CMS plan to phase out inpatient only list sparks debate over safety for vulnerable patients

Editor's Note

The Centers for Medicare & Medicaid Services (CMS) is moving to eliminate its Inpatient Only (IPO) List over the next 3 years, a decision that could permanently shift more surgical procedures from hospitals to outpatient settings. According to an August 24 article from Fierce Healthcare, the policy promises greater flexibility, lower costs, and better alignment with commercial and Medicare Advantage (MA) plans. But it also raises concerns that frail, high-risk patients could face serious safety risks if complex procedures are performed outside the hospital.

As detailed in the article, the IPO List has functioned as a safeguard by requiring certain high-risk procedures for Medicare beneficiaries to be covered only in hospitals. Removing it would allow fee-for-service Medicare patients to receive these surgical procedures in outpatient centers, and hospitals would still be reimbursed for overnight admissions for a 2-year period. However, CMS has not outlined a plan to study whether this flexibility actually improves safety or reduces complications.

Shifting more cases to ambulatory surgery centers (ASCs) could benefit healthier patients with strong support systems, but it could pose dangers for older adults with multiple comorbidities or limited caregiver resources. Unlike hospitals, ASCs have fewer resources to respond to complications, raising the risk of harm for vulnerable populations. Physician experts emphasize that patient selection is key to ensuring safe outcomes.

According to the article, proponents note hospital care carries downsides such as higher costs and infection risk, but hospitals also provide more staff, continuous monitoring, and rapid escalation if problems arise. Without safeguards, the burden of recovery and risk management could shift onto caregivers at home. Additionally, the outlet notes that eliminating the IPO List may lead to insurers, through prior authorization, overriding physician and patient preferences in favor of less costly sites of care.

CMS has tools to mitigate these risks, including claims data, electronic health records, and quality reporting, which could enable real-time monitoring of outcomes. Policy options include restoring procedures to the IPO List if evidence of harm emerges, tailoring coverage to patient complexity, and requiring flexibility so site-of-care decisions are based on medical need rather than financial incentives. As the article concludes, innovation in surgical care should continue, but only with mechanisms that detect and address unintended harm.