April 23, 2018

New CMS Policy Puts Critical Access Hospitals in Danger of Losing Status
The Trump Administration is pursuing a new policy that could jeopardize the status of dozens, if not hundreds, of Critical Access Hospital across the United States.  The issue involves the location of designated Hospital Outpatient Departments within 35 miles of a CAH.  CMS now says that an HOPD is an extension of a hospital and, therefore, a CAH within 35 miles of an HOPD is in violation of the rules.  How this impacts existing CAHs that had been designated as Necessary Providers (prior to January 1, 2006) is unclear.  An example of this is Curry General Hospital in Oregon that is having to prove it is a “necessary provider” or lose its CAH designation.  In 2013, the Office of Inspector General audited all the critical access requirements and found a number of critical access hospitals didn’t comply.  CMS is interpreting provider-based clinics as extensions of the hospital they bill Medicaid and Medicare under the hospital license. Curry General Hospital was never designated as a necessary provider because “we clearly met the distance requirement.” Click here for more.

  • Nebraska Congressman Adrian Smith proposed the Critical Access Hospitals Relief Act last week. The brief bill simply removes the “Medicare 96-hour physician certification requirement for inpatient Critical Access Hospital services.” To read more on the bill, click here.
  • The CAH Coalition has taken up the cause of Critical Access Hospitals and is now working to reverse this new CMS policy. Click here to learn more.


Free-Standing EDs Lobby for Medicare Reimbursement; Hospitals Fight MedPAC ED Plan

Free-standing emergency departments – those not affiliated with a hospital – are now lobbying for Medicare reimbursement they say could help them overcome increasing medical care shortages in rural areas. The fast-growing industry includes nearly 600 facilities often located in well-heeled, fast-growing neighborhoods of major metro areas, near patients with good-paying commercial insurance. Medicare only reimburses free-standing emergency departments that are affiliated with a hospital — about two-thirds of the total nationwide. Click here for MedPAC’s report on these facilities.  They have also formed their own national association.  Click here.  As free-standing emergency departments multiply, the Medicare Payment Advisory Commission recommended a 30 percent reduction in some federal reimbursements for those within 6 miles of a hospital.  Click here for a good Washington Post summary.


Trump To Tackle High Drug Prices; Pharma Spending Millions To Lobby

The White House announced that the President has postponed a “major speech” on drug prices that was set for Thursday. No rescheduled date has been set. His remarks were expected to coincide with a formal request for information from HHS on various drug pricing ideas including policies that were in his 2019 budget request, which includes more changes to the 340B drug discount program.  Another would require Medicare Part D drug plans for seniors to share the savings from drug rebates with patients, would cost the government about $42.16 billion over 10 years. Also a possible proposal could be the budget request to let states band together to negotiate Medicaid prices using closed formularies. Click here.

  • NIH Director Francis Collins announced last week that that the agency will take the recommendations from its advisory committee and, “decline cash contributions through partnerships from the private sector,” click here.
  • The trade association representing pharmaceutical manufacturers spent a record amount on lobbying in the first three months of 2018 as it fought against the CREATES Act, a bipartisan bill aimed at increasing competition between generic and brand-named drugmakers. The group spent nearly $10 million on lobbying between Jan. 1 and March 31, a $2 million increase from the same time last year, click here.


Committees Schedule Votes on Opioid Bills and Other Opioid Developments

Both House and Senate Committees will vote on their proposals to deal with the nation’s opioid crisis. First up on April 24th, the Senate Health Committee will vote on bipartisan opioid and over-the-counter drug monograph reform legislation. The House Energy and Commerce Health Subcommittee announced a markup on some of the opioid legislation that it has held hearings on the past couple of months on April 25th. The exact bills have not been determined yet. Click here for the Senate Markup information, and here for the House.

  • New analysis published in the American Journal of Psychiatry found that 16 million American adults have used prescription stimulants, and 5 million admitted to abusing them, click here.
  • Last week, CMS released an updated version of the Part D opioid prescribing tool that is a web-based visualization resource that offers geographic comparisons of opioid prescribing rates, click here.
  • Leading up to the mark-up the Energy and Commerce Health Subcommittee health a roundtable to listen to personal stories from the opioid crisis, click here.
  • Doctors are prescribing fewer pain medication due to the more scrutiny of how they contribute to the opioid epidemic – 2017 saw a 10 percent drop in prescriptions, an increase over the the 1.5 percent decrease of 2016, according to a study from the IQVIA Institute for Human Data Science, click here.
  • HHS Announces 57 grants totaling an additional $485 million in second installment of grant awards to combat opioid crisis, click here to see how the money was distributed.

The American Society of Addiction Medicine and the American Medical Association have announced a collaborative value-based payment model for opioid addiction treatment by increasing utilization and access to medications for opioid treatment, and combining them with the appropriate level of medical, psychological and social support services, click here.


Farm Bill Includes SNAP Work Requirements, Association Health Plan Support

The House Agriculture Committee sent the controversial Agriculture and Nutrition Act of 2018 (H.R.2) to the House Floor on April 19th on a party line (26-20) vote. The bill would expand mandatory work requirements in the Supplemental Nutrition Assistance Program (SNAP), known as food stamps, and require that most adults between 18 and 59 who enroll work at least part time to receive benefits, a policy unlikely to find majority support in the Senate. The legislation would also authorize $65 million for the secretary of Agriculture to create up to 10 loans and grants to help support the creation of agricultural association health plans. The bill is expected to be voted on by the full House next month. To read the bill click here, for a summary, click here, and to view contentious debate at markup, click here.


