DCMedical News: Friday, February 9, 2018
DCMedical News
Washington, D.C.
Friday, February 9, 2018
To our new readers: This is an independent newsletter, published every day that one or another House of Congress is in session. Subscription information will be found at the bottom of these pages.
THE BIG STORY TODAY IN HEALTH CARE
Last minute challenges to the “stop-gap” spending and “increased” spending bill(s) focused on the amount of spending, the resulting projected growth in the national debt, and the fate of immigration legislation:
The once and future measure (combined spending continuation, spending authorization and related and unrelated measures being considered together are referred to below as the “Budget bill”) would keep the government operating through March 23. The text of the House passed 515-page bill is here. The text of the Senate 652-page bill is here.
Between passage and March 23 the appropriations committees would write twelve Fiscal Year 2018 spending bills within the higher levels allowed under this Budget bill. These appropriations measures would then carry federal spending through September 30, the end of FY 2018.
The higher spending is estimated at a $320 billion increase over existing Fiscal Years 2018 and 2019 levels (Congressional Budget Office total estimate here). In the health field, the largest cost is $7.8 billion for two-year renewal of funding for the Community Health Centers (up from last year’s $3.6 billion) and $6.4 billion for repeal of the Medicare payment cap for speech, occupational and therapy services. Also of major importance is deferral of $5 billion over the two fiscal years for Disproportionate Share Hospital (DSH) funds. Other important measures (a total of 44 health-related measures are in the House bill, see DCMN of 2-7) include funding for the Teaching Health Centers and the National health Service Corps, and more money for NIH.
Last minute objections focused on the size of the spending increases, and on the lack of definitive action concerning immigration and especially the Deferred Action for Childhood Arrivals program (DACA). On spending, the Committee for a Responsible Federal Budget noted that the Budget bill could possibly add $2 trillion to the debt, bringing the total debt to 105% of the Gross Domestic Product.
(Also not included in the Budget bill are any measures to stabilize the individual health insurance market through reinsurance, or to provide for restoration of the health Cost-Sharing Reduction payments.)
A summary of health items in the Senate bill is found here. Projected increased expenditures on these health field items are found here.
The net total $320 billion increase includes an estimated $100 billion offset, that is, “takeaways” from existing authorized expenditures. The most important “takeaway” for the health field is the extension of the Medicare 2% sequestration for provider payments. Another major offset is the loss of $2.9 billion from the Prevention and Public Health Fund, a set of public health measures included in the Patient Protection and Affordable Care Act (PPACA).
Other offsets in the health field are $4 billion for “third party” Medicaid liability (under which Medicaid, like Medicare currently, becomes the last, not the first, payer); $3.5 billion reduction in home health care payment under the “market basket” adjustment for such services; and $475 million for restriction or elimination of Medicaid eligibility for lottery winners. Automatic sequestration (pursuant to the 2011 Budget Control Act) is otherwise eliminated for non-defense spending.
Other important items are also found in the bill, including (a) an increase in the federal borrowing limit estimated to last until March, 2019; (b) creation of two new Joint Select Congressional committees, one sought by unions on the solvency of multiemployer pension plans; (c) elimination of IPAB, the Independent Payment Advisory Board, a never-implemented part of the PPACA, derided by its opponents as “death panels.” Because IPAB was projected to save money, its elimination has a cost of $17 billion; (d) important increases in disaster-area (hurricane, fire) aid, including $4.9 billion in Medicaid funds for Puerto Rico; (e) $6 billion to fight opioid addiction; (f) a two-year extension of expired Community Health Centers funding and (g) a 10-year extension of Children's Health Insurance Plan funding (CHIP). Extension of CHIP authorization for six years was contained in the last Continuing Resolution, #4; this measure would add four more years.
DOCTORS
The AMA and other major medical societies were unsuccessful in removing “misvalued coding” from CMS’ agenda, see letter here, Budget bill section 2704.
