Weekly Roundup: February 3, 2023

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Healthsperien Summary: CMS Proposed Rule Advancing Interoperability and Improving Prior Authorization Processes

The Centers for Medicare & Medicaid Services (CMS) released the Advancing Interoperability and Improving Prior Authorization Processes proposed rule that outlines the Agency’s goals to advance interoperability and to improve overall prior authorization processes to enhance communication between patients, providers, and payers. Significant policies addressed in this rule include changes to prior authorization processes, interoperability standards for patient and provider access APIs, and payer-to-payer data exchange on FHIR. The proposed rule also includes requests for information on adopting standards related to social risk data, advancing an electronic data exchange among behavioral health providers, the electronic exchange of information in Medicare FFS, advancing the Trusted Exchange Framework and Common Agreement, and improving interoperability and prior authorization processes for maternal health.

Healthsperien has provided a detailed summary of the proposed rule, including relevant background information and areas where CMS is seeking comments, which can be accessed here

Sens. Sanders and Cassidy Lay out HELP Committee Agenda

Yesterday, the Senate made committee assignments official, naming Sens. Bernie Sanders (I-VT) and Bill Cassidy (R-LA) as Chair and Ranking Member, respectively, of the Senate Committee on Health, Education, Labor, and Pensions. Both Senators outlined (subscription required) their top priorities for the committee and where there is an opportunity for bipartisan collaboration.

Both senators cited addressing the national shortage of nurses as a potential area for bipartisanship. Chairman Sanders also highlighted expanding access to community health centers and improving dental coverage as issues where democrats and republicans can find agreement. Ranking Member Cassidy highlighted mental health care legislation and investigating the implementation of the No Surprises Act as potential areas of bipartisan cooperation. On the issue of drug pricing, Chairman Sanders named slashing drug prices as a top priority and stated that the Inflation Reduction Act provisions that allowed Medicare to negotiate drug prices did not go far enough. In contrast, Ranking Member Cassidy was critical of drug price negotiation and voiced concern that it could harm innovation.

HHS Commits to Building a Healthier America in 2023

Recently, the U.S. Department of Health and Human Services (HHS) announced the continued role they will play in the Biden-Harris Administration’s efforts to expand access to affordable health care. In 2023, HHS will implement the Inflation Reduction Act and continue to advance health equity. In 2022, HHS focused on key areas to support the health and wellbeing of Americans, including:

Tackling the COVID-19 pandemic
Reducing health care costs and expanding access to coverage and care
Strengthening mental and behavioral health care
Improving nutrition and encouraging health choices
Strengthening supports for vulnerable children and families
Investing in health innovation
Strengthening public health preparedness and response

The snapshot of key HHS accomplishments in 2022 and their renewed commitment to building a healthier America in 2023 and beyond, follows recent research that found the U.S. spends more on health care than any other high-income country, however, the nation often performs worse on measures of health and health care.

Modern Healthcare Finds Medical Interpreters Face High Demand

Yesterday, Modern Healthcare published (subscription required) an article highlighting the high demand for medical interpreters in the U.S. According to the U.S. Census Bureau, approximately 8.3% of the U.S. population have limited English-language proficiency. While the demand for healthcare interpretation has increased over the past couple of decades, the field continues to face significant challenges related to the availability of language services and reimbursement of those services by insurers. Even though healthcare entities receiving federal funds are required to provide free interpreter services, neither Medicare nor Medicaid is required to reimburse providers for the services. As a result, healthcare providers are often responsible for covering the cost to provide interpreter services.

Zippia, an online recruitment service platform, found that the number of medical interpreter jobs is projected to increase by 20% between 2021 and 2031. Modern Healthcare reported the most difficult part of recruiting and training medical interpreters is identifying skilled individuals in a wide range of languages with the necessary experience/certification to teach. The profession is often interconnected with issues of social justice and plays a crucial part in helping patients understand their prognosis, treatment, and care instructions.

Execution Action

On Monday, President Biden announced to Congress his plans to end the COVID-19 Public Health Emergency (PHE) on May 11. The announcement came in response to resolutions brought to the floor this week by House Republicans to immediately end the PHE. This also comes on the heels of an announcement by the World Health Organization, which also declared that COVID-19 continues to constitute a public health emergency of international concern. Certain flexibilities tied to the PHE will conclude, including telehealth parity with in-office visits, eased rules for prescribing controlled substances without an in-person physician visit, and more.
Recently, on the one-year anniversary of the reignition of the Cancer Moonshot, the Biden Administration announced actions that will build on measures taken in the past year. In addition to new activity, President Biden announced his intent to appoint six members to the National Cancer Advisory Board, which will help guide the Director of the National Cancer Institute (NCI) in setting the course for the research program.

