HealthCare Roundtable e-News – August 28, 2023


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Webinar – September 19, 2023 – 2:00 PM (EST)

Assessing the Congressional Landscape for Drug Cost Containment: Legislative and Policy Considerations in the context of Pharmacy Benefit Manager (PBM) Reforms

The persistent challenges surrounding pharmacy benefit manager reforms (PBM) have garnered significant Congressional attention on a bipartisan basis, and the Roundtable has played an active role in the debate. Before Congress adjourned for the August recess, the Senate Finance Committee (SFC) conducted a bipartisan markup session on the Modernizing and Ensuring PBM Accountability (MEPA) Act, which culminated to its passage out of committee. Without question, the next several months will be a critically important time where Congress will determine potentially major changes to the PBM marketplace.

Join us to hear from the Public Sector HealthCare Roundtable’s senior policy team and policy experts on the hot topic issue of PBMs and how these policies relate to public sector purchasers, an analysis of the evolving legislative landscape, and a lens on crucial considerations as the current year draws to a close and anticipation builds for the year ahead in 2024.

This webinar is being produced in conjunction with Roundtable corporate member Rx Savings Solutions.

Register Here 

Top News

Biden Administration Set to Name First 10 Drugs for Medicare Negotiations Next Week

The Biden Administration is expected to disclose early next week the first 10 prescription drugs selected for Medicare price negotiations, ahead of a White House event Tuesday to celebrate the milestone. Industry experts believe the list could potentially include some of the most widely prescribed treatments for arthritis, blood disorders, heart disease, and diabetes. The negotiation process arrives one year after President Biden signed the Inflation Reduction Act (IRA) and will mark a major step in a bid to lower drug prices through the first-ever direct negotiations between Medicare and pharmaceutical manufacturers over a set of medicines. Since its inception, the price negotiation provisions in the IRA have been met with significant legal backlash from prominent pharmaceutical companies. The Biden Administration and top health officials have vowed to fight those court challenges, embracing the lawsuits as evidence that they’re making strides in the fight to slash drug prices. The Centers for Medicare and Medicaid Services (CMS) is required to publish up to 10 Medicare Part D drugs that it selects for negotiation by September 1 of this year.


CMS Issues Draft Guidance on Medicare Prescription Payment Plan to Implement a Monthly Cap on Out-of-Pocket Payments

The Centers for Medicare and Medicaid Services (CMS) released draft guidance (press releasefact sheet) implementing Inflation Reduction Act (IRA) provisions that allow beneficiaries, starting in 2025 to pay out-of-pocket costs in monthly payments spread out over the year. The guidance is the first in a series related to monthly caps on out-of-pocket payments. Provisions include:

  • Details on calculations of the capped monthly payment amounts in the program.
  • Information on what must be included in monthly bills provided by Part D plans to beneficiaries.
  • Requiring plans to make full payments to pharmacies when medications are dispensed for program enrollees, protecting them from any risk of nonpayment by beneficiaries.
  • Details on claims adjudication processes to eliminate copays at pharmacy point of sale for program enrollees.
  • Thresholds for proactive identification of beneficiaries who would benefit from the payment plan and mechanisms to inform these beneficiaries through their pharmacies.
  • Discussion on how the program would function for beneficiaries who are eligible for low-income subsidy programs.
  • Information on election periods, processing of payment plan election, various protections for beneficiaries (details on grace periods for payment, revocation of the program enrollment due to nonrepayment, eligibility for re-enrollment, dispute resolution requirements and complete disbarment from the program).

The program is intended to reduce the burden of annual copayment obligations which may prevent some beneficiaries from receiving medically necessary therapies. CMS is seeking comments on the guidance, with comments due September 20, 2023.


Aon Projects Increase in Health Care Costs for Employers in 2024

Last week, Aon released projections estimating average costs for U.S. employers that pay for their employees’ health care will increase 8.5% to more than $15,000 per employee. The 2024 estimations from the global professional services firm are nearly double the 4.5 percent increase in health care budgets that employers experienced from 2022 to 2023. On average, the budgeted health care plan cost for clients is $13,906 per employee in 2023. Aon uses its Health Value Initiative database, which captures information from more than 800 U.S. employers representing approximately 5.6 million employees and $77 billion in 2023 health care spending, to track this data. The report indicates that contributing factors adding pressure on health care cost trends are the proliferation of newly indicated weight-loss drugs, new technologies, the severity of catastrophic claims, and the increasing share of specialty drugs.


Business Group on Health’s 2023 Health Care Strategy Survey Projects Increases in Overall Health Care Spending for 2024

Last week, the Business Group on Health released the results from their 2023 Large Employers’ Health Care Strategy and Plan Design survey. The survey was completed by 135 large employers that cover more than 18 million lives in the United States and includes questions that explore the employers’ views on health and well-being, health care delivery reform, prescription drugs, and health care costs. The results show that mental health needs among workforces have continued to increase, with 77% of large employers reporting an increase and another 16% anticipating one in the future. This represents a 33% increase from last year when 44% of employers saw an increase in employee mental health concerns. While costs pertaining to mental health needs are on the rise, employers still cited cancer as the primary driver of health care costs with 86% saying it ranked among their top three areas of costs. Pharmacy costs were also highlighted in the report with 92% of employers expressing concerns about high-cost drugs in the pipeline.

