Insights^

Find our analysis on legislation, regulations, MedPAC meetings, and more. 

MedPAC Starts as They Mean to Continue, Focusing on Sustainability and Rural Health

It’s the beginning of the season!  Nope, not election or back-to-school season – it’s MedPAC season!  The Medicare Payment Advisory Commission opened up their annual cycle last week discussing the sustainability of the Medicare program and issues in rural health care.  And we are here for all of it!  

MedPAC Has a Job to Do 

Congress created the Medicare Payment Advisory Commission (MedPAC) to recommend Medicare payment updates and strategies to improve the Medicare program. MedPAC is mandated in their charter to submit recommendations on annual payment updates for several fee-for-service payment sectors within Medicare. The other half of the MedPAC charter focuses on improvements and innovations for the Medicare program.   

MedPAC Weighs in on Medicare’s Future 

So, what did MedPAC say in their September 5, 2024 meeting about the future financial sustainability of the Medicare program?  Staff reported that national healthcare spending is now at $4.5 trillion (2022) or 17.3% of GDP and said those levels will increase to 19.7% in 2032.  Staff also pointed out that Medicare’s HI Trust Fund will become insolvent in 2035.  While discussing factors increasing spending like demographics (more older Americans) and inflation, the Commission purposely called out the cost of GLP-1 drugs and said that those drugs alone will increase Medicare Part D spending by $36 billion over the next 10 years.  The Commission rounded out the meeting discussing beneficiary enrollment/financial obligations, beneficiary care disparities, and clinical workforce shortages in the U.S.  

Rural Beneficiary Cost-Sharing is a Major Problem 

Shifting from the financial side, MedPAC switched to one of their main focuses for this year’s agenda – how to ensure the viability of rural health care in America.  The most animated discussion of the day revolved around cost-sharing obligations for rural Medicare beneficiaries receiving care in Critical Access Hospitals (CAHs).  Staff analysis showed that rural Medicare beneficiaries receiving care in CAHs pay significantly more than beneficiaries in Prospective Payment System (PPS) hospitals due to a byproduct of how CAHs are paid.  One analysis even showed that half of CAHs’ outpatient payments come from beneficiary copayments.   

The debate among Commissioners was not about whether this is a problem – all agreed it was – but whether to address the situation with a quick fix or to fix the entire CAH payment system.  The majority of Commissioners seemed to settle around the idea of changing beneficiary cost sharing on services to 20% of FFS payment rates, while a faction wanted to not only change cost-sharing but also the entire payment system for CAHs.  There was also discussion of placing a cap on outpatient coinsurance for rural beneficiaries to limit out-of-pocket costs.  This issue will be discussed again publicly in the January 2025 Commission meeting. 

Rural Quality Reporting is Harder to Understand 

The final session revolved around rural quality reporting – and if there were metrics available from rural providers.  Staff outlined all available metrics but did note that some rural providers are not required to participate in Medicare quality reporting programs.  Staff and Commissioners also pointed out the difficulty of Medicare Advantage plan reporting – which is done at the contract level – making it hard to tell what is going on within specific health care markets.  Many Commissioners also discussed the difficulty of measuring quality if providers only have small amounts of patients/data (sample size issues).  The Chairman said this would be a chapter in an upcoming report, but there were no recommendations or further work outlined on the issue. 

What’s Next 

So, next steps?  After the payment adequacy discussions in October/November/December, we expect these topics and discussions on Medicare Advantage to resurface in January.  And we will be in the virtual front row with popcorn! 

Navigating Healthcare Transparency: Administration’s Push for Medicare Advantage Clarity

Medicare beneficiaries are often uninformed on prices, supplemental benefits, and the use of prior authorization in their Medicare Advantage (MA) plans.  In a landscape where healthcare decisions can feel opaque, transparency could empower patients in navigating the Medicare Advantage program. New initiatives and regulations by HHS and CMS are working to enhance transparency within Medicare Advantage, creating more informed decision-making and ensuring equitable access.

The Administration’s goal is to provide tools so beneficiaries can make informed choices about their healthcare coverage. By bolstering transparency within the Medicare Advantage program, the Administration aims to address longstanding challenges and equip beneficiaries with the information needed to select plans that align with their healthcare needs and preferences.

At the core of this initiative lies a multifaceted approach designed to enhance transparency across various dimensions of the Medicare Advantage program. Key components of the Administration’s efforts include:

Enhanced Access to Plan Information

The initiative seeks to enable beneficiaries to compare coverage options with greater ease and clarity. By centralizing plan data and making it readily accessible to beneficiaries, the Administration aims to facilitate informed decision-making and empower individuals to select plans that best meet their healthcare needs.

Improved Cost Transparency

By providing beneficiaries with clear and comprehensive information regarding plan costs, including premiums, deductibles, and copayments, the initiative aims to empower individuals to assess the financial implications of their healthcare choices and make informed decisions aligned with their budgetary constraints.