Administrative Action

On Monday, HHS and the Departments of Labor and the Treasury proposed to expand and strengthen access to birth control coverage under the Affordable Care Act (ACA). The rules would also establish a new pathway, called the individual contraceptive arrangement, that individuals enrolled in plans or coverage by objecting entities that are not eligible for or have not opted for the existing accommodation may use to obtain contraceptive services at no cost directly from a willing provider or facility that furnishes contraceptive services. In the wake of the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization, the proposed rule aims to ensure broader access to contraceptive services by enabling individuals enrolled in plans offered by objecting entities to still access contraceptive services directly.

Congressional Action

On Tuesday, Sens. John Cornyn (R-TX) and Richard Blumenthal (D-CT) reintroduced the Affordable Prescriptions for Patients Act (S. 1435), which aims to address anti-competitive practices by drug companies. During the previous legislative session, the bill passed the Senate Judiciary Committee with bipartisan support. The bill has support from stakeholders such as the Pharmaceutical Care Management Association (PCMA), which is the national organization representing pharmacy benefit managers (PBMs).
On Wednesday, Rep. Larry Bucshon (R-IN) called (subscription required) for oversight hearings on Medicare physician payment reform as he works through stakeholders’ comments on flaws in the system set up by the Medicare Access and CHIP Reauthorization Act. This is consistent with a range of provider groups representing more than a million clinicians urging lawmakers to move on comprehensive reforms. Rep. Bucshon mentioned that the partial mitigation included in last year’s spending bill isn’t enough for physicians or to protect Medicare beneficiaries’ access to care.

Medicare

Last week, CMS released a final rule (press release, fact sheet) on changes to the Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) program, which CMS uses to recover improper risk adjustment payments made to MA plans. Through RADV audits, a sample of beneficiary medical records are provided by MA plans, and CMS reviews those records to verify that diagnoses reported for risk adjusted payments are accurate and supported in the medical record. Risk adjustment discrepancies can be aggregated to determine an overall level of payment error, which can then be extrapolated.
On Wednesday, CMS released the Advancing Interoperability and Improving Prior Authorization Processes proposed rule that outlines the Agency’s goals to advance interoperability and to improve overall prior authorization processes to enhance communication between patients, providers, and payers. Significant policies addressed in this rule include changes to prior authorization processes, interoperability standards for patient and provider access APIs, and payer-to-payer data exchange on FHIR. The proposed rule also includes requests for information on adopting standards related to social risk data, advancing an electronic data exchange among behavioral health providers, the electronic exchange of information in Medicare FFS, advancing the Trusted Exchange Framework and Common Agreement, and improving interoperability and prior authorization processes for maternal health. A detailed summary of the proposed rule can be accessed here.
On Wednesday, CMS released the Calendar Year (CY) 2024 Advance Notice of Methodological Changes for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies (the Advance Notice). CMS will accept comments on the CY 2024 Advance Notice through March 3, 2023, before publishing the final Rate Announcement by April 3, 2023.

Medicaid

CMS issued new guidance and frequently asked questions (FAQ) on a temporary special enrollment period for individuals disenrolled from Medicaid and CHIP due to the unwinding of the COVID-19 maintenance of effort requirement. States will begin Medicaid and CHIP eligibility redeterminations over the coming months for all individuals who were enrolled in the programs during the COVID-19 public health emergency (PHE). Individuals who no longer meet the eligibility criteria for Medicaid or CHIP will be eligible for a new Marketplace Unwinding Special Enrollment Period (SEP) between March 31, 2023 and July 31, 2024.

Litigation

CMS issued new guidance and frequently asked questions (FAQ) on a temporary special enrollment period for individuals disenrolled from Medicaid and CHIP due to the unwinding of the COVID-19 maintenance of effort requirement. States will begin Medicaid and CHIP eligibility redeterminations over the coming months for all individuals who were enrolled in the programs during the COVID-19 public health emergency (PHE). Individuals who no longer meet the eligibility criteria for Medicaid or CHIP will be eligible for a new Marketplace Unwinding Special Enrollment Period (SEP) between March 31, 2023 and July 31, 2024.

Research

On Tuesday, the Commonwealth Fund released their updated cross-national comparison of health care systems to assess U.S. health spending, outcomes, status, and service use relative to other high income countries. The data from this analysis uses the Organisation for Economic Co-operation and Development (OECD) and reflects the impact of the COVID-19 pandemic. Among other outcomes, the Commonwealth Fund found that while the U.S. spends more on health care than any other high-income country, the nation often performs worse on measures of health and health care.