In the Lede
The House and Senate passed a continuing
resolution (CR) to fund government operations
through February 18. While a group of conservative Republican
Senators had threatened to hold up the CR because of concerns with
the President's vaccine mandate, they accepted a Senate floor
vote on an amendment – that failed
48-50 – to bar funding to implement private sector
vaccine mandate as well as requirements for federal employees,
federal contractors, health care workers and the military. The CR
did not include fixes to Medicare spending cuts starting in
January, including a four percent reduction to Medicare
reimbursements, a separate two percent sequestration cut, and
reductions to reimbursements for physicians and clinical laboratory
services. A temporary 3.75 percent increase to doctors'
pay through the annual physician fee schedule is also scheduled to
end in January. House Appropriations Committee Chair
Rosa DeLauro (D-CT) said during a House
Rules Committee hearing that lawmakers are working on
"comprehensive bipartisan solution by the end of the
year" for all of the outstanding health care provider
issues.
The President announced new executive actions
to combat COVID-19 as the United States heads into the winter
months and with the emergence of the
new Omicron variant. The President
announced:
- New steps to ensure that the nearly 100 million eligible Americans who have not yet received their booster, get one as soon as possible, including expansion of pharmacy availability for booster shots through December, and a new public education campaign to encourage adults to get boosters, with a focus on seniors through the AARP and the Center for Medicare and Medicaid Services (CMS).
- New actions to get more kids ages five and older vaccinated and to keep our schools open, including launching hundreds of family vaccination clinics across the country, requiring Medicaid to pay healthcare providers to talk to families about getting their kids vaccinated, releasing findings from the Centers for Disease Control and Prevention (CDC) on quarantine and testing policies in schools, issuing a new "Safe School Checklist" to give schools a clear game plan for how to get as many of their staff and students vaccinated as soon as possible, and providing every resource to the Food and Drug Administration (FDA) to support timely review of applications for vaccines for individuals under the age of five.
- New steps to ensure Americans have access to free at-home testing, including providing health plan coverage of no-cost rapid, over-the-counter (OTC) COVID-19 tests and expanding community distribution of free at-home tests through neighborhood sites such as health centers and rural clinics.
- Additional steps to strengthen the safety of international travel, including strengthening global pre-departure testing protocols and extending the requirement to wear a mask on airplanes, rail travel, and public transportation.
- Additional progress in protecting workers and keeping the economy growing and businesses open by calling on businesses to move forward with vaccination or testing programs.
- New actions to help states battle any potential COVID-19 outbreaks this winter, including of the Omicron variant, including making 60+ Winter COVID-19 emergency response team deployments available to states and strengthening the national volunteer emergency medical response corps to support communities in need.
- Ensuring that if and when any new COVID-19 treatment pills have been found to meet FDA's scientific standards, they are equitably accessible to all Americans by securing enough supply and ensuring pills are widely available in the hardest-hit, highest-risk communities.
- Continued commitment to global vaccination efforts, including donating 1.2 billion doses to the world, accelerating the delivery of more vaccines to countries in need by pledging to deliver 200 million more doses in the next 100 days, taking steps to ramp up manufacturing here and abroad, and working with country partners to help their population get vaccinated.
- Steps to accelerate the development and deployment of new vaccines and boosters if needed for the Omicron variant.
The Centers for Medicare and Medicaid Services (CMS) issued a memo indicating that it has suspended activities related to the implementation and enforcement of its November 4 interim final rule (IFR) which requires staff working in Medicare or Medicaid-certified providers to have the shots necessary to be fully vaccinated against COVID-19 by January 4, 2022, and to receive their first shot prior to December 6, 2021. On November 29 and November 30, 2021, the United States District Court for the Eastern District of Missouri and United States District Court for the Western District of Louisiana issued preliminary injunctions against the implementation and enforcement of the IFR against Medicare and Medicaid-certified providers and suppliers. CMS has appealed both of these decisions, and has filed motions for stays of these orders. CMS indicated that it remains confident in its authority to protect the health and safety of patients in facilities certified by the Medicare and Medicaid programs.
On the Hill
The Congressional Budget Office (CBO) released a presentation on potential effects to drug manufacturers, Medicare beneficiaries, Part D plans, and the Federal Government under proposed redesigns of the Part D prescription drug benefit. According to the CBO presentation, proposals to revamp the Part D benefit would generally make these changes:
- Eliminate the coverage gap, extending the initial coverage phase to the catastrophic threshold.
