HealthCare Roundtable e-News – July 10, 2023


Roundtable Activity

The Roundtable is pleased to welcome Quantum Health as our newest corporate member.

Quantum Health is an industry-leading consumer healthcare navigation and care coordination company that delivers an unparalleled consumer experience to its members, as well as validated claims savings and high satisfaction rates for its self-insured employer clients. Quantum Health’s proprietary Real-Time Intercept® model identifies opportunities for early intervention in a member’s healthcare journey, resulting in better engagement, outcomes and cost efficiencies. To learn more, visit


Innovations in Virtual Care – Webinar Follow-Up

Thank you to those who joined our recent webinar “Innovations in Virtual Care: How Public Sector Purchasers Are Navigating the Changing Telehealth Policy Landscape”. As you will recall, the Kentucky Employees’ Health Plan (KEHP) team discussed their first-hand experience implementing a digital musculoskeletal (MSK) solution that enabled them to expand access to their members while simultaneously reducing their healthcare costs.

During that discussion, they shared that, by providing easy access to tackle pain, Hinge Health has been transformational for employees and retirees: a 69% reduction in surgery intent per member. As we promised at the close of the call, we are attaching this case study for a deeper look into how pain reduction in Kentucky has decreased MSK spend and increased quality of life for KEHP’s members.

The Roundtable would like to thank the Kentucky Employees’ Health Plan (KEHP) and Hinge Health for making this webinar so successful.


Roundtable Legislative Update – Roundtable Advocates for Congress to Recognize Public Sector Employees’ and Retirees’ Unique Needs in Drug Pricing Reforms

On June 29, the Roundtable sent a letter to members of the congressional leadership to share its unique perspective on the issue of rising prescription drug prices and proposals to reform the Pharmacy Benefit Manager (PBM) industry. In the letter, the Roundtable –

  • Urges Congress to consider the unique needs of public sector employees and retirees when addressing the issue of rising pharmaceutical prices, including protecting the passage of rebate savings onto plan sponsors.
  • Supports reforms to the current rebate system to ensure formularies reflect clinical appropriateness rather than the best rebates and Congress’ efforts to improve transparency across the pharmaceutical supply chain, including the PBM industry.
  • Encourages Congress to examine the pharmaceutical industry’s anticompetitive practices and build on the success of the Inflation Reduction Act (IRA) to rein in exorbitant drug prices. The proposed reforms are an important first step, but are alone insufficient because they fail to address the role of pharmaceutical manufacturers in high drug costs.

The Roundtable can serve as an important resource for Congress as it develops policies to address rising drug prices.

Top News

FDA Grants Full Approval for Alzheimer’s Drug, Leqembi

The U.S. Food and Drug Administration (FDA) granted traditional full approval to the Alzheimer’s drug, Leqembi, the first medicine proven to slow the course of Alzheimer’s disease. The decision is expected to trigger a change in how the Centers for Medicare and Medicaid Services (CMS) covers the drug, broadening access for up to an estimated million people with early forms of the disease. The agency previously granted Leqembi, developed and manufactured by Eisai and Biogen, accelerated approval before evaluating late-stage clinical trial data earlier this year. According to the data, the drug moderately slowed trial participants’ cognitive decline compared to a placebo but had potentially serious side effects, including brain swelling and bleeding. Medicare will cover the approved drugs when a physician and clinical team participate in the collection of evidence about how these drugs work in the real world, also known as a registry. Eisai estimates that roughly 10,000 patients will receive Leqembi by the end of March 2024.


HHS Announces Measures to Safeguard Consumers from Healthcare Pitfalls and Excessive Costs

The U.S. Department of Health and Human Services (HHS) announced several actions to protect consumers and lower healthcare costs. These actions include measures to address junk health plans, surprise medical bills, and excessive costs leading to medical debt. HHS also released a report projecting that nearly 19 million seniors will save around $400 per year on prescription drug costs when the $2,000 out-of-pocket spending cap from President Biden’s lower cost prescription drug law goes into effect in 2025. Additionally, HHS has taken steps to lower the price of prescription drugs, protect consumers from inadequate insurance coverage, improve transparency regarding out-of-pocket costs, and address surprise billing. The department has collaborated with other agencies to gather public input on medical credit cards and similar payment products and their impact on consumers and the healthcare system.

