September 17, 2021
The Honorable Chiquita Brooks-LaSure
Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
CMS- 1753-P
Mail Stop C4-26-05
7500 Security Boulevard
Baltimore, MD 21244-1850
Submitted online via www.regulations.gov
RE:CMS- 1753-P: Medicare Program: Hospital Outpatient Prospective Payment andAmbulatory Surgical Center Payment Systems and Quality Reporting Programs; Price
Transparency of Hospital Standard Charges; Radiation Oncology Model; Request for
Information on Rural Emergency Hospitals

Dear Administrator Brooks-LaSure,
Thank you for the opportunity to comment on the proposed rule entitled, "Medicare Program:
Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systemsand Quality Reporting Programs; Price Transparency of Hospital Standard Charges; Radiation
Oncology Model; Request for Information on Rural Emergency Hospitals," as published in theFederal Register on August 4, 2021 (hereinafter "Proposed Rule"). Specifically, we will focus ourcomments on the opportunity before the Centers for Medicare & Medicaid Services (CMS) to
expand patient and provider access to non-opioid pain management therapies across all caresettings. This policy change is especially critical given the record-breaking number of opioidrelated overdose deaths in 2020.
While the COVID-19 pandemic has had a profound and undeniable impact on all Americans, weare particularly concerned by the public health crisis’ contribution to the country’s highest rates
of drug-related fatalities in history. The Centers for Disease Control and Prevention (CDC)
reported that over 95,000 Americans i died from a drug-related overdose in the 12 months
ending in January 2021 – a 31 percent increase from 2020.ii Three-quarters of these deaths(71,318) involved opioids. iii To address this, we implore CMS to take the necessary steps toprevent addiction before it starts by advancing policies that have been demonstrated toincrease the availability and utilization of non-opioid approaches to managing acute pain.
As the most influential health care payer in the U.S., CMS has a unique role in reshaping thetrajectory of the opioid crisis and the opportunity to break the cycle of opioid dependency,
misuse, and addiction. In fact, CMS has already identified a proven solution to minimize
exposure to opioids by properly incentivizing non-opioid pain management strategies.

Beginning in CY2019, CMS adopted a policy to provide separate reimbursement for non-opioid
options to patients undergoing procedures in the ambulatory surgery center (ASC) setting. As aresult, utilization of non-opioid pain management approaches in the ASC increased by 120
percent in just one year. iv
While we appreciate this policy change, CMS has chosen to not separately reimburse for nonopioids in the hospital outpatient (HOPD) setting, leaving tens of millions of surgical patients atrisk of being unnecessarily exposed to opioids. Therefore, while utilization of non-opioid pain
management approaches has grown significantly in the ASC, utilization of such approaches inthe HOPD setting has increased by only 10 percent over this same time period. v
Most surgeries in the United States occur in the HOPD setting, and the status quo for treatingthese patients' pain is all too often with opioid-based pain management approaches. vi In fact,
estimates show that over 80 percent of surgery patients receive opioids to manage theirpostsurgical pain. vii On average, patients are prescribed over 80 pills after surgery, whether
they need them or not; this is well above international standards. viii
As a result, it is hardly surprising that some of these patients initiate long-term opioid use
following a surgical procedure. In fact, every year, more than 3.75 million or 9.2 percent ofpatients become long-term opioid users after a low-risk surgery. ix To reduce the risk of opioid
misuse among Americans, we urge CMS to ensure site of care parity by increasing access to theavailable opioid alternative pharmacologic and non-pharmacologic modalities to manage
postsurgical pain for all Medicare beneficiaries.
Non-opioid approaches administered by highly qualified and trained professionals offer
patients many clinical and health benefits compared to traditional, opioid-based methods.
Research has documented the advantages, which include lower pain scores, x quicker
recoveries,xi shorter hospital stays, xii fewer opioids consumed, xiii and fewer opioid-related
adverse events and rehospitalizations. xiv Despite these outcomes, the current payment system
has created a barrier that has limited the tools available to providers to cater to their patient's
needs for acute pain management.
We know that this upstream, common-sense solution to preventing opioid addiction can have asignificant and lasting impact on the current state of the opioid use disorder crisis in thecountry. Patients and providers deserve a choice and a voice in how they manage acutepostsurgical pain. Therefore, we, the undersigned, urge CMS to provide all patients, regardlessof where they are treated, access to the wide array of FDA-approved, safe, effective, andclinically appropriate non-opioid therapies.
Thank you so much for your consideration of these comments.
Sincerely,
A Voice in the Wilderness Empowerment Center
A.C.T. Drug Free Community Coalition

