Welcome back! Well that was a nice break, but it is time to get to back to work in Washington! September is going to be a potentially HUGE month in health policy. We are looking at possible legislative advances on big issues like drug prices, surprise bills and (hopefully) a delay of Medicaid DSH cuts before the Oct. 1 deadline. We also had the final “public charge” rule as well as regulatory changes to the somehow even-arcane-for-Washington 42 CFR Part 2 regulations. Oh – and that pesky little thing called funding the government also needs to be handled before Oct. 1 …

Your authors thoroughly enjoyed the August recess! One of us finally got around to seeing the wildly popular Broadway show Hamilton (and will now have one of its various catchy songs randomly stuck in his head from here until the world turns upside down – now you will too!), while the other spent WAY too much time waking up at 5 a.m. with her tiny human ...  

All in all it was a good break, but let’s not throw away our shot – and dig in for a full month of health policy ahead!

They’re baa-aaack

Congress returned to Washington last week and is facing an incredibly packed September. And since September quickly melts into December, it’s going to be an absolute mad-house rush to try to accomplish some big ticket items this year. And there’s the small matter of the president possibly releasing a health reform plan. Shake off your summer doldrums and buckle up … because it’s about to get bumpy. 

On Sept. 9, the House and Senate convened again in Washington following the August recess. Congress is facing several significant policy items, with the most pressing being legislation to fund the government and avoid a shutdown at the end of the month. While Congress and the administration already reached an agreement on the top-line spending numbers in the recently approved budget deal, the specifics of the 12 must-pass funding bills still need to be negotiated and approved by Congress. Rumor has it they won’t be able to complete every individual appropriations bill and instead, plan to vote on a short-term continuing resolution during the week of Sept. 16. The temporary measure would extend funding past the end of the fiscal year (Sept. 30) to provide additional time to complete the remaining funding bills for any unfunded agencies.

For hospitals, a key priority in September will be urging Congress to again delay the implementation of the scheduled $4 billion reduction in Medicaid DSH payments that will go into effect Oct. 1 without congressional intervention. The House Energy and Commerce Committee advanced legislation in July that would delay the cuts, though the outlook for the full House and Senate to approve the legislation in September is unclear. The bill approved by the Energy and Commerce Committee also included another priority item for Congress – policies to protect patients from surprise bills.

The Senate Health, Education, Labor and Pensions (HELP) Committee also advanced legislation to address surprise bills, along with a wide range of other health care cost reduction provisions. While there is a strong bipartisan desire in both the House and Senate to act to prevent surprise bills, there is still an ongoing debate about how best to reach that goal.

Hospitals have raised concerns about both the House and Senate bills regarding the inclusion of a benchmark payment rate where there is disagreement between insurers and providers. Hospitals have instead supported the development of an independent dispute resolution process that would protect patients and leave disputes over surprise bills between providers and insurers. It is expected that the House Ways and Means Committee may also wade into the debate over surprise bills with hearings early in September.

Another priority focus area in September will be the ongoing effort to address high drug prices. The Senate Finance Committee advanced comprehensive drug pricing legislation before the recess. The bill includes a wide range of significant changes designed to hold down drug prices, including new rebate requirements if drug costs exceed inflationary targets, out of pocket spending caps in Medicare Part D and changes to pharmacy benefit manager practices in Medicaid, among numerous other provisions. The Senate Judiciary Committee may also seek to take up separate components related to drug pricing, such as the Vizient-endorsed CREATES Act.

During the August recess, staff from HELP, Finance and Judiciary worked to combine their three bills into one, large piece of legislation. It is possible the full Senate could take up the bill in the near future, but it is unclear whether Majority Leader Mitch McConnell (R-Ky.) plans to put the legislation on the floor for consideration as concerns have been raised by numerous stakeholders regarding various elements of the legislation. It is also expected that House Speaker Nancy Pelosi (D-Calif.) will unveil her drug pricing legislation that has been privately under development for some time. While still not public, the comprehensive plan reportedly will include several controversial proposals, including potentially allowing for government negotiations for selected high price drugs.

Finally, on top of the congressional activity, it is also been reported that the president could be releasing a formal health care reform proposal during September. While the details are still to unclear, it is expected to be similar to previous Republican plans with increased focus on health savings accounts and catastrophic coverage. Even if the proposal is released, it is highly unlikely that Congress will act on it given competing priorities, and a Democratic-controlled House of Representatives.