HOSPITALS AND HEALTH CARE FACILITIES
The most important (largest dollar amount) measures in the Budget bill for hospitals are (a) Restoration of DSH (a temporary measure, as the $5 billion is added by way of additional reductions in distal years) and (b) continuation of Medicare sequestration, and its extension through FY 2027. (The mandatory sequester began with the Budget bill of 2011, and was originally scheduled to expire in 2021.)
HEALTH INSURANCE, MEDICARE, MEDICAID, COMMERCIAL
One theme emerging from the Tax bill and now from this Budget bill is the incremental dismantling of PPACA, including, to date, (a) loss of the individual mandate, (b) lack of premium stabilization, (c) elimination of Cost-Sharing Reducing payments, (c) elimination of IPAB and (d) use of the public health fund PPHF for budget offsets.
Notwithstanding, the National Academy of State Health Policy reported Wednesday that state-based PPACA marketplaces had modest increases in enrollment for 2018 coverage, while states using the federally-facilitated marketplaces (with shorter enrollment periods and a 90% decrease in advertising and outreach support) had a 5% plus decline.
PHARMA
In the Budget bill, pharma and associated astro-turf (faux citizen) groups were unsuccessful in fending off changes to pharmaceutical payments under Medicare Advantage and Medicare Part D programs. The most important of these was movement in the Senate bill from 2020 to 2019 of a requirement that pharmaceutical manufacturers absorb a larger portion of their cost for Part D beneficiaries who have reached the “donut hole,” that is, the gap in Medicare coverage requiring substantial out-of-pocket payments by the patients. The CEO of PhRMA called this a “massive bailout for insurance companies.”
A different subject: Where are we with opioids? The House Ways and Means Committee attended Tuesday to Medicare policy, and the potential for alterations in the policy which would address the opioid epidemic. The hearing was a testament to the role of Medicare as our national health policy (not merely the set of rules surrounding health services for the aged).
Witnesses, beginning with Vermont Governor Phil Scott (testimony here), focused on medication-assisted treatment, noting that in Vermont “we treat opioid addiction like we do any other chronic condition.” Jason Kletter, president of BayMark, testimony here, noted that Medicare would pay for pain medications, but not for opioid addiction treatment. Ramsin Banyamin, testimony here, speaking for pain management physicians, proposed the elimination of co-payments for non-opioid pain treatment, review of prescription drug monitoring programs, and compulsory education for physicians who prescribe opioids.
Harold Paz, M.D., Aetna’s chief medical officer, testimony here, noted that his company was focused on alternative pain treatments, physical and mental; limitation of opioid prescriptions; and removal of prior authorization for generic medication prescription. He proposed that Medicare Advantage and Part B Medicare programs allow limitations on prescription supplies.
EVENTS & MEETINGS
Your February & March Calendar:
February 13
12:30 to 5:00, the ONC and the ASPE present a webinar on “Blockchain in Healthcare,” agenda and registration page here.
February 14
9:00, various advisory committees for the Substance Abuse & Mental Health Services Administration (SAMHSA) continuing on the 15th, information @ https://www.samhsa.gov/about-us/advisory-councils/meetings, agenda here.
February 15
12:30 p.m., The Health Subcommittee of Energy and Commerce will hold a hearing entitled, “Oversight of the Department of Health and Human Services.”
February 21
11:00, at Medicare.gov, Physician Compare 90-minute webinar on PQRS.
March 1
MedPAC, Ronald Reagan Building, Horizon Ballroom, 1300 Pennsylvania Ave, continuing March 2.
March 1
MACPAC, advisory body on Medicaid and the Children’s Health Insurance Program, continuing March 2.
March 26
PTAC, Physician-Focused Payment Model Technical Advisory Committee, continuing March 27, information at www.regonline.com/PTACMeetingsRegistration or livestream at www.hhs.gov/live.
FOR REFERENCE
Members of the Senate (here) and Members of Senate Committees (here), Senate Calendar (here).
Members of the House with their House Committees (here), House Calendar (here).
DCMN: February publication dates: 12, 13, 14, 15, 16, 26, 27, 28.
Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com