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September 1, 2023
In this issue we feature:
LUGPA Submits Comments on 340B Program Calling for Reform
In late August, LUGPA submitted comments to Senators Thune, Stabenow, Capito, Baldwin, Moran, and Cardin regarding their 340B Program Request for Information (RFI). In the comments, LUGPA addresses our concerns about the 340B program's expansion leading to unintended consequences. Hospitals have been utilizing the program to generate revenue and consolidate the market, raising patient costs and Medicare.
LUGPA recommends Congress take steps to address this issue: prohibiting 340B eligibility for hospital-acquired physician practices, revising the 340B patient definition for clarity, reforming the use of contract pharmacies, requiring CMS to survey acquisition costs, and imposing a minimum level of charity care for hospitals to qualify for tax exemption. The comments also emphasize the need for program reform to ensure its original purpose of helping vulnerable patients while encouraging collaboration with Congress in implementing these recommendations.
LUGPA’s Recent Advocacy for Medicare Genetic Testing Coverage
LUGPA, in partnership with key allies like AUA and AACU, is actively engaged in addressing concerns related to Medicare coverage guidelines on Genetic Testing for Oncology. The introduction of the Genetic Testing for Oncology Local Coverage Determination (LCD) policy by Novitas and First Coast in June 2023 has raised worries about potential reimbursement challenges. These challenges could adversely impact access to crucial genetic tests, including specific bladder markers and FISH testing. LUGPA is working to ensure comprehensive communication with the Medical Administrative Contractors (MACs) in response to the initial LCD and the new version being considered. Our shared objective is to highlight the clinical significance of these tests and their role in patient care. LUGPA will soon submit its comments on the proposed LCD and sign a joint letter with AUA and AACU.
CMS Releases 2024 Projected Medicare Part D Premium and Bid Information
The Centers for Medicare & Medicaid Services (CMS) have announced that the projected average total monthly premium for Medicare Part D coverage in 2024 is approximately $55.50. This represents a noteworthy 1.8% decrease from the 2023 premium of $56.49. According to CMS, these reductions in premiums are attributed to enhancements made to the Part D program under the Inflation Reduction Act. These improvements aim to provide cost savings to Medicare beneficiaries. The projected premium information is being provided well ahead of the Medicare Open Enrollment period, allowing individuals to gain insights into Part D premium trends and make informed plan selections for the upcoming benefit year.
To learn more, you can visit CMS 2024 Part D Premium Information.
New CMS Rule Seeks to Promote High-Quality Care
CMS has issued a conclusive payment rule concerning inpatient and long-term care hospitals. This regulation centers on bolstering historically underserved communities, enhancing high-quality outcomes, and ensuring safe care delivery.
The rule introduces revisions to Medicare payments and hospital policies and implements quality metrics to augment safety and fairness in the hospital environment. Notably, the CMS recognizes homelessness as a key factor linked to heightened resource utilization in acute inpatient hospitals.
Unveiling its final rule for the fiscal year (FY) 2024, the CMS outlines adjustments to the inpatient prospective payment system (IPPS) and long-term care hospital prospective payment system (LTCH PPS). This rule encompasses updates to payment structures and operational policies for inpatient hospitals and LTCHs in FY 2024.
Acute care hospitals participating in the Hospital Inpatient Quality Reporting program and meaningful electronic health record users can anticipate a 3.1% increase in their operating payment rate. Similarly, the standard Federal payment rate for LTCH PPS will experience a 3.3% rise in FY 2024. Furthermore, the rule introduces modifications designed to promote health equity within the Hospital Value-Based Purchasing Program while acknowledging the added expenses hospitals incur when treating individuals experiencing homelessness.
For a fact sheet on the final payment rule, visit CMS FY 2024 Payment Rule Fact Sheet.
LUGPA Advocates for Key Legislative Changes in Medicare APMs
In our ongoing efforts to promote the expansion of alternative payment models (APMs), LUGPA has urged Congress to enact legislative changes encouraging greater physician participation in these models. The bipartisan Value in Health Care Act (H.R. 5013) addresses some of these concerns by gradually empowering the HHS secretary to increase the revenue threshold for APM bonuses. This aligns with the goal of achieving value-based care, promoting equity, and offering incentives for high-quality care. The bill also emphasizes transparency, rural care support, and evaluating parity between APMs and Medicare Advantage payment policies. LUGPA has developed a Policy Brief on the new bill that will be released to members in the coming weeks.
CMS Initiates New Medicare Prescription Payment Plan
Under the Inflation Reduction Act, CMS has introduced a new Medicare Prescription Payment Plan that allows Medicare Part D beneficiaries to pay out-of-pocket prescription drug costs in monthly installments starting in 2025. CMS has released draft guidance outlining the requirements and procedures for this program. The guidance will be released in two parts, with the current draft focusing on helping plan sponsors and pharmacies prepare for successful implementation. The guidance solicits feedback on key topics and strategies to assist eligible Part D enrollees in lowering their prescription drug costs. Comments are open for 30 days, with final guidance expected in early 2024.
A fact sheet on the Medicare Prescription Payment Plan is available at CMS Medicare Prescription Payment Plan Fact Sheet.
Prescription Drug Distribution and Drug Costs
LUGPA is committed to addressing the role of pharmacy benefit managers (PBMs) in determining prescription drug availability and pricing. We are currently examining the buy-and-bill and white-bagging models employed by PBMs and insurers, advocating for provider flexibility and patient autonomy in accessing needed medications.
While white bagging can generate some savings for expensive medications like infusion drugs, in many cases, patients pay higher cost sharing when white bagging is used. According to a report from the Massachusetts Health Policy Commission, while some patients only saw increases, white bagging could lead to significantly higher cost sharing for other patients, such as those on Medicare.
