The Centers for Medicare and Medicaid (CMS) has issued a final rule on drug price transparency. It requires all Medicare Advantage and Part D plans to offer a drug price transparency tool that can be integrated into physician Electronic Health Records (EHRs). This rule will come into effect after a time period that allows EHR developers and healthcare providers to obtain the technology.
“For those who are Medicare-eligible with drug coverage through a stand-alone Part D drug plan or a Medicare Advantage Prescription Drug plan, the rule requires these plans to include price transparency and low-cost drug alternative lists in their monthly explanation of benefits (EOB) letters to beneficiaries that they already receive…
“Today’s rule requires Part D plans to adopt tools that provide clinicians with information that they can discuss with patients on out-of-pocket costs for prescription drugs at the time a prescription is written,” CMS Director, Seema Verma, said. “By empowering patients with information on the cost of their prescription drugs, today’s rule will ensure that pharmaceutical companies have to compete on the basis of price. This effort builds on new requirements for hospitals to disclose chargemaster prices and other agency initiatives to promote price transparency.”
There is also a mandate included in the provisions to empower clinicians by letting them negotiate prices for physician-administered medications, thereby lowering the cost to patients. Most of these medications are biologics, which CMS acknowledged are exceptionally expensive.
As more biosimilars come to market for these drugs, physicians must be empowered to negotiate lower-cost options on behalf of their patients, CMS suggested.
“Additionally, the final rule outlaws pharmacy “gag clauses,” which are payer-imposed rules that prohibit pharmacists from informing patients about lower-cost medication options.
Reference: Sara Heath, “PatientEngagementHIT”
“Scott Gottlieb, MD, announced his resignation as chief of the FDA on March 5. He plans to leave his post sometime next month.
“Dr. Gottlieb has served in his post since May 2017, and has been a staunch advocate for developing new drugs and regulation. His resignation may especially affect biotech and pharmaceutical companies, as well as tech companies looking to move into the healthcare space.
“Before appointing Dr. Gottlieb, President Donald Trump considered a variety of candidates for the position, including individuals who sought to dismantle FDA drug oversight and review process — a move that worried many pharma executives and health sector investors, STAT News reports.
“‘I think Scott was pretty much a best-case scenario for the sector that one could see under a Trump administration, so any replacement is probably going to be worse. Hopefully not much, much worse,’ a Baird biotech analyst told STAT.
“During his time at the FDA, the physician and former venture capitalist also gained a reputation as a supporter of healthcare innovation, establishing programs like Pre-Cert, software that allowed tech giants like Apple to get approval for low-risk health products faster, CNBC reports.
“‘Scott did a lot culturally to make the agency easier to work with,’ Bob Kocher, a partner at venture capital firm Venrock, told CNBC. ‘I think he’ll be missed by many in the tech industry, including the startups.'” Source: “Becker’s Hospital Review”
Medicare wants to change how it pays for emergency ambulance services to give seniors more options besides going to a hospital emergency department, according to officials at HHS, Health and Humans Services, the federal agency the oversees CMS, the Centers for Medicare and Medicaid.
“Other options could include going to an urgent care center, a doctor’s office, or even treatment at home under supervision of a doctor via telehealth links
“It’s just a pilot project for now, but if adopted nationwide the idea could save Medicare more than $500 million a year and allow local fire departments and ambulance services to focus the time and energy of first responders on the most serious emergencies…
“Unveiling the ambulance proposal at a Washington, D.C., fire station, Adam Boehler, the innovation center director, said he was astounded to learn that under current rules Medicare will only pay for emergency ambulance services if the patient is going to a hospital, in most cases.
“‘I thought that was a joke,’ said Boehler, a former health care entrepreneur who ran a company providing in-home medical care to seriously ill patients. He called Medicare’s current policy a “ridiculous incentive” to funnel patients to the most high-cost setting. Most private insurance plans discourage emergency room use by imposing higher copays, and some state Medicaid plans are trying similar tactics.