- Significantly increase plans' liability for spending that exceeds the initial coverage limit (that is, spending that occurs in the coverage gap and in the catastrophic phase of the current-law benefit).
- Cap beneficiaries' out-of-pocket costs at a fixed dollar amount.
- Shift some or all of the discount that manufacturers are obliged to provide from the coverage gap to the catastrophic phase (or, possibly, the initial coverage phase).
Capping enrollees' out-of-pocket costs would push up federal
spending by shifting spending from enrollees to plans, according to
CBO. The federal subsidy covers 74.5 percent of plans' expected
spending, so an increase in those costs translates into higher
federal spending. A cap also would increase prescription drug
utilization by enrollees and thus raise the government's costs
for the Part D program. That rise in spending would be partially
offset by reduced Medicare spending on other healthcare services,
such as hospital care and physicians' services. Extending the
required manufacturer discount on brand-name drugs to other phases
could either increase or decrease federal spending depending on how
those changes affected total discounts as a share of that spending.
If manufacturer discounts rose, then federal spending would tend to
decline; conversely, if discounts fell, then federal spending would
tend to rise because the government subsidizes the costs paid by
plans but not the discounts extended by manufacturers. In 2020,
about 47 million Medicare beneficiaries (or 75 percent) were
enrolled in Part D. Roughly 13 million of them receive a low-income
subsidy that pays most or all of their premium and cost-sharing
requirements; as a result, those enrollees face only limited costs.
The base Part D premium is about $33 per month. Part D plans
receive a fixed payment per enrollee from the federal government
and bear financial risk for part of enrollees' drug costs, so
plan administrators have an incentive to control costs by managing
drug utilization and negotiating lower prices. When enrollees reach
a high level of spending known as the catastrophic threshold, the
federal government reimburses plans for 80 percent of spending
above that limit, which reduces plans' incentives to control
costs.
CBO also released a presentation on the
"Economic Effects of Expanding Home- and
Community-Based Services in Medicaid", finding that
if policies of the House-version of the Build Better
Act (H.R. 5376) were enacted, the number of workers
providing those services would grow, and their earnings would
increase. Some people who are currently providing home and
community-based services (HCBS) to family members would be
paid for that work, and some would return to their primary
occupations, according to CBO. However, in anticipation of
lower costs for such services in the future, some people would save
less money for future long-term services and supports (LTSS) needs
and increase their spending on other goods and services. Under H.R.
5376, HCBS would be available to Medicaid beneficiaries living in
participating states who have income and assets lower than their
state's requirements for Medicaid and meet their
state's functional eligibility criteria for Medicaid HCBS.
CBO has estimated that new federal spending for HCBS provided
through Medicaid would increase federal deficits by $150 billion
from 2022 to 2031.
At the Agencies
The Department of Health and Human Services (HHS) released a report to show that increases in the use of telehealth helped maintain some healthcare access during the COVID-19 pandemic, with specialists like behavioral health providers seeing the highest telehealth utilization relative to other providers. The report analyzed Medicare fee for service (FFS) data in 2019 and 2020, which highlighted that telehealth services were accessed more in urban areas than rural communities, and Black Medicare beneficiaries were less likely than White beneficiaries to utilize telehealth. Other findings from the report:
- The share of Medicare visits conducted through telehealth in 2020 increased 63-fold, from approximately 840,000 in 2019 to 52.7 million.
- States with the highest use of telehealth in 2020 included Massachusetts, Vermont, Rhode Island, New Hampshire and Connecticut, while states with the lowest use of telehealth in 2020 included Tennessee, Nebraska, Kansas, North Dakota and Wyoming.
- While overall healthcare visits for Medicare beneficiaries declined in 2020 as compared to 2019, telehealth was particularly helpful in offsetting potential foregone behavioral healthcare. In 2020, telehealth visits comprised a third of total visits to behavioral health specialists, compared to 8 percent of visits to primary care providers and 3 percent of visits to other specialists.
