HealthCare Roundtable e-News – July 31, 2023


Roundtable Media Alert

Public Sector Plans’ Statement on Recent Biden Administration Administrative Action to Implement Mental Health Parity Law

Today, the Public Sector HealthCare Roundtable, a non-profit, non-partisan coalition of public sector purchasers from across the United States, including states, counties, and municipalities, expressed continued support for the Biden Administration’s ongoing commitment to improving mental health care in the U.S., a commitment Roundtable members share given their longstanding delivery of comprehensive, high-quality health – and mental health – care benefits to active and retired public sector employees and their dependents…

“Over 15 percent of the American workforce is employed by public sector entities, and collectively they spend $43 billion annually on health care benefits,” said Tom Lussier, Administrator of the Public Sector HealthCare Roundtable. “These current and former public servants are the bedrock of their communities, performing vital roles such as teachers, firefighters, and law enforcement. Our members ensure they have access to the highest quality benefits – including mental health benefits — at a cost that is affordable to the employee and taxpayers alike,” said Lussier…

“The Roundtable places significant importance on mental health equity and access as a key policy priority. We are committed to supporting policies that advance equitable access to mental health care, reduce utilization and costs, and improve overall mental health. As such, we were discouraged by the President’s suggestion that our members use a ‘loophole’ in the law to avoid providing mental health benefits at a cost that is at parity with traditional medical benefits,” said Lussier. “By advocating for these policy priorities, we aim to foster a more inclusive and accessible health care system that promotes the well-being of public sector employees, retirees, and their dependents,” he said.

To read the full statement, click here.

Legislative Alert

U.S. Senate Committee on Finance Markup of Modernizing and Ensuring PBM Accountability Act

The markup session for the Modernizing and Ensuring PBM Accountability Act in the U.S. Senate Committee on Finance on July 26 resulted in adoption of several amendments, significantly expanding the scope of the underlying bill. Notably, the bill includes provisions which are well aligned with the recent letter submitted by the Roundtable to Congress.

  • The bill does not include any provisions to change the definition of the safe harbor to only protect post-sale rebates, and therefore preserves the current structure of post-sale rebates which are passed onto the plan sponsors.
  • It delinks any PBM compensation from drug prices, ensuring that PBMs do not have perverse incentives to cover inappropriate and/or more expensive drugs on their formularies.
  • Several reporting requirements for PBMs, as well as studies and reports required from GAO and HHS will result in increased transparency into PBM actions, including preferential formulary positioning of more expensive drugs when cheaper alternatives are available.
  • Provisions on auditing and PBM reporting requirements also significantly increase transparency into PBM actions, giving sponsors a better understanding of their pharmaceutical spend.

Together, these provisions will ensure that formularies are designed to be clinically appropriate and cost conscious. This bill did not include steps to reform pharmaceutical patents or increase supply competitiveness on the supply side in pharmaceutical industry. Although most requirements in this bill are limited to Medicare Part D, some provisions may ultimately affect PBM behavior and desired spillover in commercial markets as well.

To read the full analysis of Senate legislation, click here.

Top News

House Ways & Means Committee Holds Markup on Health Care Price Transparency and Consolidation Bills

The House Committee on Ways & Means met on Wednesday for a markup session of two Roundtable-supported pending pieces of legislation, the Health Care Price Transparency Act of 2023 and the Providers and Payers COMPETE Act. H.R. 4822, the Health Care Price Transparency Act of 2023, passed through committee largely along party lines via a 25-16 voice vote. The proposed legislation would build on the Hospital Price Transparency Rule by extending the reach of the rule to other sites of service including ambulatory surgical centers as well as providers of imaging and laboratory services. H.R. 3284, the Providers and Payers COMPETE Act also passed via a 23-17 voice vote. The bill would require the Secretary of Health and Human Services to submit an annual report detailing the impact of certain Medicare regulations on provider and payer consolidation.

While the current provisions within the Health Care Price Transparency Act did not raise alarms, House Democrats expressed concerns with the lack of provisions in the legislation pertaining to the role of private equity firms in today’s healthcare system. House Republicans were accused by their Democratic colleagues of fast-tracking the legislation in an effort to protect private equity firms in the healthcare industry. The need to increase transparency in the Medicare Advantage space was also a significant talking point for several House Democrats throughout the markup. The Providers and Payers COMPETE Act received pushback from House Democrats as well with Ranking Member Neal (D-MA) citing the gaps in H.R. 4822 as rendering the tasks required under provisions in H.R. 3284 more difficult due to the lack of essential data and information being supplied to the Department of Health and Human Services from industry stakeholders.


