NCPA Endorses Bill to Ban PBM Spread Pricing Tactics
The National Community Pharmacists Association is endorsing H.R. 5281, the Drug Price Transparency in Medicaid Act, which would ban the use of spread pricing by pharmacy benefit managers in Medicaid managed care. Currently, PBMs can overbill Medicaid managed care programs, under-reimburse pharmacies for medications dispensed, and retain the difference, which is referred to as the "spread." The bipartisan legislation was introduced by Reps. Buddy Carter (R-Ga.) and Tony Cárdenas (D-Calif.).
"Time and time again, PBMs have been caught using tactics like spread pricing to take advantage of the system, lining their pockets while harming patients and the taxpayers they are supposed to serve," says Karry La Violette, NCPA's senior vice president of government affairs. "We're grateful to Reps. Carter and Cárdenas for recognizing the problem and for their leadership in putting forward a proposal to stop this abuse. We look forward to working with them to advance this bill."
Studies of Medicaid managed care programs in Ohio, Michigan, Kentucky, and New York as well as a state auditor's report in Pennsylvania have indicated that PBMs are using spread pricing as a way of overcharging taxpayers for their services. The Centers for Medicare & Medicaid Services in 2019 issued guidance prohibiting Medicaid managed care programs from counting the spread towards medical costs in the medical loss ratio, after NCPA encouraged the agency to eliminate spread pricing.
Watchdog Praises House Ways & Means For Passing Bill to End Surprise Billing
Today, the Taxpayers Protection Alliance (TPA) praised Ways and Means Committee Chairman Richard E. Neal (D-Mass.) and Ranking Member Kevin Brady (R-Tex.) for passing a pro-patient solution to solve the pressing issue of surprise medical billing. Released on February 7, the Consumer Protections Against Surprise Medical Bills Act of 2020 would use a market-oriented mediation process known as arbitration to solve billing disputes between physicians and insurers while holding patients harmless for runaway expenses. Shortly after the legislation's release, Chairman Neal and Rep. Brady emphasized the need to "minimize the burden on patients and keep the dispute resolution process neutral." According to the Congressional Budget Office, the burden on taxpayers would also be minimized. The budget watchdog projects taxpayer savings of $17.8 billion over the next ten years if the bill is enacted.
TPA President David William praised the proposal, noting, "for the millions of Americans facing a medical ordeal in one of America's 7,200 hospitals, an endless barrage of surgeries and tests is bad enough without having to worry about the financial burden of a surprise medical bill. Surprise medical bills, totaling hundreds of even thousands of dollars, have become an issue because insurance networks are far too narrow thanks to onerous federal policies such as Obamacare. This has left thousands of attending physicians out-of-network - and out of financial reach - for patients. Chairman Neal and Rep. Brady's approach wisely avoids getting the government further involved in the healthcare system, allowing market forces to course-correct after decades of failed federal policies."
Williams continued: "The legislation draws on the successful experiences of Florida and New York State, which have successfully used arbitration to resolve billing disputes between doctors and insurers without leaving patients in the lurch. Under this system, providers and insurers are free to submit competing claims to a neutral third-party with ample experience in the healthcare system, who can then determine the outcome based on multiple, relevant factors. The biggest winner from this process is patients, who have seen out-of-network billing drop by 34 percent and in-network ER costs fall 9 percent."
Williams concluded: "Now is not the time for the government to double-down on failed healthcare solutions and fix prices for millions of patients and their doctors. California's failed experiment in rate-setting has led to fewer healthcare options for patients and skyrocketing care access complaints. Yet, lawmakers such as Committee on Education and Labor Chairman Robert C. "Bobby" Scott (D-Va.) and Ranking Member Virginia Foxx (R-N.C.) want to expand this disastrous approach nationwide. Patients across the country deserve real solutions and the Ways and Means proposal offers the only realistic path to ending the scourge of surprise billing."
Healthcare Leaders Voice Concerns Over Proposed CMS Medicaid Regulations
Rick Pollack, President and CEO at the American Hospital Association (AHA), and Mark Parkinson, President and CEO at the American Health Care Association (AHCA), issued the following joint statement in response to the Centers for Medicare & Medicaid Services' (CMS) proposed Medicaid Fiscal Accountability Regulation.
