HealthCare Roundtable e-News – March 28, 2022


Roundtable News

Save-the-Date – Wednesday, April 13th at 3:00 PM (EDT)
“Biosimilars in the U.S.: Benefits, Public Policies and Opportunities – A Roundtable Webinar”
Please plan to join us on April 13th for a webinar: “Biosimilars in the U.S.: Benefits, Public Policies and Opportunities,” on how the marketplace has benefited from the use of biosimilars to lower healthcare costs and improve patient access to life-changing therapeutics. This webinar will offer perspectives from the Biosimilars Council and Sandoz on the evolving biosimilar federal and state policy landscape and how key stakeholder groups will be affected. We will also offer policy considerations that can help our organizations to achieve these savings and increased access for your members.
Further details, together with a registration link, will be provided after the beginning of April.
Separating Fact from Fiction on Medicare Advantage EGWPs
In a recent blog post for the Better Medicare Alliance, the Roundtable’s Senior Policy Advisor, Andrew MacPherson, joined BMA President and CEO, Mary Beth Donahue, pushing back against some recent criticism of Employer Group Waiver Plans (EGWPs). In their post, they conclude “Heightened focus on EGWPs calls upon all of us to look beyond the headlines and dig deeper to unearth the truth of EGWPs’ valuable role in fulfilling the promise of Medicare and protecting seniors’ health and financial security.”
To read the full blog post, click here.
FTC Requests Comments on PBMs – Roundtable Requests Member Feedback
The staff of the Federal Trade Commission (FTC) is inviting public comments about the practices of Pharmacy Benefit Managers (PBMs) and their impact on patients, physicians, employers, independent and chain pharmacies, and other businesses across the pharmaceutical distribution system. They are encouraging the public to comment on any issues or concerns they believe are relevant or appropriate for their consideration.
Since Roundtable members generally contract with PBMs to support the administration of their pharmacy benefits, we are considering submitting comments in response to the FTC’s solicitation. If you would like to submit comments for inclusion in the Roundtable’s response, please send them to Tom Lussier, Roundtable Administrator, no later than Monday, April 18th.
If you prefer to respond directly to the FTC, please note that the solicitation closes on April 25th.
To read the full Solicitation for Public Comment, click here.

Top News

Bipartisan Lawmakers Work to Lower the Price of Insulin

In his news conference this week, Senate Majority Leader Schumer (D-NY) said a bipartisan effort to pair an insulin price cap with additional policies to drive down drug costs “has a good chance of passing.” Sens. Susan Collins (R-ME) and Jeanne Shaheen (D-NH) are working to craft legislation in collaboration with Sen. Raphael Warnock (D-GA), who introduced a bill, S. 3700, that would cap what Americans with insurance pay for insulin at $35 per month. In his news conference, Sen. Schumer said he intends to put the bipartisan legislation on the Senate floor after the mid-April recess. Furthermore, Sens. Collins and Shaheen are working on additional policies that would drive down the price of insulin, like targeting PBMs, who negotiate the price of insulin and other drugs.


Rice University Study Finds Less than Half of Texas Hospitals are Complying with Federal Transparency Regulations

This week, researchers from Rice University’s Baker Institute for Public Policy released a report finding that less than half of Texas hospitals comply with federal price transparency regulations. In 2019, CMS finalized new regulations requiring hospitals to make public a list of their standard charges for the items and services they provide. This list must include the cash prices, as well as the minimum and maximum rates the hospital has negotiated with insurers. According to this report, as of June 2021, 55% of the general acute care hospitals in Texas that treat Medicare patients had not met CMS requirements involving reporting of commercial negotiated prices. This issue does is not only rampant in Texas. Thus far, CMS has issued 335 warnings to hospitals, nationwide, for violations but has not yet enforced the requirements through fines. Opponents of such regulation posit that if they release pricing information, it will be useful for their competitors. The study highlights that for larger hospital systems the size of the fines are relatively small compared to their annual profits and can afford to not be in compliance. 

Administrative Action

The Department of Health and Human Services (HHS) through the Substance Abuse and Mental Health Services Administration (SAMHSA) announced two Certified Community Behavioral Health Clinics (CCBHCs) funding opportunities, including Certified Community Behavioral Health Clinic – Planning, Development, and Implementation (CCBHC-PDI) and Certified Community Behavioral Health Clinic – Improvement and Advancement (CCBHC–IA). This announcement is part of an HHS-wide initiative to tackle the nation’s mental health crisis and will be promoted as part of HHS’s National Tour to Strengthen Mental Health, led by Secretary Xavier Becerra. This will expand and increase access to evidence-based mental health and substance use services for all Americans, which includes providing essential mental health services—such as 24-hour mobile crisis teams, screening, and case management—to vulnerable communities that would otherwise lack access to services. 

