President Biden is putting his foot down on a price transparency rule that many hospitals have skirted over the past seven months.
On Friday, Biden released an executive order instructing the Secretary of Health and Human Services to “support” price transparency regulations issued by the Trump administration.
Starting on Jan. 1, hospitals were required to post the prices they charge cash-paying customers and the rates they negotiate with insurers — figures that were largely obscured from public scrutiny. Proponents of greater hospital transparency championed the change, saying it would help patients shop for better deals and drive down health care prices. Until now, it was unclear exactly how the Biden administration would approach the Trump-era rules, even as advocates and some lawmakers urged stronger enforcement amid signs of widespread noncompliance.
Friday’s executive order still didn’t provide many details, but it signaled that the new administration views the transparency rules as valuable, even if they ultimately don’t pack as much of a punch as former president Donald Trump had claimed.
Many hospitals provided a price estimator tool for patients, the JAMA study found, but far fewer provided an easy-to-use file with the prices the hospital negotiated with different insurers.“Because patient-oriented price estimator tools make prices visible only for a given patient and insurance plan and not to payers or the public, selective compliance may fail to expose abuses of market power, affect price negotiations, or support broad analysis of price variation to the extent intended by the transparency initiative,” the study authors write.
Biden’s executive order is sparse on details, saying that the health secretary should “support existing price transparency initiatives for hospitals” along with any future transparency requirements. But the Department of Health and Human Services began in April to send letters to hospitals that weren’t complying with the rule and indicated it plans to audit a sample of hospitals.
Transparency advocates, who’d been disappointed by hospitals’ lack of compliance, are hoping the fresh attention from the Biden administration could signal stronger enforcement.
“Biden’s executive order hands the torch to both [Health and Human Services Secretary Xavier] Becerra and Health and Human Services to boldly enforce the rules. It gives them the power to do what they need to do even if it means they need harsher penalties and stricter enforcement,” said Cynthia Fisher, the founder of Patient Rights Advocate, a nonprofit that pushes for price transparency.
The response from hospitals themselves was muted, but Molly Smith, vice president for public policy at the American Hospital Association, told Health 202 that the organization “strongly encourage[s]” hospitals to follow federal guidelines on transparency.
Experts in health care finance have said that the new transparency rules are unlikely to be a silver bullet when it comes to driving down health care costs.
Many Americans are insulated from the direct cost of treatment because their insurance picks up the tab, and even those patients who pay directly may have a hard time wading through hundreds of pages of complex pricing documents.
Even when hospitals do post their prices, many Americans don’t know to look for them. Fewer than 1 in 10 Americans say they are aware that hospitals are required to post their prices, according to a recent Kaiser Family Foundation poll.
“Healthcare goods are very complex. We care a lot about quality, and we in essence listen to what our doctor recommends,” said Zack Cooper, a professor of health policy and economics at Yale University. “I think the idea somebody is going to be out there with a price transparency tool figuring out where to go in this market is just not realistic.”
The health care provisions come in a sweeping executive order that has 72 initiatives aimed at scaling back monopolies and offering consumers more options in technology, finance, and health care.
The order encourages Federal Trade Commission to crack down on hospital mergers that are harmful to patients and to ban “pay-for-delay” tactics that allow brand name drug manufacturers to pay generic manufacturers to keep their products off the market.
It also directs the Food and Drug Administration to work with states on importing drugs from Canada, another initiative started during Trump’s time in office, as our colleague Amy Goldstein reports.
“Just a handful of companies control the market for many vital medicines, giving them leverage over everyone else to charge whatever they want,” the president said before a signing ceremony at the White House. “As a result, Americans pay two and a half times more for prescription drugs than any other leading country.”
The House Appropriations Committee on Sunday, July 11, released the draft fiscal year 2022 Labor, Health and Human Services, Education, and Related Agencies funding bill, which will be considered in subcommittee on Monday, July 12. The bill is scheduled for full committee consideration on Thursday, July 15. This WSC Brief outlines the major health care-related provisions of the bill.
NOTE: The current draft of the bill is limited to top-line appropriations and does not include the specific, granular provisions of the eventual final bill; these will be available as part of the committee report that is likely to be released on Wednesday, July 14.
President Joe Biden’s executive order to bolster competition includes 72 initiatives by more than a dozen federal agencies, affecting everything from restricting noncompete agreements for workers to allowing imports of prescription drugs from Canada.
While there’s a long way to go from a presidential directive to final regulations, the president’s directive seeks to address the sharp increase in consolidation of industries over the last two decades, which has raised worries that the biggest companies are choking off competition and innovation.
The White House blames declining competition across the economy for raising prices of necessities like prescription drugs, lowering wages for workers and acting as a drag on growth and innovation.
Here are details on some of the initiatives outlined in the order and reaction from industry groups:
The Federal Communications Commission is asked to reinstate net neutrality rules that barred internet service providers from blocking or slowing certain content or speeding up delivery for a price. Those rules had been implemented under former President Barack Obama but rolled back under former President Donald Trump.
The order also calls on the FCC to prevent internet providers from negotiating exclusive deals with landlords that leave renters with just one internet option, and to limit high termination fees cable companies charge when consumers switch providers.
The Federal Trade Commission is asked to establish rules on data collection by tech companies and regulations barring “unfair methods of competition” by the biggest tech platforms in order to protect businesses that depend on the companies to reach customers.
Many of the steps outlined in the order reprise Obama administration policies that were unpopular with both industry and Republicans, presaging a fight at the agencies.
A major cable group Friday called Biden’s statements “misleading,” and a group representing largest phone companies AT&T Inc. and Verizon Communications Inc.said “context and facts are largely missing” from the White House’s release outlining its broadband policies.
The order, which blames consolidation in banking for raising costs for consumers and restricting credit to small businesses, calls on the Justice Department and banking regulators to update guidelines on bank mergers to toughen scrutiny of deals.
The Consumer Financial Protection Bureau is asked to issue rules to make it easier for consumers to switch banks by allowing them to download their banking data and take it with them.
