On behalf of everyone who attended the 19th Annual Conference of the Public Sector HealthCare Roundtable last week in Washington, DC, we’d like to express our appreciation to the following speakers:
Christen Linke Young
Sabrina Corlette, J.D.
Richard (Curt) Dame
Michael S. Kolber
William H. Dietz, MD, PhD
Congressman Patrick Kennedy
Julianne Holt-Lunstad, Ph.D.
Melissa A. Schulman
Senate Finance Committee Releases Discussion Draft on Mental Health and PBM Reform
Senate Finance Committee Chair Ron Wyden (D-Ore.), and Ranking Member Mike Crapo (R-Idaho) released a discussion draft including policies aimed at expanding mental health care under Medicaid and Medicare and reducing prescription drug costs for seniors. The package also includes the extension of certain Medicaid and Medicare provisions that will expire this year, as well as changes to Medicare payment to support providers. The committee intends to advance these legislative proposals, in addition to pharmacy benefit manager (PBM) reforms previously passed out of Committee in July. Key provisions include:
- Expanding the number of mental health and substance use providers participating in Medicare–including psychologists, clinical social workers, marriage and family therapists, and mental health counselors–in rural and underserved communities.
- Expanding the use of licensed clinical social workers (LCSWs) and occupational therapists under Medicare.
- Funding primary care physicians to deliver behavioral health and primary care to Medicare beneficiaries in the same setting.
- Improving access to Medicare mental health services delivered through telehealth.
- Requiring Medicare Advantage plans to have up-to-date and accurate provider directories.
- Improving mental health services and substance use disorder care for youth enrolled in Medicaid and CHIP.
- Improving integration of mental health services and substance use disorder care with primary care for youth enrolled in Medicaid and CHIP.
- Assuring pharmacy access and choice for Medicare beneficiaries.
- Protecting seniors from paying higher copays on certain prescription medicines.
- Increasing access to more affordable biosimilar medicines in Medicare Part D.
- Supporting physicians and professionals by mitigating predicted Medicare payment cuts.
- Extending Medicaid and Medicare provisions that will expire this year.
These proposals will be discussed during a markup on Wednesday, November 8 at 10 a.m.
Congressmen Urge the Centers for Medicare and Medicaid Services (CMS) to Increase Transparency of Broker Participation and Compensation in the Medicare Advantage Market
Congressmen Frank Pallone (D-NJ) from the Committee on Energy and Commerce and Richard Neal (D-MA) from the Committee on Ways and Means wrote a letter to CMS urging increased oversight and transparency of broker participation and compensation in the Medicare Advantage market in the upcoming Contract Year 2025 Part C and D Policy and Technical Changes proposed rule. Concerns have been raised around the convoluted process for enrolling in a Medicare Advantage plan and financial incentives influencing which plans brokers highlight without taking into account seniors’ health needs and budget. As a result, they are urging CMS to require Medicare Advantage plans to report total broker compensation amounts, inclusive of any bonus administrative or incentive payments made to brokers. In addition, CMS is being urged to reform total broker payments by including standardized limits on compensation. This is in effort to remove incentives that encourage enrollment in plans with the highest broker payment that may not be best suited for seniors’ health needs. Further, these limits may encourage seniors to utilize trusted sources of information such as Medicare Advantage PlanFinder and SHIPs.
HHS Addresses Information Blocking Among Health Care Providers
The U.S. Department of Health and Human Services (HHS) announced a proposed rule aimed at establishing disincentives for health care providers that have committed information blocking. Information blocking occurs when a provider “knowingly and unreasonably interferes with the access, exchange, or use of electronic health information except as required by law or covered by a regulatory exception.” If a health care provider participates in information blocking, as determined by the HHS Office of Inspector General (OIG), they would not be considered a meaningful user of certified electronic health record (EHR) technology, would receive a zero score in the Promoting Interoperability performance category of MIPS (if applicable), and would be deemed ineligible to participate in their ACO (if applicable) for at least one year. If an eligible hospital or critical access hospital (CAH) is found to participate in information blocking, they would also not be considered a meaningful EHR user. The HHS Secretary holds this authority under the 21st Century Cures Act (Cures Act). These disincentives aim to promote the sharing of electronic health information. In the coming weeks, the Office of the National Coordinator for Health Information Technology (ONC) and the Centers for Medicare & Medicaid Services (CMS) will host an information session to discuss this proposed rule. Public comment is requested by January 2, 2024.
