DCMedical News: Tuesday, April 2, 2019
DCMedical News-DCMN
Washington, D.C.
Tuesday, April 2, 2019
DCMedical News is published every day both the House and the Senate are in session. Subscription information below.
THE BIG STORY IN HEALTH CARE
Life Without PPACA:
Stakeholders are considering the implications of any court decision to eliminate the Patient Protection and Affordable Care Act. A Kaiser Family Foundation summary of implications, here. The Hill reports that “Two Republican state attorneys general want a federal appeals court to overturn the ruling from a Texas judge that declared the entire Affordable Care Act unconstitutional. In a brief filed Monday with the 5th Circuit Court of Appeals, the attorneys general of Montana and Ohio argued that District Judge Reed O’Connor overstepped his authority in his original ruling.” The Small Business Majority Foundation files a brief (here) in support of Texas and allied states suing to overturn PPACA.
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
Prior Authorization Victory for Physicians in Kentucky:
A report from the AMA (here) details a new law in Kentucky protecting physicians and their patients from “prior authorization” (PA) roadblocks from health plans. The Governor signed the bill March 26 after it passed the Kentucky House by a vote of 97-1 and the Kentucky Senate by a vote of 37-0.
No more faxes: the Kentucky law, effective January 1, 2020, mandates that “Physicians will receive responses on PA requests within 24 hours for urgent services and within five days for nonurgent services; Prescriptions for chronic-condition maintenance drugs will be valid for one year, and any change in dosage during this period will be covered. Insurers’ PA procedures will be posted online as well as a complete list of services requiring PA. Insurer PA reviewers will be licensed physicians and, when possible, of the same specialty as the requesting physician. Physicians and other clinicians will be able to electronically request and transmit PAs.” In this “all transparent electronic” approval process, “facsimile, proprietary payer portals, and electronic forms shall not be considered electronic transmission.”
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
Insurers Become Increasingly Dependent on Government Programs:
A feature in Modern Healthcare (story here, infographic here) notes that “The latest data from ratings agency A.M. Best published in August 2018 showed that U.S. health insurers' Medicaid premiums grew to $224 billion in 2017 – or 27% of total industry net premiums written – from $43.1 billion in 2007, or 10.2%. Medicare premiums grew to $202.7 billion in 2017, or 24.2% of total industry net premiums written, compared with $69.9 billion, or 16.6%. Advantage membership totaled 22.4 million as of January, an increase of nearly 7% in a year.” For Blue Cross plans nationally, such as Anthem, the same trend applies: “Its operating revenue from government health programs exceeded that of its commercial and specialty business for the first time in 2015 and has ever since, thanks to its growing Medicare membership. Aetna has experienced a similar shift, collecting more premiums from government programs than commercial customers for the first time in 2017. UnitedHealth Group, meanwhile, has long captured more revenue from public programs but is growing even more dependent on government revenue. According to A.M. Best, 58.2% of UnitedHealthcare's business mix was composed of government-sponsored programs, up from 47.2% in 2013.”
Basic Health Program Rules Published:
Rules for 2019 and 2020 for the optional Basic Health Program (BHP) will be published (here) in today’s Federal Register. Section 1331 of the Patient Protection and Affordable Care Act provides states with an option to establish a Basic Health Program (BHP). According to the proposed rule, “In the states that elect to operate a BHP, the BHP will make affordable health benefits coverage available for individuals under age 65 with household incomes between 133 percent and 200 percent of the federal poverty level (FPL).” By way of background, the proposed rule notes that “States may find a BHP a useful option for several reasons, including the ability to potentially coordinate standard health plans in the BHP with their Medicaid managed care plans, or to potentially reduce the costs to individuals by lowering premiums or cost-sharing requirements.” Funds available for the program are calculated “based on the amount of premium tax credit (PTC) and cost-sharing reductions (CSRs) that would have been provided for the fiscal year to eligible individuals enrolled in BHP standard health plans in the state if such eligible individuals were allowed to enroll in a qualified health plan (QHP) through Affordable Insurance Exchanges. These funds are paid to trusts established by the states and dedicated to the BHP, and the states then administer the payments to standard health plans within the BHP.”
DRUGS & DEVICES
Insulin Prices in the Spotlight:
The House Energy and Commerce Oversight Subcommittee’s first hearing on insulin costs is today, featuring physicians, patients and their advocates, with a second hearing planned for manufacturers. Subcommittee Chair Rep. DeGette, whose daughter has Type 1 diabetes, and who is co-chair of the Congressional Diabetes Caucus, has said that while other committees have also taken up drug pricing, her subcommittee's approach will be different because of its focus on one commonly used drug. In Massachusetts, the Health Policy Commission, chaired by former White House adviser Stuart Altman (Nixon) will focus on the 50% rise in insulin costs over the past three years, to an average cost of $4,684 per patient in 2016. An HPC study shows that out-of-pocket (consumer) spending for insulin was 27% of the total, compared to all non-insulin prescriptions (26%), outpatient care (13%) and inpatient care (7%).
READINGS AND REFERENCES
A Commonwealth essay on the potentials future(s) of pharmacy benefit management companies, here.
“Choosing Wisely” goes international, here.
U.S. House of Representatives:
Members at https://www.house.gov/representatives, Committees and Members at https://www.house.gov/committees.
U. S. Senate:
Members at https://www.senate.gov/general/contact_information/senators_cfm.cfm, Committees and Members at https://www.senate.gov/committees/membership_assignments.htm.
House and Senate 2019 Calendar of Regularly Scheduled Sessions, here.
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
April publication dates: 3, 4, 9, 10, 11, 12, 29, 30
May publication dates: 1, 2, 7, 8, 9, 10, 14 15, 16, 17, 20, 21, 22, 23
Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com.