The Occupational Safety and Health Administration (OSHA) gave notice that they are reopening a comment period to allow for additional public comment on their interim final rule establishing an Emergency Temporary Standard (ETS) related to COVID-19 vaccines for large employers as well as an informal public hearing on the matter. The notice outlines several rulemaking outcomes that would depart from the provisions of the ETS such that OSHA has decided to provide this additional notice and an opportunity to comment. Notably, OSHA will be holding an informal public meeting on April 27, 2022 virtually.

The Department of Health and Human Services (HHS), through Health Resources and Services Administration (HRSA), announced this week that provider relief payments released totaled more than $19 billion across US states and territories. Phase 4 distributions (March 2022) totaled $413 million. This sum was disbursed among more than 3,600 providers. For total distributions by state/territory, including the number of providers who received a payment, click here. Payments can be used until the end of June 2023.

Congressional Action

The Senate Special Committee on Aging held a hearing to discuss the importance of home and community-based services (HCBS) and potential policy solutions to increase access to these services. One witness noted the need to streamline the current patchwork of HCBS waivers to reduce administrative burden and complexity. The critical role family caregivers play in delivering HCBS was discussed highlighting that higher pay and benefits are needed to attract individuals to the workforce. Senator Casey expressed support for the Better Care Better Jobs Act that he has sponsored, and Senator Scott referenced the importance of self-directed care, pointing to a report released by his office in June 2021. 


The ACA’s role in US healthcare system improvement has been critical for reducing health care costs, increasing access to quality care, and making health care more affordable. With recent investment from the American Rescue Plan Act of 2021, this year has record low health care costs and coverage was more affordable than ever through tax credits. Additionally, the ACA’s establishment of the Marketplace impacts patients today, with the most recent open enrollment period having 14.5 million new sign-ups for healthcare insurance coverage. Thirty-nine states expanding Medicaid brought coverage to 18.7 million American adults. The ACA continues advancing in progress to providing better care to millions, over a decade later.


CMS notified the public that they will utilize a reimbursement metric that will change the amount physicians make when administering the Alzheimer’s drug Aduhelm. Starting April 1, CMS plans to use the widely available market price (WAMP) rather than the average sales price (ASP) metric in the Part B formula to bring doctor reimbursement in line with the Aduhelm price cut that took effect on January 1. Generally, Medicare pays doctors 106% of the ASP to administer Part B drugs. But when the ASP of a drug exceeds the WAMP by 5% for two out of four consecutive quarters, CMS may substitute the WAMP for the ASP. 


The Centers for Medicare and Medicaid Services (CMS) released a Medicaid Drug Rebate Program (MDRP) notice for participating drug manufacturers and a notice for states that provides technical guidance for Value Based Purchasing (VBP) Arrangements for drug therapies using multiple best prices. Beginning July 1, 2022, manufacturers will be able to report varying “best price” points for a covered outpatient drug to the MDRP if associated with a VBP arrangement and that arrangement is offered to all states. The guidance provides an overview of the interaction between section 1927 federal rebates and VBP arrangement rebates as well as highlights several issues relating to multiple best price VBP arrangement implementation.
CMS released templates and resources for two state reporting requirements to support Medicaid, Children’s Health Insurance Program (CHIP), and Basic Health Program (BHP) enrollment and renewal efforts as states resume routine operations following the end of the COVID-19 public health emergency (PHE). They include the State Report on Plans for Prioritizing and Distributing Renewals Following the End of the Medicaid Continuous Enrollment Provisions (Renewal Distribution Report) and the Unwinding Eligibility and Enrollment Data Report Excel workbook and specifications. These resources are in addition to a series of ongoing announcements and resources that have been released as CMS works with states to return to routine eligibility and enrollment operations, given the numerous flexibilities that will expire at the end of the PHE. 


America’s Health Insurance Plans (AHIP) released an issue brief offering policy solutions to improve maternal health as well as supporting the movement toward value-based care. In addition to their proposed policy solutions, AHIP highlighted several examples of how health plans have implemented cost-effective initiatives aimed at improving maternal health outcomes.
The Foundation for Social Connection (F4SC) published recommendations for cross-sector stakeholders to address the widespread, urgent public health issue of social isolation and loneliness in a report entitled, Creating the Conditions for Social Well-Being. The report summarizes key takeaways, shares resources, and spotlights innovations from the eight-part Connect+Conversations series, which was produced in partnership with the U.S. Department of Health & Human Services, Administration for Community Living, the AARP Foundation, and Commit to Connection. Notably, the series convened over 2,500 community members and highlighted the importance of collaboration and dialogue to improve social well-being through the lens of various sectors including healthcare, education, and government. The Foundation’s press release can be found here.