“Appearing at the same event, the chief medical officer for the New York City fire department endorsed Medicare’s experiment. Dr. David Prezant said his agency is overwhelmed with non-emergency calls and transporting patients to a hospital is a time-consuming process that keeps ambulance crews needlessly tied up.
“‘If only 20 percent of our calls no longer required transport to an ED (emergency department), we would save lives in cases when every second counts,’ Prezant said. Associated Press.
The hospital price transparency rule takes effect on January 1, requiring providers to publicize their rates for all items and services.
“Starting January 1, 2019, hospitals will be required to post their price lists online in an effort to increase price transparency and empower consumers to make informed choices about their care.
“The mandate stems from the 2019 inpatient and long-term care hospital prospective payment system (IPPS/LTCH PPS) final rule, released in August, in which CMS included the requirement for hospitals to update their public price lists at least annually.
“‘The policies in the IPPS/LTCH PPS final rule further advance the agency’s priority of creating a patient-centered healthcare system by achieving greater price transparency, interoperability, and significant burden reduction so that hospitals can operate with better flexibility and patients have what they need to be active healthcare consumers,’ CMS wrote…
“While hospitals can choose the format for presenting the data, as long as it’s machine-readable, the list must include all items and services provided by the facility, CMS stated.
“‘CMS encourages hospitals to undertake efforts to engage in consumer friendly communication of their charges to help patients understand what their potential financial liability might be for services they obtain at the hospital, and to enable patients to compare charges for similar services across hospitals,’ the agency said.”
Source: Jennifer Bresnick, “HealthPayer Intelligence”
“The federal deadline for insurers to file rate proposals with the federal government is June 21. Many insurers had been hoping that the Trump administration would say for certain whether it would continue to pay cost-sharing reduction (CSR) subsidies for covering low-income enrollees.
“No such assurances from the administration appear to be coming, leaving insurers with a difficult choice.
“Next week’s filings will give the most comprehensive look yet at what the ObamaCare markets could look like next year. It’s not clear whether the Trump administration will make the requests public, though sometimes individual states will release the information for their insurers.
“Still, early filings already show several insurers requesting double-digit rate increases. Some have already announced they won’t participate in the law’s marketplaces next year, leaving an unprecedented 47 counties with no options on the exchanges for 2018.
“‘We’ve seen so far pretty high premium increases in a number of states. Some of that seems to be because of uncertainty insurers are facing over CSR payments and individual mandate enforcement,’ said Cynthia Cox, an insurance expert with the Kaiser Family Foundation.” Source: The Hill.
The Department of Health and Human Services (HHS) is actively working to reduce regulatory burdens and improve health insurance options under Title I of the Patient Protection and Affordable Care Act. Executive Order 13765, “Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal,” directs the Secretary of Health and Human Services to achieve these aims. HHS seeks comment from interested parties to inform its ongoing efforts to create a more patient-centered health care system that adheres to the key principles of affordability, accessibility, quality, innovation, and empowerment.
Comments must be submitted on or before July 12, 2017.
For more information click here.
In today’s news there is still talk of US House of Representatives continuing with the lawsuit against the government demanding an end to deductible and co-pay cost-sharing subsidies. These subsidies help Americans pay for their Affordable Care Act (ACA) health plan deductibles, co- insurance, and co-pays.
Up to 87% of people with an Affordable Care Act plan get help paying for their insurance premium and/or out-of-pocket costs.
Insurers know there would be devastating effects to them and American households both, if the cost-sharing subsidies were to be stopped. Many, if not most, households with an ACA plan would simply be forced to incur medical bills that they have no way to pay. This would end up creating waves and waves of medical care by providers all across the country to go completely unpaid.
In light of this situation: “16 state attorneys general have asked a federal appeals court to let them intervene in a legal case to keep those payments flowing.
