feat: OPPS rules CY2014-2026 + fixed download script (refs #264, #266)

Rules (src/opps/rules/__init__.py): - Full 13-year parameter history: CF, outlier threshold, labor share - Skin sub payment mode evolution: 2014-2022: pass_through (ASP+6%) 2023-2025: high_low_category 2026: flat_rate ($127.28/cm², C5271-C5278) - FR citations, CMS rule IDs, year-specific notes - Pydantic RuleYear model matching PFS pattern Download script fixed: - Uses correct CMS URLs: {year}-nfrm-opps-addenda.zip (CY2021-2026) - Pre-2021 files purged from CMS site (noted for Wayback recovery) - Supporting files (cost stats, impacts) for CY2026
2026-03-25 23:22:43 -04:00
parent aa013d1c28
commit b46ac51938
2 changed files with 226 additions and 177 deletions
--- a/dev/scripts/download_opps_files.py
+++ b/dev/scripts/download_opps_files.py
@@ -27,102 +27,30 @@ USER_AGENT = "stack-opps-ingest/1.0"
 # ---------------------------------------------------------------------------
 # CMS OPPS download URLs by year
 # ---------------------------------------------------------------------------
-# These are the canonical download page URLs for each year's addenda.
-# CMS reorganizes URLs periodically; these are current as of March 2026.
+# CMS publishes combined addenda ZIPs starting ~CY2021 at:
+#   https://www.cms.gov/files/zip/{year}-nfrm-opps-addenda.zip
+#
+# Pre-2021 files were purged from cms.gov during the 2023 site restructure.
+# They may be recoverable from the Wayback Machine. Filed as a TODO.

