HealthCare Roundtable e-News – January 30, 2023



New Congress, New Policies & Possibilities: Public Sector Purchaser Priorities in 2023

Tuesday, February 14th at 2:00 PM (EST)

With newly elected members of congress, committee leaders, and an expanded Democratic majority in the U.S. Senate and Republican takeover in the U.S. House, the landscape for federal health care policy has changed dramatically in a few short weeks. Join us on Tuesday, February 14th at 2:00pm ET to hear from the Public Sector HealthCare Roundtable senior policy team who will provide a legislative and regulatory policy and political forecast for public sector purchaser priorities in the 118th Congress and second half of the Biden Presidency. 

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Top News

Roundtable Joins Allies in Advocating for CMS to Protect MA Plans

The Public Sector HealthCare Roundtable has supported the role of Medicare Advantage and EGWP plans in ensuring public sector retirees have access to stable and affordable health care benefits. Ahead of this year’s annual rate announcement, the Roundtable joined the Better Medicare Alliance and its allies in sending a letter to the Centers for Medicare & Medicaid Services urging the administration to protect MA coverage and safeguard MA benefits including those focused on health equity and patient-centered care. The Roundtable encourages CMS to protect MA plans, particularly EGWPs, so they can continue to promote high-quality care, offer important supplemental benefits, and lower costs for beneficiaries and taxpayers.


Coalition Releases Report Highlighting Cost of Anticompetitive Practices by Pharmaceutical Industry

The Public Sector HealthCare Roundtable has been a longtime advocate for federal policies to curtail anticompetitive behavior by pharmaceutical companies that leads to higher costs for the public sector purchasers they serve. Last week, the Coalition for Affordable Prescription Drugs (CAPD) released a report from Matrix Global Advisors (MGA) on the consequences of “patent thickets.” According to the report, pharmaceutical companies accumulate overlapping sets of patents that protect their profits and delay competition from generics and biosimilars. According to the report, certain drug costs patients and the health care system an estimated $1.8 billion to $7.6 billion per year.


Reports Show Improved Hospital Compliance with 2021 Price Transparency Law

New reports show more hospitals are complying with the 2021 price transparency law, but some are either reluctant to publicize their data or do not have sufficient resources. According to Turquoise Health, 65 percent of U.S. hospitals posted negotiated rates with commercial insurers by the end of September. In June 2021, another study found less than half of American hospitals posted machine-readable files with negotiated prices. Despite the improvement in compliance, only 55 percent of hospitals were fully compliant with the price transparency law at the end of September. Another peer-reviewed study published earlier this month in the Journal of General Internal Medicine found only 19 percent of hospitals were in full compliance but noted that at least 72 percent of hospitals complied with key pricing metrics.

Meeting the guidelines set forth by the price transparency law requires significant work from hospitals, especially smaller facilities, amidst labor shortages and other financial challenges. The law is meant to encourage individuals to compare prices before receiving care, with the expectation that this ability to shop will lower costs. However, hospital administrators maintain patients rarely shop for healthcare and are more concerned with out-of-pocket costs rather than negotiated rates. To date, the Centers for Medicare & Medicaid Services has only fined two hospitals in Georgia for not complying with the law.


Avalere Analysis Concludes Some Enrollees Face Affordability Challenges Under Part D Redesign

A new analysis from Avalere found the upcoming Medicare Part D redesign could cause significant cost burden for some patients. According to the analysis, approximately 800,000 beneficiaries in 2024 and 200,000 in 2025 will face out-of-pocket (OOP) costs exceeding 10 percent of their annual income. Part D reforms in the Inflation Reduction Act include an OOP spending cap at the catastrophic threshold. Beginning in 2025, the spending cap, which is set at roughly $3,233 for 2024, will lower to $2,000 and allow enrollees to spread that amount across the plan year, known as “OOP smoothing.” Avalere found that in 2024 about 1.5 million enrollees not qualifying for low-income subsidies (LIS) would have enough OOP costs to reach the catastrophic spending threshold for the year. The patients most likely to incur their OOP cap are those taking asthma drugs, blood thinners, immunology therapies, cancer therapies, and HIV drugs. According to the report, among non-LIS beneficiaries with costs greater than $1,500 in 2025, Black, Asian, and Hispanic beneficiaries are more likely to incur those costs in the last three months of the year and receive limited benefits from the OOP smoothing option.

Executive Action

Recently, the Biden-Harris Administration announced that more than 16.3 million people, a 13 percent increase over last year and new overall record, selected an Affordable Care Act (ACA) Marketplace health plan nationwide during the 2023 Marketplace Open Enrollment Period (OEP). The OEP ran from November 1, 2022 – January 15, 2023 for most Marketplaces. Of the total plan selections, 22% are new to the Marketplaces for 2023, and 78% had active 2022 coverage and made a plan selection for 2023 coverage or were automatically re-enrolled. 

Administrative Action

  • Last Thursday, the Department of Health and Human Services (HHS) released a report entitled, “Marking the 50th Anniversary of Roe: Biden-Harris Administration Efforts to Protect Reproductive Health Care,” which outlines actions HHS has taken in light of the Dobbs decision, which overturned Roe v. Wade. HHS’ actions have been centered on six core priorities: 1) Protecting Access to Abortion Services 2) Safeguarding Access to Birth Control 3) Protecting Patient Privacy 4) Promoting Access to Accurate Information 5) Ensuring Non-discrimination in Healthcare Delivery 6) Evidence-Based Decision Making at FDA.

