DCMedical News: Friday, May 17, 2019
DCMedical News-DCMN
Washington, D.C.
Friday, May 17, 2019
DCMedical News is published every day both the House and the Senate are in session. Subscription information below.
Drug-PPACA Bill Passes the House
An amalgam of measures intended to (1) expedite approval paths for generic drugs and (2) bolster the workings of the Patient Protection and Affordable Care Act passed the House Thursday, 234-183. One part of the bill would void an Administration rule to expand the life-span of short-term limited duration health insurance (STLDI) plans. STLDIs do not have to provide the “Essential Health Benefits” required of all other plans under PPACA. Other provisions of the bill would authorize $100 million for the navigator program and also authorize the restoration of marketing and outreach funding for the exchanges. Another amendment approved during passage would prevent the Department of Health and Human Services from banning the practice of “silver-loading,” that is, allowing premium increases as financial substitutes or off-sets for the loss of Cost-Sharing Reduction funds.
HOSPITALS, NURSING HOMES AND OTHER HEALTH CARE FACILITIES
More Surprises in Solutions Proposed for Surprise Medical Billing
The Cassidy-Hassan bipartisan Senate push for a solution to surprise medical bills has produced a flyer (here), although not yet a detailed bill. The heart of the proposal is independent dispute resolution (IDR, arbitration) after the fact: “For any service where the surprise bill ban applies, providers will automatically be paid the median in-network rate. Should the provider or plan like to adjust this payment amount, they would have 30 days to initiate the independent dispute process.” But other features of the proposal are also certain to gain attention in the hospital field: “Each hospital shall disclose on its internet website and in printed materials, any financial relationship or profit-sharing agreement that the hospital has with a physician group.” Good news for health plans, if not enrollees, in this proposal: “Group health plans may include the costs of arbitration as part of medical care costs in their medical loss ratio calculations.” And possibly in really small type: “A health plan/issuer shall clearly list on any insurance card issued to enrollees in its plan the amount of the in-network and out-of-network deductibles.” Neither the Administration nor the House E & C Committee (their bill here) favor arbitration.
340B Program Grows as Hospital Charity Care Flatlines
Or so says the headline in Drug Channels, here. The 340B program, begun with a handful of safety net hospitals in 1992, compels pharmaceutical manufacturers to sell drugs at a discount to qualifying hospitals. The hospitals, in turn, are allowed to bill third parties at the list price for the drugs, and use the difference to support charity care. The discounted (invoice less discounted price) value is estimated at $15 billion. Drug Channels reports “The 340B Drug Pricing Program continues to expand at double-digit rates . . . discounted 340B purchases hit a record $24.3 billion in 2018,” 26% greater than the total in 2017. Hospital charity care, on the other hand, is not experiencing similar growth: “The total value of hospitals' uncompensated care has declined, from $46.8 billion in 2013 to $38.4 billion in 2017 (the most recent year available),” says the AHA (here), while uncompensated care as a percentage of hospitals’ total expenses has also declined, from 5.9% in 2013 to 4.0% in 2017.
MEDICARE, MEDICAID, COMMERCIAL HEALTH INSURANCE
Medicare Final Rule on Part D and Medicare Advantage Drug Plans
Medicare finalized a new rule (Federal Register publication here, CMS summary here) amending the Medicare Advantage (MA) program (Part C) regulations and Prescription Drug Benefit program (Part D) regulations to support health and drug plans’ negotiation for lower drug prices and reduction of out-of-pocket costs for Part C and D enrollees. Prior authorization is encouraged here, although a known bane to practicing physicians, as well as “step therapy,” a spanner-in-the-works for many patients. These two measures are a substitute for allowing plans to exclude drugs on the “protected class” lists. “Except in limited circumstances, current Part D policy requires Part D sponsors to include on their formularies all Part D drugs in six categories or classes: (1) antidepressants; (2) antipsychotics; (3) anticonvulsants; (4) immunosuppressants for treatment of transplant rejection; (5) antiretrovirals; and (6) antineoplastics. We proposed three exceptions to this protected class policy that would allow Part D sponsors to: (1) implement broader use of prior authorization (PA) and step therapy (ST) for protected class Part D drugs, including to determine use for protected class indications; (2) exclude a protected class Part D drug from a formulary if the drug represents only a new formulation of an existing single-source drug or biological product, regardless of whether the older formulation remains on the market; and (3) exclude a protected class Part D drug from a formulary if the price of the drug increased beyond a certain threshold over a specified lookback period.” Only #1 of these 3 exceptions is approved in this final rule.
This Sunday (the 19th) is Deductible Relief Day
The Kaiser Family Foundation explores (here) the impact of eroding employer-sponsored group health insurance on individual employees and families. May 19, according to the authors, is “Deductible Relief Day” – the day when enrollees have on average incurred enough health spending to hit the average deductible in an employer plan. Ten years ago, it was March 18.
And We Knew This, Too
Katherine Baicker and colleagues add to our knowledge of employer-sponsored “wellness” programs, here. “[A] workplace wellness program resulted in significantly greater rates of some positive self-reported health behaviors among those exposed compared with employees who were not exposed, but there were no significant differences in clinical measures of health, health care spending and utilization, and employment outcomes after 18 months.”
DRUGS AND DEVICES
How to Pay for Transformative Therapies
The Duke-Margolis center tackles the problem of “transformative therapies,” one-time treatments with expected long-term, or even curative, effects. “Despite their potential benefits, the high cost of transformative therapies presents a challenge within the current fee-for-service health care system. Value-based payment (VBP) arrangements could be part of the solution.” The policy brief, here, notes that “Continuing with traditional payment approaches may lead to limited reimbursement for the high upfront costs of transformative therapies; in turn, this may result in reduced investment and access to innovative therapies. These financial challenges not only cast doubt on the health system’s capacity to keep pace with technological change, but present tangible obstacles for patients who may struggle today to access life-altering treatments.”
AHRQ on Infertility
The Agency for Healthcare Research and Quality publishes a “Comparative Effectiveness Review” (here, 418 pgs.) on management of infertility. The bottom line: “The ability to compare the effectiveness of treatments would be enhanced by greater consistency in reporting of outcomes, particularly live birth rates, as well as reporting of diagnosis-specific outcomes for treatments, such as assisted reproductive technology, that are used for multiple diagnoses.”
READINGS AND REFERENCES
HRSA has a new series of interactive maps showing location, sponsorship, grant amounts, etc., for its programs here. FQHCs? The map shows the $5 billion in funding to 1,365 centers. Workforce grants? Take a look.
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
May publication dates: 20, 21, 22, 23
June publication dates: 5, 6, 7, 8, 11, 12, 13, 14, 25, 26, 27, 28
Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com.