HealthCare Roundtable e-News – August 21, 2023

 

Top News

Federal Court of Appeals Rules ERISA Preempts Oklahoma Law that Seeks to Curb PBM Practices

On Tuesday, the Tenth Circuit Court of Appeals ruled to invalidate four provisions of an Oklahoma law marking a major victory for pharmacy benefit managers (PBMs). The court stated that an Oklahoma law that prohibits the use of preferred pharmacy networks or incentivizes the use of mail-order pharmacies through cost-sharing discounts or copay reductions is preempted by the federal Employee Retirement Income Security Act (ERISA) and the Medicare Part D program. The decision from the appeals court reverses the previous Western District Court of Oklahoma ruling, which was in favor of Oklahoma and upheld four provisions included in the state’s Patient’s Right to Pharmacy Choice Act against the same federal preemption challenge.

 

Blue Shield of California Announces Plans to Shift to New Pharmacy Management Model

Blue Shield of California issued a press release on Thursday detailing plans to drop CVS Caremark as its sole PBM and move towards a new pharmacy care model. The health plan will sever most of its ties with its current pharmacy benefit manager under the new Pharmacy Care Reimagined program and instead leverage five insurance partners with the new program. CVS Caremark will still handle specialty drugs, and other partners under the new initiative include Amazon Pharmacy, Abarca, Mark Cuban Cost Plus Drug Company, and Prime Therapeutics. Following the implementation of its new multi-year strategy, Blue Shield of California expects to save up to $500 million annually on drug costs. Touted as a “first-of-its-kind” model, the health plan hopes other plans may follow suit with their approach.

 

The Joint Commission and National Quality Forum Announce Strategic Affiliation to Help Accelerate Improvements in Health

The Joint Commission (JC) and National Quality Forum (NQF) announced a strategic affiliation between the two organizations to help accelerate improvements in healthcare quality and measurement. The affiliation will allow both organizations to build upon their shared expertise in measuring quality and rationalizing the measurement landscape allowing for the focus to shift from competing measures to advancing key outcomes. The NQF will join the JC enterprise while maintaining its independence in convening and developing consensus-based measures, implementation guidance, and practices that benefit all stakeholders.

Administrative Action

  • The Administration for Community Living (ACL) is awarding $2.9 million to grantees in the Lifespan Respite Care Program for fiscal year 2023. The awards go to eight grantees, with seven awards going toward State Program Enhancement Grants in Arizona, Idaho, North Carolina, Rhode Island, South Carolina, Tennessee, and Washington. ACL intends for these funds, totaling $2,699,847, to help the states better provide equitable respite services, improve coordination and dissemination of service delivery between different state programs, and reduce challenges consumers face when accessing and navigating respite programs and services. These awards come after ACL released the 2022 National Strategy to Support Family Caregivers, which was developed by the advisory councils created by the RAISE Family Caregiving Act and the Supporting Grandparents Raising Grandchildren Act.
  • The Office of Management and Budget (OMB) and the Office of Science and Technology Policy sent a memo to federal agencies outlining the Biden Administration’s multi-agency research and development (R&D) priorities for formulating fiscal year (FY) 2025 budget submissions to OMB. Key healthcare priorities include funding the Cancer Moonshot, bolstering the capacity to mitigate current and emerging health threats, supporting behavioral and mental health, improving public health, advancing clinical trials, and reducing environmental burdens.
  • The Centers for Medicare and Medicaid Services (CMS) released an anniversary fact sheet covering the Inflation Reduction Act (IRA)’s impact over the past year. Signed into law on August 16, 2022, the IRA includes provisions affecting Medicare benefits, drug costs, and prescription drug premiums. The legislation also increases financial assistance for purchasing health insurance plans through HealthCare.gov and the state-based Marketplaces. CMS’ fact sheet provides details on the IRA’s provisions, along with statistics on its effects following enactment. Paralleling CMS’ fact sheet, the White House also released a fact sheet highlighting the IRA’s effects over the year. According to the White House, the IRA continues to make improvements to the Affordable Care Act (ACA) and has contributed to the nation’s uninsured rates reaching a historic low.

