HealthCare Roundtable e-News – November 7, 2022


Top News

CMS Releases CY 2023 Medicare Physician Fee Schedule & Quality Payment Program Final Rule

On Tuesday, CMS released the Calendar Year (CY) 2023 Medicare Physician Fee Schedule (MPFS) and Quality Payment Program (QPP) Final Rule (fact sheetfull rule). CMS notes that the final rule is one of several rules that reflects a broader Administration-wide strategy to create a more equitable health care system that results in better accessibility, quality, affordability, and innovation. Key highlights from the final rule include the finalization of the CY 2023 MPFS conversation factor, proposals related to telehealth, behavioral health, and the Medicare Shared Savings Program (MSSP).


Health Insurers’ Price Transparency Efforts Experience Setbacks

Difficulties with accessing and reviewing data has setback health insurers’ efforts to improve price transparency. In July, health insurance companies published public, machine-readable files including the negotiated prices they pay in-network providers and the allowed rates for out-of-network providers. However, the data sets from large health insurance companies are difficult to analyze due to their size. Regulators have asked for input on additional upcoming transparency requirements. Before regulators issue final guidance, insurers, developers, and researchers are pressuring the Centers for Medicare and Medicaid Services (CMS) for more guidance on existing regulations. The Transparency in Coverage rule, which emerged from the Affordable Care Act, aims to improve transparency on rates health insurance companies negotiate with individual providers, which can vary greatly. Over the next few years, health insurers must release additional data, signaling the importance for addressing current setbacks.


Hospitals and Pharmacies Experience Revenue Losses from Pharmaceutical Restrictions on 340B Drugs

Hospitals and pharmacies are losing (subscription required) revenue from the 340B drug pricing program. Although pharmacies have benefitted from the program for a decade, a new wave of restrictions from pharmaceutical companies has significantly reduced their profits. According to some experts, 340B contract pharmacies profit from the fees paid by hospitals and clinics that receive the drug discounts, so restrictions on the discounts cut into their business. Since 2020, 18 drug companies have imposed restrictions on 340B discounts, including AbbVie, Novartis, and AstraZeneca. Pharmaceutical companies have imposed strategic restrictions, most commonly limiting the discounts to a single contract pharmacy for each hospital and clinic.

Administrative Action

  • The Quality, Safety, and Oversight Group (QSOG) within the Centers for Medicare and Medicaid Services (CMS) released a revised memo on health care staff vaccination requirements. This revised guidance applies to every state and continues to require that all CMS-certified providers and suppliers are 100% vaccinated against COVID-19, and have received the appropriate number of doses, unless exempted by law or CMS recommendation. The revised guidance requirements state that noncompliant providers who have implemented a good faith plan to achieve 100% vaccination are not subject to enforcement. The revisions also address immediate jeopardy, condition-level, and actual harm determinations related to deficiency citations of egregious noncompliance. Healthsperien’s summary of the original November 5th staff vaccination requirement is available here.

  • The Centers for Disease Control and Prevention (CDC) released new clinical guidelines for pain care for outpatient adults. Compared to the previous guidelines, issued in 2016, the new recommendations emphasize the need for providers to balance benefits of mitigating patients’ pain with the risks of opioid use disorder, overdose and death. The CDC states that all patients with pain receive appropriate treatment, and that providers should consider the related biologic, psychosocial, and social factors contributing to a patient’s pain. Additionally, they note several harmful policies and practices that were implemented in response to the previous guidance, such as rapid opioid tapers and patient abandonment, that severely limited the availability and use of opioids. The updated guidance re-emphasizes that opioids should be considered a part of the spectrum of evidence-based pain treatment available to patients and their providers.

Congressional Action

A bipartisan group of 46 Senators submitted a letter to Senate leadership to address their concerns regarding the stability of Medicare payments to healthcare providers. The letter urges Senate leaders Schumer and McConnell to work with members to address imminent payment cuts to Medicare before they take effect on January 1, 2023, and to work on long-term payment reforms to Medicare in a fiscally responsible manner. Additionally, 40 bipartisan House members submitted a letter to Speaker Pelosi and Leader McCarthy asking them to extend the 5-percent payment increase to incentivize alternative payment models (APMs) under the Medicare Access and CHIP Reauthorization Act (MACRA). These payments currently expire at the end of 2022. Specifically, they ask that Congress include Section 4 of the Value in Health Care Act (H.R. 4587) in an end-of-year legislative package.



  • CMS approved an amendment for Arkansas’ Medicaid section 1115 demonstration, Arkansas Health and Opportunity for Me (ARHOME), to address social determinants of health through the provision of Life360 HOMEs. The support services approved in this demonstration will test interventions to stabilize and improve the housing and nutrition of eligible Medicaid enrollees and increase the likelihood they will keep receiving and benefitting from services to which they are entitled. Life360 HOMEs provides nutrition management and education for rural, pregnant and postpartum, and young adult populations. The demonstration is one of several CMS-approved initiatives to carry out the Biden Administration’s National Strategy on Hunger, Nutrition, and Health in practice, where programs will be systematically evaluated upon completion for positive health outcomes.

  • With the potential unwinding of the public health emergency (PHE) and consumers’ subsequent shifts from Medicaid coverage to the federal Marketplace, the Centers for Medicare and Medicaid Services (CMS) has prepared several outreach steps. Beneficiaries who have lost coverage at the end of the PHE should expect to receive reminders and instructions on how to purchase a Marketplace plan from CMS also has a limited Navigators pilot program, which will help households enroll for Marketplace coverage. While the Navigators program can employ customized, culturally appropriate methods to help enroll consumers, it is unclear how CMS will evaluate pilot success and for how long it will run. 


Health Affairs published an article highlighting trends in state policy efforts to set healthcare cost growth limits. Massachusetts was the first state to enact a health cost-growth benchmark in 2012. Recent evidence suggests the program successfully influenced payers’ and providers’ negotiations and constrained cost growth. However, the program does not have sufficient authority to enforce accountability measures. The authors recommend states consider ensuring they have transparent data, holding entities that contribute to health cost growth accountable, establishing clear criteria for applying sanctions, and creating incentives to motivate compliance. Researchers note that in order for these efforts to have a long-term impact, states must implement policies or accountability mechanisms that can affect payer and provider behavior in lowering cost growth.