HealthCare Roundtable e-News – April 10, 2023


Roundtable Welcomes Newest Member

Wisconsin Department of Employee Trust – Group Health Insurance Program

The State of Wisconsin Group Health Insurance Program (GHIP) covers approximately 232,000 public sector employees, retirees, and their dependents. The GHIP offers health, pharmacy, dental, wellness, life, vision, and accident plan benefits, as well as pre-tax savings accounts. 

For more information click here.

Top News

Senate HELP Committee Plans to Markup Drug Pricing Legislation Following Spring Recess

The Senate Committee on Health, Education, Labor, and Pensions (HELP) plans to markup drug pricing legislation targeting pharmacy benefit managers (PBMs) and generic drugs when Congress returns from its spring recess on April 19. The bill, which staffers are still writing, comes amid efforts from lawmakers to increase access to generic drugs and increased scrutiny of PBMs. Last month, top aides for Chair Bernie Saunders (I-VT) and Ranking Member Bill Cassidy (R-LA) reached out to staffers for other committee members, notifying them of the planned markup focused on bipartisan policies.

Though the provisions of the bill are unclear, in 2019 the HELP Committee proposed a package from former Sen. Lamar Alexander (R-TN) and Sen. Patty Murray (D-WA). That package led to a ban on surprise medical billing, which President Trump signed into law in 2020, but the PBM-related provisions were dropped. The current committee could pull from the 2019 bill’s language requiring PBMs to be more transparent about their business and put limitations on PBMs’ ability to use spread pricing.

Also of note, Sens. Roger Marshall (R-KS) and Peter Welch (D-VT) introduced the Drug Price Transparency in Medicaid Act of 2023. The proposed legislation is meant to limit certain pricing practices by PBMs in Medicaid programs. Companion legislation was introduced in the House by Reps. Buddy Carter (R-GA) and Vincente Gonzalez (D-TX).


Senate Finance Committee Holds Hearing on Potential Role of PBMs in Increasing Drug Costs

On Thursday, March 30th, the Senate Finance Committee highlighted the potential role of pharmacy benefit managers (PBMs) in driving up prescription drug costs. Industry experts gathered to answer questions regarding congressional measures to 1) cap the drug rebates and administrative fees PBMs collect in negotiating drug manufacturers’ list prices, 2) increase supply chain transparency, and 3) introduce clarity in how PBMs grade and fine pharmacies. The Committee expects to have a follow-up discussion in coming weeks to identify key actions Congress can take to crack down on PBMs. Click here to view Healthsperien’s comprehensive coverage of the hearing.

Administrative Action

  • Recently, the U.S. Department of Health and Human Services (HHS) released a National Cancer Plan developed by the National Institutes of Health’s (NIH) National Cancer Institute (NCI). The plan provides a framework for public and private partners to end cancer. This announcement comes after the recent Proclamation on National Cancer Control Month by the Biden-Harris Administration. The plan, created in collaboration with the Cancer Moonshot, HHS, and representatives of the cancer stakeholder community, includes eight essential goals and accompanying strategies that outline what needs to be accomplished to prevent more cancers, reduce deaths, and improve the quality of live for those with cancer diagnoses. Goals of the National Cancer Plan include: 1) Preventing cancer through adoption of proven strategies that reduce risk 2) Detecting cancers early, enabling more effective treatment and reducing morbidity and mortality 3) Developing effective treatments, with minimal side effects, and ensure it is accessible to all people with all cancers, among others.

  • On Wednesday, the U.S. Department of Health and Human Services (HHS) released a Fact Sheet detailing the progress made in the last year in responding to Long COVID as well as additional actions planned for the future. The Fact Sheet reflects President Biden’s actions directing HHS to coordinate a whole-of-government response to Long COVID last year, including delivering high-quality care and making services and supports available for individuals experiencing Long COVID and increasing public awareness and understanding of Long COVID. Specifically, the Fact Sheet calls for the following: 1) Delivering high-quality care for individuals experiencing Long COVID 2) Making services and supports available for individuals experiencing Long COVID 3) Advancing the nation’s understanding of Long COVID 4) Addressing the long-term impacts of the pandemic, among other areas.

