16 Dec December 16, 2019

Some Good News to End the Year
It has been a challenging year in federal health policy. Although much of the focus has been on reforming the pharmaceutical sector, hospitals, physicians and other providers have been fighting regulatory and legislative battles over payment streams.  Several developments over the past week provided some encouragement:

• HOPD Site Neutral Payments:  Providers will receive approximately $800 million in payments that were cut in 2019 when CMS implemented its HOPD site neutral payment policy impacting certain E/M codes.
• Surprise Billing legislation:  Not moving forward in 2019.  This will be a 2020 issue, but its passage was a near certainty only six months ago.
• Medicaid DSH Cuts:  The House and Senate now support another two-year delay in the $4 billion cut to disproportionate share hospital payments and the delay is expected to be part of final year-end legislation.

Details follow below.

Dueling Surprise Billing “Agreements” Bring More Uncertainty
The Senate Health Committee along with the House Energy and Commerce Committee jointly announced last week that they had an agreement on surprise billing legislation that includes both an arbitration provision as well as a rate setting policy. Their compromise also included measures to encourage competition in the pharmaceutical industry, raise the tobacco smoking age to 21, and eliminate anti-competitive clauses in contracts between physicians and insurance plans. The bill was quickly opposed by most provider organizations due in large part to the rate setting, benchmark provision.  In an unexpected move, the House Ways and Means Committee announced its own bipartisan fix that would let insurers and providers work out billing disputes on their own and impose an outside mediation process if there’s no resolution. It is highly unlikely this issue will be resolved this year. Click here for the HELP, Energy and Commerce Proposal, and here for the Ways and Means proposal.

CMS Quietly Announces Payments for 2019 Site-Neutral Cuts Then Files Appeal
CMS has very quietly announced it will repay hospitals approximately $800 million for the 2019 cuts to hospital outpatient department site neutral payments, but it also filed a Notice of Appeal of the court ruling that CMS had exceeded its statutory authority in making the cuts. As you will recall, the US District Court’s ruling vacated the relevant portions of the 2019 OPPS rule and remanded it to CMS to determine a remedy. Subsequently, CMS’ request for a stay of the Court’s order was denied. Click here for the CMS announcement on repayment on page 3 of MLN Connects and click here for the Notice of Appeal. Meanwhile, post-trial motions are pending whereby the hospital plaintiffs argue the Court’s order also applies to the cuts in the 2020 OPPS rule. Click here to read the Motion, here to read HHS’ response to the Motion, here for the hospitals’ reply and here for a supplemental notice in support of its Motion. No word yet on when the post-trial motions will be considered.

Hospital Spending Driving Growth: CMS
New data from the Centers for Medicare and Medicaid Services indicate that national health spending as measured by the National Health Expenditure Accounts (NHEA) grew by 4.6% in 2018. Small downward revisions occurred despite an upward revision to 12.0% in growth of the net cost of health insurance resulting from the health insurance tax and insurer profitability. Altarum analysts estimate national health spending growth for the first 10 months of 2019 to be 4.9%, year over year. This acceleration is primarily due to growth in hospital spending. Click here for details from Altarum.

Drug Pricing Bill Passes House, Senate Unlikely to Vote on it, White House Threatens Veto
The House passed last week what has become known as the Pelosi drug pricing package on a mostly partyline vote of 230-192. It would curb rising drug prices by authorizing the federal government to negotiate prices with drugmakers for a minimum of 50 drugs per year.  The White House has issued a veto threat. The bill is all but certain to die in the Republican-controlled Senate, where Sens. Chuck Grassley (R-IA) and Ron Wyden (D-OR) have introduced their own plan that is backed by the White House. Several amendments were adopted into the bill including grants for health care administrative costs and rural hospitals, drug advertising disclosure, Medicare Star ratings changes, and studies for treatments on unmet medical needs. The Congressional Budget Office predicted that the Pelosi legislation would lower federal spending by $456 billion over 10 years. However, the bill would also expand Medicare benefits costing the government $358 billion over 10 years. Click here for the bill and here for the CBO report, which is an excellent summary.