For more: Banking Merger Frenzy May Meet Early End After Biden Order
The order targets areas where it says the lack of competition increases prices and reduces access to quality care, starting with prescription drug prices.
Biden’s order will call on federal health officials to work with states to come up with plans to import medicines from Canada, where they are cheaper.
The president’s plan in some ways echoes policies that Trump proposed a year ago. Then, Canada balked at the proposal to let Americans import medicines, and the neighbor to the north later imposed measures limiting distribution of drugs to protect its supply from bulk sales across the border.
Biden has directed the Department of Health and Human Services to issue a comprehensive plan within 45 days to counter high drug prices. That could bring back proposals by Trump and some Democrats to benchmark drugs to the cheaper prices paid in countries with national health systems. It’s a move that drugmakers said would stifle innovation.
Biden will also urge the FTC to stop pharmaceutical manufacturers from paying their generic counterparts to delay entry into the market of lower-priced versions of medications. That idea is part of pending legislation in the Senate and aligns with campaign promises Biden made last year.
The Association for Accessible Medicine, the leading trade group for the generic drug industry, said it’s looking forward to working with the Biden administration to increase adoption of lower-cost generics and biosimilars “and remedy the growing number of government and payer policies that perversely reward the use of high-cost brands over generic or biosimilar competitors.”
Hospital consolidation has increased health-care costs and reduced service for some communities, especially rural areas, the order notes. The executive order directs the Justice Department and FTC to tighten their merger guidelines for hospital deals. It also directs HHS to support hospital price transparency rules and finish implementing legislation to address surprise hospital billing.
Health-care interests that could face tighter antitrust scrutiny pushed back on the order and asserted that it could block patients’ from needed care. “Miring hospitals in legal and bureaucratic red tape will simply slow critical care to the bedside,” said Chip Kahn, Chief Executive Officer of the for-profit hospital trade group Federation of American Hospitals.
The Biotechnology Innovation Organization said it’s evaluating the order, but urged Biden to focus on lowering out-of-pocket costs influenced by other companies in the supply chain. “That price is set by PBMs, insurers and the government, NOT by biopharmaceutical companies,” BIO policy chief John Murphy said.
Steve Ubl, CEO of the Pharmaceutical Research and Manufacturers of America, said the U.S. already had “the world’s most competitive market for prescription medicines” in a statement that cited falling net prices and high rates of generic drug uptake.
The order calls for new rules to benefit farmers and ranchers. It directs the Agriculture Department to make it easier for cow, pig and poultry farms to sue large processors if they are underpaid or retaliated against. It also asks the USDA to consider issuing new rules defining when meat can bear “Product of USA” labels to restrict companies from labeling food produced overseas as American-made when it was simply processed domestically.The measure also orders the Agriculture Department to help farmers access markets and receive a fair return on their goods, including supporting alternative food distribution systems like farmers’ markets and developing standards and labels so that consumers can choose to buy products that treat farmers fairly.It encourages the FTC to keep equipment manufacturers from limiting consumers’ ability to repair products at independent shops or on their own. The move is intended to especially benefit farmers, who face expensive repair costs from tractor manufacturers that use proprietary tools and software to prevent third parties from working on equipment.
Farmer advocates say the rules are much-needed to combat heavy consolidation in crops, seeds, chemicals and meat, in which a small group of multinational companies are capturing an increasingly large share of profits at the expense of family farms.
The labor market element of the order focuses on restricting the non-compete agreements that have become common in certain industries and limit worker mobility. The measure also asks for updated antitrust rules regarding companies that share wage and benefit information to avoid competing for workers.
It asks the FTC to eliminate occupational licensing requirements that can create barriers of entry for new job applicants in certain fields. Biden also reiterated his support for a pro-labor bill that passed the House and is stalled in the Senate, which would make it easier for workers to organize in unions.
Biden is also taking aim at consolidation in the airline industry, especially the extra feesfor things like baggage, on-flight services and cancellations, which are “often raised in lockstep, demonstrating a lack of meaningful competitive pressure,” according to the White House. The EO says the top 10 airlines collected $35.2 billion in assorted fees in 2018, compared to only $1.2 billion in 2007.
The order instructs the Transportation Department to make sure those fees are transparent and, when the service isn’t provided, refunded.
The order also directs DOT to examine other potentially controversial issues, including consumer protections for airline passengers and how carriers are awarded slots at congested hubs.
DOT and the Justice Department must also consult on how to “ensure competition in air transportation and the ability of new entrants to gain access,” which could prompt reviews of recent agreements between carriers.
For railroads, currently dominated by just a handful of freight rail companies, the measure would require track owners to give right of way for passenger rail and to treat other freight companies equally. The measure also addresses shipping fees, which domestic manufacturers are currently forced to pay to foreign companies.
Freight railroad and shipping trade groups expressed opposition to Biden’s order, saying that there’s sufficient competition among their industries and the order would put them at a disadvantage.
“We urge everyone to make decisions based on the real facts about the situation before we create long-term negative results through ill-considered regulatory changes to handle a temporary situation,” John Butler, president and CEO of the trade group World Shipping Council, said in a statement.
Competition within the U.S. airline industry has produced historically low inflation-adjusted air fares and expanded opportunities for travel, including from two new carriers that started operations this year, Airlines for America said in a statement Friday.
The Biden order echoes an Obama administration order in 2016 that said government agencies beyond those responsible for antitrust enforcement had a role to play in protecting consumers, workers and business from being harmed by instances of market power in the economy. Unlike the Biden order, however, Obama’s didn’t direct individual agencies to take specific actions and instead required them to come up with their own plans.
That order built off a report by the Council of Economic Advisers outlining evidence that industries across the U.S. economy suffer from rising consolidation and declining competition.
Since then, attention to the power of dominant companies has only grown as economists and policy makers raise concern that rising concentration is ailing large swaths of the economy and contributing to problems including income inequality, stagnant wages and low productivity growth.
