail Health Clinic (POS 17) and “Office” (POS 11)? If not, how might these Place of Service code definitions be modified?
- Does the existing code set accurately describe and value services personally performed by professionals and costs incurred by the facility in these settings?
- How might potential strategies to reduce overcrowding and wait times in EDs advance equity in access to health care services?
Some brief commentary to address the four questions appear below:
1. Types of Services Needed in Alternative Settings
To meet beneficiaries’ non-emergent urgent care needs, alternative settings to EDs should offer:
• Basic diagnostic services: X-rays, ultrasounds, and basic laboratory tests.
• Minor procedural capabilities: Suturing for lacerations, splinting for fractures and sprains, and treatment for allergic reactions.
• Management of common infections: Treatment for respiratory infections, urinary tract infections, strep throat, and other bacterial or viral infections.
• Preventive and follow-up care: Vaccinations, routine check-ups, and follow-up visits for minor illnesses or injuries.
• Telehealth services: Virtual consultations for triage, follow-ups, and minor health concerns.
2. Adequacy of “Urgent Care Facility” Place of Service Code (POS 20)
• Current Adequacy: The current POS 20 code generally captures urgent care settings but may not clearly distinguish the full range of services provided compared to other codes like POS 17 and POS 11.
• Distinctiveness: POS 20 should be distinct from POS 17 (Walk-in Retail Health Clinic) and POS 11 (Office) by emphasizing more acute, immediate care capabilities that fall short of ED-level care.
• Suggested Modifications: Consider refining POS 20 to include detailed subcategories that specify the range of services available, possibly distinguishing between basic and advanced urgent care services.
3. Accuracy and Valuation of Code Sets
• Service Description: The existing code set may not fully capture the breadth of services and associated costs at urgent care facilities.
• Valuation: Adjustments might be needed to ensure the code set accurately reflects the intensity and cost of services provided, including facility overhead and advanced procedural capabilities.
• Potential Enhancements: Developing a more granular coding system for urgent care services that reflects different levels of care and associated costs can provide better alignment with the actual services rendered.
4. Strategies to Reduce ED Overcrowding and Promote Equity
• Improved Access to Alternative Care: Expanding the availability and awareness of urgent care centers, walk-in clinics, and telehealth options can reduce ED visits for non-emergent issues.
• Enhanced Care Coordination: Implementing robust care coordination programs that direct patients to appropriate care settings based on their needs can alleviate ED congestion.
• Insurance and Payment Reforms: Ensuring adequate insurance coverage and reimbursement for urgent care and other alternative settings can make these options more accessible to all populations.
• Community Outreach and Education: Educating communities about the appropriate use of urgent care versus EDs and the availability of alternative care options can guide patient behavior.
• Infrastructure Investment: Investing in the physical and technological infrastructure of urgent care centers, especially in underserved areas, can enhance capacity and access, thus promoting equity.
These strategies aim to enhance system capacity, improve care quality, and ensure equitable access to healthcare services for all beneficiaries. Your feedback and further discussion on these topics are welcome to develop comprehensive solutions.
Your comments must be submitted no later than 5 p.m. on September 9, 2024 to be considered by CMS