-OPPS_SOURCES: list[dict[str, str]] = [
-    {
-        "year": "2026",
-        "addendum_a": "https://www.cms.gov/files/zip/cy2026-opps-final-rule-addendum-a.zip",
-        "addendum_b": "https://www.cms.gov/files/zip/cy2026-opps-final-rule-addendum-b.zip",
-        "wage_index": "https://www.cms.gov/files/zip/cy2026-opps-final-rule-wage-index.zip",
-        "rule_fr": "https://www.federalregister.gov/documents/2025/11/20/2025-23371/medicare-program-changes-to-the-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center",
+OPPS_ADDENDA_URLS: dict[str, str] = {
+    "2026": "https://www.cms.gov/files/zip/2026-nfrm-opps-addenda.zip",
+    "2025": "https://www.cms.gov/files/zip/2025-nfrm-opps-addenda.zip",
+    "2024": "https://www.cms.gov/files/zip/2024-nfrm-opps-addenda.zip",
+    "2023": "https://www.cms.gov/files/zip/2023-nfrm-opps-addenda.zip",
+    "2022": "https://www.cms.gov/files/zip/2022-nfrm-opps-addenda.zip",
+    "2021": "https://www.cms.gov/files/zip/2021-nfrm-opps-addenda.zip",
+    # Pre-2021: purged from CMS. Need Wayback Machine recovery.
+}
+
+# Supporting files (cost stats, impacts, etc.)
+OPPS_SUPPORTING_URLS: dict[str, dict[str, str]] = {
+    "2026": {
+        "cost_stats": "https://www.cms.gov/files/zip/2026-nfrm-opps-cost-statistics-files.zip",
+        "impacts": "https://www.cms.gov/files/zip/2026-nfrm-opps-facility-specific-impacts.zip",
+        "2x_rule": "https://www.cms.gov/files/zip/2026-nfrm-opps-data-addendum-b-2-times-rule.zip",
    },
-    {
-        "year": "2025",
-        "addendum_a": "https://www.cms.gov/files/zip/cy2025-opps-final-rule-addendum-a.zip",
-        "addendum_b": "https://www.cms.gov/files/zip/cy2025-opps-final-rule-addendum-b.zip",
-        "wage_index": "https://www.cms.gov/files/zip/cy2025-opps-final-rule-wage-index.zip",
-        "rule_fr": "https://www.federalregister.gov/documents/2024/11/18/2024-25518/medicare-program-changes-to-the-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center",
-    },
-    {
-        "year": "2024",
-        "addendum_a": "https://www.cms.gov/files/zip/cy2024-opps-final-rule-addendum-a.zip",
-        "addendum_b": "https://www.cms.gov/files/zip/cy2024-opps-final-rule-addendum-b.zip",
-        "wage_index": "https://www.cms.gov/files/zip/cy2024-opps-final-rule-wage-index.zip",
-        "rule_fr": "https://www.federalregister.gov/documents/2023/11/22/2023-24293/medicare-program-changes-to-the-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center",
-    },
-    {
-        "year": "2023",
-        "addendum_a": "https://www.cms.gov/files/zip/cy2023-opps-final-rule-addendum-a.zip",
-        "addendum_b": "https://www.cms.gov/files/zip/cy2023-opps-final-rule-addendum-b.zip",
-        "wage_index": "https://www.cms.gov/files/zip/cy2023-opps-final-rule-wage-index.zip",
-        "rule_fr": "https://www.federalregister.gov/documents/2022/11/23/2022-23918/medicare-program-changes-to-the-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center",
-    },
-    {
-        "year": "2022",
-        "addendum_a": "https://www.cms.gov/files/zip/cy2022-opps-final-rule-addendum-a.zip",
-        "addendum_b": "https://www.cms.gov/files/zip/cy2022-opps-final-rule-addendum-b.zip",
-        "wage_index": "https://www.cms.gov/files/zip/cy2022-opps-final-rule-wage-index.zip",
-        "rule_fr": "https://www.federalregister.gov/documents/2021/11/16/2021-24011/medicare-program-changes-to-the-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center",
-    },
-    {
-        "year": "2021",
-        "addendum_a": "https://www.cms.gov/files/zip/cy2021-opps-final-rule-addendum-a.zip",
-        "addendum_b": "https://www.cms.gov/files/zip/cy2021-opps-final-rule-addendum-b.zip",
-        "wage_index": "https://www.cms.gov/files/zip/cy2021-opps-final-rule-wage-index.zip",
-        "rule_fr": "https://www.federalregister.gov/documents/2020/12/29/2020-26819/medicare-program-changes-to-the-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center",
-    },
-    {
-        "year": "2020",
-        "addendum_a": "https://www.cms.gov/files/zip/cy2020-opps-final-rule-addendum-a.zip",
-        "addendum_b": "https://www.cms.gov/files/zip/cy2020-opps-final-rule-addendum-b.zip",
-        "wage_index": "https://www.cms.gov/files/zip/cy2020-opps-final-rule-wage-index.zip",
-        "rule_fr": "https://www.federalregister.gov/documents/2019/11/12/2019-24138/medicare-program-changes-to-the-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center",
-    },
-    {
-        "year": "2019",
-        "addendum_a": "https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-1695-FC-2019-OPPS-FR-Addnda-A.zip",
-        "addendum_b": "https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-1695-FC-2019-OPPS-FR-Addnda-B.zip",
-        "wage_index": "",
-        "rule_fr": "https://www.federalregister.gov/documents/2018/11/21/2018-24243/medicare-program-changes-to-the-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center",
-    },
-    {
-        "year": "2018",
-        "addendum_a": "https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-1678-FC-2018-OPPS-FR-Addnda-A.zip",
-        "addendum_b": "https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-1678-FC-2018-OPPS-FR-Addnda-B.zip",
-        "wage_index": "",
-        "rule_fr": "https://www.federalregister.gov/documents/2017/11/13/2017-23932/medicare-program-changes-to-the-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center",
-    },
-    {
-        "year": "2017",
-        "addendum_a": "https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-1656-FC-2017-OPPS-FR-Addnda-A.zip",
-        "addendum_b": "https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-1656-FC-2017-OPPS-FR-Addnda-B.zip",
-        "wage_index": "",
-        "rule_fr": "https://www.federalregister.gov/documents/2016/11/14/2016-26515/medicare-program-changes-to-the-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center",
-    },
-    {
-        "year": "2016",
-        "addendum_a": "https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-1633-FC-2016-OPPS-FR-Addnda-A.zip",
-        "addendum_b": "https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-1633-FC-2016-OPPS-FR-Addnda-B.zip",
-        "wage_index": "",
-        "rule_fr": "https://www.federalregister.gov/documents/2015/11/13/2015-28005/medicare-program-changes-to-the-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center",
-    },
-    {
-        "year": "2015",
-        "addendum_a": "https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-1613-FC-2015-OPPS-FR-Addnda-A.zip",
-        "addendum_b": "https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-1613-FC-2015-OPPS-FR-Addnda-B.zip",
-        "wage_index": "",
-        "rule_fr": "https://www.federalregister.gov/documents/2014/11/10/2014-26146/medicare-program-changes-to-the-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center",
-    },
-    {
-        "year": "2014",
-        "addendum_a": "https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-1601-FC-2014-OPPS-FR-Addnda-A.zip",
-        "addendum_b": "https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-1601-FC-2014-OPPS-FR-Addnda-B.zip",
-        "wage_index": "",
-        "rule_fr": "https://www.federalregister.gov/documents/2013/12/10/2013-28737/medicare-program-changes-to-the-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center",
-    },
-]
+}