While the drafting and implementation of new rules and regulations may take months and will be largely handled by individual departments and agencies, the White House has made clear it expects that the executive order could lead to significant changes that entail a major impact on several industries.
The measure advances the administration’s push to step up antitrust enforcement amid widespread criticism that enforcers at the Justice Department and the Federal Trade Commission haven’t gone far enough to police mergers and anticompetitive conduct.
Last month, Biden unexpectedly named Columbia Law School professor Lina Khan to lead the FTC, putting one of the most prominent advocates for a far more forceful antitrust agenda in charge of the agency.Biden has yet to nominate a chief for the Justice Department’s antitrust division, leaving the unit without political leadership five months into the administration as it forges ahead with a monopoly case against Alphabet Inc.’s Google and a lawsuit to block Aon Plc’s proposed $30 billion acquisition of Willis Towers Watson Plc.
The White House effort adds to a widespread push for stronger antitrust enforcement in Washington, where bipartisan majorities on the House Judiciary Committee in June advanced six antitrust bills, primarily aimed at the biggest tech companies. The proposals represent an effort to revamp antitrust laws and give competition enforcers more authority.
Business groups in Washington quickly criticized the order. “Today’s executive order is built on the flawed belief that our economy is over-concentrated, stagnant and fails to generate private investment needed to spur innovation,” said Neil Bradley, executive vice president of the U.S. Chamber of Commerce. “Such broadsided claims are out of touch with reality, as our economy has proven to be resilient and remains the envy of the world.”
The National Association of Manufacturers added, “some of the actions announced today are solutions in search of a problem; they threaten to undo our progress by undermining free markets and are premised on the false notion that our workers are not positioned for success.”
Senate Majority Leader Chuck Schumer warned senators Friday to be prepared to cut short their planned August recess as he seeks to pass both a bipartisan infrastructure package and a budget blueprint teeing up a larger Democrat-only tax and spending bill.
“Senators should be prepared for the possibility of working long nights, weekends, and remaining in Washington into the previously scheduled August state work period,” the New York Democrat said in a letter to senators outlining his July agenda.
The Senate currently plans to begin its monthlong recess on Aug. 9.
Schumer said committee staff members have been working during the two-week break straddling July 4 to turn the bipartisan infrastructure framework into legislative text. The Senate Budget Committee meantime has been working on a budget resolution, a vehicle that will include instructions for the reconciliation bill encompassing the tax and social spending that Democrats want to pass later this year.
Schumer said the reconciliation package will include at least three priorities — climate change, health care and the “caring economy.”
With a 50-50 Senate, Democrats can’t afford a single defection or absence in their caucus on the budget blueprint. Some liberal senators are insisting on assurances that moderate members will agree to the bigger package before they sign on to back the $579 billion bipartisan infrastructure bill.
Democrats have yet to agree on the scope of the bigger package. Senate Budget Committee Chairman Bernie Sanders wants a $6 trillion total, while moderates like Joe Manchin of West Virginia have suggested a much smaller figure that wouldn’t add to the deficit.
Schumer said that other issues could also arise in the coming month — a bipartisan group is trying to iron out a policing bill — and that the Senate will continue to confirm nominees.
“As always, Senate Democrats stand ready to expeditiously fill any potential vacancies on the Supreme Court should they arise,” Schumer added. Some Democratic-aligned groups have hoped Justice Stephen Breyer, 82, would retire this year, so the Senate could push through a younger nominee to join the other two justices on the liberal wing of the court.
The U.S. Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology (ONC) today released the United States Core Data for Interoperability version 2 (USCDI v2), a standardized set of health data classes and constituent data elements for nationwide, interoperable health information exchange.
With this new update, health IT stakeholders nationwide will have clearer direction toward the standardized, electronic exchange of social determinants of health (SDOH), sexual orientation, and gender identity (SO/GI) among several other updated data elements. This lays the foundation for the provider community to start systemizing the capture and use of SDOH and SO/GI data in the clinical setting. While encouraged, this update does not require health professionals, such as doctors and nurses, to record this data or individuals to share such data. It does however set a path forward for health IT to build in support for exchanging these data as they become applicable to an individual’s care.
“USCDI version 2 builds on the feedback we received from a wide variety of stakeholders,” said Micky Tripathi, Ph.D., national coordinator for health information technology. “We heard that this new version of the USCDI should reflect America’s diversity and include data elements like sexual orientation, gender identity, and social determinants of health while helping to address disparities in health outcomes for minoritized, marginalized, and underrepresented individuals and communities.”
The COVID-19 pandemic exposed many challenges in the nation’s healthcare system and among them, the need for more reliable data to better understand the public health needs of all Americans – particularly vulnerable individuals or those long felt marginalized by the medical community. Currently, many health care facilities have not developed systems to collect structured SO/GI data from all patients. Without this information, lesbian, gay, bisexual, and transgender (LGBT) patients and their specific health care needs cannot be identified, targeted, and addressed. Similarly, without insights into social determinants factors that may be impacting one’s ability to successfully manage their health, health professionals may be hampered from truly delivering quality care.
“The updated US Core Data for Interoperability takes an important step in reflecting the needs of all patients who access the nation’s healthcare system,” said Dr. Rachel Levine, HHS assistant secretary for health. “For accurate, compassionate, and safe care, it is important for a patient’s sexual orientation and gender identity to be part of their care coordination and this new version helps prioritize next steps for the healthcare community as well as help identify patients’ specific nonmedical needs— like housing, transportation, and poverty — that affect health to coordinate care and assistance to improve health outcomes.”
More than 600 data classes and elements, including merged and duplicated data elements, were submitted by the health IT community as part of USCDI version 2’s development cycle. The USCDI will continue to grow as standards mature and industry needs evolve. USCDI version 2 includes three new data classes and a total of 22 new data elements. Today’s release makes USCDI version 2 available for consideration as part of ONC’s Standards Version Advancement Process (SVAP), which will take place this fall. The SVAP allows health IT developers to update their certified health IT to support newer versions of the USCDI (among other standards) and provide those updates to their customers, including providers and hospitals, before they are required by regulation. Equally, USCDI version 2’s release will kick-off additional work within standards development organizations to update implementation guides and other technical requirements to come into alignment with version 2’s new data elements.
