HealthCare Roundtable e-News – March 6, 2023


Top News

Roundtable Submits Comments on CMS Advance Notice

Today, the Roundtable submitted comments in response to the Centers for Medicare & Medicaid Services 2024 Medicare Advantage (MA) and Part D Advance Notice. Combined, the proposed changes would result in a 3.12 percent reduction in 2024 plan payments. The Advance Notice also includes a coding intensity adjustment based on conditions more frequently coded in MA than fee-for-service, removing over 2,000 unique ICD-10 codes. While the Roundtable recognizes the importance of periodic updates to MA payment policies, we are very concerned that the proposed changes would lead to increased costs for public sector retirees and their dependents who often rely on fixed incomes. The Roundtable letter to CMS can be viewed here.


House Oversight and Accountability Committee Opens Investigation into PBMs

Last Wednesday, the House Oversight and Accountability Committee opened an investigation into the business practices of pharmaceutical business managers (PBMs). The Committee’s chair Rep. James Comer (R-KY) claimed that PBMs increase drug prices and harm patients. Rep. Comer and the committee are focusing their investigation on CVS Caremark, Express Scripts, and OptumRx. As part of the investigation, Comer sent letters to the Office of Personnel Management, the Centers for Medicare and Medicaid Services, and the Defense Health Agency to determine how PBMs impact healthcare programs administered by the federal government.

Last month, the Roundtable submitted a statement for the Senate Committee on Commerce, Science, and Transportation full committee hearing on increasing federal oversight of PBMs. The Roundtable’s statement emphasized our members’ support of efforts to constrain health care cost growth, and highlighted the role that PBMs play in maintaining affordable drug costs for Roundtable members’ active and retired populations. Our members rely on the ability of PBMs to negotiate with all parties in the prescription drug supply chain for the best possible price.


Eli Lilly Announces Significant Reduction in List Price of Insulin Product

Last Wednesday, Eli Lilly announced it will cut the list price of its most commonly prescribed insulin products by 70% in the fourth quarter of 2023. Additionally, Eli Lilly will expand its Insulin Value Program, which caps patients’ out-of-pocket costs at $35 or less per month. The announcement comes after new pressure from biosimilar manufacturers to lower prices, as well as efforts by lawmakers to cap the cost of insulin. The company will also cut the list price of its non-branded insulin lispro injection to $25 a vial, effective May 1. During his State of the Union Address, President Joe Biden called for manufacturers to lower insulin costs. Last summer, Democrats attempted to cap copayments for insulin at $35 a month for all plans, including the private market, as part of the Inflation Reduction Act. However, the final law only applied to Medicare beneficiaries. Beginning July 1st, the Inflation Reduction Act provision will go into effect for Medicare beneficiaries.


Sens. Hassan and Braun Reintroduce Legislation to Close Pharmaceutical Loophole

Last Wednesday, Sens. Maggie Hassan (D-NH) and Mike Braun (R-IN) reintroduced a bill that aims to close a loophole that pharmaceutical companies use to block other firms from selling competing drugs, including low-cost generics. The Food and Drug Administration (FDA) can require manufacturers to have a Risk Evaluation and Mitigation Strategy program for potentially dangerous drugs, which some companies patent to delay potentially cheaper versions from entering the market. The Increasing Prescription Drug Competition Act would allow the FDA to immediately approve drugs if a REMS patent is the only barrier to approval.

Executive Action

Last Tuesday, the President’s Domestic Policy Advisor Susan Rice and Surgeon General Dr. Vivek Murthy hosted a roundtable (summary here) on addressing the mental health crisis among young Black men. Ambassador Rice and Dr. Murthy were joined by selected young people speaking about their lived experience on this issue, as well as a provider discussing how to improve treatment and support for the community. The conversation outlined challenges and opportunities to address mental health among Black young men in America including: 1) Understanding stressors and stigmas that are unique to young Black men including the issue of racism and racial trauma. 2) Increasing access to treatment by expanding the mental health workforce and supporting policies that remove barriers to workforce diversity, including addressing the cost of education and debt. 3) Considering young Black men’s and their communities’ strengths to support their mental health. 