Key takeaways:

  • It will be an incredibly busy month, and many of the individual policy proposals may be packaged with other bills and move quickly through the legislative process
  • It will be important to closely monitor congressional action throughout the month and be prepared to engage with your members of Congress and senators on key legislative items
  • Whether or not the president does release a health reform bill during September, it is not likely to have any immediate impact because the Democratic-led House will not consider such a proposal, and the GOP-led Senate will be focused on other issues
  • Despite the unlikely outlook for immediate congressional action, the president’s health plan will be important to monitor due to the uncertainty surrounding the ongoing legal challenge that could invalidate the ACA 

2021 sure seems like an awfully long time in the future …

CMS announced that it would be using the current flawed methodology to refresh the Overall Hospital Quality Star Ratings for 2020, but would consider implementing additional changes based on stakeholder feedback in 2021. That sure seems like a long ways away. I mean I guess it is almost December already, so I’m sure it will just fly by.

On Aug. 19, the Centers for Medicare & Medicaid Services (CMS) announced that it would be updating the methodology it uses to determine the Overall Hospital Quality Star Ratings beginning in 2021. In the announcement, CMS indicated that it would continue to use the current methodology to refresh the Star Ratings in 2020. While the controversial Overall Hospital Quality Star Ratings were designed with the intention to give consumers an easy-to-understand tool to compare hospitals on their quality performance, the current methodology CMS uses is based on a problematic scoring model that can produce inaccurate shifts in hospitals’ ratings.

CMS has acknowledged concerns about the methodology, and in February solicited additional feedback on its approach. Vizient commented on the solicitation and will continue to work with CMS to improve the accuracy and usability of the Overall Hospital Quality Star Ratings. The agency is hosting a public listening session on Sept. 19 to hear additional feedback on the Star Ratings system and has accepted nominations for a technical expert panel to review and update the Star Ratings methodology. Hospital groups, including Vizient, have urged CMS to consider taking down the current Star Ratings until improvements can be made to the methodology. 

Key takeaways:

  • CMS announced that it would update the methodology for the Overall Hospital Quality Star Ratings in 2021, but will refresh the Star Ratings in 2020 using the current methodology
  • Hospital groups have encouraged CMS to remove – or at the very least – not refresh the Star Ratings on Hospital Compare until the methodology is updated so that patients have access to a clear, simple and objective tool to identify high performing hospitals
  • While hospital groups are disappointed with the decision to continue using the existing methodology in 2020, Vizient is pleased CMS has committed to working collaboratively with stakeholders to make improvements to the Star Ratings methodology 

Public charge rule could discourage patients from receiving needed care

No jokes here. The Department of Homeland Security (DHS) released the final “public charge” rule. Unfortunately the rule maintains some very concerning elements that could discourage legal immigrants from accessing needed health care services.

On Aug. 12, DHS released the final “public charge” rule. Under the rule, legal immigrants may face significant questions about whether they are able to adjust, extend their immigration status or gain full citizenship, based on the extent to which they receive, or will receive, public benefits. Currently, the government takes into account whether individuals can support themselves or whether they may become a “public charge” before making immigration status determinations.

This new rule expands the list of benefits that characterize an immigrant as a “public charge” to include Medicaid, public housing and certain nutrition programs, such as the Supplemental Nutrition Assistance Program (SNAP). Hospital groups have opposed the rule, arguing that it will negatively impact public health by potentially discouraging many legal immigrants from getting needed care and public health services out of fear it could impact their immigration status. The rule clarifies that DHS will only consider public benefits received directly by the individual for their own benefit, and that a public benefit received by one or more members of their household will not be attributed to them unless they are also listed as a beneficiary of the public benefit.

It is expected that the Department of Justice will conduct additional rulemaking related to the rule to ensure that the updated standards under the rule are consistent. The final rule will become effective Oct.15.

Key takeaways:

  • The Department of Homeland Security released the “Inadmissibility on Public Charge Grounds” final rule to establish new criteria regarding which public benefits will be taken into account in deciding whether legal immigrants are able to adjust, extend their immigration status or gain full citizenship
  • The proposed rule received significant attention during the comment period, including over 260,000 comments, most of which were negative. The rule will take effect next month. 
  • Several states and other groups have filed a lawsuit challenging the final rule, so there still may be delays or significant changes forced by the courts before the rule ultimately goes into effect

42 CFR what now?  

The administration took a small, but important step to try to address a very serious problem for health care providers. The Substance Abuse and Mental Health Services Administration (SAMHSA) released a proposed rule that would relax 42 CFR Part 2 regulations to potentially allow for greater sharing of treatment records for Substance Use Disorder (SUD) patients. The regulation may be helpful, but Congress will likely still need to approve legislation to allow for better care coordination for SUD patients.

On Aug. 22, SAMHSA released a proposed rule to update regulations related to sharing the health information of patients with SUDs. Currently, under a section of federal code (42 CFR Part 2), medical records for publicly funded SUDs treatments are segregated from a patient’s medical record. As a result, that information is not allowed to be shared even with other physicians. The proposed rule would clarify which records are subject to the 42 CFR Part 2 regulations, and potentially offer greater clarity for privately funded SUDs treatment records to be more easily shared as part of the medical record.