As required by ONC’s Cures Act Final Rule published in May 2020, and in a subsequent interim final rule extending the compliance deadline published in April 2021, certain developers of certified health IT are required to provide their customers with upgraded certified health IT that supports USCDI version 1 by December 31, 2022. Any future versions of USCDI, as approved through the SVAP, would be voluntary for implementation until a new final rule is published requiring such an update.###
President Joe Biden’s sweeping executive order to boost competition in health care and other markets directs HHS to create a standardized plan option that would be sold in the federal exchange and help people to more easily compare plans.
“Consolidation in the health insurance industry has meant that many consumers have little choice when it comes to selecting insurers. And even when there is some choice, comparison shopping is hard because plans offered on the exchanges are complicated–with different services covered or different deductibles,” the executive order says. It then directs HHS to create the standardized option.
Numerous state-based exchanges, including Covered California, have had standardized plans in place since launching in 2014. All plans provide the same benefits and cost-sharing and deductibles so that consumers get an “apples to apples” comparison and avoid surprises, according to Covered California.
CMS does not have authority to require insurers sell standardized plans, but the Obama administration did encourage adoption by displaying those plans more prominently on healthcare.gov. The policy went into effect for 2017, but the Trump administration scrapped the option in the fiscal 2019 exchange rule.
Meanwhile, a group of cities, represented by Democracy Forward, sued HHS over several provisions in the 2019 rule, arguing that they violated the Administrative Procedure Act.
In March, a federal district court in Maryland ruled in favor of the cities on four of nine provisions they’d challenged, including the standardized option, a change to medical loss ratio reporting, increased document verification for low-income consumers, and deferring review of network adequacy to the states.
CMS acknowledged the case in the third installment of the fiscal 2022 Notice of Benefit and Payment Parameters out in late June. The agency said it intended to implement the court’s decision as soon as possible. But it added the agency needed to design and propose new options — which would then need to be adopted by insurers and approved by regulators — and said that wasn’t feasible for the fiscal 2022 plan year. CMS said many of the variables used to craft the most recent iteration of the standardized options, including state cost-sharing laws, have changed considerably since they were finalized in 2018, and there’s not enough time to conducted needed analysis.
The agency said it would restart the standardized option designation and propose specific plan designs in the fiscal 2023 payment notice. “As such, we seek the views of stakeholders regarding issues related to the proposal of new standardized options, including specifically the views of states with FFEs or SBE-FPs regarding how unique state cost-sharing laws could affect standardized option plan designs to assist in our development,” the agency said.
Maura Caslyn, managing director of health policy for the Center for American Progress (CAP), says that CMS is taking the right approach to crafting the new options since so much more information is out now compared to in 2016.
As far as plan designs, Caslyn says that CAP supports efforts to encourage the use of high-value, lower-cost services. For example, policies could require very low cost-sharing for primary care or out-patient treatments. Allowing coverage pre-deductible for primary care could also make a huge difference to many families, particularly parents with young children, she adds.
Standardized plans can also form the foundation for other policies, like an auto-enrollment mechanism that could place eligible enrollees into those plans.
The insurance lobby says it’s too early to comment on specific pieces of the executive order, but in general AHIP reiterated its position that the best way to achieve high quality, affordable care is through market competition.
Opioid treatment program directors across the country say Medicaid reimbursement in their states isn’t adequate to ensure the highest quality services and some facilities might stop accepting Medicaid if they aren’t paid more — but a representative for Medicaid directors says while most Medicaid providers want more money, OTPs aren’t closing their doors en masse.
Opioid treatment programs (OTPs) are the only settings in the United States where methadone can be distributed to people with opioid use disorder. Other FDA-approved medications for opioid use disorder treatment, buprenorphine and naltrexone, can also be distributed at OTPs.
The SUPPORT Act requires state Medicaid plans to cover medication-assisted treatment (MAT) for all beneficiaries between October 2020 and Sept. 30, 2025. MAT was not a required benefit before the SUPPORT Act, and many states did not previously cover methadone. A CMS spokesperson said CMS may authorize exemptions in the case of a provider shortage. Hawaii, South Dakota, Wyoming, American Samoa, Northern Marianas Islands and Guam are currently exempt from covering MAT under Medicaid.
OTPs are particularly important for treating patients with opioid use disorder, but low Medicaid reimbursement is endemic across addiction medicine, said American Society for Addiction Medicine Chair of Legislative Advocacy Shawn Ryan, president and chief medical officer for a group of OTPs in Ohio.
Some states, like Virginia and Ohio, provide better reimbursement than others, he said. But generally, across the country, “we’re not even close to the gap, right, between population need, and services available, and they’re not going to grow or even be maintained at current level if Medicaid does not look at this very seriously,” Ryan said.
Matt Salo, executive director of the National Association of Medicaid Directors, said essentially every Medicaid provider across the country wants higher reimbursement.
“Literally everybody says that — they don’t go out of business,” Salo said.
Across the country, the number of OTPs increased by 39% between 2003 and 2016, going from 1,067 OTPs to 1,482, according to a Substance Abuse and Mental Health Administration report from 2017. SAMHSA’s website now lists 1,837 OTPs, though numbers vary greatly from state to state.
Medicaid directors describe a tension between ensuring high quality services and increasing provider reimbursement, added Lindsey Browning, program director at NAMD.
“Whenever you see Medicaid, or other payers, sort of opening the door to new services, you sort of see a floodgate of providers come in,” she said. “As a payer and particularly as a public payer, [we’re] wanting to make sure we put the necessary guardrails in place to get the highest quality services.”
But providers say low reimbursement does impact service quality — and in some cases, access to services for Medicaid beneficiaries at all.
