07 Jan January 7, 2019

House Votes to Join Legal Defense of ACA; Committee Plans Hearing on Judge’s Decision 
In one of the first votes after taking over the House, Democrat leaders pushed through a measure to allow the chamber to defend the Affordable Care Act in court by joining the appeal of the federal lawsuit that found the ACA unconstitutional. As part of a large, sweeping rule package approved on the first day of the new Congress, the largely symbolic measure which most likely will not impact the outcome, is an act that leaders say keeps a campaign promise to protect people with pre-existing conditions. A separate standalone bill on the lawsuit is expected this week. Additionally, the House Energy and Commerce Committee announced a hearing to examine the impact of the Judge’s decision striking down the law. Click here to read the rules package, and here to view the hearing announcement.

Hospitals’ Posting of Prices May Be Adding To Confusion
As of Jan. 1, in the name of transparency, the Trump administration required that all hospitals post their list prices online. But what is popping up on medical center websites is a variety of medical codes, abbreviations and dollar signs — in little discernible order — that may initially serve to confuse more than illuminate. That’s because the price lists displayed this week, called chargemasters, are massive compendiums of the prices set by each hospital for every service or drug a patient might encounter. To figure out what, for example, a trip to the emergency room might cost, a patient would have to locate and piece together the price for each component of their visit — the particular blood tests, the particular medicines dispensed, the facility fee and the physician’s charge, and more. Click here for more.

CMS Mandatory Joint Replacement Bundles Saved Some Money
A two-year review of CMS’ Comprehensive Care for Joint Replacement model by researchers at Harvard, Brigham and Women’s Hospital, and Washington University shows that there is modest savings from the bundles. The authors say that over two-years the program saved about 3-percent per procedure mainly from a reduction in spending at nursing homes and inpatient rehabilitation. Additionally, the researchers state that there was no increase in complications during the time period that led to no true increase in costs. However, the study notes that the success of the mandatory bundled payment model – when applied to other therapeutic areas – has been inconsistent. To read the review published in the New England Journal of Medicine, click here.

Insurers Kept $9.1 Billion in Medicare Dollars Over Decade: WSJ
According to a Wall Street Journal investigation, private insurance companies kept $9.1 billion more in taxpayer funds than they would have if estimates for providing prescription-drug benefits to Medicare beneficiaries had been accurate from 2006 to 2015. Citing Medicare data, the WSJ states that due to arcane payment rules that the incorrect estimates have led to more revenue for health insurers. Part D providers submit bids, or estimates, on how much it will cost them to provide drug benefits, CMS then uses these bids to determine monthly payments to each of the plans. However, if the insurer overestimates the actual costs, they can keep some of the extra funds it received leading often times to profits. For example, in 2015, insurers overestimated costs by about $2.2 billion and kept about $1.06 billion of it after paying back $1.1 billion to CMS. Providers such as CVS Health, UnitedHealth Group, and Humana, among others, who benefited state that this is largely due to “unpredictable drug pricing.” To read the full WSJ article, click here.

The Effort To Keep Physician Referrals within a Health System
A new analysis looks at the process that physicians utilize within hospital systems to keep patients within their system and not be referred to outside competing providers. Using various reports, the Wall Street Journal pieced together the reasoning behind the efforts to refer to providers within and the array of strategies to encourage “keepage” within hospital systems leading to higher costs for payors and patients, according to the article. This notion is backed up by a 2016 survey of hospital executives found 55% were actively managing, or planning to manage, referrals to keep them inside their systems. Click here for the WSJ article.

Depending on the State, Same Drug Could Be $20 or $130
By looking at prices across Medicaid plans in different states, Bloomberg has found that drug costs can vary greatly – as much as $100 or more between prices. The analysis looked at 90 widely-used generic drugs in 31 Medicaid drug plans and found that in some states the prices are very reasonable while others pay markups of threefold or more on some treatments. According to Bloomberg, a major issue causing the discrepancies is “spread pricing,” where a contractual arrangement allows PBMs to pay pharmacies one price for a generic drug while charging higher prices to their health plan customers. Click here to read the full article.

After Failed Lobbying Efforts PhRMA Stands to Lose $12 Billion Over the Next Decade 
As 2018 ended, PhRMA – the lobbying arm of the pharmaceutical industry – failed in its efforts to overturn a policy that will cost the industry as much as $12 billion over the next few years. For the first time in years, PhRMA finds itself on the losing end of its lobbying efforts despite the potentially record-breaking sums it spent on lobbying and tremendous track record for having legislation go its way. STAT recently investigated the story behind the failure of the once thought “untouchable and unstoppable” lobby, click here.

Final Snapshot of ACA Open Enrollment Down 3.4-Percent Overall
A robust economy and Medicaid expansion in Virginia are the reasons that CMS says there was a 3.4-percent decrease in enrollees this year from last year – down to 8.4 million people from 8.7 million. CMS attributed the more than 2 million jobs added in the last year to the economy and Virginia adding 100,000 eligible for Medicaid in the state as the main drivers behind the drop in people enrolling through the ACA exchanges. The outreach efforts to encourage sign-ups included over 700 million reminder emails and text messages to consumers, as well as 3.2 million outreach emails to help navigators, agents, and brokers assist consumers; however, Congressional democrats say severely underfunded marketing and outreach for the ACA contributed to the decline in enrollment. To view the CMS press release, click here, and for the snapshot, click here.

HHS Provides New Guidance for Physician Technical Advisory Committee
In response to concerns expressed by the members of the Physician-Focused Payment Model Technical Advisory Committee that none of the models that they had recommended to CMS had been tested or implemented, HHS released a new fact sheet containing guidance for PTAC. The guidance outlines for PTAC the priorities that CMS’ innovation center stating that they are most interested in “proposed payment models focused on local delivery of health care, where patients and providers determine the best care plan, and providers are accountable for patients’ outcomes.” Click here to view the guidance document.

There is No Such Thing as Too Much Screentime for Kids
According to Royal College of Paediatrics and Child Health in the UK, there is little evidence that screen time is in itself harmful to a child’s health and it is impossible to recommend age appropriate time limits. The guidance suggests that parents approach screen time based on the child’s developmental age, the individual need and value the family place on positive activities such as socializing, exercise and sleep – when screen time displaces these activities, the evidence suggests there is a risk to child wellbeing. The new guidance has however advised against children using devices an hour before bedtime because of evidence that this can disrupt sleep. To view the guidance, click here.