• The Democratic Congressional Campaign Committee has already leveraged the bill to hit some swing-state Republicans with an ad campaign, click here.
• The Senate passed an overhaul of FDA’s over-the-counter drug regulations, the first change since 1972, by a 91-2 vote, the bill (S. 2740) changes the rules that govern approval of medications other than prescription drugs, click here.

Conflict Between HHS, CMS Chiefs Said To Be Resolved 
After several weeks of reports of infighting between HHS Secretary Alex Azar and CMS Administrator Seema Verma, a truce has been proclaimed following a White House meeting. Both sides reportedly contributed to the conflict making allegations against each other and secretly giving items to the press – such as Verma’s use of contractors and request for reimbursement for stolen jewelry, as well as stories of how Azar sparred with the White House domestic policy team. A new tweet from Verma praises Azar. Click here for more on the issue from the Washington Post, and here for the Verma tweet.  In addition, the LA Times columnist is calling Verma “a threat to public health programs,” click here.  Congressional Democrats are urging the President to fire Verma in a letter stating that she has “put her needs ahead of those she serves”, click here.

In the Closing Weeks of Open Enrollment, Overall Sign-Ups Still Down Over Previous Year
Open enrollment closed on Dec. 15th. The closing weeks have shown that sign-ups on healthcare.gov are still lower overall from last year – about 4 percent – however, week six data does show that the number of people who have stayed with plans on the exchanges remains high. There has been a slight uptick with more than 1 million people enrolling in ACA coverage during the fifth full week of open enrollment, an 8-percent increase from the same week last year. Additionally, CMS announced that 10.2 million people had ACA coverage at the end of June, down about 400,000 from the end of March and virtually unchanged from the same period in 2018. Click here for the update from CMS.

• HHS OIG report shows that private insurers in the Medicare Advantage program may have improperly collected billions of federal dollars by inflating their enrollees’ health conditions, click here.
• The Catalyst for Payment Reform released its latest version of the National Scorecard on Payment Reform, which showed that that 90 percent of value-based payments were based on fee-for-service, while 6 percent were from an alternative payment model putting downside financial risk on providers, click here.

Neuro, Thoracic, Orthopedic Surgeons Are Highest Paid; Primary Care In Highest Demand
Neurosurgery, thoracic surgery, and orthopedic surgery are the three highest paying specialties with each paying more than $500,000 per year. Primary care however, does not make the top ten, yet it is one of the most in-demand specialties nationwide, According to a new report from Doximity. Cities such as El Paso, TX and Miami have a huge demand for physicians in general, but are especially lacking primary care. Primary care is also in demand in the telehealth sector. The report also found that the cities where doctors receive highest compensation are not the cities in need of physicians. To read the report, click here.

House Committee Leaders Alarmed About Medicare Open Enrollment Tool
House Committee on Energy and Commerce Leaders Frank Pallone, Jr. (D-NJ) and Greg Walden (R-OR), and House Committee on Ways and Means Leaders Richard Neal (D-MA) and Kevin Brady (R-TX) sent a letter to CMS Administrator Seema Verma expressing their concerns over the Medicare Plan Finder tool used during open enrollment. In the letter, the leaders respond to reports from users and Medicare counselors that the system is not providing accurate information to allow beneficiaries to choose a plan needed to cover prescriptions and other services. They say it is critical for information to be up to date and easy to understand and for CMS to give beneficiaries the opportunity to re-enroll with a more appropriate plan. To read the letter, click here.

Demand Grows for Telehealth in Rural Communities
Agricultural communities have a strong need for more telehealth, especially for mental and behavioral health services, as suicidal rates in rural communities grow larger than in urban ones, according to a new report.  Large metro areas had a suicide rate of 11.9 compared with 17.3 in rural areas. With rural hospital closures, telemedicine becomes critical.  States are starting to step in to to provide stress assistance programs. NY FarmNet, a Cornell University program that helps farmers in New York will be holding a webinar to help families and workers with a multitude of challenges including substance use, stress and conflict management, and family/relationship issues. Click here for the Pew study, and here for the webinar information.