Several OTP directors told Inside Health Policy they want and intend to keep treating patients with Medicaid coverage, but low Medicaid reimbursement rates, particularly compared to private insurance or Medicare, are not enough to cover rising costs.
Margaret Rizzo directs an OTP in New Jersey, which did update its rates in 2016 for the first time since 1985, according to Rizzo. But she previously had to cap the amount of Medicaid recipients her clinic could accept.
“We had a waiting list if you had Medicaid to come on to the program, which was devastating,” said Rizzo. “It was a budget buster — we couldn’t afford to treat a patient for $77.50 per month.”
Dave Kneesy, who oversees six OTPs in Florida, said he could easily see a point where Florida clinics stop treating Medicaid beneficiaries.
“We want to take care of as many patients as we can. [But] we got to make a living,” he said.
OTPs that treat large numbers of Medicaid enrollees say their staffing stability suffers. Linda Hurley, president and CEO of Rhode Island’s largest and oldest OTP, said she feels embarrassed to offer low wages to staff, even those with graduate degrees.
With higher Medicaid reimbursement rates, Hurley said she could retain more staff, which in turn would improve the quality of her OTP’s treatment services.
OTP directors say long periods between reimbursement increases provide another hurdle. Kneesy has been treating Medicaid beneficiaries in Florida since 2003, and he’s never seen an increase in reimbursement rates.
There’s no set formula across states for when rates need to be reset, Salo said. If rates for every service were readjusted regularly, he said that’s basically all the state Medicaid agency would do.
However, state Medicaid agencies are still bound by the Medicaid Equal Access Provision and 2015 rules that require states to measure access to a set of Medicaid services for beneficiaries who receive care through a fee-for-service system. The Trump administration proposed to roll back these regulations, but a final rule unwinding them was never released. Mark Parrino, president of OTP trade organization American Association for the Treatment of Opioid Dependence, said he’s not sure how this rule impacts OTPs as MAT didn’t become a required Medicaid benefit until last year, but he’s looking into it. Salo said the rule likely does impact OTPs, though his team isn’t focused on that issue currently.
Typically, though, a crisis like fraud or lack of providers triggers a rate change, as could political pressure from a coordinated group of providers, Salo said.
Some OTP staff are turning their frustration with low and unchanging pay rates into activism. Over the past three and a half years, Hurley has knocked on doors, gone to the statehouse and talked with business leaders and lawmakers to push for higher rates. Kneesy is in the early stages of getting a group of substance abuse and mental health stakeholders together to advocate for better Medicaid rates in Florida.
Self-advocacy was successful for OTPs in New Jersey, Rizzo said. But even with a strong provider network advocating for OTPs, it still took six years for higher rates to go into effect.
Now, it’s been five years since the New Jersey Medicaid rates were raised, and they’re already starting to feel out of date, Rizzo said. But there is talk in New Jersey of aligning the Medicaid rates with Medicare reimbursement rates, a gold standard that many providers say they’d like to see. As of January 2020, Medicare has paid OTPs through a bundled rate. The rate was established in a final rule stemming from the SUPPORT Act. OTPs weren’t recognized as Medicare providers before the final rule.
Allegra Schorr, owner and vice president of an OTP in New York, said she feels there’s a broad lack of understanding about OTPs, which has contributed to allegedly inadequate reimbursement rates. However, she added that New York officials have been quick to respond to OTP needs during the COVID-19 public health emergency and a state plan amendment was recently approved to make an emergency bundled Medicaid rate for MAT permanent.
Jan Kauffman, an OTP director in Massachusetts who’s been working in OTPs since 1973, thinks this lack of understanding is partly due to lack of education and stigma around addiction. Health professional schools need to better incorporate addiction medicine into their core curricula, Kauffman said.
“Until the schools are really training, we’re not going to see stigma diminish,” she said.
There is some evidence the political tide is turning — bipartisan bills to expand addiction medicine education in health professional schools have been introduced in Congress this year.
Ultimately, it comes down to a need to dedicate long-term funding to substance use disorder treatment, Ryan said. He and other policy watchers say this funding should come from Medicare and Medicaid.
President Joe Biden’s fiscal 2022 budget requests $6.6 billion for the Substance Abuse and Mental Health Services Administration’s substance use prevention and treatment programs, and another $2.3 billion for SAMHSA’s State Opioid Response Grants program, among several other requests. But a sustainable treatment model needs to be built around Medicare, Medicaid, commercial payers and other public funding, said Ryan.
Sustainability needs to include Medicaid rate increases for OTPs, said Hurley.
Provider relief recipients will not receive an extension beyond Sept. 30 to report use of their relief funds and the burden of proof is on them to show they used the money to prevent, prepare for and respond to the pandemic, HHS staff said Thursday (July 8) during the first COVID-19 relief reporting webinar. Those with provider relief not spent by June 30 will have until Oct. 30 to return the unspent funds to HHS.
Providers waited nearly six months before the provider relief reporting portal went live last week. HHS opened the complete portal and supporting documents after hospitals, providers and lawmakers spent weeks asking the department to extend the provider relief spending deadline, which is tied to the reporting requirements, beyond Wednesday (June 30). HHS stopped short of a complete extension in guidance released June 11 and tied spending and reporting deadlines to when providers received their relief.
Providers who received $10,000 or more in relief before June 30, 2020 will have a hard deadline of Sept. 30 to report how they used their relief over the past year, said staff from the agency in charge of distributing the funds, Health Resources and Services Administration.
“You may not receive an extension on the deadline to report. If you do not report by the deadline, you will be deemed out of compliance with the terms and conditions of the payments and may be subject to recoupment,” HRSA staff said during the webinar.
Meanwhile, it’s up to providers to explain why they used provider relief for certain expenses and to make up for lost revenue due to COVID-19. Providers will have 30 days to respond to HRSA if it determines the provider’s calculation is not reasonable.
“So the burden of proof is on the provider to ensure that documentation is maintained to show that expenses are in fact to prevent, prepare for and respond to coronavirus,” HRSA staff said.
