September 11, 2017



Hospitals Involved in Congressional 340B Probe; Comments on CMS’ 340B Rule Due Today 15 hospitals and health systems have been asked to submit detailed information on their 340B programs as part of the House Energy & Commerce Committee’s review of the government mandated drug discount program. The committee, which has jurisdiction over the program, sent letters to the health systems and four FQHCs last week. Click here to read the letters to each organization. Click here for the committee’s announcement.  In July, CMS proposed to pay separately-payable, non-pass-through drugs (other than vaccines) purchased through the 340B program at the average sales price minus 22.5%, rather than ASP plus 6%, starting in January. Comment letters to CMS are due by midnight EDT today (Monday, September 11).  CMS’ 340B proposal is contained in the CY18 Hospital Outpatient PPS rule. Click here to see the rule and see all the comment letters submitted thus far.


Anthem Cuts Hospital Outpatient Payments for MRIs, CTs, Following CMS’ Site-Neutral Lead

CMS’ ongoing move to a ‘site-neutral’ payment policy is having reverberations in the commercial insurance market. Anthem has added five states (NY, OH, CO, NV and GA) where it won’t pay hospitals for MRIs and CT scans performed on an outpatient basis.  This policy took effect September 1 for those states.  It was already in effect, since July 1, in IN, KY, MO, WI.  Imaging services can be just as safely provided in a lower cost, free-standing center as in a hospital outpatient setting, according to Anthem. Anthem’s policy follows a move in July by CMS to make hospital outpatient payments more site neutral.  Click here for more.  Click here for a detailed Q&A from Anthem.


Senate Moving Forward on Bipartisan ACA Marketplace Fixes

The chairman of the Senate health committee hopes the panel would reach a consensus within days on a small, bipartisan bill to stabilize health insurance markets and prevent prices from skyrocketing next year under the Affordable Care Act.  Senator Lamar Alexander (R-TN) laid out elements of a possible compromise at a hearing last week: Republicans would agree to continued payment of subsidies to insurance companies to compensate them for reducing deductibles and other out-of-pocket costs for low-income people. Democrats would agree to give states freedom to relax some insurance requirements in the Affordable Care Act.  Click here for the NYTimes story.  Click here for the testimony from governors from five states.  Click here for the testimony from insurance commissioners from five states. Testimony continues this week.  Click here for details.

  • Senators are also expressing interest in reigning in health care costs.  Click here.
  • The Senate Finance Committee holds a hearing this week on issues impacting health care costs.  Click here.

GOP Senators Propose New Obamacare Repeal and Replace Bill

A new Obamacare repeal and replace bill proposed by two GOP senators would set aside $1.2 trillion in state block grants by 2026 and create two formulas to determine funding, according to details released last week.  Forthcoming legislation from Lindsey Graham (R-SC) and Bill Cassidy (R-LA) would replace Obamacare funding for Medicaid expansion and private insurance subsidies with block grants. The Washington Post has an excellent summary comparing this proposed bill with the ACA and the legislation that failed in the senate two months ago. Click here.
Senate Has 20 Days Left for Special Obamacare Repeal and Replace Process

The Senate parliamentarian has determined that rules governing the effort will expire when the fiscal year ends Sept. 30. The rules allow Republicans to dismantle the Obama health care law with just 51 votes, avoiding a filibuster. Republicans control the Senate 52-48 and were using the special filibuster-proof process in the face of unified Democratic opposition. Now, if Republicans can’t revive the repeal measure in the next three weeks, they will be forced to work with Democrats to change it. Click here and here for more.


Bipartisan Senators Want National Commission Appointed To Fix Health Care

U.S. Senators Sherrod Brown (D-OH) and Bill Cassidy (R-LA) last week sent a joint letter to HHS Secretary Tom Price urging that he form a national commission to fix health care.  The senators said a national group of experts should be appointed to the commission, which would work with Price and a bipartisan group of lawmakers.  The letter notes that the U.S. lags behind on effectiveness of healthcare – spending more money treating disease than preventing it.  Click here for the letter.  Click here for their press release.


Access to Obstetric Services Declining in Rural Areas A new analysis has found that closures of rural obstetric units and rural hospitals has exacerbated concerns for access to care for the more than twenty-eight million women living in rural America. The report found that 9 percent of rural counties experience the loss of all hospital obstetric services between 2004 and 2014. The loss of obstetric care in rural counties helps signify the unique challenges rural Americans face with access to health care. To read the full report, click here for details.  The new CAH Coalition is working with Critical Access Hospitals across the nation to develop national health policies supporting CAH issues.  Click here for details.


