July 15, 2019

House Subcommittee OKs Surprise Billing Package Favoring Insurers, Approves DSH Cut Delay
The House Energy and Commerce Health Subcommittee voted in favor of a controversial surprise billing bill that favors insurers over providers.  The panel also approved several bills that would extend various Medicare and Medicaid programs as well as a drug pricing transparency bill.  The Fair Drug Pricing Act  (HR 2296) would require certain drug manufacturers to disclose and justify price hikes to HHS. The surprise billing legislation would establish a payment benchmark set at the median in-network rate for services in a geographic area. Several members expressed concerns with the No Surprises Act (H.R. 3630), specifically its lack of an arbitration provision or other mechanisms to appeal the benchmark rate. The Full Committee plans to vote on the measures as early as this week. Click here to watch the markup session and view all the bills, and here for the Strategic Health Care surprise billing memo. The subcommittee also approved legislation to delay the Disproportionate Share Hospital payments cuts for 2020 and 2021 and to reduce the cuts in 2022 from $8 billion to $4 billion.

  • Physicians for Fair Coverage launched an advertising campaign to highlight its objections to the benchmarking approach, click here.

Senate Finance Chair Set to Roll-Out Drug Pricing Legislation
Sen. Chuck Grassley (R-IA), Chairman of the Senate Finance Committee, told reporters last week that he plans roll out a bi-partisan bill to lower drug prices that he is working on with the Ranking Member of the Committee, Sen. Ron Wyden (D-OR). A vote on the package in the committee could come as soon as next week or the week after, although lawmakers are still waiting for analysis from the Congressional Budget Office. Some Republicans have expressed concerns that the bill could be very close to creating price controls. For more on the proposal and the plans of the Committee, click here.

  • The Trump Administration dropped its plan to proceed with a proposal to curb industry rebates that drugmakers give to middlemen in Medicare, click here.
  • Federal District Judge Amit Mehta has ruled against a regulation that requires pharmaceutical manufacturers to include drug prices in their TV advertisements – saying HHS does not have the authority to compel manufacturers to disclose list prices, click here.

President Signs Executive Order on Kidney Health, Wants to Increase Home Dialysis and Transplants
President Trump has signed an Executive Order – Advancing American Kidney Health – aimed at transforming kidney care and increasing transplants. The policy is intended to improve kidney care in three major ways: by emphasizing more effective and convenient treatments; making more kidneys available for transplant; and improving preventive care and education with the goal of reducing the number of people who develop end-stage renal disease by 25% by 2030. Immediately following the signing of the EO, CMS released a proposed a rule containing a mandatory payment model as well as four optional payment models to adjust payment incentives to encourage preventative kidney care, home dialysis, and kidney transplants. Approximately twenty-percent of Medicare dollars  – $114 billion a year – are spent on 37 million patients who suffer from chronic kidney disease and more than 726,000 who have end-stage renal disease. Click here for the EO, here for the HHS statement, here for the proposed rule, and here for the payment models.