In addition, it may also improve the data available to state prescription drug monitoring programs. Hospitals and physicians have argued that the current law and regulation makes it more difficult for clinicians to respond to the ongoing opioid abuse crisis by preventing them from learning of a patient’s potential abuse of opioids. SAMHSA will be accepting comments on the proposed rule until Oct. 25.

Key takeaways:

  • The proposed rule clarifying 42 CFR Part 2 regulations is a small, but positive step that may lead to some limited improvements in data sharing related to SUD patients
  • Congress has been engaged on the issue and may consider further changes to statute that would make more significant updates to the existing law to ensure a physician will have access to patient’s history of treatment for SUDs 

MedPAC: Always a party!

I can’t think of much else that is more fun than technical details of health policy discussed at a high level by a Congressional advisory board with no actual policy-making authority. The Medicare Payment Advisory Commission (MedPAC) met in Washington for its September meeting, and discussed Indirect Medical Education, the Hospital Readmissions Reduction Program and other issues.

On Sept. 5-6, MedPAC hosted its September meeting in Washington, D.C. During the meeting the commissioners discussed, among other topics, possible updates to Medicare’s Hospital Readmissions Reduction Program (HRRP) as well as Indirect Medical Education (IME) payments. Staff presented ways that IME payments could be reallocated so that IME adjustments would apply to both inpatient and outpatient care. The Commission showed how making this change could be done in a budget neutral manner so that aggregate Medicare payments to teaching hospitals would not be affected.

MedPAC also discussed Medicare Advantage “spillover” and its impact on Medicare fee-for-service spending (which they found to be minimal), and the value incentive program for post-acute care providers. MedPAC is accepting comments on their proposals through email until Sept.13.

Key takeaways:

  • MedPAC hosted a public meeting in Washington, D.C. to discuss relevant Medicare policy questions, including revisions to IME policy and the Hospital Readmissions Reduction Program
  • As always, MedPAC is well regarded by policymakers, but they do not have formal policymaking authority. However, the recommendations made by MedPAC are often seriously considered.

Rural request for response

The Health Resources and Services Administration (HRSA) released a Request for Information (RFI) seeking feedback on rural health care needs. Rural health care issues are growing in urgency, and between Congress and the administration, policymakers are taking a serious look at the issue and working to find answers.

On Aug. 22, the HRSA released an RFI seeking public input on how to best understand and measure access to health care in rural communities. The RFI cited the higher disease burden in rural America as well as reduced access to care and risk of rural hospital closures as key reasons why the agency was seeking feedback about how to best address the needs of rural America.

HRSA is seeking specific, data-backed answers to four specific questions:

  1. What are the core health care services needed in rural communities and how can those services be delivered?
  2. What are the appropriate types, numbers, and/or ratios of health care professionals needed to provide core health care services locally for rural populations of different compositions and sizes?
  3. What other factors are important to consider when identifying core health services in different rural communities, such as current and projected population size, distance to the nearest source of care, availability of telehealth, and sustainability of services?
  4. How should we measure access to health care services in rural communities? What are the best ways of measuring quality of care in rural communities?

HRSA will be accepting comments on the RFI until Oct. 9.

Key takeaways:

  • HRSA released an RFI seeking stakeholder feedback on several specific questions related to providing health care in rural America
  • Both Congress and the administration have been talking about taking steps to support health care in rural America. While the conversation is ongoing, and rural health has long had strong bipartisan support, legislation to significantly change the existing reimbursement and delivery paradigms have not been able to advance in Congress.

Although we don’t want to lose you here …

Please click here for our summary of the FY 2020 Physician Fee Schedule/Quality Payment Program proposed rule – and don’t hesitate to reach out to us with any feedback you may have!

Quotes of note:

“I look forward to coming together, both Republicans and Democrats, so that we can complete our work on the FY2020 appropriations bills as soon as possible. The American people deserve no less.”

 - Senate Appropriations Committee Chairman Richard Shelby (R-Ala.) highlighting the importance of completing the appropriations bills in September – Aug. 1, 2019 

“Transparency is the cornerstone of the Trump administration’s commitment to patients. President Trump knows the status quo doesn’t work, and has directed us to enhance transparency for patients. CMS is delivering by refreshing and updating the Hospital Star Ratings. Today, CMS is empowering patients to make informed healthcare decisions, leading providers to compete on the basis of cost and quality.”

 - CMS Administrator Seema Verma in announcing the plan to update the Overall Hospital Quality Star ratings in 2021 – Aug. 19, 2019

We want to hear from you …

As always, let us know how we are doing, and what you’d like to see from the Washington office. We are happy to report on other initiatives that may be of interest to you and would be even happier to meet with you in person, should a D.C. update ever be of interest! Email us at: shoshana.krilow@vizientinc.com and steve.rixen@vizientinc.com. For more information, visit us online.

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Published: September 19, 2019