"We appreciate CMS' responsibility to oversee appropriate Medicaid financing and service delivery. However, the bleak reality is that Medicaid funding is already inadequate. Enacting this proposed rule would cut up to $50 billion nationally from the Medicaid program annually, further crippling Medicaid financing in many states and jeopardizing access to care for the 75 million Americans who rely on the program as their primary source of health coverage.
"Entire communities could lose access to care under this proposal, especially in rural areas where 15 percent of hospital revenue and nearly two-thirds of nursing facility revenue nationwide depend on Medicaid funding. The supplemental payment programs targeted in this rule are also a critical lifeline at hospitals, health systems and nursing facilities that serve some of the most vulnerable Americans.
"CMS has provided little to no analysis to justify these policy changes, nor has the agency assessed the impact on providers and the patients they serve. Many of the proposed changes would also violate federal laws, including the current Medicaid statute. The AHA and AHCA request that the agency withdraw the proposed rule in its entirety."
Statement from Richard Besser, MD, on Medicaid Block Grant Guidance
The following statement from President and CEO Richard Besser, MD, of the Robert Wood Johnson Foundation (RWJF) is in response to the Centers for Medicare and Medicaid Services' Healthy Adult Opportunity initiative announcement, which would allow states to apply for capped funding, or block grants, for the portion of federal Medicaid funding they receive to cover adults under the age of 65 without a disability.
"Medicaid, a program that for more than 50 years has been a lifeline for people throughout the United States, should not be reinvented without the assurance that the people it has served so well for decades will have their health needs met.
We are deeply concerned that the Centers for Medicare and Medicaid Services' (CMS) new Healthy Adult Opportunity initiative does not meet this test and could hurt the health of individuals and families across our country. A few reasons why:
- Estimates predictthat allowing states to convert Medicaid funding to block grants or per capita caps will likely reduce enrollment and limit access to important health services among those currently eligible to receive health coverage through Medicaid.
- Block grants with built in limits could hamper a state's ability to respondto emergent health needs, such as during unpredictable events like public health crises or natural disasters.
- Our Foundation's commentson Tennessee's block grant proposal late last year examined the flaws and inherent dangers of this state-directed approach, which could put millions of Americans for whom Medicaid makes it possible to live a healthy life at risk.
At RWJF, we believe that every person in America should have a fair and just opportunity for health and well-being, regardless of who they are, where they live, how much money they make, or where they are from. A critical component of this is ensuring that people are able to access important health services, such as those available through Medicaid, which provides coverage to nearly 65 millionpeople in this country, including children, the elderly, and people with disabilities.
Medicaid's statutory requirements were put in place to ensure that the program serves its intended purpose of helping those who need it most. Allowing states to operate Medicaid without having to adhere to these requirements could undermine the essential mission of this time-tested program and have serious consequences for the health of millions of people. If adopted in every state, the demonstrations would impact nearly 30 million adults.
We encourage states considering the option outlined in the Healthy Adult Opportunity to utilize the nonpartisan research and guidancethat has been developed by many of our grantees, partners, and others to understand the potential health implications, fiscal risks, and administrative burden of implementing block grants and per capita caps."
Kennedy, Cooper Lead Rejection Of Trump Medicaid Plan
Lawmakers call on Administration to abandon Medicaid block grant proposal
Congressman Joe Kennedy III (MA-04) and Congressman Jim Cooper (TN-05) today led House Democrats in rejecting the Trump Administration's reported plan to approve Medicaid block grant waivers. In anticipation of tomorrow's announcement, the lawmakers wrote a letter to Department of Health and Human Services Secretary Alex Azar and Centers for Medicare and Medicaid Services Administrator Seema Verma outlining concerns with the legality and morality of any proposed Medicaid block grants.
"Limiting treatment options and denying access to prescription drugs will never lead to healthier outcomes for patients or better opportunities for working families," said Congressman Kennedy. "If the Trump Administration chooses to unleash this dangerous plan tomorrow, it will only underscore the flagrant disregard they have for the health of the American people. Along with our colleagues, advocates, experts and patients, we will continue to make clear that any effort to steal Medicaid coverage from deserving Americans is not only immoral, it's illegal."
