10 Feb February 10, 2020

New Surprise Billing Legislation Emerges; Committee Action This Week
The House Ways and Means Committee released it much anticipated Surprise Billing legislation late last week.  The 200+ page document does not include the benchmark provision that was championed by the insurance industry and adopted into other versions of the legislation. Instead the bill creates a process for an independent arbitration when there is no agreement within 30 days between providers and payers. The bill was immediately applauded by the Association of American Medical Colleges. (Click here.) Later the same day, the House Education and Labor Committee released its proposal that does contain a federal benchmark to settle disputes for bills under $750, for those over that amount providers and payers would have the option to appeal to an independent arbiter. While the Ways and Means plan does not ban surprise bills from air ambulance services, the Ed and Labor package would allow disputed air ambulance costs above $25,000 to be appealed to an independent arbiter. Ways and Means has scheduled a markup on Wednesday and Ed and Labor the day before on Tuesday. Click here for the Ways and Means proposal, here for the summary, and here for the section-by-section. Click here for the Ed and Labor summary, and here for the bill text.

• Leaders of the House Energy and Commerce Committee and Senate Health Committee were quick to send out a statement touting their own bills, which passed their committees last year, click here.
• Former Health and Human Services Secretary and Florida Democratic Congresswoman Donna Shalala announced she will vote against the proposed Education and Labor legislation unless changes are made – citing fears this could harm her hospitals, click here.

House Condemns CMS Medicaid Block Grant Proposal; Verma Responds
In a vote of 223-190, the House disapproved of the Administration’s proposed Medicaid block grant demonstration titled the “Healthy Adult Opportunity” that will let states cap some federal Medicaid payments. The resolution says the proposal would hurt people that rely on the program. Critics say the proposed demo will limit opportunities for people to sign up for Medicaid and drastically cut the threshold of eligibility for Medicaid. Some states are already jumping on the chance for the demo with Oklahoma and Alaska considering plans to apply for the demo. Click here for the resolution, and here for the CMS fact sheet on the demo.

• CMS Administrator Seema Verma was swift to respond to the resolution with an opinion piece in the Washington Post stating “No, the Trump administration is not cutting Medicaid. We need to tackle Medicaid’s structural problems head on,” click here.

CMS’ Proposal Allows ESRD Patients to Enroll in MA and Also Cover Kidney Acquisition Costs
Stating it would “give seniors more choices and lower out-of-pocket costs, and to encourage price transparency,” CMS has issued a proposed rule that updates Medicare Advantage (MA or Part C) and the Medicare prescription drug benefit (Part D). Under the proposal, CMS would implement the 21st Century Cures Act provision that provides ESRD patients the option to enroll in MA plans starting in 2021 as well as a proposal to cover MA enrollee costs for kidney transplant acquisition costs. CMS also proposes to expand opioid-related drug management and medication management programs through Part D. Within Part D, CMS would additionally offer real time drug price comparison tools, allow for a second, specialty drug pricing tier with a lower cost sharing amount, and require plans to disclose to CMS how they measure or evaluate pharmacy performance. The proposal also makes several changes to the star ratings system, including an increase of the impact patient experience. For the CMS fact sheet, click here, and here for the proposed rule.

• The insurance industry’s association president says Social Determinants of Health interventions should be classified as quality improvements or patient care instead of administrative costs. Health insurers are required to pay 80 percent of premiums on medical claims and quality improvements. Changing how SDoH interventions are classified, insurance companies could provide more for the patients improving insurance quality. Click here for the full story.

U.S. Hospitals are Preparing for the Coronavirus
12 people in the United States have been diagnosed with the novel coronavirus that has infected more that 34,000 people worldwide as of last Friday. Hospitals in the U.S. are preparing for a spike in local outbreaks, by gathering supplies, spaces, and staff. While U.S. health officials have shared that the risk to U.S. remains low, hospitals are trying to improve their emergency preparedness just in case. This is as HHS briefed the public on the work that the President’s Coronavirus Task Force including funding to combat the virus worldwide and emergency preparedness information. To read more on what hospitals are doing, click here and for more on the Task Force, click here.  Click here for the latest from the CDC.  Coronavirus death toll has now surpassed SARS worldwide, click here.

• The Bill and Melinda Gates Foundation said it will commit up to $100 million as part of a global response to fighting the novel coronavirus, click here.

