Health Policy Report – July 10, 2024

The US Oncology Network PAC Hosts Dinner with RMCC and Rep. Diana DeGette (D-CO)

On Tuesday, June 18, The US Oncology Network and Rocky Mountain Cancer Centers (RMCC) hosted a dinner discussion with Rep. Diana DeGette (D-CO) in downtown Denver. The discussion focused on cancer care delivered in Denver, research and clinical trials at RMCC, and the importance of medically integrated dispensing to the continuity of care.

Thank you to RMCC Practice President Dr. Timothy Murphy, Executive Director Glenn Balasky, Dr. Les Busby, Dr. Mabel Mardones, and Pharmacy Director Evan Slater for joining.

Rep. Diana DeGette is a senior member of the House Energy & Commerce Committee and leader in healthcare. RMCC and The US Oncology Network look forward to working with her on important issues impacting community oncology.

To learn more, CLICK HERE.

HHS Finalizes Information Blocking Penalties

In a final rule released on June 24, the Department of Health and Human Services (HHS) finalized disincentives for providers engaging in information blocking. The final rule will impose Medicare pay cuts for hospitals, clinicians, and provider groups found guilty of blocking the flow of electronic health data. Additionally, accountable care organizations (ACOs) may not be able to participate in the Medicare Shared Savings Program if they engage in information blocking.

The latest final rule is part of a multi-year effort to put penalties in place for providers that block the exchange of electronic health information. In 2020, the Trump administration finalized regulations to officially bar information blocking, enacting provisions of the 21st Century Cures Act, which was passed by Congress in 2016. This new regulation also complements an HHS Office of Inspector General final rule issued last July that levies fines up to $1 million for technology companies and health information exchanges found to have engaged in information blocking.

In its comments to the Office of the National Coordinator for Health Information Technology (ONC) at the Department of Health and Human Services (HHS) earlier this year, The Network expressed its concern that the practice of information blocking to control patient referrals is not directly addressed in the rule and noted that it continues to see hospitals engage in information-blocking type behavior to control referrals.

To read the final rule, CLICK HERE.

To read The Network’s comments, CLICK HERE.

To read more, CLICK HERE.

New Study Reveals Markups at Mail-Order Pharmacies

Drugs delivered by mail-order pharmacies, especially those that are owned by pharmacy benefit managers, are costing more than those picked up at the pharmacy counter, according to a new report. Increasingly, employers have turned to mail-order pharmacies to save money on prescriptions, lured by the promise of lower costs as compared to brick-and-mortar rivals.

Instead, the report, which looked at 2.4 million claims by self-insured employers in Washington state from 2020 to 2023, revealed that drugs ordered through mail-order pharmacies are costing more and raising employers’ spending. Generic prescriptions dispensed by mail pharmacies were marked up on average more than three times higher than prescriptions filled by brick-and-mortar pharmacies, according to the report.

In response, the Pharmaceutical Care Management Association (PCMA), stated the report was “cherry-picked and therefore gives an incomplete and inaccurate picture of reimbursement across different pharmacy types.”

PBM business practices have in recent years drawn scrutiny from regulators and lawmakers, who are likely to use this latest report in their continued probe into rising drug costs. 

To read the report, CLICK HERE.

To read more, CLICK HERE.

Senator Ron Wyden (D-OR) Calls on CMS to Step Up Oversight of PBMs in Part D

In a recent letter to the Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure, Senator Ron Wyden (D-OR) urged the agency to better enforce Medicare Part D program requirements for pharmacy benefit managers. By evading such requirements, using unfair contracting terms, and implementing subpar reimbursement levels, PBMs are threatening the financial health of small, independent pharmacies, Wyden argued. 

“I am alarmed to hear reports that PBM contracting practices are straining the finances of pharmacies and directly contributing to their closures,” he wrote. “Specifically, I am concerned PBMs are not adhering to the new rule reining in direct and indirect remuneration (DIR) fees that took effect on January 1 and undermining Medicare’s pharmacy access standards as intended by Congress.”

Wyden highlighted that, under a Part D final rule released in January, CMS has the authority to enforce pharmacy price concessions, implement standardized pharmacy measures, and review formal or informal complaints about PBM contracting practices. 

Wyden’s letter comes after community oncologists raised similar concerns earlier this year and urged CMS to curb improper PBM practices. 