While limited federal legislation has been proposed to regulate white bagging, several states have considered laws in the past three years to restrict or eliminate this practice. Most of the proposed rules aim to prohibit payers and PBMs from mandating the use of specific pharmacies for provider-administered drugs as a condition for reimbursement or patient coverage. LUGPA has written and posted a new policy brief that members can use to educate themselves and others. It is available here: https://www.lugpa.org/prescription-drug-distribution-and-drug-costs.
No Surprises Act Update
LUGPA continues to monitor the implementation of the No Surprises Act (NSA), which protects consumers against surprise medical bills. The Act bans balance billing and establishes dispute resolution mechanisms for payment disputes between health plans and providers.
Since the No Surprises Act’s passage, patients have made hundreds of thousands of claims. According to an April 2023 report from CMS, between April 15, 2022, and March 31, 2023, disputing parties initiated 334,828 disputes through the federal IDR portal, with initiating parties being the prevailing party in approximately 71 percent of the disputes.
LUGPA believes it is essential for physicians to understand how the No Surprises Act will affect them, as it imposes limitations and grants certain rights to physicians caring for patients in these situations. LUGPA and CMS have developed resources to assist providers and consumers in navigating the new NSA laws.
LUGPA’s No Surprises Act Information and Resource Hub is available here: https://www.lugpa.org/no-surprises-act-hub
In June, CMS updated its online information on the No Surprises Act with several new user-friendly web pages. You can view the latest news online here: https://www.cms.gov/medical-bill-rights.
A Spanish-language version of the site is available here: https://www.cms.gov/derechos-facturas-medicas.
Our Policy Update on the No Surprises Act can be found here: https://www.lugpa.org/update--no-surprises-act.
Site-Neutrality Advocacy
The LUGPA has long advocated for reforms to the rules within the Medicare payment system that favor large hospitals over independent providers. Hospitals currently receive higher payments for the same services as independent providers. This has led to increased healthcare costs due to physician practice acquisition by hospitals. The prevalence of ambulatory surgical centers, often owned by LUGPA members, adds complexity, as they provide cost-effective care but are reimbursed less than hospital-based facilities.
LUGPA seeks to promote site-neutral payments, where services are reimbursed at the same rate regardless of the setting. This could save Medicare billions. Various proposals in Congress aim to introduce site neutrality to federal healthcare programs. LUGPA recently released a new Policy Update that addresses this issue and our recommendations for reform, which can be found here: https://www.lugpa.org/update--site-neutral-payment-reform.
CMS Program to Promote ACOs Saves $1.8 Billion in 2022
On August 24, 2023, the Centers for Medicare & Medicaid Services notified Congressional Health Staff regarding the 2022 Medicare Shared Savings Program’s (MSSP) results for Accountable Care Organizations (ACOs).
The CMS developed and managed the Medicare Shared Savings Program (MSSP), encouraging healthcare providers to form or participate in Accountable Care Organizations (ACOs). The primary goal of the MSSP is to improve the quality of care for Medicare beneficiaries while reducing the overall costs of healthcare services. ACOs participating in the MSSP are incentivized to achieve these goals through a shared savings model.
The announcement highlighted that the MSSP achieved substantial savings for Medicare, amounting to $1.8 billion in 2022 compared to the designated spending targets for the year. This achievement marks the program's sixth consecutive year of generating cost savings and maintaining a high care quality standard. More information about the 2022 MSSP Program Financial and Quality Performance results can be accessed here: https://www.cms.gov/newsroom/press-releases/medicare-shared-savings-program-saves-medicare-more-18-billion-2022-and-continues-deliver-high.
New GOP Budget Committee Health Care Task Force Launched and Seeks Feedback from Independent Experts
In August, Chairman Rep. Jodey Arrington (R-TX) and Rep. Michael Burgess (R-TX) of the House Budget Committee introduced the Budget Committee Health Care Task Force, overseen by Rep. Burgess. This GOP initiative aims to tackle the issues of rising healthcare costs and suboptimal patient outcomes. The task force aims to “find solutions to reduce health care spending, examine opportunities to modernize and personalize the health care system, and support policies to fuel innovation and increase patient access to quality and affordable care.”
The task force will serve as a platform for crafting legislation to optimize spending efficiency and federal investments while building a more cost-effective healthcare system. Task force members have initiated a request for information (RFI) to gather insights from experts and stakeholders by October 15, 2023, to guide their efforts. LUGPA will follow this task force's efforts and respond where appropriate.
CMS Reveals New Drug List for the Medicare Drug Price Negotiation Program
On August 29, the U.S. Department of Health and Human Services unveiled the initial selection of 10 drugs covered by Medicare Part D for inclusion in the Medicare Drug Price Negotiation Program. Scheduled to transpire between 2023 and 2024, these negotiations with pharmaceutical companies are anticipated to enforce new pricing effective by 2026.
CMS is encouraging the public and patients to engage in patient-focused listening sessions, where insights concerning the chosen drugs, alternative therapies, unaddressed medical requirements, and their implications for specific demographics can be shared. Comprehensive details and resources, including a roster of selected drugs and session particulars, are accessible through the provided links.
For a detailed list of drugs earmarked for the initial negotiation phase and additional pertinent information, consult the fact sheet at: https://www.cms.gov/files/document/fact-sheet-medicare-selected-drug-negotiation-list-ipay-2026.pdf.
For a fact sheet courtesy of the Office of the Assistant Secretary for Planning and Evaluation (ASPE), visit https://aspe.hhs.gov/reports/aspe-ira-drug-negotiation-fact-sheet.
Further information regarding the Medicare Drug Price Negotiation Program is obtainable at: https://www.cms.gov/inflation-reduction-act-and-medicare/medicare-drug-price-negotiation.
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