Medicare Inpatient Hospital Payments: CMS Has Used External Data for New Technologies in Certain Instances and Medicare Remains Primary Data Source

Under Medicare, hospitals generally receive fixed payments for inpatient stays based on diagnosis-related groups (DRG), a system that classifies stays by patient diagnoses and procedures. The Centers for Medicare & Medicaid Services (CMS) annually uses its own data to reclassify DRGs. CMS also makes add-on payments for stays involving new technologies that meet three eligibility criteria. Stakeholders may submit data that are external to CMS as part of a DRG reclassification request or an add-on payment application. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 required GAO to examine whether CMS could improve its use of external data, including using data collected by other government agencies for DRG payments. As discussed with the committees of jurisdiction, GAO examined (1) to what extent CMS has used external data in determining payments for inpatient stays involving new technologies, and (2) to what extent can external data from other government agencies be used by CMS in determining DRG payments for inpatient stays involving new technologies. GAO interviewed officials from CMS and industry stakeholders. GAO interviewed officials from Bureau of Labor Statistics (BLS), Department of Veterans Affairs (VA), Department of Defense (DOD), and Agency for Healthcare Research and Quality (AHRQ) because these agencies may have data useful to CMS. GAO also reviewed regulations and other CMS materials.