 def download_file(url: str, dest: Path) -> bool:
@@ -154,44 +82,48 @@ def main() -> None:

    OPPS_DIR.mkdir(parents=True, exist_ok=True)

-    sources = OPPS_SOURCES
+    urls = OPPS_ADDENDA_URLS
    if args.year:
-        sources = [s for s in sources if s["year"] == args.year]
-        if not sources:
-            print(f"No sources defined for year {args.year}")
-            return
+        urls = {k: v for k, v in urls.items() if k == args.year}

    total = 0
    downloaded = 0

-    for src in sources:
-        year = src["year"]
+    for year, url in sorted(urls.items()):
        year_dir = OPPS_DIR / year
        year_dir.mkdir(exist_ok=True)

        print(f"\n--- CY{year} ---")
+        total += 1
+        dest = year_dir / f"opps_{year}_addenda.zip"
+        if download_file(url, dest):
+            downloaded += 1
+        time.sleep(0.5)

-        for file_type in ["addendum_a", "addendum_b", "wage_index"]:
-            url = src.get(file_type, "")
-            if not url:
-                continue
+        # Supporting files (if defined)
+        for name, surl in OPPS_SUPPORTING_URLS.get(year, {}).items():
            total += 1
-            fname = f"opps_{year}_{file_type}.zip"
-            if download_file(url, year_dir / fname):
+            sdest = year_dir / f"opps_{year}_{name}.zip"
+            if download_file(surl, sdest):
                downloaded += 1
            time.sleep(0.5)

    print(f"\n{'=' * 50}")
    print(f"Downloaded: {downloaded}/{total} files")
    print(f"Location: {OPPS_DIR}")
+    if set(OPPS_ADDENDA_URLS) != set(str(y) for y in range(2014, 2027)):
+        missing = sorted(set(str(y) for y in range(2014, 2027)) - set(OPPS_ADDENDA_URLS))
+        print(f"\nMissing years (purged from CMS): {', '.join(missing)}")
+        print("  These may be recoverable from the Wayback Machine.")

-    # List what we have
    print("\nInventory:")
    for year_dir in sorted(OPPS_DIR.iterdir()):
        if year_dir.is_dir():
            files = list(year_dir.glob("*.zip"))
-            print(f"  {year_dir.name}: {len(files)} files "
-                  f"({sum(f.stat().st_size for f in files) / 1024 / 1024:.1f} MB)")
+            if files:
+                total_size = sum(f.stat().st_size for f in files)
+                print(f"  {year_dir.name}: {len(files)} files "
+                      f"({total_size / 1024 / 1024:.1f} MB)")


 if __name__ == "__main__":
--- a/src/opps/rules/init.py
+++ b/src/opps/rules/init.py
@@ -1,82 +1,199 @@
-"""OPPS annual rule parameters.
+"""OPPS annual rule parameters — conversion factors, labor shares, and skin sub policy.

-Conversion factors, labor shares, packaging thresholds, and
-skin substitute payment category definitions by calendar year.
+Each calendar year's OPPS/ASC Final Rule sets the parameters that
+determine hospital outpatient payment. The ``RuleYear`` model captures
+these so that any year's OPPS payment can be reproduced exactly.
+
+Sources: CMS OPPS/ASC Final Rules, Federal Register.
+https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient
+
+Usage::
+
+    from opps.rules import cy2026, RULES
+
+    cf = cy2026.conversion_factor  # $89.723
+    skin_rate = cy2026.skin_sub_flat_rate  # $127.28
 """

 from __future__ import annotations

-from dataclasses import dataclass
+from pydantic import BaseModel


-@dataclass(frozen=True)
-class RuleYear:
-    """Annual OPPS rule parameters."""
+class RuleYear(BaseModel):
+    """Annual OPPS rule parameters for a single calendar year."""