Increased Quality Reporting

Quality of care is a fundamental consideration for Medicare Advantage beneficiaries seeking to maximize the value of their healthcare coverage. By changing the way plans are rated and creating more transparency around key quality metrics, such as clinical outcomes and patient satisfaction ratings, the initiative aims to empower beneficiaries to make informed assessments of plan performance and quality of care delivery.

Accessible Tools and Resources

The Administration’s initiative prioritizes the development of accessible online tools and resources designed to support informed decision-making. From online comparison tools to personalized assistance through the Medicare Plan Finder, these resources are intended to empower beneficiaries with the information and support necessary to navigate the complexities of the Medicare Advantage program effectively.

Conclusion

The Administration’s push for increased transparency within the Medicare Advantage should foster transparency across various dimensions of the program.  CMS is laying the groundwork for a more equitable, accessible, and patient-centered healthcare system that prioritizes the needs and preferences of Medicare Advantage beneficiaries. Major health plans and coalitions are objecting to many aspects of these proposals, so we will need to continue watching to see which of these proposals actually become finalized.

If you would like to connect with Chamber Hill Strategies, please do not hesitate to contact us.

Navigating Healthcare Transparency: Administration's Push for Medicare Advantage Clarity

MedPAC Payment Basics – Our Christmas in October

It’s Christmas in October!  For policy geeks like us, the release of the Medicare Payment Advisory Commission’s (MedPAC) payment basics are like a gift that keeps on giving.

Not familiar with these beauties?  Well, read on, my friend.  MedPAC’s payment basics are a Medicare 101 for every payment system within Medicare.  They cover all players in the Medicare healthcare work from hospitals to physicians to all post-acute care providers.  Want to know how DSH payments for hospitals work? It’s in there.  Want to know about GPCIs for physicians?  In there.  Medicare Donut hole?  Yep.

In addition to the well laid out explanation of each intricate aspect of each payment system, the payment basics also contain excellent graphics that outline the “flow” of each payment system and how one adjustment (for example, a rural payment adjustment) fits into an overall payment rate for each provider.  They are great power point fodder and really help visually explain all of the payment adjustors in the system.  The Basics also cover payments for Accountable Care Organizations (ACOs), Durable Medical Equipment (DME), Federally Quality Healthcare Centers (FQHCs), Medicare Advantage Plans, and Part B and Part D drugs.

The payment basics are not just used by us policy nerds to brush up on our conversion factor calculations, but they are also used to train new Members of Congress and their staff.  And even those of us who have been doing this for far too many years, return to them year after year as the Basics are updated for all new legislative/administrative changes.

Happy Reading!

avery-evans-RJQE64NmC_o-unsplash-1920x1080

What Happened, What You Missed: October 2-6, 2023

Makers of 10 Drugs Agree to Participate in Medicare Price Negotiations

The manufacturers of all 10 drugs selected for Medicare drug price negotiations have agreed to participate in the program, according to a White House announcement.  The announcement comes as several drugmakers have filed lawsuits against the Biden administration to stop the drug price negotiation program, including one that has already committed to participate in the negotiations.  The administration named its first 10 drugs to participate in the program over a month ago, which includes two diabetes drugs, a blood thinner, and a rheumatoid arthritis treatment.  Initial price offerings on the drugs will be announced on February 1, 2024, although Medicare beneficiaries won’t be able to access drugs with the negotiated prices until 2026.

75K Kaiser Permanente Workers Kick Off Largest Health Care Strike

More than 75,000 unionized employees of Kaiser Permanente, one of the nation’s largest health care providers, started the largest health care strike in US history this week.  Union leaders say they’re hitting the picket lines for outsourcing protections, safe staffing, and better wages to reduce turnover.  The strike comes amid an uptick in organized labor across the country, with unions representing auto workers and actors calling for higher pay.  While Kaiser’s hospitals and emergency departments will stay open during the strike, the company has warned that elective and non-emergency services may be rescheduled.

Moderna’s Combination COVID-Flu Shot Shows Promise

Moderna is moving on to late-stage clinical trials for its combination COVID-19 and influenza vaccine after early-stage trials found the shot to be effective against both viruses.  The combined vaccine has been shown to have a similar safety profile to existing mRNA COVID-19 vaccines, and no new safety concerns have been reported.  The company’s efforts to create a two-in-one COVID-19 and flu shot mirror similar efforts at Pfizer and Novavax.  Health experts say a combination vaccine has many logistical benefits, such as a reduced need for storage space and fewer injections for patients.  Known as mRNA-1083, Moderna’s experimental vaccine could become available to the public in time for the 2025 flu season.

Study: “Good” Cholesterol Linked to Dementia

“Good” cholesterol may not be as good as previously thought, according to a new study.  The researchers found a correlation between high-density lipoprotein (HDL) cholesterol and dementia in older adults, although they did not conclude if high or low levels can directly cause dementia.  The study, which was supported by the National Institutes of Health (NIH), included more than 180,000 California residents who now have an average age of 70 years old.  The average HDL cholesterol level in the study was 53.7 mg/dL, which is within the recommended range of 40 mg/dL in men and 50 mg/dL in women.  People whose cholesterol levels deviated too far from these numbers were more likely to develop dementia, according to the study.  Too much HDL cholesterol in the brain can cause inflammation that causes the production of amyloid plaques, which are attributed to dementia.