“On Thursday, attorneys general from both Republican- and Democratic-led states filed a motion to intervene in House v. Price, a case originally brought by House Republicans to block federal payment to insurers to fund the Affordable Care Act’s cost-sharing reductions for low-income exchange plan members.
“The U.S. Court of Appeals for the District of Columbia Circuit is scheduled to hear a status report in the case on May 22. Meanwhile, insurers around the country, citing uncertainty about the cost-sharing reduction payments, have filed requests for 2018 premium hikes in the double digits. The CSR payments are estimated to total $7 billion this year.”
So the natural question is: What happens to the healthcare industry in America if nearly $7 billion dollars goes missing to pay for medical care?
If we are going to be forced to live under the law called the Patient Protection and Affordable Care Act, those in Congress need to develop understanding about the current situation that American households are in, and they need to free insurance companies to manage premiums, claims, and their own business.
Source: Modern Healthcare.
The Trump administration has announced new Affordable Care Act (ACA) rules for individuals and employers for this fall open enrollment and for the health insurance plans next year.
1. As of now, the ACA open enrollment period will start on November 1st and end on December 15th. This is substantially shorter than the most recent open enrollment period. The intention seems to be to provide a standard 12- month policy period for everyone, and shore up complexities in processing insurance plans that could have a 1/1, 2/1, or a 3/1 effective date.
2. Anyone who signs up for health insurance outside of the open enrollment period, will have to provide specific and verifiable proof of eligibility to enroll based on a qualifying life event. In the years before the ACA this was always the case, and is a reasonable requirement. The intention to return to this protocol is to eliminate the opportunity to “game the system” and for people to obtain coverage when they were not actually eligible to do so. In many cases, over the years, expensive medical procedures and treatments were covered for some of these people, but then they stopped paying premiums and cancelled their plans as soon as the coverage was not needed for those procedures and treatments. This ultimately affects everybody’s premiums.
3. The administration’s new ACA rule allows insurers to refuse to cover a person who hasn’t paid their premiums. The insurance companies will have to apply this to all employers or individuals. Supposedly some state laws will have to change regarding this rule. Also, this rule will apparently not be applied to employer plans sold on the federal small business SHOP marketplace due to “operational constraints,” according to the information available.
Regardless, Evansville Insurance Center deems this to be creating an uneven playing field. The problems with SHOP enforcement of this rule should be resolved before it is a rule levied on all other insurance plans.
4. Health plans will also get more flexibility in creating products to sell in their market- and not be restricted to the bronze, silver, gold, and platinum Qualified Health Plan benefit designs that were required by ACA rules. This is the great news! Insurance companies should now be able to design health insurance plans that are more suited to the particular people they are intended to cover. Hopefully this new rule will be the mark that we are on the way to good changes.
Source: Virgil Dickson, Modern Healthcare.
“State Rep. Brad Raffensperger has introduced a resolution that would urge Republican Gov. Nathan Deal to submit a request for a 1115 waiver to transition the state’s Medicaid program into a per-capita capped system…Under that model, the CMS would distribute a limit of federal dollars per person in the state. Spending would grow as the number of enrollees did, and the state could set eligibility, benefits and delivery system approaches however it chooses.
“Raffensperger said that change could expand Medicaid to people living below the poverty line, which would reduce uncompensated care costs for hospitals. The Georgia Hospital Association’s most recently estimated that its members faced $1.02 billion in uncompensated care costs for indigent Georgia citizens in 2014. That same year, 66% of rural hospitals had negative margins. In all, 41% of Georgia’s hospitals ended 2014 with negative margins, according to the Georgia Hospital Association. Currently, there are about 565,000 uninsured low-income Georgians below the poverty line in a recent Deloitte study.
“‘Working together for both the nation’s and Georgia’s best interest, I believe [(Governor) Deal and (HHS nominee) TomPrice] can craft the block grant funding solution that reflects the desire of Congress, President Trump and our conservative, fiscally responsible values,’ Raffensperger said.” Source: Modern Healthcare.