Congressional Action

  • Last Wednesday, the House Committee on Energy and Commerce Subcommittee on Health held a hearing to discuss the fiscal year (FY) 2024 HHS budget. HHS Secretary Becerra explained that the FY24 budget has been developed with the goal of shifting the nation from an illness care system to a wellness care system, as it aims to provide comprehensive care, increase investments in Medicare, and commit to mitigating hunger and malnutrition. Healthsperien’s coverage of the hearing can be found here.

  • Earlier this week, Representatives Raul Ruiz, M.D. (D-CA), Larry Bucshon, M.D. (R-IN), Ami Bera, M.D. (D-CA), and Mariannette Miller-Meeks, M.D. (R-IA) introduced H.R. 2474, the Strengthening Medicare for Patients and Providers Act. The legislation would change the physician payment rate above the current law by providing an annual Medicare physician payment update tied to inflation, as measured by the Medicare Economic Index (MEI).  The Medicare Trustees and MedPAC have previously called for legislative action to address the Medicare physician payment system by providing physicians with an annual inflation-based update tied to the MEI. A March 2023 report from the Medicare Trustees states that the trustees “expect access to Medicare-participating physicians to become a significant issue in the long term” unless Congress takes steps to bolster the payment system.


  • On Friday, the Board of Trustees for the Medicare Trust Fund released its 2023 annual report. The report projects that the Medicare Part A Hospital Insurance (HI) Trust Fund will be depleted in 2031, with a 75-year shortfall of 0.62 to 1.46 percent of payroll. The report outlines several factors contributing to the new insolvency projection including lower average morbidity among the surviving population from COVID-related deaths, lower Part A spending due to the movement of dually eligible beneficiaries to Medicare Advantage, and the movement of joint replacements to outpatient settings. Specifically, the Medicare Trustees find that: 1) The HI Trust Fund will be insolvent in 8 years 2) The HI Trust Fund faces a large shortfall with spending expected to exceed revenue by $333 billion over the next decade. It would take about a 21 percent increase in the payroll tax rate, or a 13 percent spending cut to restore solvency 3) Gross Medicare spending is projected to grow from 3.7 percent of GDP in 2022 to 6.0 percent by 2046 and remain above that level thereafter.

  • Last week, CMS released three proposed rules related to Medicare payment policies and rates. CMS released the FY24 Inpatient Rehabilitation Facility (IRF) Prospective Payment System Proposed Rule (fact sheetfull rule text). This rule updates IRF payment rates based on the IRF market basket update and a productivity adjustment. CMS also released the FY24 Medicare Inpatient Psychiatric Facility (IPF) Prospective Payment System Proposed Rule (fact sheetfull rule text), consistent with the legal requirement to update payment policies for IPF on an annual basis. Another major provision of the final rule is a 5% cap policy to smooth the impact of year-to-year changes in IPF payments related to decreases in the IPF wage index. Lastly, CMS released the FY24 Skilled Nursing Facility (SNF) Prospective Payment System Proposed Rule (fact sheetfull rule text) which updated Medicare payment policies and rates for skilled nursing facilities. In addition, the proposed rule includes proposals for the SNF Quality Reporting Program (QRP) and the SNF Value-Based Purchasing (VBP) Program for FY24 and future years.

  • CMS released their annual Medicare Advantage (MA) and Part D Final Rule for 2024 (fact sheet) which governs requirements for MA and Part D plans. Among its provisions, the rule finalizes stricter prior authorization requirements, increases beneficiary marketing protections, better incorporates health equity into Star Ratings, provider directories, and quality improvement programs, and improves access to behavioral health. The proposed expanded eligibility criteria of the Medication Therapy Management (MTM) Program under Part D were not finalized at this time.

