Inside this Edition
Texas Medical Association Files Lawsuit Challenging Departments’ Surprise Billing Final Rule | Medicaid and CHIP Payment and Access Commission Holds September Meeting | CMS Reopens Comment Period on Additional State Flexibilities Provided Under the Medicaid Maintenance of Effort Requirement | Biden-Harris Administration Announces New Actions and Funding to Address the Overdose Epidemic and Support Recovery | Early Childhood, Elementary, and Secondary Education Subcommittee Debate Efficacy of ESSER Funds for Students’ Academic, Social, and Emotional Needs | Administration Action | Congressional Action | Medicare | Marketplace | Litigation | Research |
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Texas Medical Association Files Lawsuit Challenging Departments’ Surprise Billing Final Rule
Today, the Texas Medical Association (TMA) announced they filed another lawsuit challenging the August 2022 Requirements Related to Surprise Billing Final Rule released by the Departments of Labor, Treasury, and Health and Human Services. TMA asserts the rules still favor health insurers over physicians in arbitrating out-of-network rates. In their first lawsuit over the October 2021 Surprise Billing Interim Final Rule, TMA argued that federal agencies were discounting true provider compensation by having arbitrators default to insurers’ qualifying payment amount (QPA), or median in-network rate, as the appropriate out-of-network rate. While TMA won its first lawsuit and the Departments released the Final Rule to address the District Court’s decision, they argue the current language still gives insurers an unfair advantage over providers in setting out-of-network rates. By having arbitrators first consider insurers’ QPAs over provider estimates, TMA maintains federal agencies are still favoring health plans over providers and patients. The American Hospital Association and American Medical Association announced today they plan to file an amicus brief in support of TMA’s lawsuit.
Medicaid and CHIP Payment and Access Commission Holds September Meeting
Last week, the Medicaid and CHIP Payment and Access Commission (MACPAC) held its September policy meeting. The Commissioners discussed a number of issues related to Medicaid payment policy. Specifically, the Commission held hearings on:
- Background on Medicaid race and ethnicity data collection and reporting
- State processes and stakeholder engagement for unwinding continuous coverage requirement
- Improving rate setting and risk mitigation in Medicaid managed care
- Principles for assessing Medicaid nursing facility payments relative to costs
- Countercyclical disproportionate share hospital policies
- Medicaid coverage of monoclonal antibodies directed against amyloid for the treatment of Alzheimer’s disease
- Review of proposed rule on core set reporting and Congressional request for information on long-term services and supports
- Panel on integrating care for dually eligible beneficiaries in Medicaid fee-for services (FFS)
CMS Reopens Comment Period on Additional State Flexibilities Provided Under the Medicaid Maintenance of Effort Requirement
CMS is reopening a comment period on an interim final rule (IFR) originally published on November 6, 2020, titled “Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency.” This IFR provided additional flexibility to states in meeting the maintenance of effort (MOE) requirement to claim a 6.2% FMAP increase provided under the Families First Coronavirus Response Act (FFCRA). Specifically, the IFR still required states maintain beneficiary enrollment in Medicaid, but further permitted states to make certain changes to the amount, duration, and scope of benefits and to beneficiary cost sharing.
CMS now notes that it has become aware of this policy change negatively impacting some Medicaid beneficiaries, and that the fiscal situations of many states may have changed since the IFR was originally issued. CMS is now considering rescinding this additional flexibility provided in the IFR, and returning to its original interpretation, where states are not permitted to reduce the amount, duration, or scope of benefits or modify cost sharing of their enrolled Medicaid beneficiaries.
The comment period will be open for 30 days following publication.
Biden-Harris Administration Announces New Actions and Funding to Address the Overdose Epidemic and Support Recovery
Today, the Biden-Harris Administration announced a set of recent actions to address the opioid crisis as a part of National Recovery Month. The Administration’s new actions include awarding $1.5 billion for all states and territories to address addiction and the opioid crisis; investing over $104 million in public, private, and non-profit entities to expand access to substance abuse treatment and prevention in rural communities; awarding $20.5 million to organizations that help connect individuals with substance use disorders with community resources to increase access to recovery supports; and releasing new guidance to support and facilitate greater access to U.S. Food and Drug Administration-approved naloxone products.
Early Childhood, Elementary, and Secondary Education Subcommittee Debate Efficacy of ESSER Funds for Students’ Academic, Social, and Emotional Needs
This week, the Early Childhood, Elementary, and Secondary Education Subcommittee debated the usage of Elementary and Secondary School Emergency Relief (ESSER) funds to address learning loss and mental health issues due to COVID-19. The subcommittee questioned education policy thinktank leaders and state DOE commissioners to evaluate how school districts and states leveraged funds to target evidence-based literacy efforts, address national staffing shortages, incorporate social and emotional learning in curricula, and build out school-based mental health supports. Notes on the subcommittee hearing can be found here.
Administration Action
- The Centers for Disease Control and Prevention (CDC) released a brief presenting data from the Maternal Mortality Review Committees’ (MMRCs) review of maternal mortalities from 2017 to 2019. MMRCs are multidisciplinary committees that convene at the state or local level to comprehensively review deaths during or within a year of pregnancy. The brief found that over 80% of pregnancy-related deaths are preventable, with nearly a quarter stemming from mental health conditions, 14% from excessive bleeding, and 13% from cardiovascular issues. The data also revealed race- and ethnicity-based inequities, where cardiovascular issues were the main cause of pregnancy-related death for Black individuals and excessive bleeding for Asian individuals.