To read more about Wyden’s call on PBM oversight to CMS, CLICK HERE.

To read Wyden’s letter to CMS, CLICK HERE.

Supreme Court Decision Alters How Federal Agencies Regulate

On June 28th, a divided Supreme Court overturned Chevron v. Natural Resources Defense Council, a 1984 ruling that has been used as a legal building block for new federal regulations. In a 6-3 decision in the case, Loper Bright Enterprises et al. v. Raimondo, the majority said the Chevron decision improperly transferred the power to interpret the law from the judiciary to federal agencies. “Agencies have no special competence in resolving statutory ambiguities. Courts do,” Chief Justice John Roberts wrote in the majority opinion.

In a dissenting opinion, the court’s liberal justices raised alarm about the decision’s impact on complex technical healthcare regulations, including those involving artificial intelligence, CMS reimbursement and FDA drug approvals.

The landmark decision opens the door for legal challenges against countless healthcare policies, both past and present. Experts predict that the threat of legal battles may encourage regulators to exercise greater caution, leading healthcare agencies to rely on nonbinding guidance and enforcement activity more than rules. Additionally, Congress may attempt to write statutes in greater detail and reduce flexibility given to agencies.

To read more, CLICK HERE.

House Ways & Means Subcommittee Hearing Centers on Value-Based Care

During a Ways & Means Subcommittee hearing on June 26, lawmakers and healthcare executives raised concerns about how the Centers for Medicare & Medicaid Services (CMS) is implementing value-based payment models. Topics of the hearing included the transition from fee-for-service to value-based care, the successes and shortcomings of models put forth by the Center for Medicare and Medicaid Innovation (CMMI), challenges facing rural healthcare providers, the role of Medicare Advantage (MA), and the need for improved data collection and sharing. Witnesses included Dr. Sarah Chouinard of Main Street Health, Stephen Nuckolls of Coastal Carolina Health Care, Dr. Matthew Philip of Duly Health & Care, and Dr. Robert Berenson of the Urban Institute.

“I am a proponent of the need to move to value-based care, improving quality while decreasing wasteful spending and ensuring access,” Robert Berenson, MD, an institute fellow at the Urban Institute in Washington, D.C., said in his testimony. “However, I believe that value-based payment as a mechanism to promote better care delivery has gotten off track and needs a thorough reevaluation and reformulation.”

Meanwhile, Stephen Nuckolls, CEO of Coastal Carolina Health Care, a physician-owned multi-specialty medical practice that serves several counties in eastern North Carolina, acknowledged that one model – the Medicare Shared Savings Program (MSSP) – has improved patient outcomes. However, he acknowledged that the program’s benchmarks are established based on an organization’s most recent costs, making it less likely that their ACO is unlikely to renew their contract at the end of the year. 

Subcommittee members empathized with the physicians. Representatives, including Representative Brad Wenstrup (R-OH) emphasized prevention as crucial for cost savings in value-based care and called for better engagement from the Center for Medicare and Medicaid Innovation (CMMI) to support ACO participation, particularly in rural areas.

To watch the hearing, CLICK HERE. 

To read more, CLICK HERE.

Medicare Cutting Price of 64 Drugs That Outpaced Inflation

The Biden Administration on June 26 announced that Medicare enrollees will pay less for 64 prescription drugs from July through the end of September because drug companies raised prices faster than the rate of inflation.

The list includes Bristol Myers Squibb’s Abecma, a cell therapy for multiple myeloma, Pfizer’s Adectris, a targeted cancer treatment for certain lymphomas, and Pfizer’s Padcev, a targeted cancer treatment for advanced bladder cancer. Officials estimated that more than 750,000 people with Medicare annually use these drugs.

The announcement comes as a new analysis released by the Milliman Institute and commissioned by the Pharmaceutical Research and Manufacturers of America (PhRMA) found the new Medicare Part D drug price negotiation program could raise out-of-pocket costs in 2026 for 3.5 million seniors. Specifically, the report found that drug price negotiation in Medicare will increase out-of-pocket costs by 12% annually for beneficiaries who use the selected drugs. For beneficiaries with low incomes, this number more than doubles to 27%.

To read more about the Biden Administration’s announcement, CLICK HERE.

To read the report, CLICK, HERE.