"States may be enticed by the 'flexibility' of block grant waivers, but in reality it just means less federal funding and less accountability for states to do their constitutional duties," said Congressman Cooper. "They are threatening health care for millions of Americans who need it most. The Trump administration should stop experimenting on people and start extending health care to everyone."
Along with 34 of their colleagues, Kennedy and Cooper wrote that "Guidance providing states a roadmap to obtain Medicaid block grant waivers not only defies Congress and the federal Medicaid statute but if implemented, will threaten health care for millions of individuals, hurting them when they are the most vulnerable. The Administration should not issue any guidance encouraging block grant waivers, should reject these waivers and the concept of block grants, and urge any state that is considering this misguided policy to commit its energy to implementing the Medicaid Act as Congress intends."
To read their full letter, please click here.
Emergency Physicians Dismayed by Trump's Administration New Medicaid Block Grant Approach
In response to the recent announcement of the Trump Administration's Healthy Adult Opportunity, William Jaquis, MD, FACEP, president of the American College of Emergency Physicians (ACEP), issued the following statement:
"ACEP is concerned the Trump Administration's decision to change how the federal government funds Medicaid could negatively impact patients' access to care. While we appreciate the intention to provide states greater flexibility and embrace value-based care, curtailing federal funds may leave states without sufficient resources to meet the needs of those most vulnerable in our communities.
"Having access to a full range of health care services keeps patients in better health. Without access to affordable preventive care, patients may avoid seeking treatment until their condition is dire and the emergency department is their only option."
The American College of Emergency Physicians (ACEP) is the national medical society representing emergency medicine. Through continuing education, research, public education and advocacy, ACEP advances emergency care on behalf of its 40,000 emergency physician members, and the more than 150 million Americans they treat on an annual basis. For more information, visit www.acep.org.
AMA Statement on CMS Medicaid Block Grant Proposal
Statement attributable to: Patrice A. Harris, M.D., M.A., President, American Medical Association
"The AMA opposes caps on federal Medicaid funding, such as block grants, because they would increase the number of uninsured and undermine Medicaid's role as an indispensable safety net. The AMA supports flexibility in Medicaid and encourages CMS to work with states to develop and test new Medicaid models that best meet the needs and priorities of low-income patients. While encouraging flexibility, the AMA is mindful that expanding Medicaid has been a literal lifesaver for low-income patients. We need to find ways to build on this success. We look forward to reviewing the proposal in detail."
AHIP Statement on New CMS Medicaid Block Grant Initiative
Matt Eyles, president and CEO of America's Health Insurance Plans (AHIP), issued this statement following the Centers for Medicare and Medicaid Services' (CMS) release of the "Healthy Adult Opportunity" - a new 1115 demonstration program providing states with new administrative and program design flexibilities within a defined budget.
"One in five Americans depend on the Medicaid program for their health care coverage. It is the largest health care program in the country, serving over 70 million individuals - including children, older adults, people with disabilities, and 2 million veterans. More than two-thirds of those enrolled are served by a private plan through Medicaid Managed Care, and research has shown these plans deliver a high quality of care just like people receive through employer-sponsored or individual coverage.
"Different populations have different, evolving health care needs, and states should be supported to serve those needs. We support offering state policymakers flexibility to design their Medicaid programs to best meet the needs of their citizens. At the same time, funding mechanisms for Medicaid should not undermine Americans' access to the care they need and deserve.
"We are reviewing the details of the guidance to assess the program's consistency with our principles for coverage and access to care for people with Medicaid. Moving forward, we will continue to work closely with federal and state policymakers to ensure Medicaid remains effective, affordable and efficient for the tens of millions who rely on it and the hardworking taxpayers who pay for it."
Emergency Physicians Oppose Supreme Court Decision to Allow "Public Charge" Rule
The American College of Emergency Physicians (ACEP) strongly opposes the recent Supreme Court decision upholding the Trump Administration's "public charge" rule, which denies certain immigrants their legal status if they rely on public benefits.
