2026 OPPS final rule does no favors for our nation’s hospitals

By Brian Murphy

The OPPS final rule, incredibly late this year, is finally out. Here I piece together some thoughts on (generously) four hours of sleep after a late night trip to Boston to pick up my daughter from a weekend getaway, so excuse any illogic.

You can read the fact sheet easily enough (see link below), so rather than regurgitate the updates I’ve instead chosen to pose some questions and offer up some hot-takes.

The OPPS does lend itself to hot takes, surprisingly. Who would have thought?

Let’s dig in.

Does anyone actually care about price transparency or believe it will make a difference? I am sliding ever further into the “meh” camp. How “shoppable” are healthcare services for the consumer? Answer: Unless its an elective service, pricing transparency means nothing. You have no choice in urgent care.  This is not just the case for rural hospitals; widespread hospital mergers and healthcare consolidation means that the “competitor” down the street is now likely owned by your hospital with the same high prices and markups. Reading is in steep decline and to expect a “machine-readable file (MRF)” on a hospital website to make a difference in driving down prices is on its face ridiculous. Much better data presented in a much transparent way for elective procedures might make a difference, but the OPPS rule fails here.

Is elimination of the inpatient only list good or bad? It’s probably mixed, but in the short term it will be terrible for hospitals. In general I like policies that cede clinical decision-making to physicians rather than government panels or insurance companies. Allowing physicians to decide whether to admit a patient for surgery rather than the dictates of a CPT code on a list seems like a good thing. But, I believe this move at least short term is going to further harm hospital and provider reimbursements, and will lead to further denials as insurance “experts” have added fuel to deny your IP stays.

Site neutral payment policies on their surface seem fair … but aren’t. Hospitals get paid more than ASCs for the exact same service, leading to greater spending, so CMS is taking further steps to remove this imbalance in the 2026 OPPS final rule. OK, fair enough. The problem is, this imbalance in hospital charges is part of the convoluted system CMS itself has built over decades. Hospitals must charge more because they have greater overhead, and need to factor that in. CMS tells them to! You can get that IV infusion safely and at lower cost in an ASC… until something goes wrong, you have a reaction and need hospital care. Site neutral is probably due, BUT hospital EDs need better funding to offset. CMS needs to fix how hospitals charge before they start breaking things.

• Speaking of charges, there’s an important update on IP rates in the rule, too. CMS finalized its proposal to collect from hospitals charges negotiated with Medicare Advantage organizations, and plans to use the data to help determine Medicare payment rates for inpatient hospital services. I’m very interested to see the impact of this change on IPPS reimbursement.
• I’m glad CMS is considering separate reimbursement for software as a service (SaaS). But don’t get too excited; no policy (yet).
• There’s a lot in here about quality measures. The usual nonsense about stripping out vaccinations and SDOH, but I’m more interested in the new Emergency Care Access & Timeliness eCQM. Will be taking a closer look as my brain awakes.

References

• CMS, 2026 OPPS fact sheet: https://www.cms.gov/newsroom/fact-sheets/calendar-year-2026-hospital-outpatient-prospective-payment-system-opps-ambulatory-surgical-center
• CMS, Hospital Price Transparency Changes: https://www.cms.gov/newsroom/fact-sheets/cy-2026-opps-ambulatory-surgical-center-final-rule-hospital-price-transparency-policy-changes