The next webinars on the provider relief reporting portal will be July 14 and July 20.
The Senate is aiming to move the bipartisan infrastructure bill and the fiscal 2022 budget resolution as early as July 19, and the size and framework of the budget resolution could drive which health care provisions are ultimately included in Democrats’ upcoming reconciliation bill. Sources say it’s still unclear what Medicaid, Medicare and drug-pricing provisions might make it into the bill.
Senate Budget Committee Chair Bernie Sanders (I-VT) is seeking a $6 trillion budget resolution, but moderate Democrats want it ratcheted back to $2 trillion.
House Majority Whip Jim Clyburn (D-SC) and other lawmakers and beneficiary advocates are pushing hard for a federal solution to the Medicaid gap, and Senate Democratic leadership supports a gap fix as well but is also pushing to expand Medicare benefits. Whether and what form of drug-pricing legislation — considered a key pay-for — is factored into the budget resolution could help determine what Medicaid and Medicare reforms make it into the reconciliation package.
A Democratic Senate aide Thursday (July 8) told Inside Health Policy that leadership is supportive of the effort to close the so-called Medicaid coverage gap in states that haven’t expanded Medicaid eligibility under the Affordable Care Act, and is reviewing options for the best path forward.
House Democratic leaders have also shown support for legislation to close the coverage gap. A spokesperson for Clyburn said earlier this week that closing the gap is the lawmaker’s priority for the reconciliation package.
Multiple committees are said to be discussing how to best close the coverage gap. The only concrete proposal so far is a bill introduced by Rep. Lloyd Doggett (D-TX), chair of the House Ways & Means health subcommittee, that would allow local governments to contract with CMS directly to expand Medicaid in their jurisdictions, though Doggett himself has said a more comprehensive solution would be welcome.
Meanwhile, Senate Majority Leader Chuck Schumer (D-NY) has also thrown his support behind expanding Medicare to cover dental, hearing and vision care. Doggett also introduced a bill Tuesday (July 6) to add the three benefits to Medicare Part B.
The bill has wide support among House Democrats, with more than 75 cosponsors, though a Families USA staff member said it’s possible a provision in the reconciliation bill won’t look exactly like Doggett’s proposal. A spokesperson for Rep. Robin Kelly (D-IL) said in June that there have been some discussions around including only one of the three benefits in a reconciliation package due to financial considerations.
Concerned about rising health care costs and cost differences between sites of care for the same procedures, the U.S. Congress and the Centers for Medicare and Medicaid Services (CMS) in recent years have begun implementing legislation and regulatory policies that would lower reimbursement for certain off-campus HOPDs to a level comparable with freestanding and/or non-hospital facilities.
The practice of reimbursing HOPDs (on- or off-campus) at the same rate as freestanding clinics is known as “site-neutral” payment and are intended to close the payment gap between off-campus HOPDs and other freestanding facilities.
On July 1st, the Health Resources and Services Administration (HRSA) opened the Provider Relief Fund (PRF) Reporting Portal for providers who need to report on the use of funds in Reporting Period 1. All recipients of PRF payments must comply with the reporting requirements described in the Terms and Conditions.
You may recall that, on June 11th, HRSA announced updated PRF reporting requirements, which included extending the amount of time that providers have to report from 30-days to 90-days. Providers who are required to report during Reporting Period 1 have until September 30, 2021 to enter the Portal and submit their information.
Reporting Requirements Timeline
HRSA is committed to supporting the providers who have received PRF payments in completing their reporting requirements successfully. For technical assistance, we encourage providers to call the Provider Support Line at (866) 569-3522; for TTY dial 711. Hours of operation are 7 AM to10 PM CT, Monday through Friday.
HRSA will also host a recorded webcast on July 8, 2021, at 3 PM ET to provide technical assistance on reporting requirements for PRF recipients and interested stakeholders. Interested parties can register to attend here.
Additional resources to aid providers in the reporting process, HRSA has shared the following documents with PRF payment recipients:
An Obama-era veteran of the Affordable Care Act wars and surgeon will take charge of the nation’s Medicare program under President Joe Biden, the Centers for Medicare & Medicaid Services announced.
Meena Seshamani, a head-and-neck surgeon who most recently was vice president of clinical care transformation at MedStar Health, became deputy administrator of CMS and director of the Center for Medicare Tuesday.
MedStar is a 10-hospital health system in the Washington, D.C. area.
“Dr. Meena Seshamani brings her diverse background as a health-care executive, health economist, physician and health policy expert to CMS,” said CMS Administrator Chiquita Brooks-LaSure. “Providing quality health care to the people who rely on Medicare and advancing health equity as we do it is a priority for CMS. I am delighted to say Dr. Seshamani will bring her unique perspective on how health policy impacts the real lives of patients to her leadership role as Deputy Administrator and Director of the Center for Medicare.”
Seshamani has decades of policy experience under her belt, She served as director of the Office of Health Reform under President Barack Obama, where she helped lead implementation of the ACA, including coverage policy, delivery-system reform, and public-health policy, the CMS said.
She also served as Biden administration’s transition team for the Department of Health and Human Services.
At MedStar, Seshamani helped design and carry out population-health and value-based care initiatives in the areas of community health, geriatrics, and palliative care.
She also cared for patients as an assistant professor of Otolaryngology-Head and Neck Surgery at the Georgetown University School of Medicine, the CMS said.
When asked about the prospects for long-term telehealth coverage, I often hear people say that permanent expansion is inevitable because “the genie is out of the bottle” or “Congress never takes benefits away.”
The truth is they can, and they will, unless we effectively break down persistent misconceptions about the impact of telehealth policy changes. If we can’t do it quickly, we should pivot to asking Congress for an extension of the pandemic flexibilities, thereby affording the industry more time to support the formal publication of government studies and peer-reviewed research that bears out the cost-effectiveness, quality and access expansion of telehealth.
