September 15, 2025
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1834-P
P.O. Box 8010
Baltimore, MD 21244-8010
Dear Administrator Oz,
The Society of Hospital Medicine (SHM), representing the nation’s more than 50,000 hospitalists, appreciates the opportunity to provide comment on the proposed rule entitled Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems; Quality Reporting Programs; Overall Hospital Quality Star Ratings; and Hospital Price Transparency (CMS-1834-P).
Hospitalists are physicians who work only or predominantly in acute care hospitals and whose professional focus is the general medical care of hospitalized patients. In addition to managing the clinical care of patients, hospitalists work to enhance the performance of their hospitals and health systems.
We are writing to provide comments on proposals in section IX. Services That Will Be Paid Only as Inpatient Services.
CMS proposes phasing out the inpatient only list (IPO) over a 3-year period,
beginning with removing 285 mostly musculoskeletal procedures for CY
While we are supportive of efforts to modernize Medicare policy in light of medical advances for many procedures, SHM strongly urges CMS to exercise great caution in eliminating the IPO list. We are wary of inadvertently creating a dynamic where outpatient is the default site of care for procedures and new barriers or impediments to providing necessary procedural care to patients in the hospital will emerge. It is essential that the decision regarding the appropriate site of care remain a shared decision between the treating physician and their patient. Physicians are best positioned to assess the full clinical situation, risks of a given procedure for a specific patient, and comorbidities that may significantly impact safety in a hospital versus outpatient setting.
Further, elimination of the IPO list without adequate safeguards will open the door to inappropriate denials from Medicare Advantage (MA) plans as they endeavor to save money on procedures. We respectfully ask CMS to prioritize patient safety and physician judgment as the guiding principles in any reforms to the IPO list. CMS must ensure that elimination of the IPO list does not erode patient protections or weaken the role of physician judgment.
To do so, there must be clear guardrails requiring MA plans to honor physician determinations of medical necessity around site of care, particularly when patient safety is at stake. These guardrails must also be enforced. We have already seen a troubling pattern of MA plans prioritizing cost savings over patient safety, often denying inpatient status for procedures or conditions that clearly warrant hospitalization. This not only puts patients at risk but also undermines the clinical judgment of physicians. We cannot risk shifting decision-making power from the patient-physician relationship to insurers motivated by financial considerations.
A final concern that we ask CMS to address with this proposal is the negative impact it will have on payments hospitals receive for Graduate Medical Education (GME). Medicare is the principal funder of GME in the nation, and CMS uses the number of inpatient stays a hospital manages to determine the scope of these payments. CMS must ensure this proposal does not erode the viability of physician training programs. This is more important than ever as we continue to face a widespread physician shortage that is predicted to only grow worse in the coming years.
SHM appreciates the opportunity to provide feedback on this proposed rule. If you have any questions or require further information, please contact Josh Boswell, Chief Legal Officer, at jboswell@hospitalmedicine.org or 267-702-2632.
Sincerely,
Chad T. Whelan, MD, MHSA, SFHM
President
Society of Hospital Medicine