To help beneficiaries maintain some access to care amid
stay-at-home orders to reduce COVID-19 related exposure, CMS used
emergency waiver authorities enacted by Congress, as well as
existing regulatory authorities to implement policies expanding
access to telehealth services during the pandemic. These included
waiving several statutory limitations such as geographic
restrictions and allowing beneficiaries to receive telehealth in
their home. Outside of the public health emergency (PHE), Medicare
is generally restricted to payment for telehealth services in
certain, mostly rural areas, and when beneficiaries leave their
home and go to a clinic, hospital, or other type of medical
facility for the service. Additionally, in response to the
pandemic, the HHS Office for Civil Rights relaxed enforcement of
Health Insurance Portability and Accountability Act (HIPAA) of 1996
privacy requirements for videoconferencing. To help protect access
to care as informed by data, CMS recently announced that for the first
time outside of the COVID-19 PHE, Medicare will pay for mental
health visits furnished by Rural Health Clinics and Federally
Qualified Health Centers via interactive video-based telehealth,
including audio-only telephone calls. Additionally, CMS is
permanently eliminating geographic barriers and allowing patients
in their homes to access telehealth services for diagnosis,
evaluation, and treatment of mental health disorders, including via
audio-only communications technology. While utilization of
telehealth services increased and improved access to services for
many beneficiaries, CMS acknowledged that more research is needed
to understand the impact on quality of care and why certain
beneficiaries used less telehealth than others.
The Centers for Medicare & Medicaid Services
(CMS) issued a Request
for Information (RFI) to solicit stakeholder and
public feedback that will be used to inform potential changes and
future rulemaking to improve the organ transplantation
system and seek to enhance the quality of life of
those living with organ failure, which includes 106,000 people who
are waiting to receive a life-saving or life-enhancing organ
transplant. CMS is focused on identifying potential system-wide
improvements that would increase organ donations, improve
transplants, enhance the quality of care in dialysis facilities,
increase access to dialysis services, and advance equity in organ
donation and transplantation. Critical to these system-wide
improvements is the close, collaborative relationship among Organ
Procurement Organizations (OPOs), donor hospitals, transplant
programs, and End-Stage Renal Disease (ESRD) facilities to ensure
that organs are successfully recovered and transplanted. Despite
the higher risks associated with kidney disease among minorities,
data shows that Black and Latino patients on dialysis are less
likely to be placed on the transplant waitlist and have a lower
likelihood of transplantation. Because of inequities, CMS'
RFI asks the public for specific ideas on advancing equity within
the organ transplantation system, particularly on potential changes
to the health and safety standards for transplant programs, ESRD
facilities, and OPO operations. The RFI seeks feedback from
those on organ transplant waitlists, transplant recipients, their
families, living donors and those who sign up to be posthumous
donors, families of donors, chronic kidney disease and ESRD
patients. The feedback will help inform future regulatory
requirements that transplant programs, OPOs, and ESRD providers and
suppliers would need to meet to participate in the Medicare and
Medicaid programs. Comments must be submitted by February 1,
2022.
The Health Resources and Services Administration
(HRSA) announced the
distribution of $7.5 billion in American Rescue Plan
(ARP) Rural payments to providers and suppliers who
serve rural Medicaid, Children's Health Insurance Program
(CHIP), and Medicare beneficiaries. The average payment being
announced is approximately $170,700, with payments ranging from
$500 to approximately $43 million. More than 40,000 providers in
all 50 states, Washington, D.C., and six territories will receive
ARP Rural payments. Rural providers play an integral role in
the Administration's focus on addressing health equity.
Research has found that 47 percent of rural providers
were operating in the red pre-pandemic, and this Administration has
heard from providers on the ground that the pandemic worsened this
reality. To help mitigate some of these pandemic-related financial
losses, providers were invited to begin applying for this ARP Rural
relief funding starting September 29, 2021 and asked to complete
their applications by November 3, 2021. In just three weeks, HRSA
processed nearly 96 percent of the more than 55,000 ARP Rural
applications submitted. Many ARP Rural payment recipients will also
be eligible for additional funding through the $17 billion Provider Relief Fund (PRF) Phase
4 opportunity that was also made available during the same
time period. Providers could apply for both opportunities through a
single application. To streamline the application and payment
process as much as possible, ARP Rural payments are based on
Medicare, Medicaid, and CHIP claims for services to rural
beneficiaries from January 1, 2019 through September 30, 2020,
which was chosen as it represents the most recent comprehensive
data available to HHS and takes into account both pre-pandemic and
pandemic operations. To provide equitable relief to these
providers, ARP Rural payment calculations were generally based on
Medicare reimbursement rates, regardless of whether the service was
provided to a Medicare, Medicaid, or CHIP patient. Every eligible
provider that serves at least one rural Medicare, Medicaid, or CHIP
beneficiary will receive funding.
In the News
Wall Street Journal: Some Hospitals Prepare to Lose Staff Over Covid-19
Vaccination Mandate
New York Times: Biden's winter Covid plan includes insurance
reimbursement for at-home tests.; Democrats' Bill Would Go Far Toward
'Patching the Holes' in Health Coverage
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