Health Policy Report – July 25, 2023

Southern Cancer Center Hosts Congressman Jerry Carl  

On Thursday, July 6, Southern Cancer Center (SCC) hosted Congressman Jerry Carl (AL-01) for a site visit at their Daphne location. Dr. Brian Heller, Executive Director Lauren Pettis led a tour of the clinic and spoke to Representative Carl about the cancer services being offered in the southern Alabama region, as well as issues impacting community cancer care, such as challenges from pharmacy benefit managers and the payment disparity between hospital outpatient departments and physician offices. 

Congressman Carl is a member of the House Appropriations and Natural Resources Committees. The Network and SCC look forward to working with the Congressman and his staff on these important issues. 

To learn more, CLICK HERE.  
 

CMS Releases Proposed Physician Fee Schedule; OPPS Rules 

The Centers for Medicare & Medicaid Services (CMS) on Thursday, July 13, issued the CY 2024 Medicare Physician Fee Schedule (PFS) and Quality Payment Program (QPP) proposed rule, in addition to the Outpatient Prospective Payment (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule.  

In the Medicare Physician Fee Schedule proposed rule, CMS proposed a conversion factor of $32.75, a decrease of $1.14 (or 3.34%) from the CY 2023 PFS conversion factor. The conversion factor is the multiplier that Medicare applies to relative value units (RVUs) to calculate reimbursement for services or procedures under Medicare’s fee-for-service system. 

In response, provider groups expressed concerns over the decrease in physician payments, noting that the cuts exacerbate instability in the healthcare system. The American Society for Radiation Oncology (ASTRO), expressed concern with proposed cuts to radiation oncologists and radiation therapy centers. “ASTRO is disappointed that CMS once again undervalues the impact of radiation oncology and intends to cut reimbursement by an additional 2% in 2024 for this essential cornerstone of cancer care,” Geraldine Jacobson, MD, MPH, chair of the ASTRO board of directors, said in a statement.  

Douglas White, MD, PhD, president of the American College of Rheumatology, said, “While the ACR appreciates CMS’ continued recognition of the value of complex care provided by rheumatologists and other cognitive care specialists by continuing to operationalize the Evaluation and Management (E/M) coding changes, we are gravely concerned that the proposed rule’s physician payment cuts contained in CMS’ conversion factor would add to physicians’ uncertainty about their continued ability to provide the highest quality of care to Medicare patients.”  

The American Medical Association (AMA) called on Congress to find a long-term solution, “The proposed Medicare physician payment schedule released today is a critical reminder that patients and physicians desperately need Congress to develop a permanent solution that addresses the financial instability and threatens access to care,” Jesse M. Ehrenfeld, M.D., M.P.H., President of the AMA, said in a statement.  

CMS also unveiled several new services that would be covered under the fee schedule, including coverage of some dental services for cancer patients and payment for Principal Illness Navigation services to help patients navigate cancer treatment and treatment for other serious illnesses.  

Meanwhile, in the Outpatient Prospective Payments (OPPS) proposed rule, CMS proposed to increase Medicare outpatient payments by 2.8% next year. This increase would also include a proposed 3.0% market basket update, offset by a 0.2% cut for productivity. Notably, the OPPS rule seeks to implement new enforcement measures to ensure compliance with hospital transparency requirements. 

Healthcare stakeholders can comment on the proposed rules through September 11.  

To read the PFS/QPP proposed rule, CLICK HERE. 

To read The Network’s overview of the PFS/QPP proposed rule, CLICK HERE. 

To read more about the PFS/QPP proposed rule, CLICK HERE. 

To read the OPPS/ASC proposed rule, CLICK HERE.  

Senate Committee on Finance Seeks to Advance Modernizing and Ensuring PBM Accountability Act 

The Senate Committee on Finance has developed a new plan to address middlemen in the pharmacy drug payment system. The bipartisan draft bill, entitled the Modernizing and Ensuring PBM Accountability (MEPA) Act, was authored by Senate Finance Committee Chair Ron Wyden (D-OR) and includes several provisions to regulate pharmacy benefit managers (PBMs).  

Specifically, the draft legislation aims to delink PBMs’ income from prescription drug prices, requires the HHS Office of Inspector General (OIG) to review PBM compensation to ensure fair market value, requires Medicare Advantage and Part D plans to institute standardized pharmacy performance measures, and prevents the use of spread pricing in Medicaid, among other objectives.  
 

In a letter, Senators Wyden and Crapo urged the Congressional Budget Office (CBO) to provide cost information on the draft bill before the committee is set to mark up the legislation, on July 26. For those provisions CBO cannot develop estimates for before the markup, the committee leaders ask for budgetary feedback by the end of August. 

To read a description of the MEPA Act, CLICK HERE. 
 

To read a Section-by-Section analysis of the MEPA Act, CLICK HERE. 

House Committee on Education and Workforce Advances Hospital, PBM Transparency Bills 

The House Education and Workforce Committee approved and advanced four bills aimed at increasing transparency into pharmacy benefit managers (PBMs) and hospitals on Wednesday, July 12. One of the bills, the Transparency Billing Act, is focused on hospital transparency and requires hospitals and off-campus outpatient sites to implement billing requirements such as health identifiers for the department where a service was provided.  

The other three bills included in the markup, the Transparency in Coverage Act of 2023, the Hidden Fee Disclosure Act, and the Health DATA Act, seek to improve price transparency for prescription drugs and medical services by requiring PBMs and third-party administrators to share compensation data with health plan fiduciaries.  

Lawmakers unanimously approved the Transparency in Billing Act of 2023, while all but one member voted to approve the Transparency in Coverage Act of 2023, Health DATA Act of 2023 and Hidden Fee Disclosure Act of 2023. 

This marks the second round of bipartisan legislation of its kind to come out of a House Committee this Congress. In May, the House Energy and Commerce Committee unanimously passed the Promoting Access to Treatments and Increasing Extremely Needed Transparency (PATIENT) Act of 2023, which would require PBMs to provide annual reports to employer clients on prescription drug spending and out-of-pocket expenses, among other requirements.  

To watch the markup or read the bills, CLICK HERE.  

House Energy and Commerce Subcommittee on Health Holds Hearing on Innovation in Medicare 

On Tuesday, July 18th, the House Energy and Commerce Subcommittee on Health held a hearing on how to improve Medicare coverage policies to encourage innovation and expand patient access to care.  

During the hearing, lawmakers highlighted how investment in novel therapies and diagnostic tools can lead to improved patient outcomes and health care savings. In her opening statement, House Energy and Commerce Committee Chair Cathy McMorris Rodgers (R-WA) expressed concern that excessive regulation will deter the development of innovative products.  

“As such, I remain extremely concerned about the impact of the so-called ‘Inflation Reduction Act’ price controls on innovation. I hope that Democrats heed the warnings of outside experts—who see lost innovation happening in real-time—and work with us to mitigate the damage before it is too late,” Rodgers explained.  

Witnesses included representatives from PAVmed, the American Academy of Neurology, and the Society of Thoracic Surgeons, among other organizations. In his testimony, Dr. Lishan Aklog, Chairman and Chief Executive Officer at PAVmed, highlighted how innovative screening, precision oncology, and surveillance diagnostic tests are revolutionizing cancer care. Dr. Aklog also called attention to key concerns with the Transitional Coverage of Emerging Technologies (TCET) proposed rule and urged Congress and CMS to ensure that the approval process for diagnostics is streamlined and predictable.  

To watch the hearing and view witness testimony, CLICK HERE.