Judge Allows Administration to Appeal 340B Decision
On July 10th, the U.S. District Court for the District of Columbia granted the Trump Administration’s request to move forward with appeals for two earlier court rulings that found HHS had overstepped its authority in reducing drug payments to hospitals serving low-income patients. Hospitals sued HHS over cuts to Medicare payments for certain drugs covered by the government’s 340B drug pricing program by nearly 30 percent in its 2018 and 2019 outpatient payment rules. Under the previous rulings, the Judge required HHS to provide plans on how the agency will reimburse hospitals for the $1.6 billion in cuts, this ruling will allow the appeal to move forward without providing a remedy. To follow updates on the lawsuit, click here.
Medicare Seeing Some Success Against the Opioid Epidemic
A report recently released by the HHS Inspector General concluded that opioid prescriptions have decreased in Medicare Part D, while medication-assisted addiction and overdose prescriptions have increased from 2016 to 2018. The numbers of the beneficiaries considered at serious risk dropped 46 percent and the number of providers flagged for prescribing opioids to patients at serious risk dropped by 51 percent. For the full report click here.
  • The maker of the opioid treatment drug Suboxone to pay $1.4 billion in a settlement for an alleged illegal scheme that involved promoting Suboxone film to physicians, pharmacists and others as safer than other forms of the drug buprenorphine, click here.
CMS Delays Outpatient Claims-Processing Changes
CMS has delayed of full implementation of Medicare outpatient prospective payment system claims edits for services provided by departments of hospitals and health systems for three additional months. These edits target providers with off-campus, outpatient, provider-based departments looking to require these facilities to use the same provider address as their Medicare Provider address. The delay comes after push-back from stakeholders for CMS to further examine the round 3 testing. Click here for details from CMS.
States Are Struggling to Implement Medicaid Work Requirements
As many states are considering including Medicaid work requirements, most states that have received wavers from CMS have not been able to implement this policy. CMS has approved waivers to nine states, but only Indiana is actively implementing this policy as all other states are stuck in litigation. Conservatives argue that these policies promote self-sufficiency, while liberals believe these policies will only decrease coverage. Expect these policies to continue to spread and to continue to be litigated in each state that adopts them. Click here for an article detailing these issues.
  • Last week, CMS proposed to rescind 2015 requirements that the agency says impose administrative burdens on U.S. states “without meaningful impact to beneficiaries,” click here.
CMS Set To Increase, then Cut, Home Health Payments as Part of Overhaul
CMS has released the annual home health proposed payment rule with updates to the home health payments rates for calendar year 2020, a new home infusion therapy benefit, and payment and policy changes for home health agencies. CMS projects that Medicare payments to home health agencies in CY 2020 will increase in the aggregate by 1.3 percent or $250 million. The proposed rule also includes an 8 percent rate cut for the new home health pay model (set to go into effect in January), which CMS attributes to changes expected in home health agency behavior under the new system. Additionally, the new rule includes proposals that will establish a permanent home infusion therapy benefit for 2021 required by the 21st Century Cures Act. Click here for the Strategic Health Care memo that includes links.
  • Sens. Susan Collins (R-ME) and Debbie Stabenow (D-MI), along with Reps. Vern Buchanan (R-FL) and Terri Sewell (D-GA) sent letter earlier in the week to CMS to revisit provider cuts resulting from a new home health pay system, click here.
ACOs Have Been Slow to Embrace Downside Risk Contracts Over Upside-Only Risk Contracts
The number of ACOs taking on downside risk contracts has increased. but the proportion has increased very moderately according to a new study in Health Affairs. Like upside-only risk contracts, downside risk contracts reward providers for cost and quality. The downside risk contracts, however, also financially penalizes poor performance. This increase in risk has been seen to be more effective in improving ACO performance than the upside-only risk contracts. For the study, click here.
HHS OIG Slams Hospice for Insufficient and Unsafe Care
A report released by the Office of Inspector General for HHS criticizes Medicare for weak oversight and enforcement of standards of care for the growing hospice industry. The report details multiple examples of patients suffering from the poor care of different, unnamed hospice groups. CMS has claimed that this report includes a “selective sample” of specific cases, but the problem persists as CMS has no authority to impose fines on or to close any hospice facility. Click here for the report.
  • The examples include patients dying without adequate pain management, skipped home visits, and in one case a beneficiary was living with “maggots around the opening of his wound.” A Washington Post article details this report and these problems here.
Telehealth is Crucial for Rural Patients, But Many Do Not Have Access
Telehealth technology has increasingly helped rural patients avoid long travels and high costs to reach healthcare professionals. Over 50% of rural patients say that they have used some kind of telehealth over the past few years. However, according to a report from NPR, Medicare, Medicaid, and private insurance often does not cover this newer technology and over 20% of rural patients have problems with internet, access to telehealth is still limited. For the full NPR report, click here.
United Hospital Fund Releases Four-Point Framework To Address Social Determinants of Health
The United Hospital Fund released a four-point framework to help physicians to work with community partners to address social determinants of health through primary care physicians. First, practices must screen their patients and their communities for these social determinants of health using questions that are sensitive to their community and their patients’ cultures. Second, providers must select which Community Based Organizations they will refer their patients to. Two of the health centers that helped developed these guidelines decided to pick large, multi-service organizations for their patients. Third, providers must use appropriate and efficient referrals to ensure their patients receive all needed services to address their needs. Fourth, the community organizations must inform their providers about the outcomes of the referrals to ensure follow up and to ensure that records are kept of the social resources the patients are given. The framework also suggests some overall changes, such as expansion of the social service sector and better value-based payment models. For the entire framework click here.
HIV Preexposure Prophylaxis Use and Awareness Has Greatly Increased Among At-Risk Populations
According to a CDC analysis, use of a daily pill to prevent HIV infection is rising among high risk populations. From 2014-2017, the use of this pill that greatly reduces risk for acquiring HIV has increased from 6 percent to 35 percent in their study sample of at risk populations. Awareness of this treatment has also increased from 60 percent to 90 percent among this group. This amount will need to increase significantly to help reach the Trump administration’s goal of reducing new HIV infections by 90 percent over the next decade. Click here for the CDC analysis.
Doctors Don’t Receive Significantly Better or Higher Value Care Than Non-Doctors
A new study has concluded that doctors are able to adhere to both low and high-value care guidelines only slightly better than non-doctors, and sometimes not at all. This finding is significant because it contradicts a wide-held belief that patients would be able to receive better-valued care simply by knowing all their options and having the medical background to make their own choices. If doctors, the group with the most medical knowledge, were not able to steer themselves toward higher value care, than how can consumers be considered knowledgeable enough to advocate for themselves? Click here for the study.
Psychiatric Diagnoses May Be “Scientifically Meaningless”
New research analyzed standard classifications of mental disorders, and found that these disorders may not have a scientific basis. Although they may provide explanations for those diagnosed, psychiatric diagnoses, such as schizophrenia, depression, and anxiety, may not be clinically helpful because there is no single standard for diagnosis. For the full study, click here.
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