"Efforts to deny access to federal safety-net programs, such as Medicaid, could deter people who are in our country lawfully from seeking medically-necessary treatment out of fear it could jeopardize their immigration status," said William Jaquis, MD, FACEP, president of ACEP. "This in turn puts every American's health at greater risk, particularly as we're seeing how untreated and highly-contagious infectious diseases can spread rapidly and globally."
Depriving people of essential federal benefits may also further strain our already crowded emergency departments and resources.
"Emergency physicians will continue to treat anyone who walks through our doors, but we are concerned that people who need care will delay or skip appointments until their local emergency department becomes the best, or perhaps the only, option," said Dr. Jaquis.
AHIP Submits Comments to Proposed Rule on Transparency in Coverage
Matt Eyles, president and CEO of America's Health Insurance Plans (AHIP), issued this statement following the submission of AHIP's comments to the "Transparency in Coverage" proposed rule (Transparency Rule):
"Every American should have the personalized health care information they need, when they need it to make better, more informed decisions before they seek and receive care. Health insurance providers are committed to delivering clear, accurate, and personally relevant information about cost and quality to every patient and consumer. Transparency tools should enable hardworking Americans to make health care decisions that are right for them, improve their health care experiences, and make care more affordable -- and therefore more accessible. An overwhelming majority of health insurance providers offer tools that deliver on these commitments today.
"We fully support the goal of empowering Americans with easily accessible cost and quality information to make more informed decisions. AHIP strongly urges the Departments to adopt workable solutions that ensure health care information is personalized, easy to understand, accurate, and actionable, focusing on health care treatments and services for which consumers can actually shop.
"In several ways, this proposed rule will ultimately disappoint consumers by failing to deliver what they need and want. By disclosing competitively negotiated rates for every single health care item and service, it would undermine true competition, push prices higher, reduce affordability, and complicate rather than simplify consumers' health care experience. Requiring such public disclosure exceeds the Departments' statutory authority and also risks requiring disclosure of consumers' sensitive, personally identifiable information with third party app developers that are not bound by patient privacy laws.
"Let's work together to empower patients and consumers to make better health care decisions without undermining affordability."
Read AHIP's full comment letter.
See what Americans have to say about what they want from their health care data.
ACEP Supports House Ways and Means Approach to Ending Surprise Bills
February 10, 2020
WASHINGTON, D.C.-- In response to the recently released surprise billing proposals from the House Ways and Means, the American College of Emergency Physicians (ACEP) released the following statement:
"ACEP supports this bill and is encouraged that the Ways and Means Committee recognizes that a mediation process with no qualifying threshold must be part of a reasonable Congressional solution to surprise bills.
The Committee's thoughtful and measured approach sets a promising foundation for additional discussion. ACEP looks forward to working with the Committee on improvements to the legislation, including addressing the concern that the mediator take into full consideration all of the information provided by physicians, with an eye toward ensuring the long-term sustainability of physician-insurer negotiations, and most importantly, patient access to care.
"Emergency physicians are committed to ensuring the patients to whom we provide life-saving treatment each day are protected from surprise bills. We look forward to working with Congress toward that shared goal."
The American College of Emergency Physicians (ACEP) is the national medical society representing emergency medicine. Through continuing education, research, public education and advocacy, ACEP advances emergency care on behalf of its 40,000 emergency physician members, and the more than 150 million Americans they treat on an annual basis. For more information, visit www.acep.org and www.emergencyphysicians.org.
AMA Statement on House Ways and Means Committee "Surprise" Billing Legislation
Statement attributable to:
Patrice A. Harris M.D., M.A.
President, American Medical Association
"The American Medical Association appreciates the bipartisan efforts of the Ways and Means Committee to protect patients from unanticipated medical bills.
"We support the underlying mechanism for resolving these disputes, including the eligibility of all disputed claims for negotiation and mediation. We also appreciate that the mediator must consider a wide range of supporting information submitted by physicians in rendering a final determination.
"We look forward to continuing to work with the committee and others to refine the legislation to ensure that it will achieve our shared goals of protecting patients and providing for a process that is fair to all."