HealthCare Roundtable e-News – May 6, 2024

 

 

Still Time to Register for the Medicare Prescription Payment Plan (MP3) Webinar!

The Impact on Public Sector Health Plans

Webinar | May 8, 2024 at 2:00 PM

Join us for a timely and insightful webinar hosted by the Public Sector HealthCare Roundtable, where we’ll delve into the intricacies of the upcoming Medicare Prescription Payment Plan (MP3) Program. Set to roll out in 2025 under the Inflation Reduction Act, this program promises significant changes in healthcare accessibility and affordability. We’ll explore the fundamental aspects of MP3, including its impact on public sector purchasers and how to navigate its requirements.

If you haven’t already determined how MP3 will impact your plan, this is an important discussion you won’t want to miss.

 

Register Today!

 

Meet our Featured Webinar Speakers

Erik Poppe Headshot

Erik Poppe, FSA, MAAA

Director, Health Actuary, Human Capital Practice

Willis Towers Watson

Erik Poppe is a director in Willis Towers Watson’s Health and Benefits business. He has more than 24 years of actuarial experience and over nine years with WTW. In his role, Erik has worked with clients of all sizes and industries. The majority of his time is spent on understanding the ever-changing financial aspect of medical and pharmacy benefits to guide and inform clients on the impact of future costs.

Erik’s work with clients consists of the traditional Health Actuary role which includes developing premium equivalent rates, contributions and both short and long term projections of claims experience. In addition, Erik also works with several clients that have frequent acquisitions and require in depth financial analysis.

Prior to joining WTW, Erik was the director of actuarial and quoting for a regional pharmacy benefit manager. In this role, he was responsible for guiding existing and prospective mid-market companies leveraging pharmacy benefit savings within the existing health benefit framework. Erik also worked for a national insurance company that provided long-term care and supplemental health policies, and he has experience with a regional health insurance carrier. He specializes in using software technology to provide solutions for both external and internal stakeholders.

Erik holds a B.S. degree in applied mathematics from Kettering University. He is a Fellow in the Society of Actuaries and a Member of the American Academy of Actuaries.

 

Megan Keyes

Senior Director, Regulated Markets Services Operations & Product Development

Express Scripts

Megan Keyes is a Senior Director within the Express Scripts Regulated Markets Division. Her team is responsible for Regulated Markets Financial Management, Employer Group Waiver Plan (EGWP) and Administrative Services Operations, and Plan Experience and Oversight.

Megan has over 22 years in the pharmacy benefit industry with 17 years focused on Regulated Markets including EGWP, Exchanges, Part B, and PDP benefits.  Her experience includes driving operational excellence, strategic product and business development, and change management.

Megan is currently on the Board of Directors and Compliance Committee for the Medco Containment Life Insurance Company (MCLIC) and Medco Containment Insurance Company of NY (MCICNY).

Megan has her Bachelor of Science degree from Maryville University.


Congressional Forum – June 5-6, 2024

Plan NOW to attend the Roundtable’s 2024 Congressional Forum

The Phoenix Park Hotel, Washington, DC

Whether you actively advocate with the Administration or your Members of Congress or not, you should plan to participate in the Roundtable’s Congressional Forum. You’ll learn first hand from industry leaders, DC allies, and key friends in Congress about the issues which impact health care purchasers today.

The Forum will begin with a networking reception on Wednesday, June 5th and continue with a series of educational presentations on Thursday morning, June 6th. For those who are able, the Roundtable will provide information to support meetings on Capitol Hill as health plan representatives reach out to educate their Members of Congress on Roundtable priorities.

A preliminary agenda, hotel information, and a registration link will be announced shortly. There will be no fee for this event.

We look forward to welcoming you to Washington!


Top News

CMS Releases Draft Guidance for Second Cycle Negotiation of the Medicare Drug Price Negotiation Program

The Centers for Medicare and Medicaid Services released draft guidance (fact sheet) outlining requirements and parameters for the second cycle of negotiations for the Medicare Drug Price Negotiation Program, set to begin in 2025 and potentially establish negotiated Maximum Fair Prices (MFPs) effective from 2027. Building upon the initial cycle’s policies, this updated guidance also addresses how participating drug companies will implement agreed-upon prices for 2026 and 2027. Established under the Inflation Reduction Act of 2022, this program empowers Medicare to directly negotiate prices for high-expenditure, single-source drugs without generic or biosimilar competition, with the aim of enhancing drug affordability for beneficiaries and reducing program costs. Last year, CMS selected 10 drugs covered under Medicare Part D for negotiation, with resulting MFPs expected to come into effect starting in 2026. The draft guidance is open for public comment until July 2, 2024, with CMS expected to issue final guidance in fall 2024, aligning with the program’s commitment to transparency and engagement.