Regulatory Action

The Centers for Medicare and Medicaid Services (CMS) announced that the administrative fee for using the surprise billing independent dispute resolution (IDR) portal will go back down to $50 as of August 3, 2023. CMS released an updated FAQ page detailing the amount and highlighted what parties should do under various situations. Although the IDR portal remains closed for now, the Administration noted it will reopen for new submissions “soon” and that interested parties will be notified at that time. The portal has been closed since August 3, when a federal court judge in Texas ruled that the Administration violated the Administrative Procedure Act by increasing the fee from $50 in 2022 to $350 starting January 1, 2023.

Litigation

A federal appeals court ruled that mifepristone, one of the two pills used for medication abortion, can no longer be prescribed through telehealth or accessed by mail. However, this decision will not immediately impact mifepristone availability, as the Supreme Court has stayed the status quo throughout the appeals process. The decision came from a three-judge panel from the Fifth Circuit Court of Appeals. The panel issued a divided ruling in which they agreed to limit mifepristone availability to the Food and Drug Administration (FDA)’s original prescribing terms from 2000. Still, the majority did not go so far as to rule that mifepristone must be pulled off the market, as a lower court ruled in April. Previously, U.S. District Judge Matthew Kacsmaryk of the Northern District of Texas had issued a preliminary ruling invalidating FDA’s original 2000 approval of mifepristone. The Biden administration will likely appeal the ruling to the U.S. Supreme Court. The Supreme Court could decide to hear the case in its upcoming term.

Research

  • The National Institutes of Health (NIH) announced the establishment of their Maternal Health Research Centers of Excellence, which will develop and evaluate approaches to reduce pregnancy-related complications and deaths and promote maternal health equity. These centers are intended to build on the NIH’s Implementing a Maternal Health and Pregnancy Outcomes Vision for Everyone (IMPROVE) Initiative. As part of the initiative, the NIH has awarded $24 million in first-year funding. The awarded grants are expected to last seven years and total an estimated $168 million, pending the availability of funds. They are set to include 10 research centers, a data innovation and coordinating hub, and an implementation science hub. The centers will specifically focus on populations that experience health disparities, including racial and ethnic minorities, socioeconomically disadvantaged populations, those living in underserved rural areas, sexual and gender minority populations, and people with disabilities.
  • The Health and Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation (ASPE) highlighted four new research reports that evaluated various ways individuals with long-term services and supports (LTSS) needs are supported by caregivers. These reports build on HHS-ASPE’s previous work modeling current LTSS needs and expenditures and explore how changes in U.S. demographics will impact informal caregivers for older adults and Medicaid expenditures on paid caregiving services.

Registration Open for 2023 Annual Conference

The Public Sector HealthCare Roundtable 2023 Annual Conference Moves to Washington, DC

The conference features a new location, a revised format, and a great agenda!

Wednesday, Nov. 1 to Friday, Nov. 3, 2023

 

The Roundtable’s highly-regarded annual conference provides members and guests a unique opportunity to hear presentations by high level government officials and key experts – from Congress and the Administration, academics, benefit consultants, plan administrators, advocates and industry leaders in an intimate dialogue-oriented setting.

After years of successful conferences in Old Town Alexandria, we have outgrown our space at the Alexandrian Hotel. This year we will hold our conference at the historic Mayflower Hotel in Washington, DC. The new location will undoubtedly improve the overall experience for all of our attendees.

In recent years, many of our attendees have urged us to schedule more free time in the conference agenda for networking. Since we understand the importance of this networking time, we have revised this year’s agenda to incorporate longer breaks and more time before evening receptions.

This year, the conference will begin at Noon on Wednesday, November 1st and will conclude at Noon on Friday, November 3rd. By adding time on Wednesday, we have been able to add critical content, lengthen our breaks, and add free time prior to any evening activities.

Although we certainly believe the best way to experience our conference is in-person, this year’s conference will once again feature a virtual option. Any health plan that registers at least one individual to join us in Washington, will be eligible to register online attendees.

Visit the Roundtable’s website for a preliminary Agenda, a Registration Form, and the Mayflower Hotel registration link.

We will be updating the agenda and announcing specific speakers over the course of the next couple of months.