  • The Consumer Financial Protection Bureau (CFPB), the U.S. Department of Health and Human Services (HHS), and the Treasury are requesting public comments on medical credit cards and other financial products used for healthcare expenses. They aim to understand the prevalence, impact, and potential disparities of these products, as well as their effects on patients and the healthcare system. The agencies are particularly interested in receiving input on whether these products undermine patient and consumer protections, contribute to healthcare cost inflation, and harm patients’ financial well-being. Comments are due 60 days after the request for information is published in the Federal Register.
  • HHS announced the first of five evaluation reports on the impact of the No Surprises Act (NSA) which focuses on establishing a baseline and framework for future evaluations. It examines key trends related to the implementation and impacts of state surprise billing laws, market consolidation and concentration, the effects of consolidation on prices, quality, and spending, and trends in out-of-network (OON) billing. The report also outlines a conceptual framework and potential methodologies for estimating the impact of the NSA. Preliminary assessments indicate that the NSA has protected patients from pervasive forms of balance billing, but further monitoring is necessary to assess broader impacts on health care costs, access to services, and consolidation patterns.
  • CMS released FAQs about the implementation of specific provisions of the Affordable Care Act (ACA) and Title I, also known as the No Surprises Act, which is part of the Consolidated Appropriations Act, 2021. The FAQs have been prepared collaboratively by the Departments of Labor, Health and Human Services (HHS), and the Treasury. Questions were broken down between the topics of Limitations on Cost Sharing under the Affordable Care Act and The No Surprises Act and Transparency in Coverage with Regard to Facility Fees.

Regulatory Action

The Departments of Health and Human Services (HHS), Labor, and Treasury (the Departments) released a proposed rule (fact sheet) that modifies the definition of short-term, limited-duration insurance (STLDI) and the conditions for fixed indemnity insurance to be considered an excepted benefit. These types of plans are not subject to many of the Affordable Care Act’s (ACA’s) consumer protections, including essential health benefits, pre-existing conditions, and annual/lifetime dollar limits on services. The proposed changes aim to improve access to affordable and comprehensive coverage, strengthen health insurance markets, and enhance consumer understanding of coverage options.  Specifically, the rule proposes the following: 1) Short-term, limited-duration insurance: The Departments propose to limit the length of the initial contract period to no more than three months and the maximum coverage period to no more than four months, taking into account any renewals or extensions. 2) Fixed indemnity insurance: The Departments propose to prohibit excepted benefits coverage in the individual market from paying benefits on a per-service basis, restoring previous requirements in place in a 2014 rule.


Late last week, South Dakota announced a historic expansion of Medicaid under the Affordable Care Act (ACA) making more than 52,000 South Dakotans eligible for comprehensive health care coverage. As of July 1, 2023, thousands of people in South Dakota who applied for coverage this month will begin to receive full Medicaid benefits, including access to primary, preventive, and emergency care, as well as substance abuse treatment and prescription drug benefits. In implementing its Medicaid expansion, South Dakota will be able to offer all adults aged 19 to 64 with incomes under 138 percent of the federal poverty level ($20,120) comprehensive health coverage through Medicaid. With its expansion, South Dakota is now the 39th state, along with D.C., in adopting the ACA’s Medicaid expansion. Thanks to President Biden’s American Rescue Plan (ARP), the state now receives an additional five-percentage point increase in the regular federal matching rate for most Medicaid services for two years.


  • On Monday, the Journal of the American Medical Association published a study on trends in maternal deaths by state for five racial and ethnic groups. The study looked at maternal mortality ratios from 1999 to 2019, and found that maternal mortality ratios across the U.S. more than doubled within the time period. Since 1999, maternal mortality ratios have increased for all racial and ethnic groups in the U.S, but the Black population had the highest maternal mortality ratios. Notably, the American Indian and Alaska Native population had the largest ratio increase over the two decades. Based on their findings, the authors concluded that maternal mortality is unacceptably high across all racial and ethnic groups in the U.S. and that American Indian and Alaska Native and Black individuals are at increased risk, especially in states where these inequities had not been previously highlighted.
  • On Wednesday, Health Affairs published a study on the health-related social needs (HRSNs) of Medicare Advantage (MA) enrollees. The study looked at the prevalence of HRSNs in 2019 among over 60,000 enrollees in a national MA plan, with key takeaways including. Notably, HRSNs were more common among dual-eligible beneficiaries, with 80 percent reporting at least one (on average, 2.2 HRSNs per beneficiary). In addition, 48 percent of non-dual-eligible beneficiaries reported one or more HRSNs. HRSN burden was unequally distributed across multiple beneficiary characteristics; beneficiaries younger than age sixty-five were more likely than those ages sixty-five and older to report having an HRSN. 4Based on these findings, the study’s authors emphasized the importance of considering the HRSNs of dual- and non-dual-eligible beneficiaries, along with those of beneficiaries of all ages, when exploring how to address HRSNs in the MA population.