President Biden Issues Executive Order on Safeguards for AI
President Biden issued an Executive Order that establishes new standards for innovation and risk management regarding artificial intelligence (AI). The Executive Order stems from the Biden-Harris Administration’s comprehensive strategy for responsible innovation and builds on previous work conducted by the President including commitments from 15 leading companies to drive safe, secure, and trustworthy development of AI. The Executive Order directs actions within eight areas of focus including:
- New Standards for AI Safety and Security
- Protecting Americans’ Privacy
- Advancing Equity and Civil Rights
- Standing up for Consumers, Patients, and Students
- Supporting Workers
- Promoting Innovation and Competition
- Advancing American Leadership Abroad
- Ensuring Responsible and Effective Government Use of AI
Among several other actions that were directed from the White House, the Executive Order encourages the advancement of the responsible use of AI in healthcare for the development of affordable, life-saving drugs. Additionally, the Executive Order establishes a safety program within the Department of Health and Human Services (HHS) that will receive reports of harmful healthcare practices involving AI and take necessary steps to address them.
Departments Release Proposed Rule on Surprise Billing Payment Dispute Process
The Departments of Health and Human Services, Labor, and the Treasury (the Departments) and the Office of Personnel Management released a proposed rule (fact sheet) on the federal independent dispute resolution (IDR) process under the No Surprises Act (NSA). In response to feedback and challenges posed by various stakeholders, the proposed rule addresses specific issues related to the operations of the IDR process. Comments are due by January 2, 2024. Key proposals are highlighted below:
Early Communication Between Payers and Providers
- Require that payers provide additional information at the time of initial payment or notice of denial of payment, including the legal business name of the plan (if any) or issuer, the legal business name of the plan sponsor (if applicable), and its IDR registration number.
- Require payers to communicate information to providers by using specific claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs).
- Require that a party provide an open negotiation notice to the other party and the Departments through the Federal IDR portal to initiate the open negotiation period.
- Specify that the 30-business-day open negotiation period begins on the date when the party submits the open negotiation notice and a copy of the remittance advice or notice of denial of payment to the other party and the Departments through the Federal IDR portal.
- Open negotiation notice would include several new required content elements to help parties identify the item or service, the reasons for the denial of payment or initial payment amount, and whether the Federal IDR process applies.
- New batching provisions to allow qualified IDR items and services to be batched in order to address the unique circumstances of certain medical specialties and provider types.
- Establish a Departmental eligibility review process to support eligibility determinations during a period of systemic delay or other extenuating circumstances.
- Collect the non-refundable administrative fee directly from the disputing parties rather than having the certified IDR entities collect the administrative fee on the Departments’ behalf.
- Establish debt collection procedures of the Federal IDR process in the event that a non-initiating party fails to pay the administrative fee in a timely manner.
- Charge both parties a reduced administrative fee when the highest offer made during open negotiation by either disputing party was less than a predetermined threshold, and to charge the non-initiating party a reduced administrative fee when the dispute is determined ineligible by either the certified IDR entity or the Departments.
- The Centers for Disease Control and Prevention’s (CDC) National Institute for Occupational Safety and Health (NIOSH) announced a new federal campaign called “Impact Wellbeing.” This campaign is designed to tackle healthcare worker burnout by helping hospital leadership implement solutions that sustain worker wellbeing and address the operational factors contributing to burnout. John Howard, the Director of NIOSH, highlights long work hours, risk for hazardous exposures, stressful work, and high administrative burdens as causes of burnout. Hospital leaders are encouraged to explore the following campaign resources: NIOSH Worker Well-Being Questionnaire, Leadership Storytelling Guide, and Total Worker Health® Strategies. The announcement also recommends that hospital leaders remove intrusive mental health questions on hospital credentialing applications to reduce mental health stigma and discrimination in the workplace. Impact Wellbeing is inspired by the COVID-19 American Rescue Plan of 2021 and the Dr. Lorna Breen Health Care Provider Protection Act.