Bipartisan Policy Center Recommends Lower Hospital Payments To Curb Costs
Hospitals in non-competitive markets would be forced to accept lower payment rates or a multiple of Medicare rates under a proposal released last week by the Bipartisan Policy Center. The BPC issued a series of recommendations to reduce excessive and unnecessary health care cost growth, stabilize insurance premiums in the individual health insurance marketplaces and provide relief and flexibility to employers. The recommendations include in-depth policy analysis and a variety of proposals to tackle each area of concern. Click here for the report.

• Critics are saying that many not-for-profit hospitals are not earning their tax exempt status.  Click here for the Pew Trust report.
• Helping “super-utilizers” avoid hospital stays may not bring down costs too much, according to a new study, click here.

Financial Support Available to Fight Opioids in Rural Areas
The federal government has committed to offering financial support and incentive for community programs targeting opioid addiction through HRSA’s Federal Office of Rural Health Policy. The Rural Communities Opioid Response Program offers 89 one million dollar grants over a three year performance period to reduce the morbidity and mortality of substance use disorder, including opioid use disorder. The grant program targets the opioid epidemic from a community based standpoint and relieve pressure in rural areas without the resources to combat the crisis. View the grant here.

• House Energy and Commerce Republicans have spearheaded a 2020 re-investigation into the crimes of the distributors of opioids by signing on to three letters sent to top pharmaceutical companies – Insys Therapeutics (here), Mallinckrodt Pharmaceuticals (here), and Purdue Pharma (here).

Next Gen ACO Value Called into Question
The Next Generation Accountability Care Organization Program participants are worried they could be replaced with Direct Contracting as the Administration questions its ability for Next Gens to save Medicare money, based on a new CMS report. CMS released an evaluation report examining 2016 and 2017. It found that the payment model didn’t lead to “a statistically significant difference in spending,” wrote CMS Administrator Seema Verma in a blog post last month. To read Verma’s post, click here. To read the CMS study, click here. To read about how ACO’s are reacting to the aftermath of the findings of the study, click here.

Medicaid Antibiotics Often Prescribed with No Doctor’s Visit: Study
More than one in four prescriptions had no record of clinician visits and 17 percent of prescriptions did not relate to an infection-related diagnosis, according to a study published in Health Affairs. Researchers looked at all outpatient antibiotic prescriptions filled by Medicaid patients from 2004 to 2013 and found that out of 298 million identified antibiotic prescriptions filled by 53 million patients, more than 82 million prescriptions were filled without a doctor’s visit. These findings suggest that prescriptions outside of clinician visits may factor into the high amounts of antibiotic prescriptions in the United States. For the study, click here.

More Adults Seeking Less Primary Care
The use of primary care among commercially insured adults in the United States has been declining in the past decade, a study published in the Annals of Internal Medicine recently concluded. Researchers found that visits to primary care providers made by adults under the age of 65 had dropped by nearly 25 percent from 2008 to 2016. In addition, adults who went at least a year without a single visit to a primary care provider increased from about 38 percent to 46 percent in that period. Preventative care visits increased during the period, likely due to coverage by the ACA, while problem-based visits had a sharp decline. Evidence points to rising costs as a factor, as the average out-of-pocket costs for a visit to the doctor rose from about $30 to nearly $40 during the study period. Click here for the study.

More Women Giving Birth Outside of Hospitals
A new report finds the number of women giving birth in non-hospital settings increasing. In 2004, only 0.8 percent of women gave birth outside of hospitals, but that number grew to 1.3 percent in 2017. According to the study, in 2017, 1 out of every 41 births among white women occurred outside of hospitals and around 25 percent of planned home births were among women aged 35 and older. Researchers recommended that healthcare systems make it easier for women to switch from out-of-hospital birth setting to hospitals, as this may aid in treating complications that may arise. Click here for the study.

CAQH CORE Approves Two-Day Rule to Accelerate Prior Authorization Process
The multi-stakeholder organization, CAQH CORE, has voted to set a two-day limit on how quickly health plans must act on supporting information and final determinations on prior authorizations. CAQH CORE, that represents 110 health plans, vendors, providers, and government entities, created an operating rule to establish maximum timeframes in the prior authorization process for batch and real-time transactions. Under this rule, the timeframe requirements must be met 90 percent of the time in a calendar month. These prior authorization requirements include: two-day additional information requests, two-day final determinations, and optional close outs. For more, click here.