Vaping-Related Deaths Rise to 52
U.S. health officials said last week four more deaths occurred from a mysterious respiratory illness tied to vaping, taking the total toll to 52. The Centers for Disease Control and Prevention (CDC) also reported 118 more hospitalized cases from 50 states, the District of Columbia, and two U.S. territories, as of Dec. 10. The number of people hospitalized now stands at 2,409. The median age of deceased patients was 52 years and ages ranged from 17 to 75. More cases continue to be investigated. Click here to the CDC’s updates.

Medicaid Expansion Could Reduce Maternal Mortality: CDC
Three out of five maternal deaths that occur during pregnancy, childbirth, and up to 12 months after delivery could be prevented with proper medical attention, according to the CDC. Throughout the U.S., drug overdoses, suicides, and pregnancy-related chronic diseases, such as heart disease, continue to rise. Half of all births are paid for by Medicaid, which expires 60 days after childbirth, causing many women to be uninsured during a particularly vulnerable time. Policymakers in California, Illinois, Missouri, New Jersey, South Carolina and Tennessee are trying to change this policy by extending Medicaid coverage to a full year after childbirth, in order to improve maternal health outcomes. Click here to read more.

CVS Plans to Increase Genetic Testing for Some Aetna Cancer Patients
CVS Health Corp. said they are planning to aid patients with advanced cancer, who enrolled in at-risk Aetna insurance plans, would receive broad genetic gene sequencing tests that would help identify the drug or treatment that would be best. CVS has been operating a pilot oncology program in 12 states, where patients prescribed treatment regimens that follow National Comprehensive Cancer Network guidelines automatically receive prior authorization approval, expediting the time to starting their treatment. The program has improved care, decreased hospitalizations and chemotherapy treatments, which has saved money and lessened the burden of side effects. For more from CVS, click here.

• Early success has been reported with a new myeloma CAR T-Cell therapy.  A small group of 29 demonstrated a 100 percent response rate to dual-target JNJ-4528 CAR T-cell therapy, according to a new study, click here.

Letter from IRS Saved Lives
In 2016, the I.R.S. sent letters to 3.9 million Americans stating that they had paid a fine for not having health insurance and included ways to enroll in coverage. A new paper from three Treasury Department economists says that these letters increased health insurance enrollment, which in-turn reduced premature deaths. According to the paper, Americans between the ages of 45 and 64 benefited the most with one fewer death for every 1,648 people than those who did not receive a letter. They claim the I.R.S.’s actions may have saved 700 lives. To read the paper, click here.

Google Shares Top 10 Searched Health Questions of 2019
Google shared its most popular health searches in the United States in 2019. The top three questions: How to lower blood pressure? What is keto? and How to get rid of hiccups? Additional questions asked about the flu, kidney stones, diet, human papilloma virus (HPV), and lowering cholesterol. Click here for the Google’s “Year in Search.”

Study: More People Dying at Home Than in the Hospital
According to a study published in the New England Journal of Medicine, 29.8% of deaths by natural causes occurred in the hospital while 30.7% occurred at home in 2017. This is the first time in more than 50 years that the percentage of deaths occurring at home has been higher than in the hospital. Researchers expect this trend to continue with the gap between hospital and home increasing with more home care options and hospice being available. Click here to read the study.

Health Care Data Breaches Affected Over Half a Million Patients in November
29 health care system data breaches, affecting 570,565 patients, were reported to HHS’ Office for Civil Rights in November. This is the second lowest number of affected patients in 2019 with October being the lowest. The majority of the breaches were a targeted hacking of the systems. The two largest breaches in November occurred due to an e-mail phishing scam sent to employees. To read more, click here.

LGBTQ Groups Raise Concerns Over Inaccurate Ads About HIV PrEP on Facebook
More than 50 public health, HIV, and LGBTQ organizations are sounding the alarm in an open letter stating that Facebook needs to remove false advertisements that suggest Truvada has negative health effects. The organizations claim that the ads are targeting LGBTQ users and are “causing significant harm to public health.” The ads were bought by law firms looking to recruit LGBTQ men for a class-action lawsuit against the pharmaceutical company that produces Truvada. New York Governor Andrew Cuomo and Senator Elizabeth Warren have both urged Facebook to remove the ads. To read more, click here.