HealthCare Roundtable e-News – June 27, 2022


Top News

House and Senate Advance PBM Transparency Legislation

Congress advanced two pieces of legislation aimed at pharmacy benefit manager (PBM) reform. H.R. 7666 is a mental health bill being used as a vehicle to pass a smaller PBM transparency bill from Chairman Frank Pallone Jr. (D-NJ-06) and Ranking Member Cathy McMorris-Rodgers (R-WA-05). The bill passed the House on Wednesday and was referred to the Senate Committee on Health, Education, Labor, and Pensions (HELP) on Thursday. The second bill, S. 4293, is much more comprehensive in nature. It requires greater transparency from PBMs directly to the Federal Trade Commission (FTC), and allows for the FTC and states to directly enforce its provisions. Senator Maria Cantwell (D-WA) introduced the bill last month with Senator Chuck Grassley (D-IA) and it was passed out of Committee and will be sent to the entire Senate for a vote.


Senators Shaheen, Collins Release Bill Preventing PBMs From Accepting Rebates, Capping Insulin Copays

Senators Jeanne Shaheen (D-NH) and Susan Collins (R-MA) released a bill that would block pharmacy benefit managers from accepting drug rebates or other discounts, and cap insulin copays at $35 or 25 percent of the list price per month in commercial and Medicare Part D plans. This bill builds upon the Senators’ 2019 insulin bill in an effort to lower insulin prices. The House passed its standalone version of the bill in March that was expected to cost $20.4 billion over 10 years. However, it is unclear how much this bill is expected cost, and how many Senate Republicans will support it.

Administrative Action

  • The Center for Medicare & Medicaid Innovation (CMMI) released a blog post featuring insights on increasing access to coordinated and integrated specialty care. Their four recommendations were providing data on specialist performance, designing episode-based payment models to align incentives between specialists and ACO’s, specialty care practices assuming primary responsibility for special populations, and integrating specialists into primary care delivery for the benefit of beneficiaries with complex conditions. The focus is on increasing efficient coordination of primary and specialty care providers to complement population-based models and achieve effective whole-body care,
  • The Centers for Medicare & Medicaid Services (CMS) issued the CY 2023 Home Health Prospective Payment System (HH PPS) Rate Updated proposed rule. The rule revises Medicare payments policies and rates for home health agencies (HHAs). It also includes proposals and routine updates to the Medicare Home Health PPS and the home infusion therapy services’ payment rates for CY 2023, in accordance with existing statutory and regulatory requirements. In the report, CMS also proposes to apply a permanent prospective payment adjustment to the home health 30-day period payment period to account for any increases or decreases in aggregate expenditures. Such discrepancies may arise from the difference between assumed behavior changes and actual behavior changes due to implementation of the Patient-Driven Groupings Model (PDGM) and 30-day unit of payment. CMS is soliciting comments on how to best implement a temporary payment adjustment for CYs 2020 and 2021, as well as how to best collect telehealth data on home health claims to allow CMS to analyze the characteristics of the beneficiaries utilizing services furnished remotely. CMS believes the proposed rule will improve patient care and protect Medicare’s sustainability for future generations by responsibly utilizing public funds.
  • The Centers for Medicare & Medicaid Services released its proposed rule updates for Medicare’s End Stage Renal Disease (ESRD) Prospective Payment System (PPS), payment for renal dialysis services furnished to individuals with acute kidney injury (AKI), the ESRD Quality Incentive Program (QIP), and the ESRD Treatment Choices (ETC) Model. Some of the major provisions include rebasing and revision of the ESRD Bundled market basket, updating the ESRPD PPS base rate for Calendar Year (CY) 2023, updating the AKI payment rate for CY 2023, proposing suppression of clinical measure for ESRD QIP until the end of the PHE, and ETC model updates to Participating Provider Agreement beginning January 2023.
  • The U.S. Department of Health and Human Services (HHS) announced approval of Colorado’s Section 1332 State Innovation Waiver amendment request to create the “Colorado Option,” a state-specific health coverage plan that increases health coverage enrollment and lowers health care costs, making insurance more accessible for nearly 10,000 Coloradans. Section 1332 of the Affordable Care Act (ACA) allows states to apply for State Innovation Waivers, and Colorado is the first to adopt the waiver. Colorado projects that 32,000 Coloradans will gain health insurance by 2027 under the amended waiver. The Colorado Option will work in conjunction with the existing section 1332 waiver, a state-based reinsurance program, which is expected to lower premiums by an average of $132 per person per month. The Colorado Option will cover all essential health benefits, including many high value services, like primary care, behavioral health, and prenatal visits, at no cost. It will also combine standard health benefit plans, required premium reductions, and increased state subsidies for those currently eligible and those not currently eligible for federal subsidies under the ACA to make coverage more affordable.
  • The Centers for Medicare & Medicaid Services (CMS) released an updated Disaster Response Toolkit for Medicaid and Children’s Health Insurance Program (CHIP) agencies. This new strategic framework is intended to aid state agencies after numerous recent disasters have threatened vulnerable populations. Updates to the toolkit include additional strategies, flexibilities, and lessons learned from the COVID-19 public health emergency, as well as a new strategic framework for Medicaid and CHIP agencies as they respond to future disasters.