 

HHS Publishes New Rule to Advance Protections Against Discrimination in Healthcare

The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) and the Centers for Medicare & Medicaid Services (CMS) issued a final rule under Section 1557 of the Affordable Care Act (ACA), aimed at strengthening nondiscrimination protections in healthcare. This rule enhances safeguards against discrimination based on race, color, national origin, sex, age, and disability by reducing language barriers, improving accessibility, addressing bias in health technology, and more. It underscores the Biden-Harris Administration’s commitment to health equity and patient rights. Key provisions include recognizing Medicare Part B payments as a type of Federal financial assistance for the purposes of triggering civil rights laws, expanding language and accessibility services, clarifying protections for LGBTQI+ patients, and addressing discrimination in health insurance benefit designs. The rule also extends nondiscrimination principles to include the use of artificial intelligence (AI), clinical algorithms and other support tools.

 

ASPE Releases Report Analyzing Patient Care Navigation in the Medicare Program

The Office of the Assistant Secretary for Planning and Evaluation (ASPE) published a report that explores patient care navigation in the Medicare program. Patient navigation is a vital support system aiding patients and families in navigating the intricate landscape of healthcare services. These programs, established by private health insurers and healthcare systems, offer a range of features including clinical decision support, financial guidance, and access to social and community services. To better understand the current state of available patient navigation programs, ASPE conducted a literature review examining currently available articles and held discussions with four health care service organizations. Key findings from the exploration of patient navigation programs reveal their pivotal role in healthcare access and quality improvement. Notably, patient navigation has been integrated into Medicare initiatives, such as the Oncology Care Model, signaling its growing importance in addressing the needs of the Medicare population. The diverse landscape of patient navigation encompasses a range of target populations, from high-need patients to those with specific diagnoses like cancer, and operates within various healthcare organizations, including large integrated systems and smaller clinics. Moreover, staffing models varied widely, with programs employing nurses, social workers, community health workers, and others, each with their own credentialing requirements. Policy considerations, including funding and staff retention, also emerge as crucial factors in the success of patient navigation initiatives.

Administrative Action

  • The Office of the Assistant Secretary for Planning and Evaluation (ASPE) released an issue brief analyzing Medicare fee-for-service data to understand primary care spending. The issue brief focuses on four types of measures of primary care based on provider type, specialty, and service location, and found that the estimates vary. Results show that in 2019, the average monthly per beneficiary spending on primary care in the Medicare fee-for-service program ranged from $32 to $69. The brief points out that while the estimates were variable, the trends across all four measures remained relatively consistent over the three-year period of analysis. It found that across all estimates, there was a decrease in primary care and overall health care utilization throughout 2020, due to the impacts of the COVID-19 pandemic. The report noted that female beneficiaries, Asian/Pacific Islander beneficiaries, and beneficiaries ages 65 to 74 had comparably higher percentages of spending for primary care while those with the lowest percentage were beneficiaries dually enrolled in Medicaid and beneficiaries with more chronic conditions. Looking forward, findings from the issue brief can aid in determining a foundational metric to assess if investments in primary care are effective.

 

  • The U.S. Department of Health and Human Services (HHS) through its Office for Civil Rights (OCR), finalized the Discrimination on the Basis of Disability in Health and Human Service Programs or Activities rule that bans discrimination on the basis of disability. This rule promotes equity, improves protections for people with disabilities under Section 504 of the Rehabilitation Act (Section 504), and represents the most recent HHS action supporting Executive Order 14091, entitled Further Advancing Racial Equity and Support for Underserved Communities Through the Federal Government. The rule, among other things, affirms that medical treatment decisions are not based on negative biases or stereotypes, bans the use of any metric that discounts the value of a life extension on the basis of disability to hinder access to an aid, benefit or service, and further describes what accessibility means for websites and mobile apps through identifying specific technical standards. The Final Rule also updates existing requirements for consistency with the American with Disabilities Act (ADA). The rule will come into effect 60 days after publication and the current rule will be in effect until that time.

Regulatory Action

The U.S. Food and Drug Administration (FDA) issued a final rule to enhance the safety and effectiveness of laboratory developed tests (LDTs) used in healthcare decisions. LDTs are diagnostic products used within a single laboratory and are crucial in healthcare, analyzing specimens like blood or saliva to provide health information. The FDA issued a final rule clarifying that LDTs are devices under the Federal Food, Drug, and Cosmetic Act (FD&C Act) and plans to phase out its enforcement discretion approach for LDTs over four years. This aims to address risks associated with modern LDTs, such as inaccurate results. The FDA intends to exercise discretion for certain categories of LDTs to ensure continued access to necessary tests while promoting safety and effectiveness. Additionally, the FDA released draft guidance documents regarding enforcement discretion policies for unauthorized IVDs during public health emergencies. The first draft guidance offers considerations for permitting certain laboratories to use unauthorized IVDs during emergent situations, while the second draft guidance outlines factors for developing enforcement discretion policies for certain IVDs during declared public health emergencies.


Mark your calendar:


Roundtable’s Congressional Forum

June 5-6, 2024

Phoenix Park Hotel, Washington, DC

(Registration Opens Wednesday, May 1st)


Roundtable’s 20th Annual Conference

November 6-8, 2024

The Mayflower Hotel, Washington, DC


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