Administrative Action

  • Last Monday, HHS announced the formation of several new divisions within the Office for Civil Rights (OCR) to address rapidly increasing cybersecurity breaches to better protect patient and federal data. OCR is responsible for enforcing the Health Insurance Portability and Accountability Act of 1966 (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act of 20090 by mandate. Further, OCR’s caseload increased 69 percent between 2017 and 2022, with 51,000 complaints to investigate. Due to the significant increase in cases and the continued increase in large data breaches of health care providers, OCR is reorganizing by forming a new Enforcement Division, Policy Division, Strategic Planning Division, and renaming the Health Information Privacy Division (HIP) to the Health Information Privacy, Data, and Cybersecurity Division (HIPDC).

  • Recently, CMS released CMS Waivers, Flexibilities, and the Transition Forward from the COVID-19 Public Health Emergency. The fact sheet covers information for those with Medicare, Medicaid and CHIMP, and private health insurance on COVID-19 vaccines, testing, and treatments access to telehealth services, waivers and administrative flexibilities, and Inpatient Hospital Care at Home. 

Congressional Action

  • Senator Elizabeth Warren’s office published a report on harmful Medigap marketing practices. “Medigap” coverage, also known as Medicare Supplemental Insurance, is relied on by millions of seniors nationwide to fill coverage and cost gaps in their Medicare coverage. Overall, the investigation finds that: 1) Offers of luxury vacations or other incentives to agents are pervasive in the Medigap market. 2) Bonuses and perks can incentivize agents and brokers to steer seniors to the wrong products. 3) Bonus perks for agents and brokers are both legal and minimally regulated.

  • The Senate Committee on Health, Education, Labor, and Pensions (HELP) Ranking Member Bill Cassidy (R-LA) issued a request for an updated report on Community Health Center funding titled “Health Centers: Trends in Revenue and Grants Supported by the Community Health Center Fund.” The current report covers Community Health Center revenue during Fiscal Years 2011 through 2017. The HELP committee’s request seeks to update this data to include funding provided by COVID-19-related legislation and the American Rescue Plan Act. Senator Cassidy notes in the letter his aims to assess the effectiveness of the overall program in achieving its statutorily defined goals amid the potential reauthorization of the Community Health Center Fund.

  • The Senate Committee on Health, Education, Labor, and Pensions (HELP) Chair Bernie Sanders (I-VT) and Ranking Member Bill Cassidy (R-LA) released a request for information on the drivers of health care workforce shortages and potential shortages. The request follows the committee’s recent hearing on February 16 examining the current state of workforce shortages, and how Congress can address this challenge. Healthsperien’s comprehensive summary of the HELP hearing can be found here. In their letter, Senators Sanders and Cassidy note that they plan to use the responses to develop bipartisan legislation in the future. Comments are due to by Monday, March 20.

  • Last Monday, CBO issued (IHP subscription required) an informal score of $10 billion for the  Improving Seniors’ Timely Access To Care Act. CBO initially issued a score of $16 billion shortly after the bill passed the House last year. House Speaker Kevin McCarthy’s staff requested that CBO re-score the bill in mid-January, and strongly encouraged the Agency to use a cost analysis included in CMS’ proposed rule on prior authorization. Proponents of the bill are reassessing their next steps, including a potential second informal rescore or potential tweaks to the bill. Legislators plan to meet with CBO to understand the revised baseline and to what degree the resources they provided had been considered. They noted plans to work with House and Senate Committees of jurisdiction and leadership to adjust the legislation to bring the score down to a negligible amount.


CMS posted the anticipated state timelines for initiating unwinding-related renewals. This chart details the expected first month for each state or territory’s unwinding-related renewals, as well as the anticipated effective date for the first procedural terminations. The anticipated termination date is generally the first month that members who have not had their eligibility successfully renewed in the past 12 months may be disenrolled for procedural reasons, such as non-response to a renewal form, per CMS guidelines. Terminations for individuals the state has redetermined as ineligible for Medicaid and CHIP may occur on or after April 1, 2023.


