DCMedical News: Wednesday, November 3, 2021
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
THE BIG STORY Wednesday, November 3, 2021
Drug Price Negotiation: Is There a Deal?
The Hill reports late Tuesday that “Today’s Big Deal: Democrats may actually be able to get their massive economic bill together.”
The White House distributed Tuesday what it referred to as its drug price control “plan” (here), a 1.25 page news release. CQ report additional detail (here): the “Agreement would allow Medicare to negotiate with manufacturers on a limited number of drugs in the Part B outpatient and Part D retail drug programs. Medicare could negotiate prices for small-molecule drugs nine years after they come onto the market and for biologics 12 years after they enter the market. The program would negotiate prices for 10 drugs beginning in 2023, with those prices taking effect during the 2025 plan year. That number would increase up to 20 drugs per year, the White House said.”
CQ added, “The drug industry called the plan disastrous. Under the guise of ‘negotiation,’ it gives the government the power to dictate how much a medicine is worth and leaves many patients facing a future with less access to medicines and fewer new treatments," said Stephen J. Ubl, president and CEO of the Pharmaceutical Research and Manufacturers of America, in a statement. "While we’re pleased to see changes to Medicare that cap what seniors pay out of pocket for prescription drugs, the proposal lets insurers and middlemen like pharmacy benefit managers off the hook when it comes to lowering costs for patients."
CQ adds, “The pharmaceutical industry has lobbied hard to kill provisions allowing Medicare to directly negotiate drug prices, warning of a chilling effect on new drug development. The Association for Accessible Medicines, which represents generic drugmakers, released a sharp response to a drug pricing framework circulating on K Street Monday evening. ‘Patient access to more affordable generic and biosimilar medicines would be threatened under the policies currently under consideration in Congress,’ President and CEO Dan Leonard said in a statement. ‘Competition from lower-cost generics and biosimilars has successfully led to decades of savings for patients. Continued access and savings to more affordable medicines would be jeopardized should these policies advance.’”
DOCTORS, NURSES AND OTHER HEALTH CARE PROFESSIONALS
2022 Physician Fee Schedule Final Rule Published
The rule (2414 pages, here), released today, will be published in the November 19 Federal Register. It has disappointing news for physician specialists targeted for or caught in policy changes leading to declining payments. Medicare payments to cardiologists, radiation oncologists, interventional radiologists, vascular surgeons and other specialty providers will decline, as a temporary 3.75% payment hike in 2021 will expire next year. In the final rule, the multiplier or conversion factor used to calculate physician payment in “traditional” Medicare goes from $34.89 in 2021 down to $33.59 in 2022.
At the same time, some increases will be made, for diagnostic testing facilities, portable x-ray, podiatry, hand surgery, and geriatrics. The public health emergency rules for telehealth will be extended to the end of 2023, delays by three years the measurement of “quality” by “accountable care” organizations, and for the first time in nearly 20 years, CMS will update (over a four year period) the clinical labor rates used to determine practice expenses under the fee schedule. CMS reports that “As a result, payments to primary care specialists that involve more clinical labor, such as family practice, geriatrics, and internal medicine specialties, are expected to increase.”
Bloomberg Health and Law reported (here) that “The Surgical Care Coalition, which encompasses 13 surgical professional associations and more than 150,000 surgeons, said it will continue to seek congressional action to avoid these and other potential cuts in Medicare reimbursements. ‘Despite hospital overcrowding, a health professional shortage, a backlog of some 5 million surgical cases and a fragile recovery from COVID-19, CMS chose to finalize policies that will further jeopardize patient access to surgical care,’ John H. Calhoon, first vice president of the Society of Thoracic Surgeons, said in a statement.”
Bloomberg reported that “In addition to the 3.75% cut, a moratorium on the 2% Medicare sequestration pay cut expires at the end of the year, unless Congress takes action to extend it. Additional Medicare payment cuts of up to 4% are also possible next year after the massive American Rescue Plan increased the federal budget, which triggered mandatory cuts under the Pay-As-You-Go Act of 2010. Congressional action is needed to waive the PAYGO cuts, as well. Together, the potential PAYGO and sequestration cuts—along with the 3.75% pay cut—could total 9.75%, according to the surgical coalition.”
Governors Pitched to Extend Telehealth Licensure Flexibility
250 health and mental health organizations sent a letter (here) to State Governors, imploring them to extend pandemic-era flexibility in cross-state telehealth and licensure of professionals. They wrote, “Expanded access to telehealth during the COVID-19 pandemic has shone a light on its ability to fill gaps in patient access to care. During the public health emergency, governors across the country used emergency authority to waive some aspect(s) of state licensure requirements to facilitate greater patient access to care. Doing so allowed licensed medical professionals more flexibility to treat patients in other states when there were pressing needs or specialized expertise not available where they lived.”
Racial Disparities Narrow in Thrombolytic Treatment of Stroke
A research letter in JAMA (here) reports that “Racial and ethnic disparities in IV [intravenous] thrombolysis use after stroke improved between 2009 and 2018, with the gap with White individuals narrowing for Black individuals and disappearing for Hispanic individuals. Potential reasons may include effectiveness of efforts to reduce stroke disparities and the increasing organization of stroke care.”
HOSPITALS AND OTHER HEALTH CARE FACILITIES
OPPS Rule Published for Calendar Year 2022
CMS published (here, CMS “fact sheet” here) a final rule for the Medicare program’s Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems. The document will be published in the Federal Register November 16, and is effective January 1, 2022. Medicare payments to hospitals for outpatient services will see a 2.0% increase in payment rate for 2022, not the 2.3% originally proposed in July, or the 2.7% “market basket” of price increases, reduced, however, by CMS’ “productivity adjustment.” The final rule for hospital outpatient services also increases fines for hospitals that don’t comply with a transparency rule requiring them to publish standard charges for health items and services, widely ignored or subverted by hospitals. Medicare payment rates to ambulatory surgery centers (ASCs) will also increase 2%, so long as they meet “applicable quality reporting requirements.”
Another policy change in the final rule delivers a blow both to ASCs and hospitals: to the disappointment of ASCs, CMS is reversing its decision (last year!) to remove hundreds of procedures from the “inpatient only list” (IPO), sending them from hospitals (where they are profitable for hospitals) to the ASCs (where they would be profitable for the ASCs), but now back to the hospitals. “CMS is finalizing its proposal to halt the elimination of the IPO list and add back to the IPO list the services removed in 2021, except for CPT codes 22630 (Lumbar spine fusion), 23472 (Reconstruct shoulder joint), 27702 (Reconstruct ankle joint) and their corresponding anesthesia codes. This change in policy promotes transparency . . ." For hospitals, the return of these procedures will be accompanied by the resurrection of the two-midnight rule, supposed “protection” against reimbursement gaming of short stays.
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
Four Senators Introduce ASCA Bill, Quality, Access, etc., and Higher Payment
The bill (announcement here) promotes the work of the Ambulatory Surgery Center Association in attempting to “close the Medicare reimbursement gap for identical services between hospital outpatient departments and ASCs.” The sponsors extol the virtues of ASCs, as lower cost providers, but the bill aims at “ensuring ASCs receive fair Medicare reimbursement rates,” not by lowering hospital rates, but by raising ASC rates to the hospital level.
READINGS & REFERENCES
Select Coronavirus Public Health Resources and References may be found here.
2021 CQ Congressional Calendar here.
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
November 4, 5, 15, 16, 17, 18, 30
December 1, 2, 3, 6, 7, 8, 9, 10
Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org