Adult & Teen Challenge
AdvaMedAmbulatory Surgery Center Association
American Association of Colleges of Nursing
American Association of Nurse Anesthesiology
American Association of Oral and Maxillofacial Surgeons
American Massage Therapy Association
American Psychological Association
American Society of Anesthesiologists
Arizona Public Health Association
atTAcK Addiction
Aurora Sober Living
Chatham Drug Free Community Coalition
Community Anti-Drug Coalitions of America
Cover2 Resources
Drug Free America Foundation Inc.
Drug Free Ozarks
Friends of Guest HouseHealthcare Leadership Council
Herren Project
Indiana Rural Health Association
Journey House Foundation
Mental Health Association in Delaware
National Certification Commission for Acupuncture and Oriental Medicine
National Council for Mental Wellbeing
National Hispanic Medical Association
National Rural Health Association
National Safety Council
National Transitions of Care Coalition
Overdose Lifeline
Partnership for a Healthy Iowa
Partnership to End Addiction
Pennsylvania Association of Nurse Anesthetists
Physical Medicine Management Alliance#PYDONEFAMILY Coalition
REAL LIFE
RetireSafe
Rhode Island Community for Addiction Recovery Efforts
Save Our Society From Drugs
Second Chance Center, Inc.
SeekHealing
Shatterproof
Society for Opioid Free Anesthesia
Society of Behavioral Medicine

TALK 2 Healthy Choices Coalition
The Kennedy Forum
Voices for Non-Opioid Choices
Warren Coalition
Watauga Substance Abuse Prevention
West Warwick Prevention Coalition
Will Bright Foundation
Young People in Recoveryi

Ahmad FB, Rossen LM, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics.
2021. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
ii
Ahmad FB, Rossen LM, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics.
2021. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
iii
Ahmad FB, Rossen LM, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics.
2021. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
iv
Centers for Medicare & Medicaid Services (2021). Medicare Program: Hospital Outpatient Prospective Paymentand Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Price Transparency of HospitalStandard Charges; Radiation Oncology Model; Request for Information on Rural Emergency Hospitals. FederalRegister. https://www.federalregister.gov/documents/2021/08/04/2021-15496/medicare-program-hospitaloutpatient-prospective-payment-and-ambulatory-surgical-center-paymentv
Centers for Medicare & Medicaid Services (4 August 2021). Medicare Program: Hospital Outpatient Prospective
Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Price Transparency of
Hospital Standard Charges; Radiation Oncology Model; Request for Information on Rural Emergency Hospitals.
Federal Register. https://www.federalregister.gov/documents/2021/08/04/2021-15496/medicare-programhospital-outpatient-prospective-payment-and-ambulatory-surgical-center-paymentviHall, MJ, Schwartzman A, Zhang J. Liu X. Ambulatory Surgery Data from Hospitals and Ambulatory Surgery
Centers: United States, 2014. Natl Health Stat Report. 2017 Fe;(102) Table A.
vii
Hah, J. M., Bateman, B. T., Ratliff, J., Curtin, C., & Sun, E. (2017). Chronic Opioid Use After Surgery: Implications
for Perioperative Management in the Face of the Opioid Epidemic. Anesthesia and analgesia, 125(5), 1733–1740.
https://doi.org/10.1213/ANE.0000000000002458
viii
Bicket M, et al. (2017). Prescription opioid oversupply following orthopedic surgery: A prospective cohort study.
American Pain Society annual scientific meeting 2017. https://www.jpain.org/article/S1526-5900(17)30157-8/pdf
ix
Hah, J. M., Bateman, B. T., Ratliff, J., Curtin, C., & Sun, E. (2017). Chronic Opioid Use After Surgery: Implications
for Perioperative Management in the Face of the Opioid Epidemic. Anesthesia and Analgesia, 125(5), 1733–1740.
https://doi.org/10.1213/ANE.0000000000002458
x
Halaszynski, T. Influences of the Aging Process on Acute Perioperative Pain Management in Elderly andCognitively Impaired Patients. The Ochsner Journal 2013. Vol 13 228-247.
xi
Wang MY, Chang HK, Grossman J. Reduced Acute Care Costs With the ERAS® Minimally Invasive Transforaminal
Lumbar Interbody Fusion Compared With Conventional Minimally Invasive Transforaminal Lumber Interbody
Fusion. Neurosurgery. 2017.
xii
Wang MY, Chang HK, Grossman J. Reduced Acute Care Costs With the ERAS® Minimally Invasive Transforaminal
Lumbar Interbody Fusion Compared With Conventional Minimally Invasive Transforaminal Lumber Interbody
Fusion. Neurosurgery. 2017.
xiii
Mont MA, Beaver WB, Dysart SH, Barrington JW, Del Gaizo DJ. Local infiltration analgesia with liposomal
bupivacaine improves pain scores and reduces opioid use after total knee arthroplasty: results of a randomized
controlled trial. J Arthroplasty. 2018;33(1):90-96
xivBaker, J., Brovman, E. Y., Rao, N., Beutler, S. S., & Urman, R. D. (2020). Potential Opioid-Related Adverse Drug
Events Are Associated With Decreased Revenue in Hip Replacement Surgery in the Older Population. Geriatricorthopaedic surgery & rehabilitation, 11, 2151459320915328. https://doi.org/10.1177/2151459320915328