Myth No. 1: Lifting Medicare telehealth restrictions will cost the program money
There is a long-standing perception among policymakers that if telehealth is a permanent option in Medicare, beneficiaries will have virtual and in-person visits for the same condition, or seek treatment they would have otherwise avoided, thereby creating excess utilization.
We now have data to effectively dispel this myth. Consistently, across provider type, telehealth proved to be a substitution for in-person care. Overall utilization stayed the same, while telehealth filled in for office visits during peak social distancing periods, and declined as people went back to the doctor’s office.
All of the discussion about utilization has crowded out other areas where telehealth saves Medicare money. For example, skilled-nursing facility transfers decreased during the pandemic due to telehealth. Pre-pandemic studies concluded that approximately 60% to 70% of all nursing home transfers to hospitals are unnecessary. Pandemic data from a large telehealth platform that triages SNF patients via telehealth showed that telehealth consultations from March to July of 2020 successfully diverted millions of dollars of SNF transfers. These patients were treated virtually at an overall rate of 91%, including for high-cost falls with injury (84.79%), shortness of breath (66.67%) and acute or chronic pain (95.96%).
Myth No. 2: Patients aren’t seeing their own doctors
The myth paints a picture of virtual-only providers reaching patients directly and charging Medicare for unnecessary treatment. In fact, the opposite is true. A large study of patients’ telehealth behavior during the pandemic showed that 83% of seniors saw their own provider or someone in the same practice. Only 1.4% of seniors saw someone their insurance company recommended, and a paltry 1% saw a virtual provider they didn’t know.
Myth No. 3: Telehealth is uniquely subject to fraudSensational press releases by the Department of Justice have created the false impression that telehealth is uniquely vulnerable to criminal behavior. No federal regulator or oversight body has yet issued a comprehensive study of Medicare telehealth claims during the pandemic. The reality is that the majority of fraud instances the DOJ highlighted have nothing to do with telehealth and are instead telemarketing scams aimed at billing for durable medical equipment, diagnostic or genetic tests, opioids or compounding pharmacy.
Myth No. 4: In-person relationship requirements are necessary to mitigate excessive cost and fraud
Requiring patients to first complete an in-person visit constrains the ability of providers virtually treat individuals who are homebound, have transportation challenges, or live in underserved areas. Congress instituted in-person relationship requirements in the first COVID bill in 2020 only to repeal them weeks later. All 50 state legislatures have abolished in-person requirements for telehealth visits, and the American Medical Association and Federation of State Medical Boards have said a physician-patient relationship can be established by telehealth. In-person requirements lower access to care without any meaningful impact on fraud. Cost goes down because of the barrier to people receiving care.
Myth No. 5: The Biden administration has the authority to make the telehealth changes permanent
Congress was responsible for granting the authority that federal agencies needed to allow Medicare to cover telehealth, employers to offer telehealth to part-time and seasonal workers and first-dollar coverage to employees with health savings accounts. These changes will expire with the public health emergency, and the only path to making them permanent is through Congress.
Data can and will break down these myths and enable effective long-term telehealth policy. As advocates we need to bring that evidence to Capitol Hill.
When asked about the prospects for long-term telehealth coverage, I often hear people say that permanent expansion is inevitable because “the genie is out of the bottle” or “Congress never takes benefits away.” The truth is they can, and they will, unless we effectively break down persistent misconceptions about the impact of telehealth policy changes.
Progressives are ramping up their push to expand Medicare in an upcoming legislative package, with the goal of lowering the eligibility age and adding new benefits.
The Congressional Progressive Caucus made its case to White House counselor Steve Ricchetti in a meeting Tuesday, saying they want eligibility to kick in at 60 instead of 65 and coverage extended to dental, vision and hearing.
Sen. Bernie Sanders (I-Vt.) is also vocally pushing the group’s proposals, saying too many seniors “can’t chew food properly” because they don’t have dental coverage.
But the campaign faces headwinds from a slew of health care priorities competing for a limited amount of dollars, as well as concerns from the industry and moderate Democrats who worry about lowering the Medicare age.
Advocates and congressional aides say adding new benefits has a significantly better chance of making it into the Democratic-only package than lowering the eligibility age.
Changing the age is more politically controversial, as it opens up the debate about moving toward “Medicare for All.”
Rep. Pramila Jayapal (D-Wash.), the chairwoman of the Congressional Progressive Caucus, said the White House is not opposed to adding the Medicare provisions, and is even supportive, provided the votes are there in both chambers.
“As long as we can get to 218 votes and 50 votes in the Senate, they’re excited about it,” Jayapal told The Hill.
But she said she has also been pressing the White House for more public support.
“We’ve been asking them to continue to push for that, to make it a real priority, and mostly we get positive answers,” she said.
The White House budget request for fiscal 2022 includes a call to lower the Medicare age and add dental, hearing and vision benefits, but those proposals were notably left out of President Biden’s $1.8 trillion American Families Plan, prompting questions about whether expansion is a top priority for the administration.
“We knew it wasn’t gonna be in there,” Jayapal said. “But I think the main thing is, can we get it in there? I mean, the president proposes and we write.”
The health care industry is opposed to lowering the Medicare eligibility age, seeing it as a step toward more government-run coverage and away from private coverage.
The Partnership for America’s Health Care Future, a group including pharmaceutical companies, hospitals and insurers, is running ads against lowering the Medicare age, as part of a seven-figure ad buy.
“What sounds too good to be true usually is. As analysis tells us, what seems so simple would actually result in the largest and most costly overhaul of Medicare,” Chip Kahn, CEO of the Federation of American Hospitals, said last month.
In addition to the cost to taxpayers, hospitals worry that Medicare pays lower rates to medical providers than private insurers do, which industry leaders warn could lead to damaging cuts.
The Committee for a Responsible Federal Budget estimates that lowering the Medicare age to 60 would cost $200 billion over 10 years. Adding dental, vision and hearing would cost another $358 billion over 10 years, the Congressional Budget Office estimated in 2019.
