HealthCare Roundtable e-News – April 29, 2024

 

 

Webinar Rescheduled – Medicare Prescription Payment Plan (MP3) Program

The Impact on Public Sector Health Plans

Webinar | May 8, 2024 at 2:00 PM

Join us for a timely and insightful webinar hosted by the Public Sector HealthCare Roundtable, where we’ll delve into the intricacies of the upcoming Medicare Prescription Payment Plan (MP3) Program. Set to roll out in 2025 under the Inflation Reduction Act, this program promises significant changes in healthcare accessibility and affordability. We’ll explore the fundamental aspects of MP3, including its impact on public sector purchasers and how to navigate its requirements.

If you haven’t already determined how MP3 will impact your plan, this is an important discussion you won’t want to miss.

 

Register Today!

 

NOTE: If you were already registered for the April 24th webinar, you don’t need to re-register.

 

Meet our Featured Webinar Speakers

Erik Poppe Headshot

Erik Poppe, FSA, MAAA

Director, Health Actuary, Human Capital Practice

Willis Towers Watson

Erik Poppe is a director in Willis Towers Watson’s Health and Benefits business. He has more than 24 years of actuarial experience and over nine years with WTW. In his role, Erik has worked with clients of all sizes and industries. The majority of his time is spent on understanding the ever-changing financial aspect of medical and pharmacy benefits to guide and inform clients on the impact of future costs.

Erik’s work with clients consists of the traditional Health Actuary role which includes developing premium equivalent rates, contributions and both short and long term projections of claims experience. In addition, Erik also works with several clients that have frequent acquisitions and require in depth financial analysis.

Prior to joining WTW, Erik was the director of actuarial and quoting for a regional pharmacy benefit manager. In this role, he was responsible for guiding existing and prospective mid-market companies leveraging pharmacy benefit savings within the existing health benefit framework. Erik also worked for a national insurance company that provided long-term care and supplemental health policies, and he has experience with a regional health insurance carrier. He specializes in using software technology to provide solutions for both external and internal stakeholders.

Erik holds a B.S. degree in applied mathematics from Kettering University. He is a Fellow in the Society of Actuaries and a Member of the American Academy of Actuaries.

 

Megan Keyes

Senior Director, Regulated Markets Services Operations & Product Development

Express Scripts

Megan Keyes is a Senior Director within the Express Scripts Regulated Markets Division. Her team is responsible for Regulated Markets Financial Management, Employer Group Waiver Plan (EGWP) and Administrative Services Operations, and Plan Experience and Oversight.

Megan has over 22 years in the pharmacy benefit industry with 17 years focused on Regulated Markets including EGWP, Exchanges, Part B, and PDP benefits.  Her experience includes driving operational excellence, strategic product and business development, and change management.

Megan is currently on the Board of Directors and Compliance Committee for the Medco Containment Life Insurance Company (MCLIC) and Medco Containment Insurance Company of NY (MCICNY).

Megan has her Bachelor of Science degree from Maryville University.


Congressional Forum – June 5-6, 2024

Plan NOW to attend the Roundtable’s 2024 Congressional Forum

The Phoenix Park Hotel, Washington, DC

Whether you actively advocate with the Administration or your Members of Congress or not, you should plan to participate in the Roundtable’s Congressional Forum. You’ll learn first hand from industry leaders, DC allies, and key friends in Congress about the issues which impact health care purchasers today.

The Forum will begin with a networking reception on Wednesday, June 5th and continue with a series of educational presentations on Thursday morning, June 6th. For those who are able, the Roundtable will provide information to support meetings on Capitol Hill as health plan representatives reach out to educate their Members of Congress on Roundtable priorities.

A preliminary agenda, hotel information, and a registration link will be announced on Wednesday, May 1st. There will be no fee for this event.

We look forward to welcoming you to Washington!