- The Centers for Medicare and Medicaid Services (CMS) released the Calendar Year (CY) 2024 Hospital Outpatient Prospective Payment System (OPPS): Remedy for the 340B-Acquired Drug Payment Policy for Calendar Years 2018-2022 Final Rule. The final rule comes after an extended comment period in September and is in response to the June 15, 2022, Court decision: American Hospital Association v. Becerra. The Supreme Court unanimously ruled that the differential payment rates for 340B-acquired drugs were unlawful because, before implementing the rates, the Department of Health and Human Services (HHS) failed to survey hospitals’ acquisition costs under the relevant statute. Of note, the rule finalizes policies including lump sum payments to affected providers for 340B-acquired drugs, beneficiary copayments, prospective offset for higher payments for non-drug items and services from CY 2018-2022 and new providers.
- The Centers for Medicare and Medicaid Services released (fact sheet here) their calendar year (CY) 2024 Medicare Hospital Outpatient Prospective Payment System (OPPS) and ASC Payment System final rule. CMS notes that in addition to finalizing payment rates, this year’s rule includes policies aligning with several key goals of the Biden-Harris Administration, including promoting health equity, expanding access to behavioral health care, improving transparency in the health system, and promoting safe, effective, and patient-centered care. The final rule highlights updates to OPPS and ASC payment rates, the intensive outpatient program, changes to community mental health centers conditions of participation, OPPS payment for remote mental health services, hospital price transparency, rural emergency hospitals, and OPPS payment for drugs acquired through the 340B program.
- The Centers for Medicare and Medicaid Services (CMS) released (fact sheet) the calendar year (CY) 2024 Medicare Physician Fee Schedule (MPFS) and Quality Payment Program (QPP) Final Rule, which finalizes policy changes for Medicare payments under the MPFS and other Medicare Part B issues. The overall payment rates under the MPFS are expected to be reduced by 1.25% in CY 2024 compared to CY 2023. The final CY 2024 PFS conversion factor is $32.74, a decrease of $1.15 (or 3.4%) from the current CY 2023 conversion factor of $33.89.
- CMS issued the CY 2024 Home Health Prospective Payment System (HH PPS) Rate Update final rule, which updates Medicare payment policies and rates for Home Health Agencies (HHAs). The rule includes routine updates to the Medicare Home Health PPS payment rates for CY 2024 and CMS estimates that Medicare payments to HHAs in CY 2024 will increase in the aggregate by 0.8 percent, or $140 million, compared to CY 2023. CMS is finalizing a permanent prospective payment adjustment to the CY 2024 home health 30-day period payment rate to account for any increases or decreases in aggregate expenditures as a result of the difference between assumed behavior changes and actual behavior changes, due to the implementation of the Patient-Driven Groupings Model (PDGM) and 30-day unit of payment as required by the Bipartisan Budget Act of 2018. As a result of CMS finalizing roughly half of the full permanent adjustment projected, Medicare payments to HHAs in CY 2024 will increase in the aggregate by 0.8 percent, rather than a 2.2 percent decrease as initially proposed.
- The Centers for Medicare and Medicaid Services (CMS) released (fact sheet) a final rule updating payment rates and policies under the end-stage renal disease (ESRD) prospective payment system (PPS) for renal dialysis services furnished to Medicare beneficiaries on or after January 1, 2024. This rule also updates the acute kidney injury (AKI) dialysis payment rate for renal dialysis services furnished by ESRD facilities for calendar year (CY) 2024. In addition, the rule updates requirements for the ESRD Quality Incentive Program (QIP). For CY 2024, CMS is increasing the ESRD PPS base rate to $271.02, increasing total payments to ESRD facilities by approximately 2.1%. CMS projects an increase in total payments of 3.1% for hospital-based ESRD facilities and an increase in total payments of 2.0% for freestanding ESRD facilities.