Last Monday, the American Benefits Council sent a letter to House and Senate leadership detailing their priority legislative health care objectives for the 118th Congress. The letter offers recommendations for how Congress can best support employers’ efforts to address health care challenges and continue to provide affordable, high-quality health care coverage to workers and their families. Their letter calls upon Congress to: 1) Preserve and Strengthen Employer-Provided Health Coverage 2) Lower cost and improve value 3) Leverage telehealth to improve access and value 4) Combat the mental health crisis.

Regulatory Action

Last Friday, the Drug Enforcement Administration (DEA) announced proposed rules for the permanent prescribing of controlled medications via telemedicine. The proposed rules would reimpose some restrictions on telehealth prescribing of controlled substances following the end of the COVID-19 public health emergency (PHE) on May 11. For medical practitioners who have never conducted an in-person evaluation of a patient, but a telemedicine consultation results in the prescribing of a controlled medication, the proposed rules would allow clinicians to prescribe: 1) a 30-day supply of Schedule III-V non-narcotic controlled medications; 2) a 30-day supply of buprenorphine for the treatment of opioid use disorder. The public has 30 days to review and comment on the proposed rules.


  • Last week, researchers at the RAND Corporation and University of Texas at Austin published a new study analyzing Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data collected from family caregivers of individuals receiving hospice care between 2017 and 2019. The CAHPS survey measures care experiences, a core element of hospice care quality, related to communication, timeliness of care, symptom management, and emotional and religious support. The researchers found that caregivers reported worse experiences at for-profit hospices across all CAHPS measures analyzed. Over 31% of for-profit hospices scored three or more points below the national hospice average, while just 12% of non-profit hospices received below average ratings.

  • Recently, KFF released an analysis of the 988 Crisis lifeline system’s performance since the official launch in July 2022. Nationally, the 988-lifeline received over 2 million contacts, including calls, text messages, and chat messages, an increase of 43% over the previous year, which required a 10-digit number. At the same time, the state and national 988 call centers responded to 91% of contacts, up from 64% the previous year, and experienced shorter wait times. However, the researchers caution that seven states still have lower than 70% response rates. In addition, when an in-state facility cannot answer 988 calls, they are automatically routed to out-of-state response centers, which may be less familiar with the behavioral health resources available in the caller’s area.

  • On Wednesday, CDC released a report on emergency department (ED) visits related to mental health disorders among adults by race and ethnicity. Of the 6,000 mental health-related ED visits between 2018 and 2020, Black Americans had the highest rates for any mental health disorder, including substance use, anxiety, and mood. Specifically, Black and Hispanic patients were more likely to wait more than an hour to be seen by a clinician compared to white patients. In addition, a higher percentage of Black and Hispanic adult visits had Medicaid as the expected primary payment source. This report comes at a time of increased demand for behavioral health services and growing pressures on emergency departments nationwide.

Mark Your Calendar for Upcoming Roundtable Events

Webinar – March 28, 2023 – 2:00 PM (EST) – The Cost of the Pharmaceutical Industries’ Anticompetitive Practices and its Impact on Public Sector Purchasers

To protect profits and delay competition, pharmaceutical companies often abuse patent thickets, the accumulation of an overlapping set of patents, and other anti-competitive practices which leads to higher costs for Roundtable members and the public sector purchasers they serve. A recent Matrix Global Advisors (MAG) report highlights the cost of these practices, finding that abuse of patent thickets results in certain drugs costing patients and the healthcare system an estimated $1.8 billion to $7.6 billion per year. Join us for a discussion with the Public Sector HealthCare Roundtable senior policy team and the report’s authors on the cost of anti-competitive practices by the pharmaceutical industry and policymakers’ efforts to enact legislative and regulatory reform.


Webinar – May 9, 2023 – 2:00 PM (EST) – Drivers of Health Care Costs: Hospital Consolidation and Lack of Price Transparency

With healthcare costs growing at an unsustainable rate, employers, taxpayers, and patients have to pay more for the same quality of care. Hospitals are one of the top drivers of rising healthcare costs due to the lack of market competition. Join us to hear from the Public Sector HealthCare Roundtable senior policy team and our group of experts on the impact of hospital consolidation, anti-competitive practices, and the lack of price transparency on patients and market-based solutions to increase hospital competition and reduce healthcare costs.


19th Annual Conference – November 1-3, 2023