Top News

AJHP Study Shows Specialty Drugs and Weight Loss Therapies Propel US Pharmaceutical Spending

The American Journal of Health-System Pharmacy (AJHP) released an article titled National trends in prescription drug expenditures and projections for 2024. The study aimed to analyze historical trends in pharmaceutical spending in the United States, focusing on nonfederal hospitals and clinics, to predict future spending in 2024. Data from the IQVIA National Sales Perspectives database was used to assess historical patterns, considering factors such as new drug approvals, patent expirations, and potential policy changes. In 2023, total pharmaceutical spending reached $722.5 billion, with a 13.6% increase from 2022, primarily driven by increased utilization, new drug introductions, and rising prices. Notably, specialty drugs like semaglutide played a significant role in these trends, alongside drugs for conditions like cancer and endocrine disorders. Projections for 2024 anticipate continued growth, with specialty drugs and those for weight loss likely to contribute significantly. However, local factors may affect spending trends across different health systems.

 

FDA Approval of Wegovy Could Lead to Medicare Coverage for Millions of Beneficiaries with Obesity

The U.S. Food and Drug Administration (FDA) recently approved a new use for Wegovy (semaglutide), a popular anti-obesity drug, to reduce the risk of heart attacks and stroke in people with cardiovascular disease who are overweight or obese. To better understand the impact of this new approval, the Kaiser Family Foundation (KFF) compiled a brief on potential repercussions. The new FDA-approved indication for Wegovy potentially allows for Medicare coverage of the drug, but Medicare is currently prohibited by law from covering medications that are specifically used for obesity. An estimated 3.6 million Medicare beneficiaries may be eligible for this coverage, representing around a quarter of all Medicare beneficiaries diagnosed with obesity or overweight in 2020. However, out-of-pocket costs and coverage restrictions could limit uptake. Some Part D plans may begin covering Wegovy in 2024, but broader coverage may be delayed until 2025 due to cost considerations. Expanded coverage could significantly impact Medicare spending, depending on uptake rates and negotiated prices. Moreover, this decision could influence future Medicare coverage of anti-obesity drugs, potentially reducing costs associated with legislation to lift the prohibition on their coverage.

 

FTC Announces Rule Banning Noncompetes

The Federal Trade Commission (FTC) issued a final rule banning noncompetes nationwide. In January 2023, the FTC issued a proposed rule which received more than 26,000 comments. Under the FTC’s new rule, existing noncompetes for most workers will no longer be enforceable after the rule’s effective date. Existing noncompetes for senior executives can remain in force under the FTC’s final rule, but employers are banned from entering or attempting to enforce any new noncompetes, even if they involve senior executives. Employers will be required to provide notice to workers other than senior executives who are bound by an existing noncompete that they will not be enforcing any noncompetes against them. The Commission vote to approve the issuance of the final rule was 3-2 with Commissioners Melissa Holyoak and Andrew N. Ferguson voting no. The final rule will become effective 120 days after publication in the Federal Register. Once the rule is effective, market participants can report information about a suspected violation of the rule to the Bureau of Competition by emailing noncompete@ftc.gov.