Allowing Medicare to negotiate drug prices could provide savings of up to roughly $500 billion to help pay for these measures, but it is also possible that proposal will be scaled back, depending on moderate Democratic concerns.
“It’s largely a question of how much can be squeezed into the overall reconciliation package, given the other discussions about revenue and total size,” said a senior Democratic aide. “Lowering the Medicare age can get expensive in a hurry, especially with the changes that would be needed to ensure it doesn’t have higher premiums or worse benefits than what the ACA provides older low-income Americans.”
The proposal from progressives is competing with other health care priorities, like extending Affordable Care Act (ACA) subsidies and expanding Medicaid in states that have so far refused to do so.
Sanders told reporters last month that “there are millions of older workers who would like to get Medicare but they can’t, which is why we’ve got to lower the age.”
Asked if adding dental, vision and hearing benefits is a higher priority than lowering the age, Sanders said then: “They’re both very, very important.”
Senate Majority Leader Charles Schumer (D-N.Y.) tweeted his support last month.
“There’s a gaping hole in Medicare that leaves out coverage for dental, vision, and hearing—this is a serious problem,” he wrote. “I’m working with @SenSanders to push to include dental, vision and hearing Medicare coverage in the American Jobs and Families Plans.”
But Schumer’s tweet made no mention of lowering the Medicare age to 60.
Sen. Joe Manchin (D-W.Va.), a key swing vote, told The Washington Post in April that he opposes lowering the Medicare eligibility age. “No, I’m not for it, period,” he said.
House Ways and Means Committee Chairman Richard Neal (D-Mass.) also raised some potential concerns on Wednesday with the idea, but added that “we have to take a look at it.”
“A lot of the folks that you might want to cover, they already have health insurance” through private insurers, he said, while also pointing to questions about cost.
He said he has had “at least a cursory conversation” with some members of the Congressional Progressive Caucus about the idea.
Jayapal, however, is highlighting that it is not only progressives who are backing the idea.
More than 155 House Democratic lawmakers signed a letter in May calling for lowering the Medicare age; adding dental, vision and hearing benefits; and lowering drug prices to produce savings to pay for the plan.
The signers included moderates like Reps. Jared Golden (D-Maine) and Conor Lamb (D-Pa.).
Jayapal said she has had “multiple meetings just on this topic” with White House officials. Ricchetti was open to the health care proposals in Tuesday’s meeting, she said, and “it’s been even more positive than that with others in the White House, Klain and others,” referring to White House chief of staff Ron Klain.
With five months before the surprise billing ban takes effect, the Biden administration hasn’t released many of the most important details about how the No Surprises Act will work, leaving providers and insurers little time to plan for the changes.
CMS’ first rule outlawing balance billing contained expected patient protections against surprise billing and high cost-sharing for out-of-network care, as outlined in the December law.
But providers and insurers are still in the dark about the independent dispute resolution process and how regulators will define key terms for arbitrators or calculate median in-network rates.
“It’s not really what providers or payers were looking for,” Avalere Health consultant Tim Epple said. “I don’t think there is anything that we’ve seen that differed meaningfully from the legislative text or the intent of the statute.”
Healthcare executives could start to get antsy as the Biden administration approaches its self-imposed October 1 deadline to wrap up the rulemaking process, he said. Without more information about how regulators will define geographic regions, immediate in-network rate comparison and other aspects of the law, providers could struggle to figure out their risk exposure and strategy for dealing with the surprise billing ban.
“If they wait until October, that’s a pretty tight time crunch for what is going to be a fair bit of change,” Epple said.
The patient protections will have the greatest effect on consumers, and will ultimately affect insurers’ health plan documents during open enrollment this fall, Manatt Health partner Michael Kolber said.
But later rules will squarely address provider-payer business relationships. Congress didn’t give the Biden administration much wiggle room to determine the so-called “qualifying payment amount,” which the law defines as an insurer’s historical median in-network rate for a given service. Arbitrators will use that information to help settle payment disputes among providers and insurers and, in turn, decide how much consumers must pay out-of-pocket for related services.
“It will force providers and payers to agree on a price,” Waller Law partner Patsy Powers said.
Both providers and payers have strong incentives to bill and pay reasonable rates from the outset because the surprise billing ban leans on an insurer’s median, rather than average, historical in-network rate. Neither side is likely to get much out of arbitration in most cases.
Several provider groups lobbied regulators to base the qualifying payment amount on a median of historical claims data, which would have allowed some large providers to keep charging higher rates, said Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy. But the Biden administration followed a more straightforward interpretation of the law instead.
The new rule forces plans to jump through more hoops if they want to deny claims for emergency services. They have to make those decisions based on the patient’s symptoms, not diagnosis codes alone.
Among people with commercial health coverage, an estimated 1 in 5 emergency claims and 1 in 6 in-network hospitalizations result in at least one out-of-network bill, according to the Petersen Center on Healthcare and Kaiser Family Foundation.
“We are pleased that federal policymakers recognize ongoing attempts by insurers to retroactively deny coverage of emergency care and that this rule would add additional patient protections. This reaffirmation of the prudent layperson standard helps ensure that patients no longer need to hesitate or delay seeking emergency care over uncertainty about their insurance coverage,” the American College of Emergency Physicians said in a statement.
The Congressional Budget Office estimates that the No Surprise Act will lower commercial premiums between 0.5% and 1%, saving taxpayers about $17 billion over a decade. Consumers could save another $34 billion or so thanks to lower premiums and cost-sharing, according to the USC-Brookings Schaeffer Initiative for Health Policy.
The ban on surprise billing could cost providers more than $50 billion over 10 years. Some of those losses will come from the pockets of private equity companies rather than doctors themselves, Adler said in an email.
Providers could still take the battle over surprise billing back to the states to get more favorable terms, Kolber said. The new rule defers to states that have surprise billing rules on the books, allowing them to create and enforce their own rules instead of federal rules created under the No Surprises Act. However, it’s unclear whether providers will pursue that strategy, given the surprise billing ban’s popularity among the public.
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