Senate Finance Committee Advances Pharmacy Benefit Manager Reforms

The Senate Finance Committee held a markup of the Modernizing and Ensuring PBM Accountability (MEPA) Act, bipartisan legislation containing a variety of provisions related to pharmacy benefit managers (PBM). The legislation advanced with 26 in favor and one opposed. The legislative package looks to update federal prescription drug programs to address the practices of pharmacy benefit manager practices, which Chair Wyden said have driven up health costs for patients and taxpayers. Some key provisions of the legislation include – establish specific PBM data reporting requirements to increase transparency into reimbursement and rebates, delink PBM compensation from drug prices to minimize misaligned incentives in formularies, ban spread pricing in Medicaid, and strengthen oversight of PBMs through various reporting and auditing requirements.

During the markup, multiple senators also emphasized the importance of bolstering protections for small, rural, and independent pharmacies.


Biden Administration Releases Proposed Rule on Strengthening Mental Health Parity and Addiction Equity Act Requirements

On Tuesday, the Departments of Labor, Health and Human Services, and Treasury (the Departments) announced a proposed rule (fact sheet) that implements new requirements related to health plan compliance and enforcement of the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA).

Of particular importance, the rule implements a sunset provision such that self-funded, non-Federal governmental health plans may no longer opt out of compliance with MHPAEA. When MHPAEA was first enacted, it did not require self-funded non-Federal governmental health plans, like those offered to state and local government employees, to comply with its requirements. The rule proposes to codify requirements from the Congressional Appropriations Act of 2023 that would now require these plans to adhere to MHPAEA. Additional details on the sunset provision are described below:

  • No election to opt out of compliance with MHPAEA may be made on or after December 29, 2022, and no opt-out election expiring on or after June 27, 2023, may be renewed either.
  • Includes an exception for certain collectively bargained plans with an opt-out election in effect for MHPAEA that allows for a longer transition to come into compliance with MHPAEA.
  • HHS estimates that 230 self-funded non-Federal governmental plans are affected by the sunset provision. HHS is aware of at least four plans with collective bargaining agreements whose opt out elections could be in effect beyond 2024. In total, HHS estimates that approximately 116,500 beneficiaries would be impacted by this provision.

Other details provisions of the rule include:

  • Provides clarification that MHPAEA requires that individuals can access their mental health and substance use disorder benefits in parity with medical/surgical benefits.
  • Provides specific examples that make clear that plans and issuers cannot use more restrictive prior authorization and other medical management techniques for mental health and substance use disorder benefits; standards related to network composition for mental health and substance use disorder benefits; and factors to determine out-of-network reimbursement rates for mental health and substance use disorder providers.
  • Requires plans and issuers to collect and evaluate outcomes data and take action to address material differences in access to mental health and substance use disorder benefits as compared to medical/surgical benefits, with a specific focus on ensuring that there are not any material differences in access as a result of the application of their network composition standards.
  • Codifies the requirement that plans and issuers conduct meaningful comparative analyses to measure the impact of Non-Quantitative Treatment Limits (NQTLs). This includes evaluating standards related to network composition, out-of-network reimbursement rates, and prior authorization NQTLs.

In addition, the Departments also released a request for comment that asks for feedback on proposed new data requirements for limitations related to the composition of a health plan’s or issuer’s network, evaluation of NQTL data, and enforcement of a safe harbor for plans and issuers. The Departments also released the second MHPAEA Comparative Analysis Report to Congress, which describes enforcement efforts related to parity requirements.


Smarter Health Care Coalition Sends Letter of Support for the Chronic Disease Management Act to Senate Finance Committee Leaders

On July 26, The Smarter Health Care Coalition (the Coalition) sent a letter of support for the amendment advancing the Chronic Disease Management Act filed in the Senate Finance Committee, urging unanimous adoption. The Coalition believes that the amendment filed in the Senate Finance Committee will help expand the ability for Health Savings Accounts to offer services and medications to manage chronic conditions on a pre-deductible basis. The amendment grants health plans and employers more flexibility to vary their benefit designs and offer certain high-value care pre-deductible. The Coalition aims to continue working with Congress and the Administration to ensure additional high-value items and services may be provided pre-deductible.

Regulatory Action

The Centers for Medicare and Medicaid Services (CMS) released two final rules pertaining to the prospective payment systems of Inpatient Psychiatric Facilities (IPFs) and Inpatient Rehabilitation Facilities (IRFs) for fiscal year 2024. In terms of the rule focusing on IRFs, it includes the classification and weighting factors for the IRF prospective payment system system’s case-mix groups as well as a description of the methodologies and data used in deciding the payment rates. In addition to the updates to the prospective payments, the IPF rule also changes the outlier threshold and the wage index for Medicare inpatient hospital services provided by IPFs. It also rebases the IPF market basket back to the 2021 base year. Both rules will go into effect beginning October 1, 2023, and extend through September 30, 2024.

