End-Of-Year Stop Gap Funding In Flux
With the House staying Republican, some are saying the stop gap measure to fund government by the end of the calendar year is now in flux. Some Republicans want to punt any substantive legislative action to the new Congress when the GOP is fully in control. Others want to pass substantive legislation, including several healthcare initiatives. They could include pharmacy benefit manager reform, hospital transparency, and site-neutral payments.
One of the top issues that many aim to pass in the lame-duck session is instituting site-neutral payment rules for outpatient care. This is heavily opposed by the hospital lobby, but it is gaining bipartisan momentum. It is unknown how expansive any proposal would be (some or all outpatient services) and whether it would apply just to Medicare or include commercial. The Congressional Budget Office (CBO) projects that the most robust site-neutral legislation would save more than $100 billion over 10 years. Including commercial, savings are even greater.
In other news, healthcare advocates are saying that extending Exchange premium subsidy enhancements may be a long shot but they see pathways to victory. They will argue the impact to coverage will be great if enhanced subsidies sunset. There could be some concessions on the size of the enhancements and who is eligible. The CBO says reupping the enhancements permanently would cost about $335 billion over 10 years. A sunset could mean 4 million join the ranks of the uninsured.
Additional articles: https://www.modernhealthcare.com/politics-policy/site-neutral-payment-bill-congress and https://insidehealthpolicy.com/daily-news/advocates-see-fight-over-aptcs-hard-winnable-alternative-approaches-may-be-play
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#crs #governmentshutdown #congress
https://insidehealthpolicy.com/daily-news/election-throws-uncertainty-lame-duck-package-size-timing
Kaiser Health News Sues HHS OIG Under FOIA
KFF or Kaiser Health News has sued the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG) to compel it to release details on a number of Medicare Advantage (MA) plan audits and financial records. The lawsuit was filed under the Freedom of Information Act (FOIA).
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#medicareadvantage #overpayments #riskadjustment #khn #kff
https://www.modernhealthcare.com/legal/hhs-medicare-advantage-health-plans-audit-lawsuit-cms-oig-kff
MA And Part D Plans Use Commission Strategy To Limit Enrollment
Aetna, Cigna, Elevance, and Centene are all adjusting or eliminating commissions to some products in Medicare Advantage (MA) or standalone Part D (PDP) plans. The commission strategy is meant to limit enrollment during the 2025 season. They need to do this to realign finances and hit margins over time.
In some ways, it is hard to blame MA plans. They got hit hard by rate reductions in MA and added regulatory and drug costs. Part D PDPs were killed by the impact of the Inflation Reduction Act’s cost-sharing reductions in the program. But some raise concerns about whether MA plan are effectively cherry-picking enrollees through the commission strategy.
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#medicareadvantage #partd #pdp #marketing
J & J Sues Biden Administration Over 340B
Johnson & Johnson is suing the Biden administration for barring the brand drug company from converting to a rebate approach as opposed to upfront discounts in the 340B program. The brand drug makers argue that hospitals and other providers abuse the program intended to ensure access by low-income Americans to expensive medications. There are a number of studies that show that patients are not benefiting from greater access and that hospitals are pocketing the discounts and increasing margins. J & J wanted to use the rebate approach to increase transparency. The administration stopped it but the company is now challenging in federal court.
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#340b #drugpricing #branddrugmakers #providers #hospitals
Will Trump Be Activist On Antitrust Issues?
Some are speculating that Donald Trump will be far less aggressive on antitrust issues given his big business background. But some are arguing that Trump standing up for the average guy could signal he may have an interest in scrutinizing mergers, acquisitions, and vertical integration. The issues currently active under Biden:
- Mergers and acquisitions by health plans and hospitals
- Hospitals buying physicians
- Private equity’s role in healthcare
- PBM reform and the Federal Trade Commission (FTC) lawsuit
- Food and Drug Administration (FDA) Orange Book and patent reform
#antitrust #mergers #consolidations #manda #ftc #trump
https://www.medpagetoday.com/washington-watch/washington-watch/112895
— Marc S. Ryan
