The following is the latest health policy news from the federal government for March 13-16. Some of the language used below is taken directly from government documents.
- Senator Bernie Sanders (I-VT), chair of the Senate Health, Education, Labor and Pensions (HELP) Committee, has introduced a bill, the “Primary Care and Health Workforce Expansion Act.” The bill would:
- Increase funding for community health centers by $65 billion over five years, fund the National Health Service Corps at $8.3 billion over five years, and provide $250 million for HRSA coordination for the Women, Infants, and Children (WIC) program.
- Add 10,000 graduate medical education (GME) slots over five years; reauthorize the Children’s Hospital Graduate Medical Education Program and the Teaching Health Center Graduate Medical Education Program; and reauthorize, expand, and fund other teaching and training programs for primary care, rural health care, and programs at historically Black colleges and universities (HBCUs).
- Reauthorize, expand, and create training programs and grant and loan programs to increase the number of nurses.
- Reauthorize and increase funding to increase the number of dentists,
- Create new programs and fund existing programs to expand the behavioral health workforce, the direct care workforce, and the number of family caregivers.
To help pay for these expansions, the bill proposes a number of site-neutral payment policies that would affect on- and off-campus hospital outpatient departments (HOPDs). The bill’s site-neutral payment policies would:
- Prohibit hospitals from charging health plans and issuers a facility fee for services provided by off-site physicians and prohibit the hospital and physician from separately billing for a given service.
- Cap the hospital and physician’s fee at the median amount the health plan or issuer pays when those services are provided in a physician’s office.
- Prohibit hospitals from billing a facility fee for providing on-site primary care, telehealth, and low-complexity services that can be safely provided in an ambulatory setting. The hospital and physician would be prohibited from separately billing for those services and could bill no more than the median amount the health plan or issuer pays when those services are provided in a physician’s office.
- The House Energy and Commerce Committee passed 15 bills yesterday, including:
- A bill to permit employers to offer telehealth as a tax-free benefit separate from their group health insurance plans.
- Bipartisan bills to prevent maternal deaths, expand cancer research, expand research and treatment for sickle cell and blood disorders, and reauthorize the Children’s Hospital Graduate Medical Education Program.
- Bills that passed mostly or entirely along party lines that call for oversight and reporting from government agencies for public health, CDC leadership, and pandemic and disaster preparedness.
Find the legislation, amendments, and vote counts from yesterday’s markup here.
Proposed Medicare Payment Regulations
Proposed Outpatient Prospective Payment System Rule
CMS has issued its proposed calendar year 2024 outpatient prospective payment system regulation outlining how Medicare envisions paying for outpatient and ambulatory surgical centers next year. The proposed regulation calls for a 2.8 percent increase in outpatient and ambulatory surgical center rates and also calls for:
- Expanding the current rate structure for Medicare-covered partial hospitalization program services and clarifying that such services can be used to treat substance use disorders.
- Creating a new intensive outpatient program to cover intensive outpatient services that involve less than 24 hours of daily care for behavioral health, substance use disorder, and opioid treatment services and establishing rates for such care for hospital outpatient departments, FQHCs, community mental health centers, and rural health clinics.
- Revising payment and billing practices for the delivery of mental health care via telehealth.
- Increasing monitoring and enforcement of current hospital price transparency requirements and compelling hospitals to publish their prices in a specific format.
In addition, the proposed rule includes two major requests for information: one on future price transparency policy and another on whether CMS should introduce a new payment in Medicare’s inpatient prospective payment system to help hospitals build a supply of selected drugs that might be needed in an emergency.
Learn more about the proposed outpatient prospective payment system rule from this CMS fact sheet; a separate fact sheet on the hospital price transparency proposal; and this pre-publication version of the proposed regulation. Stakeholder comments are due September 11.
Proposed Physician Fee Schedule Rule
CMS has published its proposed physician fee schedule rule presenting how Medicare envisions compensating physicians and other health care professionals in calendar year 2024. It proposes reducing overall payments under its physician fee schedule by 1.25 percent, which it would accomplish by reducing the conversion factor next year by $1.14, or 3.34 percent, from the current $33.89 to $32.75. Despite this decrease, the proposed rule would increase Medicare rates for primary care and other selected providers and some telehealth rates. In addition, CMS proposes extensive changes in telehealth payment policies and payments for a variety of behavioral health services, including substance use disorder and opioid treatment care. Other areas in which CMS proposes changes in payment and other policies include:
- Payments to physicians for caregiver training.
- Coding and payment changes to enhance accounting for resources involved in furnishing patient-centered care, including for addressing health-related social needs and performing health risk assessment for social determinants of health.
- Changes in payments for evaluation and management (E/M) visits.
