Glaukos: CMS Advisory Panel’s Recommendation Raising ASC Reimbursement Likely to Be Adopted, According to Experts

Published on Sep 23, 2021

In a unanimous decision last month, a federal advisory panel voted to recommend that the Centers for Medicare and Medicaid Studies (CMS) raise the reimbursement rate that ambulatory surgical centers would receive for surgeries that insert stents into the eye of glaucoma patients to drain excess fluid. That recommendation, according to experts, is likely to be adopted by CMS in its final rule on 2022 reimbursement rates due in November.

CMS adopting the panel’s recommendation would likely benefit Glaukos (GKOS), a manufacturer of eye stents. As The Capitol Forum previously reported, the existing proposed reimbursement rates could have made the procedure prohibitively expensive for ambulatory surgical centers, likely depressing sales of the stents.

Under the current proposal, CMS would assign a standard device offset ratio for payments that would cap device costs at 31% of the procedure. This standardized ratio, ophthalmologists explained to The Capitol Forum, overlooked the true expense of eye stents, which the doctors said typically account for about 55% of the total cost of the procedure.

During an August 23 meeting of CMS’ Advisory Panel on Hospital Outpatient Payments, Glaukos gave a presentation arguing that CMS should use historical data of the device’s cost rather than the standardized 31%. The panel unanimously agreed to recommend that CMS do the same in its final rule.

The unanimity of that recommendation makes it very likely that CMS will adopt it, according to Faisal Khan, senior counsel and hospitals and health systems practice lead at the healthcare firm Nixon Gwilt Law and a former attorney and special assistant to the general counsel at the Department of Health and Human Services.

“During my HHS tenure, a lot of deference was given to federal advisory committees like the HOP panel,” Khan said, “and the recommendation being unanimous is pretty significant. I would think CMS would take that under serious advisement.”

Stephen Bittinger, a partner in KL Gates’ healthcare practice, agreed, saying that “unanimity carries more weight for CMS. Historically, CMS doesn’t ignore well prepared data, because there have been a number of times where their proposal was just a miscalculation. If you can support a proposal with good data and you have a united committee, there is little reason for them to ignore that.”

Indeed, CMS seems to rarely ignore recommendations from the HOP panel. According to statistics compiled by the government, CMS fully implements roughly 85% of HOP panel recommendations, and partially implements another 7% of recommendations.

Glaukos did not respond to a request for comment for this article.