Conservative Leaders Urge Revival of Repeal and Replace, Graham-Cassidy Legislation

In an open letter to the American people, a group of conservatives, led by former GOP Pennsylvania Senator Rick Santorum, is urging Congress to shift its focus back to repealing and replacing the Affordable Care Act ahead of the November mid-term elections and revive the failed Cassidy-Graham bill. “Obamacare has nearly destroyed the private market for individual health insurance,” the coalition writes. “The No. 1 issue voters want their elected representatives to address this year is the high cost of health coverage.” They go on to praise the GOP’s repeal of the individual mandate and work to allow more flexibility in the ACA markets, but say that more is needed to bring down sky-rocketing premiums. Click here for the letter.


Two Senate Democrats Introduce Medicare Buy-In: Medicare Part E

New legislation introduced by Senate Democrats would dramatically expand Obamacare and Medicare as part of an effort to transition the system toward a single-payer, or government-run, program. In addition to allowing everybody to buy into Medicare, the program would set a maximum for out-of-pocket spending, and make Obamacare subsidies more generous and available to higher income levels. The senators do not include an estimate of how much the bill costs or how they would propose to pay for it. Click here for a one-page summary.  Click here for the bill text. Click here for the story.


Bipartisan Lawmakers Urge CMS to Allow ACOs to Continue Without Risk

A bipartisan group of House Members sent a letter to CMS last week requesting the agency allow Accountable Care Organizations that are not taking on risk to continue on that track for another three years. Initially, organizations could stay in Track 1 of the program, under which they share some savings with CMS but remain free of penalties, for three years, which was extended to a second three-year period. Those that have participated as Track 1 ACOs since the Medicare Shared Savings Program’s beginning are now in their final year of that second three-year period. Reps. Suzan DelBene (D-WA), Erik Paulsen (R-MN), Earl Blumenaur (D-OR), Terri Sewell (D-AL), John Lewis (D-GA), Patrick Meehan (R-PA) and Mike Thompson (D-CA) urged CMS to let those ACOs stay in Track 1 for another three years, stating that the hospitals are still not ready to take on risk. Click here for the letter.


Physician Groups Urge Significant Changes to MIPS

The Medical Group Management Association, the American Medical Association and 47 other physician organizations sent a letter CMS stating the Merit-based Incentive Payment System requires too much quality data reporting and to reduce the reporting period from 365 to 90 days among other suggestions, click here.


Advocacy Groups and Insurers Push HHS to Block Dialysis Patient Steering

In a letter to HHS Secretary Azar last week, a coalition of patient advocacy groups, insurers, and unions urged HHS to “take immediate action to address recent disclosures confirming inappropriate steering of individuals with End Stage Renal Disease (ESRD) who are eligible for Medicare or Medicaid into commercial coverage.” They state in the letter that some dialysis clinics are going so far as to pay premiums for customers in order to recoup more lucrative reimbursement rates in private coverage and gaming the system. To read the full letter and see all the organizations signed on, click here.


California AG Moving Aggressively Against Hospitals

The California attorney general is taking action against several hospitals – tackling not-for-profit status and high hospital costs.  Attorney General Xavier Becerra has ordered three California hospitals to pay out millions of dollars to local nonprofits, declining their requests to be freed from charity obligations required under state law.  He has also sued Sutter Health, accusing the hospital giant of illegally quashing competition and for years overcharging consumers and employers.  Click here for the not-for-profit story.  Click here and here for the action against Sutter.


VA Secretary Nominee Confirmation Hearing on Wednesday

The Senate Veterans Affairs Committee will hold the confirmation hearing for the President’s pick to lead the VA, Navy Read Adm. Ronny Jackson, on April 25th. Adm. Jackson, currently the president’s personal White House physician, was announced last month as the replacement to ousted VA Secretary David Shulkin. However, lawmakers and veterans groups have questioned whether Jackson has the necessary experience to run the massive bureaucracy at the second largest department in the federal government. Click here for hearing information, and here for a bio on Adm. Jackson.


Study:  Mobile App Medication Reminders Questionable

Mobile app-based medication reminders are increasingly common, but they haven’t been rigorously evaluated, a group of researchers say. A new study published in JAMA took a stab at that evaluation, and concluded that these apps aren’t all that useful for hypertension patients.  The study offered about 200 patients with high blood pressure an app called MediSafe, which pulled their medication list from their Epic EHRs and reminded them to take between one and three medications. When compared both to their previous medication adherence and to a control group, the app users showed only a slight improvement. Both the control group and the app users saw roughly the same decrease in blood pressure – around 10 mm Hg – over 12 weeks. Click here for the JAMA report.

Less Sleep Leads to a Shorter Life
A study conducted by UK researchers found that ‘definite evening types’ had a 10% higher rate of dying from than ‘definite morning types’. Definite evening types are described as individuals sleeping less than 8 hours a day. Definite morning types are described as individuals receiving more than 7 hours of sleep. The study focused on ‘definitive evening type’ rates of diabetes, psychological and neurological disorders, and respiratory disorders in an individual. Researchers investigated the risk factors that caused major diseases in men and women from ages 37 to 73 years old in the data collected from 2006 to 2010. The results revealed that ‘definite evening types’ were also more likely to have diabetes, neurological disorders, psychological disorders, gastrointestinal disorders and respiratory disorders. Click here for full study.

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