ICYMI: Biting Incidents Prompt Ouster of Biden’s Dog

Commander, President Joe Biden and First Lady Jill Biden’s German shepherd, has been removed from the White House following a string of biting incidents involving White House residence staff and Secret Service personnel.  Commander’s departure from DC is similar to Major, the Bidens’ other German shepherd, who was sent to live with family friends in Delaware in 2021 after biting people at the White House.  According to emails published by Judicial Watch, Commander bit several Secret Service agents a total of 10 times.

christina-victoria-craft-ZHys6xN7sUE-unsplash-scaled

What Happened, What You Missed: May 1-5, 2023

Study: 340B Suppresses Uptake of Biosimilars

Hospitals that participate in the 340B Drug Pricing Program see lower adoption of biosimilar drugs, according to a new study from Health Affairs. Roughly a third of the nation’s hospitals participate in the 340B program, which requires manufacturers to provide discounts on most drugs administered in the outpatient setting to help safety-net hospitals, although the discounted drugs are reimbursed by Medicare at the same rate as they are in non-340B hospitals. Researchers also found that 340B hospitals were associated with an overall increase in the use of increased use of pricier biologic medications. To conduct the study, researchers examined 340B hospitals’ 2017-2019 Medicare claims data for two commonly used biosimilars.

Vaccine Mandate for Employees at CMS-Certified Facilities Drops on May 11

The requirement for federal government employees to be vaccinated for COVID-19 will end on May 11, the same day the COVID-19 public health emergency (PHE) is set to expire. President Biden is expected to issue an executive order in the coming days to rescind the mandate, which applies to federal employees, contractors, international visitors, and people working at Centers for Medicare and Medicaid Services (CMS)-certified facilities. Originally put in place in September 2021, the vaccine mandate was blocked by a federal appeals court in March 2023 after initially being upheld by a federal court in January 2023. According to the Biden administration, nearly 98% of federal employees have been vaccinated against COVID-19.

CBO Posts Estimate on TANF Work Requirements in Debt Ceiling Bill

Congressional Budget Office (CBO) released an estimate that the work requirement provision in the recently passed House debt ceiling bill would lower federal expenditures, but increase the number of people without health insurance without increasing hours spent in employment. H.R. 2811, the Limit, Save, Grow Act of 2023 raises work requirements for certain Medicaid recipients up to 80 hours per month and increases the age through which those persons must continue working. CBO estimated that while this provision would save the federal government $109 billion over 10 years, it would increase costs to states $65 billion.

FDA Clears First RSV Vaccine for Seniors

On Wednesday, the Food and Drug Administration (FDA) approved Arexvy as the first vaccine for respiratory syncytial virus (RSV). Manufactured by GlaxoSmithKline, the vaccine is administered as a single shot, and it approved only for adults ages 60 and older. Assuming a Centers for Disease Control and Prevention (CDC) independent advisory committee votes to recommend the vaccine in June, Arexvy could be available to older adults as soon as this fall. Although RSV is mostly associated with babies and young children, an estimated 159,000 American adults 65 and older are hospitalized each year with RSV, and an estimated 10,000-13,000 die as a result of their infection. RSV vaccines for younger populations are currently under review and could made available by the end of the year.

Sen. Ben Cardin to Retire

Sen. Ben Cardin (D-MD) announced on Monday that he won’t seek a fourth term in the US Senate in 2024. A longtime fixture in Maryland politics, Cardin was first elected to the Maryland House of Delegates while he was still a student at the University of Maryland Carey School of Law. He went on to become the chamber’s youngest speaker in 1979, and in 1986, he was elected to represent Maryland’s Third Congressional District in the US House of Representatives, where he served until 2007. That same year, Cardin became Maryland’s junior senator in the US Senate, where he would serve on the powerful Finance Committee. During his tenure in the Senate, Cardin has been a strong proponent of oral health, and he frequently sponsored legislation to make dental care a covered benefit under Medicare. Cardin’s announcement has set off what’s expected to be a competitive Democratic primary to succeed him. While no formal announcements have been made, Reps. Jamie Raskin (D-MD) and David Trone (D-MD) are seen as possible candidates, as well as Prince George’s County Executive Angela Alsobrooks.

ICYMI: Freshman Lawmakers Launch Congressional Sneaker Caucus

Freshman Rep. Jared Moskowitz (D-FL) launched the Congressional Sneaker Caucus last week with fellow freshman Rep. Lori Chavez-DeRemer (R-OR). Moskowitz and Chavez-DeRemer are among a small but growing number of lawmakers and staff who are opting to wear sneakers over more traditional dress shoes on Capitol Hill. Both members of Congress say they intended to use the caucus as a way for sneaker fans on both sides of the aisle to find common ground. They also hope to host meetings and partner with manufacturers on philanthropic activities.

christina-victoria-craft-ZHys6xN7sUE-unsplash-scaled

Subscribe to Us Now!

Be a DC insider by getting our updates straight to your inbox