Administrative Action

  • The United States Preventative Services Task Force (USPSTF) released a final recommendation advocating for clinicians to prescribe preexposure prophylaxis to patients with increased risk for HIV. The A grade recommendation is consistent with the USPSTF’s 2019 ruling on preexposure prophylaxis (PrEP) and with the task force’s draft recommendation from December 2022. The final recommendation specifically lists sexually active adults and adolescents who have had anal or vaginal sex in the previous 6 months and/or a sexual partner living with HIV, a sexually transmitted infection (STI) in the past 6 months, and a history of inconsistent or no condom use, as well as those who inject drugs or have a partner who injects drugs to be considered for receiving PrEP to help prevent HIV infection. If the preventive care insurance mandate stands, insurers would be required to cover the newly recommended PrEP options in the plan year starting on or after August 31, 2024.
  • The Substance Abuse and Mental Health Services Administration (SAMHSA), announced over $64 million in funding to address the national mental health crisis. A major portion of the funding, approximately $59.4 million, is being allocated to states and territories via the Community Mental Health Services Block Grant program, which is part of the Bipartisan Safer Communities Act. The funding highlights the administration’s commitment to providing mental health services to vulnerable populations, including those affected by gun violence, disasters, and emergencies. The intention is to build a robust public mental health system that can offer support during crises and long-term recovery. The funding also includes resources for Mental Health Awareness Training grants, which equip individuals and communities, including first responders, educators, and caregivers, with the necessary skills to interact with and assist individuals facing mental health challenges. The goal is to enhance the capacity for people to access vital mental health services and support. Persistently addressing the mental health crisis remains of utmost importance to the Biden-Harris Administration, integral to President Biden’s overarching Unity Agenda for the nation. This recent influx of funding follows a series of prior grant releases through SAMHSA earlier in the summer, supplementing other ongoing initiatives aimed at enhancing accessibility and equity in the realm of mental health services.


The Centers for Medicare & Medicaid Services (CMS) announced that the Medicare Shared Savings Program saved Medicare $1.8 billion in 2022, marking the program’s sixth consecutive year of generating savings while maintaining high-quality care. This is the second-highest annual savings for Medicare since the program began over a decade ago. The program involves Accountable Care Organizations (ACOs) made up of healthcare providers who collaborate to offer coordinated, quality care to Medicare beneficiaries. As of January 2023, Shared Savings Program ACOs include over 573,000 participating clinicians who provide care to almost 11 million people with Medicare. The program’s success has led to a goal of having 100% of traditional Medicare beneficiaries engaged in an accountable care relationship by 2030. The ACOs showed better quality performance in various health measures, such as diabetes and cancer screening. Approximately 63% of participating ACOs earned payments for their performance in 2022. Low-revenue ACOs, comprised of mainly primary care clinicians, demonstrated higher savings, emphasizing the importance of primary care in the program’s effectiveness.


The Florida Health Justice Project and the National Health Law Program have brought forth a lawsuit on behalf of three individuals from Florida against the Florida Agency for Health Care Administration and the Department of Children and Families, alleging that a large number of individuals have been removed from the Medicaid program without proper explanations. This legal action is the first of its kind and targets the widespread reduction in Medicaid coverage occurring across the U.S. as states reevaluate eligibility for over 90 million people in the wake of the pandemic. The lawsuit focuses on approximately 182,000 people in Florida who were deemed ineligible for Medicaid, excluding around 225,000 others who lost coverage due to procedural reasons, and claims that Florida’s confusing notices about eligibility decisions have left individuals without a clear understanding of why they lost coverage, preventing them from appealing the decisions or seeking alternative health insurance. The legal action comes amidst a tumultuous unwinding process for state Medicaid agencies in the wake of the COVID-19 Public Health Emergency (PHE) ending in May of this year. Earlier this month, the Centers for Medicare and Medicaid Services (CMS) sent letters containing public data to Medicaid officials in all 50 states concerning the ongoing unwinding process. In an intensified effort, CMS is pressing states that might not be fulfilling federal compliance mandates as they reassess Medicaid coverage for millions of individuals for the first time since the start of the pandemic.


A new Kaiser Family Foundation (KFF) survey shows the broad reach of health misinformation, with at least four in 10 people saying that they have heard each of 10 specific false claims about COVID-19, reproductive health, and gun violence. Conducted between May 23 and June 12, the KFF Health Misinformation Tracking Poll Pilot employed online and telephone methods to reach a nationally representative cross-section of U.S. adults in both English and Spanish.

Notably, 96% of adults reported that they had heard at least one of the ten items of health-related misinformation asked about in the survey. The survey also reveals the diverse spectrum of beliefs and perceptions surrounding the definition of misinformation. With regard to sources of trusted health information, a notable 93% expressed a fair degree of trust in their doctors, and Democrats demonstrated higher levels of trust in the Centers for Disease Control and Prevention (CDC) and Food and Drug Administration (FDA) compared to both independents and Republicans. These findings underscore an overall effort to address and combat health misinformation. KFF will be releasing additional analysis from the Health Misinformation Tracking Poll Pilot examining media use and trust and exposure and susceptibility to health misinformation among key subgroups including Black adults, Hispanic adults, and rural residents.

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.