News from Congress
Better Mental Health Care, Lower-Cost Drugs, and Extenders Act – Senate Committee on Finance
Senators Wyden(D-OR) and Crapo (R-ID) introduced new bipartisan legislation to expand mental health care workforce and services, reduce prescription drug costs, and extend expiring provisions across Medicare and Medicaid. The underlying bill passed 26-0 through committee and awaits further discussion on the Senate floor. Key provisions of this bill include:
- Covering health behavior assessment and intervention services delivered by community health workers under Medicare Part B.
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Increasing payments for certain behavioral health integration services under the Medicare Physician Fee Schedule.
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Requiring Medicare Advantage plans to maintain accurate provider directories.
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Codifying regulatory requirements for Part D sponsors to contract with any willing pharmacy that meets their standard contract terms and conditions in order to expand access to pharmacies.
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Requiring coinsurance for certain covered Part D drugs, after reaching the deductible but before reaching the out-of-pocket threshold, to be based on net prices.
At the 11/8 Finance Committee mark-up of this legislation, Senator Hassan (D-NH) introduced and withdrew an amendment, which would have codified site-neutral payment policies. Senators Wyden and Crapo committed to working with Senator Hassan to look into site of service issues more closely and advance solutions.
House Energy and Commerce Health Subcommittee Markup – House Committee on Energy and Commerce
The Health Subcommittee of the House Committee on Energy and Commerce advanced 21 bills to the full committee. The package of bills is intended to address high prescription drug prices, new and innovative technology under Medicare, and preservation of patient access to independent physicians. Some highlights of this bill package with regard to payment reform and provider reimbursement include:
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H.R. 6366 (Hudson, R-NC), which would extend the floor at 1.0 of the work geographic index under the Medicare Physician Fee Schedule through 2025 and revises the phase-in of payment changes for clinical laboratory tests.
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H.R. 6369 (Schrier, D-WA and Dunn, R-FL), which would extend the current Alternative Payment Model (APM) payment bonus of 5.0% through 2026. However, it would reduce this amount by 34% and 67% for participants who have participated in APMs for a total of 4 and 7 years, respectively.
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H.R. 6371: Provider Reimbursement Stability Act of 2023 (Murphy, R-NC; Burgess, R-TX; Kelly, D-IL; Wenstrup, R-OH; Van Drew, R-NJ; Miller-Meeks, R-IA; Harris, R-MD; Babin, R-TX; Joyce, R-PA; Jackson, R-TX; McCormick, R-GA; Ferguson, R-GA; Carter, R-GA; Bucshon, R-IN; and Dunn, R-FL), which would increase existing budget neutrality thresholds in 2025, and every year thereafter. The bill would also correct estimates made using estimated utilization rates and require the Department of Health and Human Services to update the prices and rates used to calculate practice expense Relative Value Units (RVUs).
Ways and Means Committee Holds Roundtable with Biden Admin on Failed Implementation of Medical Surprise Billing Protections – House Committee on Ways and Means
Republican Representatives on the House Committee on Ways and Means held a roundtable with Biden Administration officials to discuss implementation of the No Surprises Act (NSA). In particular, they raised concerns about failure to implement the Advanced Explanation of Benefits provision and implementation of the Independent Dispute Resolution process, which was subject to multiple legal challenges and court rulings, resulting in additional rulemaking. These House Republicans wrote a letter to the Departments of Health and Human Services, Treasury, and Labor to raise further grievances with implementation of the NSA. Families USA Action and consumer advocacy allies recently sent a letter to the administration expressing concerns with the industry-led narrative and multiple lawsuits attacking the No Surprises Act.
The Latest from the Biden Administration
CY 2024 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center Payment System Final Rule - Centers for Medicare and Medicaid Services
Following an open comment period, CMS released the OPPS final rule for CY 2024, establishing payment rates for the upcoming year and making adjustments to federal regulations governing quality measures, payments for outpatient care, and the Hospital Price Transparency rule. They finalized changes to the Hospital Price Transparency rule, including around enforcement actions for noncompliance hospitals and requiring a standard format for all hospital submissions, but they failed to require reporting of all negotiated rates in dollars and cents, the information that both policymakers and consumers really need. Critically left out of this year's rule is any comprehensive site neutral payment policy.
CY 2024 Medicare Physician Fee Schedule (MPFS) Final Rule - Centers for Medicare and Medicaid Services
Following an open comment period, CMS released the MPFS final rule for CY 2024, which included a strong emphasis on improving health equity and increasing reimbursement rates for primary care and behavioral health services delivered through telehealth. Key wins for consumers included compensation of Community Health Workers under Medicare for the first time through payment codes for Community Health Integration services. Social Determinants of Health (SDOH) risk assessment will also be billable under Medicare in scenarios where SDOH factors impact health care delivery.
Proposed Rule: 21st Century Cures Act: Establishment of Disincentives for Health Care Providers That Have Committed Information Blocking - Centers for Medicare and Medicaid Services
CMS proposed a rule to establish disincentives for health care providers who, as determined by the HHS Office of the Inspector General (OIG), have knowingly and unreasonably interfered with the access, exchange, or use of electronic health information (also known as information blocking). The proposed rulebuilds on the 21st Century Cures Act which gave authority for the OIG to oversee and evaluate rates of information blocking and impose penalties on providers who have engaged in the behavior. The rule would establish different disincentives for certain health care providers, including but not limited toa score of zero in the Promoting Interoperability performance category of the Merit-based Incentive Payment System (MIPS) for providers in that program, and removal of providers from participation as an Accountable Care Organization (ACO) under the Medicare Shared Savings Program (MSSP). CMS is accepting comments on this proposed rule through January 2nd, 2024.
Proposed Rule: Federal Independent Dispute Resolution Updates - Centers for Medicare and Medicaid Services
CMS proposed a rule to establish additional rulemaking regarding the Independent Dispute Resolution (IDR) process, which serves as arbitration between providers and insurers under the No Surprises Act. The proposed rule sets forth additional procedures for providers and insurers to facilitate communication and negotiation between parties as well as updates to the batching process, which had been a persistent concern of providers. CMS is accepting comments on this proposed rule through January 2nd, 2024.
Federal Budgetary Effects of the Activities of the Center for Medicare & Medicaid Innovation – Congressional Budget Office
The Congressional Budget Office (CBO) released a new report presenting findings on CMMI’s first decade of operation. They found that CMMI increased federal spending by $5.4 billion over its first 10 years of operation, and that it will continue to increase spending over the subsequent decade. Importantly however, CMMI models yielded savings of $2.5 billion on health care benefit spending over its first decade. Unfortunately, operating costs outweighed these savings.
APM Measurement – Progress of Alternative Payment Models – 2023 Methodology and Results Report – HCP-LAN
The Health Care Payment Learning and Action Network (HCP-LAN) released results from their annual survey of health plans on alternative payment models (APMs). The percentage of health care payments not connected to fee-for-service payment architecture increased from 7.4% in CY 2021 to 9.6% in CY 2022. 72% of respondents at health plans indicated a belief that APM adoption will continue to increase in 2024. The vast majority of respondents felt that APM adoption will result in better quality care (93% agreed), more affordable care (79%), and improved care coordination (93%), while just 37% indicated a belief that APM adoption would lead to increased provider consolidation.
