HealthCare Roundtable e-News – September 11, 2023


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Webinar – September 19, 2023 – 2:00 PM (EST)

Assessing the Congressional Landscape for Drug Cost Containment: Legislative and Policy Considerations in the context of Pharmacy Benefit Manager (PBM) Reforms

The persistent challenges surrounding pharmacy benefit manager reforms (PBM) have garnered significant Congressional attention on a bipartisan basis, and the Roundtable has played an active role in the debate. Before Congress adjourned for the August recess, the Senate Finance Committee (SFC) conducted a bipartisan markup session on the Modernizing and Ensuring PBM Accountability (MEPA) Act, which culminated to its passage out of committee. Without question, the next several months will be a critically important time where Congress will determine potentially major changes to the PBM marketplace.

Join us to hear from the Public Sector HealthCare Roundtable’s senior policy team and policy experts on the hot topic issue of PBMs and how these policies relate to public sector purchasers, an analysis of the evolving legislative landscape, and a lens on crucial considerations as the current year draws to a close and anticipation builds for the year ahead in 2024.

This webinar is being produced in conjunction with Roundtable corporate member Rx Savings Solutions.

Register Here 

Top News

CMS Issues Fact Sheet on the Process for the Medicare Drug Price Negotiation Program

Following the announcement last week regarding the list of 10 drugs covered under Medicare Part D selected for negotiation, the Centers for Medicare and Medicaid (CMS) issued a fact sheet explaining what can be expected of the negotiation process. The process will begin on October 1st after the drug companies with selected drugs sign agreements to participate in the Negotiation Program. By October 2, 2023, CMS will have been sent data and will hold individual meetings with the participating drug companies. Patient-focused listening sessions will be held in October and November for the public, prior to CMS’ initial offer to each participating drug company by February 1, 2024. Initial offers will be decided based on the presence of alternative treatments, the cost of research and development, and the cost of production and distribution. Highlighting the voluntary aspect of the Negotiation Program, the fact sheet states that if an affected company refuses to participate, it will either face an excise tax or may choose to withdraw from the Medicare and Medicaid program completely. The negotiation period will end by August 1, 2024. CMS will announce the negotiated maximum fair prices by September 1, 2024, and they will go into effect in 2026.


House Republicans Unveil Major Health Care Package

House Republicans are circulating a discussion draft of a multi-faceted healthcare package recently primarily focused on transparency measures, among other issues. The legislation builds off the bipartisan PATIENT Act that passed the House Energy and Commerce committee earlier this year and expands several provisions of the surprise billing rules that were included in the No Surprises Act. The package itself includes an increase in authorized funds for community health centers, a boost of almost half a billion dollars in fiscal 2024 and 2025. It also deals heavily with drug markets, specifically site-neutral payments for Medicare and pharmacy benefit managers (PBMs). An aspect of the bill would ensure that Medicare pays the same amount for physician-administered drugs in a hospital outpatient department as beneficiaries do in a doctor’s office. In a similar spirit of transparency, PBMs would have to report rebates they extract from drugmakers, give explanations of why drugs are covered at certain levels and report hidden fees.


CMS Announces New, Voluntary Total Cost of Care Model

The Centers for Medicare & Medicaid Services (CMS) introduced (fact sheet here) the States Advancing All-Payer Health Equity Approaches and Development Model, also known as the States Advancing “AHEAD” Model, a voluntary, state total cost of care (TCOC) model. This 11-year model will use hospital global budgets and a primary care program (Primary Care AHEAD) to assist states in achieving higher quality care delivery, increasing investment in primary care, and supporting the delivery of advanced primary care while also controlling overall growth in health care costs.  Under a TCOC approach, a participating state uses its authority to assume responsibility for managing health care quality and costs across all payers, including Medicare, Medicaid, and private coverage. CMS will provide funding awards of up to $12 million to eight states selected to participate in the AHEAD Model, offering flexibility through staggered application periods and performance cohorts to accommodate varying levels of state readiness for implementation. CMS anticipates releasing a Notice of Funding Opportunity (NOFO) in late Fall 2023, with a subsequent application period in Spring 2024.