- Numerous changes in payments for a variety of types of telehealth services and where they originate, including for a variety of behavioral health services by different types of providers, as well as revised standards for the supervision of the delivery of such services.
- Supervision policy for physical and occupational therapists in private practice and for certain services provided by Rural Health Clinics and FQHCs and payments for selected behavioral health services provided by Rural Health Clinics and FQHCs.
- Diabetes self-management training services furnished by registered dietitians and nutrition professionals, including training delivered via telehealth.
- Provisions from the Inflation Reduction Act involving drugs and biologicals payable under Medicare Part B.
- Changes in the data reporting period for diagnostic laboratories and a phase-in of reduced payments for those laboratories.
- Part B payments for administering preventive vaccines.
- A pause in the appropriate use criteria for advanced diagnostic imaging.
- Extension of the Medicare Diabetes Prevention Plan through the end of 2027.
- Changes in regulations governing provider enrollment in Medicare and Medicaid.
- Changes in the Medicare Shared Savings Program.
- Changes in the quality payment program.
Learn more about the proposed rule from the following resources:
- a CMS fact sheet
- a CMS news release addressing the health equity aspects of the proposed rule
- a fact sheet on the CY 2024 Quality Payment Program proposed changes
- a fact sheet on the proposed Medicare Shared Savings Program changes
- a pre-publication version of the proposed rule
- the latest entry in the CMS blog, which addresses how both of these proposed rules – the outpatient prospective payment system rule and the physician fee schedule rule – work together to seek to enhance access to behavioral health care for Medicare beneficiaries.
Stakeholder comments are due by September 11.
Centers for Medicare & Medicaid Services
- CMS has issued a request for information seeking input from stakeholders to inform its Center for Medicare and Medicaid Innovation’s planning to create a way for specialists to participate in value-based care initiatives through episode-based payment models that achieve equitable outcomes through high-quality, affordable, person-centered care. The request for information poses a broad set of questions related to care delivery and incentive structure alignment and presents six foundational components on which the agency seeks comment. Learn more about why CMS has issued this request for information and what it seeks from interested parties from this agency announcement, which includes a link to a Federal Register notice. Stakeholder comments are due by August 17.
- CMS Administrator Chiquita Brooks-LaSure has written to Medicare plans, state Medicaid and CHIP programs, and private health insurers to outline changes that will occur amid the upcoming shift away from federal purchase of COVID-19 vaccines to a more traditional commercial market. The letter addresses coverage requirements, changes in state and consumer cost-sharing for different populations, changes in federal matching funds to cover COVID-19 vaccine costs, and more. Find the letter here.
- Simultaneous with release of this letter, HHS has announced that to help uninsured and underinsured American adults have continued access to no-cost COVID-19 vaccinations after procurement of these vaccines transitions from the federal government to the commercial market, the CDC will launch a program called “Bridge Access Program for COVID-19 Vaccines” this fall. Under this program, the CDC will purchase COVID-19 vaccines and allocate them, along with the funding needed to implement this new program, to be administered free of charge through the CDC’s established network of state and local immunization programs, including local health departments, Health Resources and Services Administration (HRSA)-supported health centers, and some national pharmacy chains. This program will end in December of 2024. Learn more from this HHS news release.
- CMS has updated its resources for providers and community partners to use when explaining the Medicaid unwinding process and encouraging patients and others to act to renew their Medicaid eligibility effectively and in a timely manner. Find those updated resources here.
- CMS has posted a summary of state mitigation strategies for complying with Medicaid eligibility renewal requirements as part of the Medicaid continuous eligibility unwinding process. The summary includes areas where individual states are not in compliance with federal requirements. Find the summary here.
- CMS has sent a memo to state survey agencies on hospital compliance with ligature (patient restraint practices) under the Medicare conditions of participation and how those agencies can monitor that compliance. Find the CMS memo here.
- CMS has released a video tutorial to assist providers with guidance application and interview strategies for the cognitive assessment known as the Brief Interview for Mental Status (BIMS). This video is designed to provide targeted guidance for accurate coding using live-action patient/resident scenarios. Find it here.
Department of Health and Human Services
- An HHS Office of Inspector General (OIG) review of prior authorization practices by Medicaid managed care plans has found that some people enrolled in Medicaid managed care may not be receiving all medically necessary health care services intended to be covered because of the high number and rates of denied prior authorization requests; the limited oversight of prior authorization denials in most states; and the limited access to external medical reviews. Learn more from the OIG report “High Rates of Prior Authorization Denials by Some Plans and Limited State Oversight Raise Concerns About Access to Care in Medicaid Managed Care” and find a summary of that report here.
