HealthCare Roundtable e-News – September 5, 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 Announces First 10 Drugs for Medicare Drug Price Negotiation

The Centers for Medicare and Medicaid Services (CMS) announced (fact sheet) the first 10 drugs up for Medicare drug price negotiation. These selected drugs accounted for $50.5 billion in total Part D gross covered prescription drug costs, or about 20% of total Part D gross covered prescription drug costs between June 1, 2022 and May 31, 2023.  The 10 drugs are as follows:

  • Eliquis
  • Jardiance
  • Xarelto
  • Januvia
  • Farxiga
  • Entresto
  • Enbrel
  • Imbruvica
  • Stelara
  • Fiasp; Fiasp FlexTouch; Fiasp PenFill; NovoLog; NovoLog FlexPen; NovoLog PenFill

There are currently eight pending lawsuits from the pharmaceutical industry against the negotiation program, which will likely end up in the Supreme Court. Absent any court ruling that postpones negotiations, drug pricing talks will begin October 1st and finish August 2024. Final negotiated prices will then be posted on September 1st of next year and go into effect at the start of 2026. Drugmakers will have 30 days to agree to participate or face steep fines and choose to withdraw their products from Medicare.  CMS will select for negotiation up to 15 more drugs covered under Part D for 2027, up to 15 more drugs covered under Part B and D for 2028, and up to 20 more drugs for each year after that.


OMB is Set to Review Draft Rules on Surprise Billing IDR Operations and Fees

The White House Office of Management and Budget (OMB) is set to review two proposed rules on the independent despite resolution (IDR) process created by the No Surprises Act that will likely address the provisions challenged by the Texas Medical Association (TMA) in their four recent lawsuits. Last week, Judge Jeremy Kernodle of the U.S. District Court of the Eastern District of Texas ruled in favor of TMA to rescind several surprise billing regulations related to health plans calculating the qualifying payment amount (QPA) in the IDR process. The court found that federal regulators “unlawfully bypassed” certain rulemaking procedures when drastically raising the arbitration fee and narrowing the law’s provisions on grouping claims together in the arbitration process. This is the fourth case, and as a result, CMS has temporarily paused the IDR portal.  Since the administration is still appealing the court’s decision in the second TMA case, it is unclear how the proposed rules will address guidance to the IDRs on the QPA and other factors used to determine the winner of a dispute.


HHS Office of the Inspector General Announces Plan to Investigate Medicare and Medicaid Managed Care

The Department of Health and Human Services (HHS) Office of the Inspector General (OIG) announced plans to investigate the Medicare Advantage and Medicaid managed care contracts as part of its new oversight strategy geared towards addressing risks of fraud, waste and abuse in managed care programs. In 2022, OIG reported that about half of all Medicare enrollees received care through Medicare Advantage which cost the government $403 billion. The federal match for Medicaid managed care organizations in 2021 was $254 billion, with nearly 80 percent of beneficiaries receiving at least one component of their care through a managed care organization (MCO).  OIG intends to analyze each part of the managed care life cycle, which includes the four phases of plan establishment and contracting, enrollment, payment, and services to people.

Administrative Action

CMS sent a letter to all 50 states requiring them to determine whether they have an eligibility systems issue that could cause individuals to be removed from their respective Medicaid or the Children’s Health Insurance Program (CHIP) programs despite their continued eligibility for coverage. Following the end of the COVID-19 pandemic, states have begun the process of redetermining individuals’ eligibility for Medicaid and CHIP. States are required by federal regulation to use information already available to them through existing reliable data sources to determine whether individuals are still eligible for Medicaid or CHIP coverage. CMS believes that eligibility systems in a number of states are programmed incorrectly and are conducting automatic renewals at the family-level and not the individual-level, even though individuals in a family may have different eligibility requirements to qualify for Medicaid and CHIP. The letter urges states to determine whether they have this problem and to protect and reinstate coverage for impacted individuals, including children.

Congressional Action

Members of the House Budget Committee have established a new Health Care Task Force, which will be led by Committee Member Rep. Michael C. Burgess (R-TX). This move comes after an opinion piece by Burgess and Committee Chairman Jodey Arrington (R-TX) was published, highlighting the significance of addressing U.S. credit downgrades and excessive health care expenses. The Task Force aims to tackle these issues by seeking ways to cut health care spending, modernize the health care system, and promote innovation for better access to affordable, quality care. The Task Force will serve as a platform to develop and model legislation to enhance spending efficiency and overall cost-effectiveness in the health care system. Task Force members, including Rep. Drew Ferguson (R-GA), Rep. Buddy Carter (R-GA), Rep. Lloyd Smucker (R-PA), Rep. Blake Moore (R-UT), and Rep. Rudy Yakym (R-IN), have requested input from experts and stakeholders through a request for information (RFI) to guide their efforts, with responses due by October 15, 2023.


  • A recent commentary in the NEJM Catalyst highlights the significant role played by employers in the U.S. healthcare system. With over $1 trillion invested in healthcare and almost half of Americans covered by employer-sponsored insurance, it is crucial to address the pervasive issue of quality variation in this sector. The commentary emphasizes that employers have a valuable opportunity to drive improvements not only for their employees but also for the entire healthcare system. The article points out that emerging data resources now offer a comprehensive understanding of the quality of care provided by clinicians, enabling the identification of high-quality healthcare providers. This data also empowers clinicians to receive actionable feedback, and it allows employers and health plans to create networks and referrals that prioritize higher-quality care. The argument is that employer-sponsored healthcare should be viewed as an investment in the overall well-being of employees and their families. Employers, as purchasers of healthcare services, have a unique position to establish a new quality standard for the entire U.S. healthcare system. This commentary underscores the importance of seizing this opportunity to enhance healthcare quality and outcomes across the commercial market.
  • A recent nationwide survey of Americans 65 and older found that participants in the Medicare Part D prescription drug program are satisfied with the current form of the program. Additionally, two out of three participating seniors said they believe that price negotiations of drugs should remain in the hands of private sector insurers rather than giving the authority to the federal government. Morning Consult conducted the survey of 1,000 seniors and found that 91 percent of Medicare beneficiaries are content with their current Part D prescription drug coverage. The majority of respondents (79 percent) are concerned that if the government sets Medicare drug prices that bureaucracy could come between seniors and their doctors. Additionally, the survey found support for the current price setting with only 23 percent of Democrats in favor of the government setting Medicare drug prices and nine percent of Republicans. The survey was conducted in anticipation of Medicare releasing the first 10 drugs that will be up for negotiation under the Inflation Reduction Act (IRA).

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.