- This week, the Biden-Harris Administration held a virtual event to discuss key areas of progress to improve outcomes for kids and families facing cancer as part of President Biden’s vision for the Cancer Moonshot. The event included updates on federal agency programs and initiatives in the areas of data sharing, drug development, research and innovation, and patient navigation. More information on the Cancer Moonshot can be found here.
- The U.S. Preventive Services Task Force (USPSTF) announced a request for public comment on its draft recommendation statement and draft evidence review on screening for anxiety in adults. In the draft, USPSTF recommends screening for anxiety in adults aged 64 years or younger, including those who are pregnant and postpartum. USPSTF gave the recommendation a B grade, meaning there is high certainty that the net benefit for patients is moderate. The public comment period for review of the draft recommendation statement and evidence review is from September 20 – October 17, 2022.
Congressional Action
- On Thursday, the Senate Finance Committee published a discussion draft and summary of workforce provisions to be included in the bipartisan mental health package. The bill calls for Medicare to update and expand coverage for certain services beginning in 2024. It also expands Medicare’s Health Professional Shortage Area bonus payments to psychiatrists and other mental health professionals, and funds 400 additional Medicare Graduate Medical Education slots for psychiatry residencies. The Centers for Medicare and Medicaid Services is also directed to provide states with strategic guidance.
- The House Energy and Commerce (E&C) Committee and Ways and Means (W&M) Committee held markups on several health-related bills. Of particular importance to commercial health plans, the W&M Committee discussed Committee Print 117-4, Improved Information in Provider Directories, Plan Definitions, and Crisis Services for Private Insurance Plans. The W&M Committee also discussed Committee Print 117-5, Improved Information for Network Coverage and Plan Documents in Private Insurance Plans. The W&M Committee approved both of the proposals, stressing how each would improve consumer understanding of mental health benefits, consumer ability to compare health plans before purchasing, and third parties’ ability to identify gaps in plan benefits.
Medicare
- A review of 62 studies by Kaiser Family Foundation researchers comparing Medicare Advantage (MA) and Traditional Medicare on beneficiary experience, affordability, service utilization, and quality found few significant trends or differences between the two programs. MA and Traditional Medicare performed similarly in measures of beneficiary experience like access to care, care coordination, and experience with prescription drugs, as well as utilization measures such as hospitalization and physician-administered drugs. Traditional Medicare slightly outperformed MA in beneficiaries experiencing affordability issues, though it was mainly due to traditional Medicare beneficiaries with supplemental coverage. Medicare also outperformed on other select measures, including receiving high-rated care for cancer treatment and in skilled nursing facilities and home health agencies. MA outperformed Traditional Medicare in services including preventative treatment, having a usual source of care, and hospital readmissions.
- The National Committee for Quality Assurance (NCQA) evaluates Medicare, Medicaid, and commercial plans each year on several patient experience and outcomes measures for consumers and businesses to use. The NCQA helps health plans evaluate progress across different treatment areas and patient satisfaction. Notably, health plans saw marked improvements in managing high blood pressure, but they have room to improve in preventive care measures like child immunization. In general, Medicaid and Medicare plans scored lower in patient satisfaction but were better than commercial insurers on care quality.
Marketplace
- On Monday, the Urban Institute published a new report highlighting that the type of health coverage a patient has can drive disparities in their care. The report details how unfair treatment in healthcare settings is associated with unmet health needs and can result in poor health care quality and health inequities. The report also suggests that publicly insured and uninsured adults indicate that they experience unfair treatment at higher rates than those with private insurance due to their income, disability status, and race and ethnicity. The Urban Institute acknowledges that additional research is needed to assess the roles insurance-related hassles and differential access to care play in shaping people’s perceptions of unfair treatment due to insurance type.
Litigation
- The American Hospital Association (AHA) and American Medical Association (AMA) moved to dismiss their challenge to the federal government’s September 2021 interim final rule (IFR) concerning the No Surprises Act. The IFR created an independent dispute resolution (IDR) process that required IDR entities to choose an offer closest to their median in-network rate or qualifying payment amount when resolving payment disputes. AMA and AHA argued in federal court that the interim rule overstepped Congressional intent. The Administration released a subsequent final rule in August, which AMA and AHA claimed made the lawsuit moot. In their official statement, AMA and AHA maintain that the final rule continues to favor insurers and does not live up to Congressional intent. They also hinted at future legal challenges.
Research
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- The Kaiser Family Foundation (KFF) released an issue brief outlining five key findings on mental health and substance use issues by race/ethnicity. The analysis highlighted the disproportionate impacts of the COVID-19 pandemic among people of color and the ongoing inequities in access to mental health care and treatment. The study cites that culturally competent care, a diverse behavioral health workforce, and a reduction in structural barriers to care could help address barriers to mental health care access for people of color.
- A study published this week showed that nearly 1 in 10 Americans experienced depression during 2020. This was driven by a significant increase in the number of adolescents and young adults with depression, rising to nearly 1 in 5 individuals between the ages of 12-25, but increases were also noted across all sexes, races, ethnicities, and education groups. Rates of depression have increased each year since 2015, but early evidence suggests that the COVID-19 public health emergency further worsened the trend. The researchers also noted that while more individuals were experiencing depression during that period, less than 6% of those sought medical care or received medication for their depression.