HealthCare Roundtable e-News – August 29, 2022


Top News

MCED Consortium Releases First Position Paper

The MCED Consortium released their first position paper, Evaluating Multicancer Early Detection Technologies for Clinical Use, which explores the landscape of emerging technologies that could allow clinicians to screen and detect multiple cancers at early stages and establishes their role in the development of guidance for use of, and education about, these tools.


Drug Negotiations May Pave the Way For More Biosimilars

Following enactment of the Inflation Reduction Act, Medicare’s ability to negotiate drug prices may alter incentives for brand-name biologic companies and drive more low-cost biosimilars, according to some drug pricing scholars. The law, which will allow the government to negotiate some drug prices beginning in 2023, requires biologics eligible for Medicare negotiation to have been on the market for 11 years and not have a biosimilar version in the pipeline. Drugmakers are left to decide whether to subject their products to Medicare price negotiations or allow for biosimilar competition. Drug pricing scholars described the importance of interchangeability, and note that the Food and Drug Administration (FDA) has only approved two interchangeable biosimilars. Over the next several years, scientific advancements may also alter manufactures’ incentives.

Administrative Action

  • The U.S. Departments of Health and Human Services, Labor, and the Treasury (the Departments) released a new resource to assist in determining whether the Federal IDR process or a specified state law (SSL) or All-Payer Model Agreement (APMA) applies for determining out-of-network (OON) rates. The resource is intended to serve as a tool for certified IDR entities to determine whether a payment dispute is subject to the Federal IDR process and to assist disputing parties as they submit or evaluate disputes.

  • CMS announced they awarded approximately $25 million in planning grants to five new states and territories to expand access to home and community-based services (HCBS) through Medicaid’s Money Follows the Person (MFP) demonstration program. Awards of up to $5 million are being announced for Illinois, Kansas, and New Hampshire, as well as for American Samoa and Puerto Rico. With these awards, 41 states and territories will now participate in MFP. Funding will support the early planning phase of their MFP programs.

  • Last Friday, the Departments of Labor, Health and Human Services (HHS), and the Treasury issued final rules (fact sheet here) concerning standards related to the arbitration process implementing the No Surprises Act (NSA). The bipartisan law, which went into effect this past January, protects consumers against surprise medical bills. The update addresses certain provisions of the July 2021 and October 2021 interim final rules that are relevant to the operation of the federal independent dispute resolution (IDR) process and revise certain provisions in light of two recent federal court cases.

Congressional Action

Last week, Chair Ron Wyden sent letters requesting 15 state insurance commissioners and state health insurance assistance programs provide information on Medicare Advantage and Part D plans’ marketing practices. Recently, CMS and the National Association of Insurance Commissioners both reported receiving more complaints about false and misleading advertising from these plans. In his letter, Chair Wyden askes states to report any complaints or misleading marketing data, examples, or trends among the plans, third-party marketing organizations, or other related organizations by September 16th


Analysis published by the Kaiser Family Foundation on Friday predicts that if current growth trends continue, over half of Medicare beneficiaries will access their care through Medicare Advantage (MA) plans as soon as next year. Currently 48% of Medicare beneficiaries are enrolled in MA, an increase of 2.2 million beneficiaries or 8% from the previous year. The majority of MA enrollees participate in plans that offer benefits not covered by traditional Medicare (including eye and hearing exams, glasses, or hearing aids) and offer some prescription drug benefits. With this growth in enrollment MA plans may face increasing scrutiny of patient experience and outcomes, health disparities, and overall expenditures. 


CMS published a bulletin outlining financial incentives states could employ to promote nursing home safety and quality, in alignment with the Biden Administration’s nursing home reform action plan. States are encouraged to use current Medicaid authorities and submit State Plan Amendments to implement value-based purchasing programs, incorporate quality data into their oversight activities, direct a proportion of future nursing home rate increases to direct care worker compensation, and implement new emergency preparedness requirements. CMS also plans to initiate programs in Medicare and Medicaid to reduce room crowding, strengthen the Skilled Nursing Facility Value-Based Purchasing program, expand financial penalties and enforcement sanctions, increasing scrutiny of poorest performing facilities and chain owners, and new minimum staffing requirements.


Last week, the Commonwealth Fund published a review of rates paid to healthcare providers across the health insurance market, and compared how they may relate to beneficiaries’ access to care, health equity, and overall healthcare costs. Medicaid fee-for-service (FFS) physician service rates were 30% lower than Medicare, and commercial insurance were 30% higher. Hospital rates are less directly comparable due to the supplemental Medicaid payments, but the FFS Medicaid payments were 22% lower than Medicare and commercial rates were nearly 90% higher. With new Medicaid access rules forthcoming, these payment disparities should be considered as potential drivers of health disparities, barriers to accessing care, and barriers to provider participation in Medicaid programs.


Last week, a federal judge blocked the U.S. Department of Health and Human Services (HHS’) guidance, which cites the Emergency Medical Treatment and Active Labor Act (EMTALA). The guidance would have directed healthcare providers who are required to provide emergency care to pregnant patients to also provide abortion services in situations where the life and health of the mother is at risk. The guidance was initially issued by HHS on July 11 following the Dobbs ruling and was subsequently challenged by Texas Attorney General Ken Paxton, who claimed that the guidance forced providers to commit crimes and risk their licensure under current Texas law.


The MCED Consortium released their first position paper, Evaluating Multicancer Early Detection Technologies for Clinical Use, which explores the landscape of emerging technologies that could allow clinicians to screen and detect multiple cancers at early stages and establishes their role in the development of guidance for use of, and education about, these tools.

Roundtable Reminders

SAVE THE DATE – November 9-11, 2022
Annual Conference Returns to Alexandria, VA

After two years of virtual meetings, the Roundtable is planning an in-person Annual Conference for this November. We will return to The Alexandrian Hotel in Old Town Alexandria, Virginia for our annual policy conference from Wednesday, November 9 to Friday, November 11, 2022.

Details will be released later this year. For now, save the dates!