CR and Healthcare Policy Bill Updates
Capitol Hill lawmakers are inching toward a continuing resolution (CR) that needs to be adopted by the end of the week. At the same time, Congress looks like it has agreed to a critical bill to extend certain healthcare programs set to expire at year’s end. Telehealth extensions will be for two years, while the hospital at home program will get a five-year extension. Medicare docs will get a 2.5% hike in 2025 vs. a 2.8% cut. At least a dozen other healthcare areas get fixes or increases under the bill.
In a bombshell, there are major offsets to pay for increases, including major pharmacy benefits manager (PBM) reforms.
- A “delinking” policy to require that Part D Plan sponsors delink PBM compensation from the price of the drug.
- Prohibition on PBM “spread pricing” in Medicaid.
- Medicare Part D transparency requirements for PBMs and Medicare Part D.
- Private Insurance PBM reforms.
Reports also suggest that Medicare Advantage (MA) prior authorization reforms are or may be included. These could include some or all of the provisions in the Improving Seniors’ Timely Access to Care Act.
The PBM trade lobby, the Pharmaceutical Care Management Association (PCMA), issued a vociferous response to reports, arguing the changes will increase costs to the government, employers, and consumers. Specifically, it says the delinking reform would increase premiums in Part D by $13 billion and will benefit drug companies.
In other news, an interesting article on the state of traditional PBMs and those dedicated to transparency. President-elect Trump declared last week he would support reform of PBMs. Major companies with PBMs saw their stocks drop on the declaration.
Additional articles: https://thehill.com/business/budget/5042654-government-funding-deal-progress/ and https://insidehealthpolicy.com/daily-news/lawmakers-close-health-package-includes-two-year-telehealth-extension and https://www.fiercehealthcare.com/payers/pbm-lobby-punches-back-end-year-package and https://insidehealthpolicy.com/daily-news/pbm-lobby-blasts-reported-inclusion-delinking-private-market-transparency-policies and https://www.fiercehealthcare.com/payers/2025-outlook-alternative-pbms-look-heap-pressure-industry-titans and https://www.modernhealthcare.com/politics-policy/cvs-unitedhealth-cigna-shares-pbms-donald-trump-middlemen
(Some articles may require a subscription.)
#crs #governmentshutdown #healthcare #pbms #drugpricing #hospitalathome #telehealth #medicareadvantage #partd #pdp #medicaid #physicians #rates #trump
RFK Jr. Making Rounds On Capitol Hill To Dampen Opposition
Robert F. Kennedy Jr., President-elect Donal Trump’s nominee to head the Department of Health and Human Services, is making the rounds on Capitol Hill to ease skepticism over approval of his nomination. Kennedy has clarified certain positions he has taken on vaccines.
#hhs #rkfjr #trump #congress
https://thehill.com/policy/healthcare/5039835-robert-kennedy-health-department-nomination
Trump’s FTC Head Designee Could Continue PBM Fight
President-elect Donald Trump’s designee to head the Federal Trade Commission (FTC) likely will continue some scrutiny of pharmacy benefit managers. Before the issuance of the now-infamous PBM report by the FTC, Andrew Ferguson concurred with its issuance but did say the agency needs to determine if the case-study findings reflect the market dynamics for other drugs and whether any reimbursement practices affect customers’ out-of-pocket costs. At the same time, he did say that the agency should take stronger enforcement actions against PBMs.
The FTC and Justice Department recently withdrew their 2000 Antitrust Guidelines for Collaborations Among Competitors, indicating it no longer provides reliable guidance and that the agencies will look at each case individually to ensure it does not harm competition. This is seen as an expansion of antitrust scrutiny. Ferguson opposed the withdrawal on the grounds that it was happening just 40 days before Trump takes office. Hospitals believe this could chill mergers, affiliations and more.
Additional article: https://www.modernhealthcare.com/providers/antitrust-guidelines-hospital-partnerships-joint-ventures-ftc
(Articles may require a subscription.)
#ftc #antitrust #healthcare
Bipartisan Senators Seek To Force Health Plans’ Hands On No Surprises Act
Sens. Dr. Roger Marshall, R-KN, and Michael Bennet, D-CO, will unveil legislation that would assess penalties against health insurance companies that violate the No Surprises Act (NSA). Courts have refused to require health plans to pay arbitration decisions. The proposed act would boost fines to $10,000 on insurers that don’t comply with reimbursements by arbitrators, among other fines.
My view is the NSA is heavily slanted to providers and this bill simply makes things worse.
(Article may require a subscription.)
#nosurprisesact #surprisebilling #nsa #healthplans #providers
CMS Says MA Plans Cannot Blanket Deny ALS Medicine
The Centers for Medicare and Medicaid Services (CMS) has said that Medicare Advantage (MA) plans can’t have blanket policies that deny coverage of Qalsody for ALS just because it is “experimental and investigational.”
#cms #medicareadvantage #healthplans #priorauthorization
Cuban’s Drug Venture Saves For Health System
MultiCare Health System says it has saved over $1 million after it joined the Mark Cuban Cost Plus Drug Co.’s Marketplace and accessed 125 generics at a discounted price. Between April and October, the partnership saved MultiCare $1 million. By the end of November, the 13-hospital system saved an additional $120,000.
#drugpricing #cuban #generics
HHS OIG Issues Special Fraud Alert On MA Marketing
The Health and Human Services’ Office of Inspector General (HHS OIG) issued a special fraud alert about the risks of fraud and abuse in certain marketing and compensation arrangements related to Medicare Advantage (MA). The OIG says the arrangements may violate federal anti-kickback statutes by incentivizing the steering of Medicare enrollees toward plans or providers based on payments rather than suitability. Despite a federal judge throwing out the rule that would have eliminated such arrangements, the OIG is urging plans to evaluate their existing partnerships and payment structures for compliance to reduce legal and reputational risks. I agree with the OIG. CMS should work with Congress to eliminate the potential harm to beneficiaries.
#marketing #medicareadvantage #cms #hhsoig
https://www.beckerspayer.com/payer/oig-warns-of-risky-medicare-advantage-marketing-schemes.html
— Marc S. Ryan