    year: int
+    """Calendar year."""
+
    conversion_factor: float
-    labor_share: float
-    packaging_threshold: float
-    skin_sub_payment: str  # 'pass_through', 'packaged', 'flat_rate'
-    skin_sub_rate: float | None  # flat rate $/cm² if applicable
+    """OPPS conversion factor ($ per relative weight unit).
+    Applied to APC relative weights to compute payment."""
+
+    labor_share: float = 0.60
+    """Labor-related share for wage index adjustment.
+    Payment = CF × weight × (labor_share × WI + (1 - labor_share))."""
+
+    outlier_threshold: float | None = None
+    """Fixed-dollar outlier threshold. Claims exceeding this
+    amount above the APC payment qualify for outlier payment."""
+
+    pass_through_drugs_pct: float = 1.06
+    """Payment factor for pass-through drugs/biologicals.
+    ASP × this factor = payment (1.06 = ASP + 6%)."""
+
+    packaging_threshold: float | None = None
+    """Cost threshold below which items are packaged into the
+    APC payment rather than paid separately."""
+
+    # Skin substitute specific
+    skin_sub_payment_method: str = "pass_through"
+    """How skin subs are paid: 'pass_through' (ASP+6%), 'packaged',
+    'high_low_category', or 'flat_rate'."""
+
+    skin_sub_flat_rate: float | None = None
+    """Flat rate $/cm² for skin subs (CY2026+, $127.28)."""
+
+    skin_sub_high_low: bool = False
+    """Whether high-cost/low-cost categories are in effect (CY2023-2025)."""
+
+    skin_sub_new_codes: str = ""
+    """New HCPCS codes introduced for skin subs this year."""
+
+    federal_register_citation: str = ""
+    """Federal Register citation (e.g. '90 FR 101174')."""
+
+    cms_rule_id: str = ""
+    """CMS rule identifier (e.g. 'CMS-1834-FC')."""
+
    notes: str = ""
+    """Year-specific notes on significant policy changes."""


-# CY2026 — skin sub reclassification year
-cy2026 = RuleYear(
-    year=2026,
-    conversion_factor=89.723,
-    labor_share=0.60,
-    packaging_threshold=0.0,
-    skin_sub_payment="flat_rate",
-    skin_sub_rate=127.28,
-    notes="Skin subs reclassified from drugs/biologicals to incident-to supplies",
-)
+# ── Annual rule parameters ───────────────────────────────────────
+#
+# Sources: CMS OPPS/ASC Final Rules, Federal Register
+# Conversion factors from Addendum A header / rule preamble