- In response to the COVID-19 pandemic, Congress passed a series of bills to provide funds to eligible hospitals and other health care providers for COVID-19 testing and treatment for uninsured individuals through the federal COVID-19 Uninsured Program. An audit conducted by HHS’s OIG has found that this program made payments to providers for significant amounts of money for services unrelated to COVID-19 and for services to patients who had health insurance. In all, the OIG estimates that nearly $784 million of $4.2 billion in such payments – 19 percent – were made to providers and that payments made for care provided to approximately 3.7 million of 19.2 million patients were improper. Learn more from this summary of the OIG’s findings, which includes a link to its complete report.
- Another OIG analysis has concluded that communities with greater concentrations of Hispanic/Latino residents were generally associated with less 2020 COVID-19 targeted Provider Relief Fund money for hospitals than communities with lower concentrations, a finding the OIG concludes is troubling because Hispanic/Latino Americans have been more likely to be hospitalized or die from COVID-19 than non-Hispanic White Americans. On the other hand, the OIG found that high concentrations of non-Hispanic Black residents were sometimes associated with more funding and that funding levels were not found to be associated with poverty. Learn more from a summary of the OIG report “Targeted Provider Relief Funds Allocated to Hospitals Had Some Differences with Respect to the Ethnicity and Race of Populations Served,” which includes a link to the full report.
- HHS and its Substance Abuse and Mental Health Services Administration (SAMHSA) have awarded $47.8 million through five grant programs to combat multiple facets of substance misuse and the overdose epidemic. The grants are intended to facilitate substance misuse prevention, treatment, recovery support, and harm reduction. Learn more about the grant funding and its purpose and the five grant programs and find a link to lists of the grant recipients from this HHS news release.
- HHS’s Agency for Healthcare Research and Quality (AHRQ) has updated its TeamSTEPPS® training program, an evidence-based resource designed to improve patient safety by optimizing the performance of health care teams. The update was developed in consultation with experts in TeamSTEPPS and team training, patients, and family caregivers and addresses changes in health care delivery and learning methods while emphasizing patient engagement. The updated curriculum is designed for use by team members in different roles, including frontline care providers, administrators, patients, caregivers, and trainers. It also can be used for virtual training. Find the updated curriculum here.
Federal Trade Commission
The Federal Trade Commission and the Justice Department have published a draft of updated guidelines for evaluating mergers to determine their compliance with federal antitrust laws. The goal of this update, according to the agencies, “… is to better reflect how the agencies determine a merger’s effect on competition in the modern economy.” If adopted, the draft guidelines could affect federal regulators’ decisions on mergers in a number of industries, including health care. Learn more about the draft guidelines from this joint FTC/Justice Department news release; this statement from the chair of the FTC; and the draft guidelines themselves. Stakeholder comments are due by September 18.
Medicaid and CHIP Payment and Access Commission (MACPAC)
States are required to engage qualified independent entities called external quality review organizations to review the quality, timeliness, and accessibility of care provided by Medicaid managed care organizations. These reviews serve as a means for federal and state oversight, monitoring, and accountability of Medicaid managed care organizations. In a new issue brief, MACPAC provides background on the external quality review process and how states and CMS use this process to oversee managed care programs and improve quality and outcomes for Medicaid beneficiaries. Learn more from the MACPAC issue brief “Managed Care External Quality Review.”
Congressional Budget Office (CBO)
The CBO provides information to Congress about the effects of legislative proposals that would modify federal health care policies. The agency is interested in new research about various topics in the area of health, including health care providers’ cost structures and the market for long-term services and supports. Learn more about the areas where the CBO is working and the kind of research it seeks from the CBO blog entry “A Call for New Research in the Area of Health.”
CMS – Hospital Price Transparency Machine Readable File Sample Format Webinar – July 26
CMS will hold a webinar on Wednesday, July 26 at 2:30 (eastern) to review voluntary sample formats hospitals may use to make their standard charges public in a machine-readable file so they can comply with the federal hospital price transparency requirement. During the webinar CMS will present sample formats that use a standardized set of data elements and a new validator tool hospitals can use to test the accuracy of their files. Go here to register to participate.
CMS – Ambulance Open Door Forum – July 27
CMS will hold an ambulance open door forum on Thursday, July 27 at 2:00 (eastern). Go here to register to participate.
CMS – Advisory Panel on Hospital Outpatient Payment – August 21-22
CMS’s Advisory Panel on Hospital Outpatient Payment will meet virtually on Monday, August 21 and Tuesday, August 22 at 9:30 (eastern) on both days. The purpose of the panel is to advise CMS on the clinical integrity of the Ambulatory Payment Classification groups and their associated weights, which are major elements of the Medicare hospital outpatient prospective payment system and the ambulatory surgical center payment system. Interested parties may contact the panel about submitting letters and comments to be added to the meetings’ agenda. Learn more, including how to participate, from this CMS notice, which also lists the panel’s members, including recent appointees.