  • The U.S. Food and Drug Administration (FDA) announced draft industry guidance, Action Levels for Lead in Food Intended for Babies and Young Children, on action levels for lead in processed foods that are intended for babies and children under two years of age. The draft guidance could help reduce potential health effects from dietary exposure to lead. FDA will consider comments on the draft guidance by March 27, 2023. The guidance addresses the lead levels for processed foods, such as food packaged in jars, pouches, tubs, and boxes.

  • To increase internal efficiency and transparency, the Centers for Disease Control and Prevention (CDC) is undergoing organizational changes (subscription required) under Director Rochelle Walensky, including the creation of a new Office of Health Equity led by Leandris Liburd, new Office of Public Health Data, Surveillance, and Technology led by Jennifer Layden, new Global Health Center, and new position for an internal director for external communications to manage public and private partnerships.

Congressional Action

  • On Tuesday, House Speaker Kevin McCarthy named the members of the Select Subcommittee on the Coronavirus Pandemic formed earlier this month. The panel will operate under the newly renamed Committee on Oversight and Accountability. This panel has until January 2, 2025 to conduct an investigation into the pandemic and submit: 1) findings on the origins of the coronavirus pandemic 2) the use of taxpayer funds and relief programs to address it 3) the efficacy of laws and regulations to address the pandemic and prepare for future pandemics 4) the development and implementation of vaccine policies or federal employees and military service members, among other issues. In addition, Energy and Commerce Chair Cathy McMorris Rodgers (R-WA) announced that Rep. Brett Guthrie (R-KY) will serve as the Chair of the Health Subcommittee. His priorities are to focus on price transparency, address the fentanyl crisis, and expand telehealth access, among other initiatives.  

  • Senate Majority Leader Chuck Schumer (D-NY) announced Senate Democratic committee memberships for the 118th Congress. All memberships have been agreed upon by the Democratic Conference and are subject to ratification by the full Senate. All members of the 117th Senate Finance Committee will remain on the committee for the 118th Congress. Sen. Sanders is the new Chairman of the Senate HELP Committee. He is replacing Sen. Murray, who is the new Chairwoman of the Senate Appropriations Committee. Sen. Markey is the newest member of the HELP Committee. He is replacing Sen. Jacky Rosen (D-NV).


  • Late last week, the National Partnership for Healthcare and Hospice Innovation (NPHI), along with LeadingAge, the National Association for Home Care & Hospice (NAHC), and the National Hospice and Palliative Care Organization (NHPCO), released a comprehensive set of program integrity reform recommendations. These recommendations follow concerns expressed by industry leaders about the rapid entry of newly created hospice organizations in several states, and the corresponding adequacy of Medicare certification, accreditation, and enforcement processes. The national hospice organizations urged Congress and the Centers for Medicare and Medicaid Services (CMS) to act to ensure that only well-qualified advanced illness care providers are permitted to care for and support beneficiaries and their families at the end of life. The organizations produced 34 specific recommendations, which can be found here.

  • On Tuesday, the Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation (HHS ASPE) released a new report projecting the estimated cost savings of the new monthly insulin cost caps. Beginning this month, Medicare beneficiaries will only pay $35 for a month’s supply of insulin. HHS estimates that if the cap were in place in 2020, 1.5 million Medicare beneficiaries would have saved an average of $500 on insulin costs for the year. This would have resulted in a total of $734 million in Part D savings and $27 million in Part B savings for beneficiaries. 


  • The Centers for Medicare and Medicaid Services (CMS) approved a section 1115 demonstration amendment that will improve access to care for individuals following release from jail, prison, or youth correctional facilities. This first-of-its-kind approval will allow California Advancing and Innovating Medi-Cal (CalAIM) to cover pre-release services to incarcerated individuals 90 days prior to their release, which builds upon past congressional, administrative, and executive actions. As part of this approval, California will increase and sustain provider payment rates and Medicaid managed care payment rates in obstetrics, primary care, and behavioral health as a condition of the approval of authority to receive Designated State Health Program (DSHP) funding.

  • The Federal Communications Commission (FCC) released new guidance to allow states and their partners to use automated calls and text messages to Medicaid enrollees to inform them about the redetermination process. The FCC issued this guidance in response to a request from Health and Human Services Secretary Xavier Becerra to clarify that states, local governments, managed care organizations, and other government contractors can use pre-recorded and automated messages to contact beneficiaries without violating the Telephone Consumer Protection Act. 


  • On Tuesday, the Center for Medicare and Medicaid Innovation (CMMI) Director Liz Fowler, Ph.D., announced CMMI’s plans to release up to four new alternative payment models in 2023. The new models will focus on advancing primary care and enabling states to assume the total cost of care. These new models align with CMMI’s goals of increasing participation of specialist physicians in value-based care and advancing health equity efforts.

  • Recently, Amazon announced its expansion into the generic drug market with a new subscription service—RxPass—targeting consumers with common health conditions like high blood pressure, acid reflux, or anxiety. The new subscription service is available to Amazon Prime members from Amazon Pharmacy to provide Prime members with affordable access to approximately 50 generic medications delivered free to their home for $5 a month. Amazon Pharmacy stated RxPass is designed for people with chronic conditions who require multiple prescription medications and pay for them out-of-pocket. The program does not accept insurance, including Medicare or Medicaid. The service begins immediately in all states except California, Louisiana, Maryland, Minnesota, New Hampshire, Pennsylvania, Texas, and Washington due to state-specific requirements.


On Tuesday, the Bipartisan Policy Center (BPC) released a report that found that enabling workers who are not licensed behavioral health specialists to provide more services could help address the healthcare workforce shortage. BPC explained that the workforce shortage has severe implications for access to treatment, rates of diagnoses, and causes of hospitalizations. The report includes two recommendations for the federal government to address shortages of behavioral health workers.