Legislative Action

The Senate Committee on Appropriations advanced the Fiscal Year 2024 (FY24) Labor, Health and Human Services, and Education Appropriations Act, which directs $224.4 billion in discretionary funding toward health and education programs along with programs intended to strengthen the U.S. workforce. The bipartisan legislation passed by a 26-2 vote. For health-related programs, the bill includes several funding increases compared to the FY23 enacted level, including: 1) Directs nearly $50 billion to the NIH, an increase of $943 million relative to FY23, with funding going toward areas including biomedical investments in research and CURES. 2) Provides $5 billion, an increase of $132.5 million relative to FY23, for improving prevention, treatment, and recovery services to combat the opioid epidemic. This action marks the first time in five years that this subcommittee has marked up a Labor-HHS bill.


Healthsperien released its comprehensive summary of the Centers for Medicare and Medicaid Services’ (CMS) calendar year (CY) 2024 Medicare Physician Fee Schedule (MPFS) and Quality Payment Program (QPP) Proposed Rule. Notably, overall payment rates under the MPFS are proposed to be reduced by 1.25% in CY 2024 compared to CY 2023. The proposed CY 2024 MPFS conversion factor is $32.75, a decrease of $1.14, or 3.34%, from the current CY 2023 conversion factor of $33.89. This year’s proposed rule also includes key provisions related to caregiver training services, services related to addressing health related social needs, telehealth, behavioral health, and more. Comments are due by September 11th. To view Healthsperien’s full summary, please click here.


  • Late last week, the Centers for Medicare & Medicaid Services (CMS) approved California and Kentucky’s proposals to cover community-based mobile crisis intervention services in Medicaid. This new Medicaid option, which was authorized under the American Rescue Plan (ARP), aims to allow states to provide Medicaid services by connecting eligible individuals in crisis to a behavioral health provider, during any time or day. The mobile crisis teams work to provide rapid response, individual assessment, and crisis de-escalation by trained behavioral health professionals and paraprofessionals. The new option also includes greater flexibility for states to design programs suitable for their communities and allows states to apply for this option under several Medicaid authorities. California and Kentucky’s approval marks six states that have successfully gained federal approval to provide mobile crisis services under the Medicaid state option. Oregon was the first state to do so, gaining approval in September 2022.
  • Recently, the Centers for Medicare & Medicaid Services (CMS), through the Center for Medicaid and CHIP Services (CMCS) released an action plan for Medicaid enrollees suffering from mental health (MH) issues and substance use disorders (SUD). CMCS referenced the lack of support, as well as shortages of MH and SUD providers in rural and historically underserved communities. The action plan is based on three strategies, coupled with steps to achieve the desired outcome in each. The first is focused on increasing access to prevention and treatment by improving coverage of MH and SUD, as well as supporting the integration of MH and SUD treatment with other health care. The action plan highlights improving engagement in care by increasing treatment in home and community-based settings, combined with supporting access to MH and SUD services through non-traditional settings. The final strategy is geared towards enhancing the quality of care by encouraging the implementation of evidence-based practices, improving quality measurement, and analyzing data on key topics.


  • A study was published in the JAMA Internal Medicine that analyzed the association of social isolation with hospitalization, skilled nursing facility stays, and nursing home placement among community-dwelling older adults over time. The study used a nationally representative cohort of 11,517 older adults which measured each participant’s social isolation on a scale of 0-6, with 6 indicating the greatest amount of isolation. The results showed that approximatively 15 percent of community-dwelling older adults in the U.S. experienced social isolation. Higher social isolation scores were found to be associated with increased odds of nursing home placement and skilled nursing stays over a two-year period. Overall, the study found that that social isolation was a significant risk factor for nursing home use among older adults. It also concluded that nursing home entry would be deterred if there was enhanced social contact at home or in the community for the older adult population.
  • The National Partnership for Healthcare and Hospice Innovation (NPHI), Aliviado Health, and Center to Advance Palliative Care (CAPC) announced today the release of a new NPHI dementia care resources guide that will improve quality of life for dementia patients, reduce hospitalizations, and ease the burden for families and caregivers. The NPHI “Dementia Care Patient & Caregiver Resource Guide” is designed to support the home care of people living with dementia and to assist caregivers, including families, with the skills and necessary information to care for, manage safety, and provide comfort for their loved one living with dementia within their home. The guide offers a detailed explanation of dementia, provides tips for symptom management, and offers resources for both patients and caregivers.