MedPAC Exploring Ways to Expand Telehealth

The Medicare Payment Advisory Commission (MedPAC) last week began exploring ways in which the federal health program could expand its coverage of a variety of telehealth services. Medicare currently covers certain services like mental health treatment and kidney disease under its traditional fee-for-service program, but offers additional flexibility to MA plans and doctors involved in payment demonstrations. Just 108,000 of Part B fee-for-service outpatient beneficiaries, or 0.3 percent, used telehealth in 2016. However, usage is on the rise — visits per 1,000 beneficiaries jumped 79 percent between 2014 and 2016. Click here for MedPAC’s slide presentation.


Hospitals Grapple with Managing Super-Utilizer Patients

Fifty-one-year-old Roy Bellamy was in and out of the emergency department more than 89 times in 2014, amassing upward of $330,000 in hospital charges. His costly pattern led him to Tracey Smith, DNP, and the team of hotspotters, a multidisciplinary group dedicated to identifying and helping hospital super-utilizers. According to the Association of American Medical Colleges, super-utilizers represent one percent of patients, yet account for up to 30 percent of health care costs. Despite the best efforts patients are getting missed. Click here for the story.  One group with a successful solution to helping manage the care of patients across an entire community is CivicHealth.  Click here to see more and schedule an educational webinar.


MedPAC May Propose Allowing Hospitals to Recommend Specific PAC Providers

MedPAC commissioners are considering a number of options that would encourage hospitals to discharge patients to higher quality post acute care providers.  At MedPAC’s meeting last week, staff reviewed the issues surrounding discharges to post acute providers and how hospitals could help assure that patients needing PAC could be referred to higher quality providers.  Hospitals are currently prohibited from making specific PAC facility recommendations. MedPAC commissioners are also considering a proposal that would require hospitals to give PAC quality information to their patients prior to discharge.  Click here for MedPAC’s slide presentation.


MedPAC Finds No Concerns with Waiving Direct Supervision Requirements for CAHs

Since 2010, CMS has not enforced its direct supervision requirements in Critical Access Hospitals and other rural hospitals, according to an analysis released last week by MedPAC.  CMS says there have been no patient safety concerns raised to the agency about hospitals using inappropriate physician supervision, although MedPAC notes that the only way to monitor this would be through a “whistle-blower.” MedPAC made several recommendations to CMS about further clarifying the definition of “immediately available” and “interruptible” related to current supervision requirement.  Click here for the MedPAC slide presentation.  The CAH Coalition is working to have this requirement removed rather than simply postponed each year.  Click here for more on the CAH Coalition.


CMS Wants Input on Hospital Star Rating Program

CMS is seeking input from stakeholders and others on its hospital star rating program.  Comments are due by September 27.  CMS wants comments on the methodology under re-evaluation for the Overall Star Rating. CMS wants comments regarding the approaches to calculating hospital summary scores and translating summary scores to star ratings. The move came after CMS last summer released the overall hospital star ratings on the Hospital Compare site, emphasizing consumer groups’ desire for the information and outreach to hospitals. Hospitals were upset with the methodology when the ratings came out. CMS had previously delayed publishing the ratings due to concerns from hospitals and lawmakers. Click here for CMS’ latest report on the star ratings program released last week and instructions for submitting comments.


Uninsured Rate Up in 2017: Survey

The uninsured rate is up for some Americans in 2017, according to a new Commonwealth Fund survey.  The situation seems to be worse for three groups: — Those living in states that have not expanded Medicaid: 19 percent are uninsured, up from 16 percent last year. — Adults ages 35 to 49: 15 percent are uninsured, up from 11 percent last year. — People earning more than 400 percent of the federal poverty level: 5 percent are uninsured, up from 2 percent last year.  Click here for the report.
Pharma Company Uses Tribe To Protect Drug Patent

The drugmaker Allergan announced late last week that it had transferred its patents on a best-selling eye drug, Restatis, to the Saint Regis Mohawk Tribe in upstate New York — an unusual gambit to protect the drug from a patent dispute.

Under the deal, Allergan will pay the tribe $13.75 million. In exchange, the tribe will claim sovereign immunity as grounds to dismiss a patent challenge through a unit of the United States Patent and Trademark Office. The tribe will lease the patents back to Allergan, and will receive $15 million in annual royalties as long as the patents remain valid. Click here for the story.

  • Another big pharma company is using a different elaborate strategy to protect its patents.  Click here for the report.

Report: Drug Company Engaged in Techniques To Boost Opioid Prescriptions

A report from Senator Claire McCaskill (D-MO) says that Insys Therapeutics Inc. engaged in “aggressive and likely illegal techniques” to boost prescriptions of a highly addictive opioid drug to patients. The report is the first in an investigation led by McCaskill in her role as the ranking Democrat on the Senate’s Homeland Security and Governmental Affairs Committee. Click here for the report.

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