Administrative Action

  • Vice-President Harris announced a series of actions aimed at improving safety, provide support for care workers and family caregivers, and expand access to affordable, high-quality care. Specifically, Vice-President Harris announced the finalization of two final rules: Nursing Home Minimum Staffing Final Rule and Ensuring Access to Medicaid Services Final Rule. The Nursing Home Minimum Staffing Final Rule requires all nursing homes that receive federal funding through Medicare and Medicaid to have 3.48 hours per resident per day of total staffing, including a defined number from both registered nurses (0.55 hours per resident per day) and nurse aides (2.45 per resident per day). It will also require facilities to have a registered nurse onsite 24 hours a day, seven days a week, to provide skilled nursing care, which will further improve nursing home safety. The Ensuring Access to Medicaid Services Final Rule requires that at least 80 percent of Medicaid payments for home care services go to workers’ wages and forces states to be more transparent in how much they pay for home care services and how they set those rates.
  • The U.S. Food and Drug Administration (FDA) announced the launch of a new initiative, “Home as a Health Care Hub” to integrate home environments into healthcare systems. This action serves as a means to address the accelerated transformation taking place in the U.S. healthcare system and the persistent challenges being faced, including physician shortages, rising costs, and limited access, particularly affecting underserved populations. The health care at home initiative aims to design augmented reality-enabled prototypes that consider home structural elements and promote health equity. Focused initially on diabetes care, the project seeks to improve access and outcomes by prioritizing personalized care and community engagement. By shifting the focus from healthcare systems to individuals, this initiative aims to foster innovation, advance health equity, and improve public health by bringing care, prevention, and wellness into people’s homes.
  • The U.S. Department of Health and Human Services (HHS) announced that 20 states have been selected to participate in two separate technical assistance (TA) programs to support states in the recruitment, training and retention of their direct care workforce (DCW). The programs were established as a part of the Biden-Harris Administration’s Care Workers Recognition Month activities, and in support of President Biden’s recent Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers. Both of the programs are being implemented through the Administration for Community Living’s Direct Care Workforce (DCW) Strategies Center, and aim to support DCWs who provide home and community-based services (HCBS) for older adults and people with disabilities. Out of the 20 states that applied to participate in the programs, the following six were chosen to join the first program: Alaska, Colorado, Delaware, Indiana, New Jersey, and New Mexico. These six states will be provided with up to 250 hours of specialized TA , and a team of subject matter experts to support them in addressing the state’s unique DCW challenges. The remaining fourteen states will be offered an opportunity to participate in a second program, which offers education on best practices, innovative strategies, and proven models for growing the DCW. In addition, each of the fourteen states will receive up to 70 hours of TA on issues specific to their state.

Regulatory Action

  • The Centers for Medicare and Medicaid Services (CMS) released the final rule (fact sheet) for minimum staffing standards for Long-Term Care (LTC) facilities and Medicaid institutional payment transparency reporting. The final rule was informed by over 46,000 public comments in response to the proposed rule. With this final rule, CMS establishes new comprehensive minimum staffing requirements to reduce the risk of unsafe and low-quality care in LTC facilities. Specifically, CMS is finalizing a total nurse staffing standard of 3.48 hours per resident per day (HPRD). The newly established HPRD must include a minimum of 0.55 HPRD of direct registered nurse (RN) care, 2.45 HPRD of direct nurse aide care, and a combination of RN, licensed practical nurse (LPN), licensed vocational nurse (LVN), or nurse aides for the additional 0.48 HPRD. CMS will introduce a staggered implementation to allow LTC facilities time to abide by these rules. Additionally, CMS is finalizing its enhanced facility assessment requirement, which requires facilities to use evidence-based methods when developing care plans for individual residents, including behavioral health needs. CMS is also finalizing a new requirement that LTC facilities have an RN on site 24 hours a day, seven days a week, to help mitigate and ultimately reduce the likelihood of preventable safety events, particularly during evenings, nights, weekends, and holidays.
  • The Office for Civil Rights (OCR) at the U.S. Department of Health and Human Services (HHS) announced a Final Rule titled “HIPAA Privacy Rule to Support Reproductive Health Care Privacy” (fact sheet). This Final Rule follows the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization which overturned the constitutional right to abortion established under Roe v. Wade and Planned Parenthood v. Casey, and supports President Biden’s Executive Order 14076 which directed HHS to consider taking additional actions, including under HIPAA, to better protect information related to reproductive health care and to bolster patient-provider confidentiality. The final rule was informed by nearly 30,000 public comments in response to the proposed rule. This rule strengthens the HIPAA Privacy Rule by prohibiting the disclosure of protected health information related to lawful reproductive health care in certain situations. It aims to protect patient confidentiality and prevent the misuse of medical records related to reproductive health care.

Mark your calendar:


Roundtable’s Congressional Forum

June 5-6, 2024

Phoenix Park Hotel, Washington, DC

(Registration Opens Wednesday, May 1st)


Roundtable’s 20th Annual Conference

November 6-8, 2024

The Mayflower Hotel, Washington, DC


Healthcare Roundtable 2023 Corporate Sponsors