Executive Action

The White House released a blueprint which outlines five strategies for reducing the country’s maternal mortality rate. The administration is acting in anticipation of the Supreme Court’s Dobbs vs Jackson Women’s Health Organization decision this week, which is expected to overturn Roe v Wade, and without key legislative action from Congress on maternal health.

The blueprint contains broad maternal and behavioral health initiatives, including calls to Congress to pass mandatory one-year Medicaid postpartum coverage and invest millions in rural care and maternal mental health. The report also outlines several actions for the Department of Health and Human Security (HHS) to strengthen social supports for women before, during, and after birth, including better data system capacity to identify who is losing Medicaid coverage, expanding the number of providers who participate in Title X, and partnering with hospitals to provide better pre-and post-natal care to those with substance use disorders. Objectives of these broad measures include providing targeted technical assistance, equitable access to care, and high-quality clinical performance, as well as advancing research efforts to better understand maternal health outcomes.

Congressional Action

Congress passed a bipartisan bill that strengthens federal gun laws and provides billions more in funding to prevent future mass shootings. The Bipartisan Safer Communities Act is expected to passed the Senate and House of Representatives this week and will go to President Biden’s desk, where it is expected to be signed into law. The legislation was finalized by Sens. Chris Murphey (D-CT), John Cornyn (R-TX), Krysten Sinema (D-AZ), and Thom Tillis (R-NC), who released a joint statement on Tuesday.

The bill supports early and periodic screening, diagnostic, and treatment services that would cover nearly 40 million children enrolled in Medicaid. The draft legislation also reauthorizes the Pediatric Mental Health Care Access (PMCHA) grant program. Section 11 of the draft includes a provision on Medicaid and Telehealth, which comes directly from the Senate Finance Committee telehealth proposal. The provision requires CMS to provide guidance to states on how they can increase access to health care, including mental health services, via telehealth under Medicaid and CHIP. This legislation would mark the most significant increase in gun regulations since the 1990s.


The Supreme Court decided that a health plan’s low End Stage Renal Disease (ESRD) reimbursement rates do not violate Medicare Secondary Payer requirements as long as all employees are offered the same benefits. In a 7-2 decision, the court ruled that Marietta Memorial Hospital’s employee health plan did not violate the Medicare Secondary Payment Act’s differentiation clause by limiting benefits for outpatient dialysis services, because it did so without regard for whether a patient had ESRD or not. In his opinion, Justice Kavanaugh asserted that while Congress could mandate health plans provide specific benefits, the text of the Medicare Secondary Payer statute does not dictate any minimum level of dialysis coverage.

As a result of this decision, group health plans and other insurers that provide coverage to Medicare-eligible beneficiaries may be more likely to limit their dialysis and ESRD benefits in the same fashion as the Marietta Health Benefit Plan. The primary consequences of these changes may be increased reliance on Medicare coverage for ESRD benefits and a corresponding increase in Medicare expenditures. There may also be coverage disenrollment (and preclusion of initial enrollment) from group health plans by beneficiaries who are diagnosed with or at-risk for ESRD.


  • The Commonwealth Fund Commission on a National Public Health System released a report Friday with recommendations for building a national public health system that addresses ongoing and future health crises, advances equity, and earns trust. The report finds that public health efforts are not organized, sufficient, or reliable. Expectations for health agencies are minimal, and the health care system is missing opportunities to support health improvement. The Commission provides recommendations to Congress, the administration, and states, localities, tribes, and territories. It concludes that the federal government should lead a strong and capable national public health system, with Congress providing stable support matched with expectations for states, localities, tribes, and territories to protect the health of their populations. The Commission recommends that the health care system work closely with public health agencies in normal times and during emergencies, and that these agencies should work to earn the public’s trust.
  • On Friday, an assortment of health care researchers released a reimbursement framework to ensure consistent and sustainable financial incentivization of artificial intelligence (AI) systems in health care. The framework analytically determines value and cost of distinct AI services by using data on ethics, workflow, cost, and value collected from affected stakeholders, including patients, providers, legislators, payors, and AI creators. The ultimate goal of the framework is to create a sustainable reimbursement system for future AI services with “guardrails” that will enforce ethical principles, including ensuring high quality of and access to care, equitable health outcomes, and mitigation of potential biases.

Other News

The Bipartisan Policy Center hosted a panel discussion on Commonwealth Fund Commission’s report and recommendations on a National Public Health System. Commonwealth Fund Commission Chair, Dr. Margaret Hamburg dove further into the four areas of the report in which the federal government could be of assistance starting with building a national public health system that has a well-defined vision, providing reliable congressional funding ($9 billion per year), ensuring collaboration between the broad healthcare system and local agencies, and making efforts to gain trust in the community. Member of the Commission, Dr. Julie Gerberding noted that tasking the Assistant Secretary for Health with bringing health care leaders together to discuss collaboration could be done immediately.

During the second half of the panel, Commission staff members, Dr. Joshua Sharfstein and Dr. David Lakey re-emphasized the imperative nature of consistent resources and funding from the federal government, adding that The Centers for Medicare and Medicaid (CMS) play a large role in using their leverage to support Medicaid collaboration and data map sharing. Closing remarks made by Former Commissioner of Public Health in D.C., Dr. Reed Tuckson highlighted the role of health equity and community engagement in decision making and health system development.