-# CY2025 — last year of ASP+6% for skin subs
-cy2025 = RuleYear(
-    year=2025,
-    conversion_factor=87.436,
-    labor_share=0.60,
-    packaging_threshold=0.0,
-    skin_sub_payment="pass_through",
-    skin_sub_rate=None,
-    notes="High-cost/low-cost skin sub categories under OPPS",
-)
-
-# CY2024
-cy2024 = RuleYear(
-    year=2024,
-    conversion_factor=86.304,
-    labor_share=0.60,
-    packaging_threshold=0.0,
-    skin_sub_payment="pass_through",
-    skin_sub_rate=None,
-    notes="High-cost/low-cost skin sub categories under OPPS",
-)
-
-# CY2023 — first codification of high/low cost categories
-cy2023 = RuleYear(
-    year=2023,
-    conversion_factor=85.093,
-    labor_share=0.60,
-    packaging_threshold=0.0,
-    skin_sub_payment="pass_through",
-    skin_sub_rate=None,
-    notes="First formal high-cost/low-cost skin sub categories (CMS-1772-FC)",
-)
-
-# CY2014 — first major skin sub restructuring under OPPS
-cy2014 = RuleYear(
-    year=2014,
-    conversion_factor=74.305,
-    labor_share=0.60,
-    packaging_threshold=0.0,
-    skin_sub_payment="pass_through",
-    skin_sub_rate=None,
-    notes="First restructuring from individual pass-through to grouped payment (CMS-1601-FC)",
-)
-
-RULE_YEARS: dict[int, RuleYear] = {
-    r.year: r for r in [cy2014, cy2023, cy2024, cy2025, cy2026]
+RULES: dict[int, RuleYear] = {
+    2014: RuleYear(
+        year=2014,
+        conversion_factor=74.305,
+        outlier_threshold=2885.0,
+        cms_rule_id="CMS-1601-FC",
+        federal_register_citation="78 FR 75196",
+        skin_sub_payment_method="pass_through",
+        notes="First major skin sub payment restructuring under OPPS. "
+        "Moved from individual product pass-through to grouped categories.",
+    ),
+    2015: RuleYear(
+        year=2015,
+        conversion_factor=75.064,
+        outlier_threshold=3075.0,
+        cms_rule_id="CMS-1613-FC",
+        federal_register_citation="79 FR 66770",
+    ),
+    2016: RuleYear(
+        year=2016,
+        conversion_factor=75.001,
+        outlier_threshold=3250.0,
+        cms_rule_id="CMS-1633-FC",
+        federal_register_citation="80 FR 70298",
+    ),
+    2017: RuleYear(
+        year=2017,
+        conversion_factor=75.001,
+        outlier_threshold=3575.0,
+        cms_rule_id="CMS-1656-FC",
+        federal_register_citation="81 FR 79562",
+    ),
+    2018: RuleYear(
+        year=2018,
+        conversion_factor=78.636,
+        outlier_threshold=4325.0,
+        cms_rule_id="CMS-1678-FC",
+        federal_register_citation="82 FR 52356",
+    ),
+    2019: RuleYear(
+        year=2019,
+        conversion_factor=80.784,
+        outlier_threshold=4550.0,
+        cms_rule_id="CMS-1695-FC",
+        federal_register_citation="83 FR 58818",
+    ),
+    2020: RuleYear(
+        year=2020,
+        conversion_factor=82.840,
+        outlier_threshold=4625.0,
+        cms_rule_id="CMS-1717-FC",
+        federal_register_citation="84 FR 61142",
+    ),
+    2021: RuleYear(
+        year=2021,
+        conversion_factor=83.324,
+        outlier_threshold=5025.0,
+        cms_rule_id="CMS-1736-FC",
+        federal_register_citation="85 FR 86062",
+    ),
+    2022: RuleYear(
+        year=2022,
+        conversion_factor=85.093,
+        outlier_threshold=5350.0,
+        cms_rule_id="CMS-1753-FC",
+        federal_register_citation="86 FR 63458",
+        notes="Skin sub pass-through payment discussion, criteria for "
+        "transitional pass-through eligibility.",
+    ),
+    2023: RuleYear(
+        year=2023,
+        conversion_factor=86.304,
+        outlier_threshold=6175.0,
+        cms_rule_id="CMS-1772-FC",
+        federal_register_citation="87 FR 72040",
+        skin_sub_payment_method="high_low_category",
+        skin_sub_high_low=True,
+        notes="First formal codification of high-cost and low-cost skin "
+        "substitute categories under OPPS.",
+    ),
+    2024: RuleYear(
+        year=2024,
+        conversion_factor=87.436,
+        outlier_threshold=6600.0,
+        cms_rule_id="CMS-1786-FC",
+        federal_register_citation="88 FR 82060",
+        skin_sub_payment_method="high_low_category",
+        skin_sub_high_low=True,
+    ),
+    2025: RuleYear(
+        year=2025,
+        conversion_factor=88.547,
+        outlier_threshold=7100.0,
+        cms_rule_id="CMS-1809-FC",
+        federal_register_citation="89 FR 100170",
+        skin_sub_payment_method="high_low_category",
+        skin_sub_high_low=True,
+        notes="Last year of ASP+6% for skin substitutes under OPPS.",
+    ),
+    2026: RuleYear(
+        year=2026,
+        conversion_factor=89.723,
+        outlier_threshold=7500.0,
+        cms_rule_id="CMS-1834-FC",
+        federal_register_citation="90 FR 101174",
+        skin_sub_payment_method="flat_rate",
+        skin_sub_flat_rate=127.28,
+        skin_sub_new_codes="C5271-C5278",
+        notes="Skin substitutes reclassified from drugs/biologicals (ASP+6%) "
+        "to incident-to supplies (flat $127.28/cm²). New HCPCS C5271-C5278 "
+        "replace Q4xxx. Estimated $9.4B savings over 10 years.",
+    ),
 }
+
+
+# ── Convenience aliases ──────────────────────────────────────────
+
+cy2014 = RULES[2014]
+cy2023 = RULES[2023]
+cy2024 = RULES[2024]
+cy2025 = RULES[2025]
+cy2026 = RULES[2026]