  • On Wednesday, the Center for Medicare and Medicaid Innovation (CMMI) released new information on the recently announced Medicare Advantage (MA) Value-Based Insurance Design (VBID) model extension for calendar years 2025 through 2030. The primary changes include: 1) Medicare Advantage Organizations (MAOs) in the model will be required to offer supplemental benefits to address health-related social needs in at least two of three health-related social needs areas: food, transportation, and housing insecurity and/or living environment 2) The model will introduce a new flexibility for MAOs to address health-related social needs in socioeconomically disadvantaged areas, using the Area Deprivation Index (ADI), to direct benefits to enrollees in underserved communities 3) Typically, Medicare enrollees who choose hospice services give up their right to receive health care services that are “curative”. Under the model extension, beginning in 2025, CMS will more closely align flexibilities for concurrent care with those offered in other CMMI models 4) When the Hospice Benefit Component was introduced, CMS required MAOs to pay for all out-of-network hospice services for their enrollees in the model because MAOs did not yet have any relationships with hospice providers, among other changes. The new guidance indicates that MAOs will be given greater flexibility to establish and maintain networks beginning with the first year of the model extension. 


  • On Tuesday, a new analysis published by the Kaiser Family Foundation estimates that as Medicaid redeterminations resume, 1.9 million Americans in 10 states who have not expanded Medicaid eligibility will fall into the coverage gap. Individuals in the coverage gap earn too much income to qualify for Medicaid coverage, but too little for Affordable Care Act (ACA) Marketplace subsidies. During the COVID-19 public health emergency (PHE), the Medicaid continuous enrollment provision required states to provide continuous coverage for Medicaid enrollees. The Consolidated Appropriations Act (CAA) delinked the provision from the PHE and set an expiration date of March 31st. With states resuming disenrollment procedures over the next 12 months, Medicaid enrollment and insurance rates overall are expected to decline.

  • Last week, the National Association of Community Health Centers (NACHC) released a survey analyzing the effect of the March 31 expiration of the Medicaid continuous coverage rule on health centers. Results reveal that Medicaid redeterminations could severely impact operations at some health centers and disrupt patient care, given that more than 80% of health center patients are uninsured or enrolled in Medicaid, Medicare, or another public insurance provider. Key findings from the survey include: 1) 85% of health centers surveyed anticipate facing financial and/or operational challenges related to the Medicaid unwinding 2) 75% of health centers surveyed noted that increased funding for outreach and enrollment assistance would smooth the redetermination process and minimize coverage gaps for health center patients, among other findings. 

Regulatory Action

Last week, the Smarter Health Care Coalition (SHCC), a broad coalition of health care stakeholders, sent a letter to the Internal Revenue Service (IRS) urging them to clarify that high-deductible health plans (HDHPs) linked to health savings accounts (HSAs) can still cover preventive services recommended by the United States Preventive Services Task Force (USPSTF) without cost-sharing prior to the deductible despite the ruling in Braidwood v. HHS. Late last week, a Texas district judge ruled preventive care recommendations made by the USPSTF do not have to be complied with, and blocked the federal government from enforcing the task force’s recommendations. Judge O’Connor granted Braidwood Management Inc.’s request for a “universal” remedy, entirely blocking the Affordable Care Act’s (ACA) requirement that most private health plans cover certain preventive health-care services without cost to patients.


On Wednesday, the Coalition for Health Artificial Intelligence (CHAI) released initial guidelines to enable trustworthy adoption and implementation of AI in health care. The report is the result of convening experts from multiple institutions representing health care systems, academia, government, and industry and identifies potential issues with AI adoption and proposed solutions. Specifically, this work summarizes collective recommendations as a step toward a blueprint for assurance standards on trustworthy AI in healthcare. Further, this blueprint will help to create health care AI standards and reporting, and educate end users on how to evaluate AI technologies in ways that can drive their responsible adoption and result in benefits for patients and the health care delivery system.

Mark Your Calendar for Upcoming Roundtable Events

Webinar – May 9, 2023 – 2:00 PM (EST) – Drivers of Health Care Costs: Hospital Consolidation and Lack of Price Transparency

With healthcare costs growing at an unsustainable rate, employers, taxpayers, and patients have to pay more for the same quality of care. Hospitals are one of the top drivers of rising healthcare costs due to the lack of market competition. Join us to hear from the Public Sector HealthCare Roundtable senior policy team and our group of experts on the impact of hospital consolidation, anti-competitive practices, and the lack of price transparency on patients and market-based solutions to increase hospital competition and reduce healthcare costs.


19th Annual Conference – November 1-3, 2023