Administrative Action

  • The Center for Medicare and Medicaid Innovation (CMMI) announced that applications are now open via web portal for the Making Care Primary (MCP) Model until November 30, 2023. MCP aims to improve care management and care coordination, equip primary care clinicians with tools to form partnerships with health care specialists, and leverage community-based connections to address patients’ health needs as well as their health-related social needs. MCP is set to launch on July 1, 2024, in eight states: Colorado, North Carolina, New Jersey, New Mexico, Upstate New York, Minnesota, Massachusetts, and Washington—and will operate over a 10.5-year period. Eligibility requirements and full model details are available in the Request for Applications.
  • The Centers for Medicare and Medicaid Services (CMS) Office of Minority Health (OMH) released a new Z code infographic on the collection of social determinant of health (SDOH) data with ICD-10-CM Z Codes. The infographic aims to assist providers with understanding and using Z codes to improve the quality and collection of health equity data. Through the use of SDOH, Z codes can enhance quality improvement activities, track factors that influence people’s health, and provide insight into existing health inequities. The Z code infographic builds upon the extensive CMS Strategic Health Equity Plan by encouraging the collection and implementation of SDOH factors to provide a more equitable health care system.
  • The Department of Health and Human Services (HHS) through the Office for Civil Rights (OCR) issued a proposed rule that would advance equity and bolster protections for people with disabilities. The proposed rule, known as the Nondiscrimination on the Basis of Disability in Programs or Activities Receiving Federal Financial Assistance, would help ensure that people with disabilities are not subjected to discrimination in any program or activity receiving funding from HHS due to having a disability. The proposed rule, if finalized, would update critical provisions that help individuals with disabilities access health and human services under Section 504 of the Rehabilitation Act of 1973. The proposed rule would amend Section 504 to update and clarify obligations in key areas that are not explicitly covered in the existing regulations. In addition, it would enhance alignment with the Americans with Disabilities Act, the Americans with Disabilities Amendments Act, amendments to the Rehabilitation Act, and important legal precedents. The Biden Administration discussed this new proposed rule during the White House Office of Public Engagement Aging and Disability Communities Call this afternoon. Public comments on the notice of proposed rulemaking are due within 60 days of the publication of the rule.
  • The U.S. Department of Health and Human Services (HHS) announced that the 988 Suicide & Crisis Lifeline will now include American Sign Language (ASL) services for people who are Deaf and Hard of Hearing nationwide. The 988 Lifeline is a collection of over 200 state and local call centers that are supported by HHS through the Substance Abuse and Mental Health Services Administration (SAMHSA) for anyone looking for support in dealing with suicide, mental health, and substance use-related crises. The addition of ASL services came just over a year after the July 2022 inception of the 988 Lifeline, which was funded by a nearly $1 billion investment from the Biden-Harris Administration. Since then, the service has received more than 5.5 million calls, texts, and chats. The Administration’s support for the 988 Lifeline stems from its Unity Agenda, which intends to tackle the nation’s mental health crisis. It is expected that more than $200 million in 988 Lifeline grants will be allocated to support states, territories, and tribes later this month.

Congressional Action

The House Ways and Means Committee announced a request for information (RFI) (press release) seeking stakeholder input on addressing chronic disparities in access to health care in rural and underserved communities. The Committee is hoping to address issues related to healthcare facility closures, longer travel distances, and wait times as they are impacting patients nationwide due to a shrinking healthcare workforce, consolidation, and inconsistent financing; challenges which are particularly severe for those in rural and underserved areas. The committee is seeking input from stakeholders to tackle these challenges and enhance healthcare access in these regions. Specifically, the committee is looking for information on geographic payment differences, sustainable provider and facility financing, aligning sites of services, the healthcare workforce, and innovative models and technology. Comments are due to the committee by 5:00PM ET on October 5, 2023.

Registration Open for 2023 Annual Conference

The Public Sector HealthCare Roundtable 2023 Annual Conference Moves to Washington, DC

The conference features a new location, a revised format, and a great agenda!

Wednesday, Nov. 1 to Friday, Nov. 3, 2023


The Roundtable’s highly-regarded annual conference provides members and guests a unique opportunity to hear presentations by high level government officials and key experts – from Congress and the Administration, academics, benefit consultants, plan administrators, advocates and industry leaders in an intimate dialogue-oriented setting.

After years of successful conferences in Old Town Alexandria, we have outgrown our space at the Alexandrian Hotel. This year we will hold our conference at the historic Mayflower Hotel in Washington, DC. The new location will undoubtedly improve the overall experience for all of our attendees.

In recent years, many of our attendees have urged us to schedule more free time in the conference agenda for networking. Since we understand the importance of this networking time, we have revised this year’s agenda to incorporate longer breaks and more time before evening receptions.

This year, the conference will begin at Noon on Wednesday, November 1st and will conclude at Noon on Friday, November 3rd. By adding time on Wednesday, we have been able to add critical content, lengthen our breaks, and add free time prior to any evening activities.

Although we certainly believe the best way to experience our conference is in-person, this year’s conference will once again feature a virtual option. Any health plan that registers at least one individual to join us in Washington, will be eligible to register online attendees.

Visit the Roundtable’s website for a preliminary Agenda, a Registration Form, and the Mayflower Hotel registration link.

We will be updating the agenda and announcing specific speakers over the course of the next couple of months.