Dec 19, 2016
Washington Healthcare Update
This Week: Congress has adjourned…The administration may release a few more regulations between now and the end of the year…Congressional staff have turned to looking
ahead to next year and how the Affordable Care Act will be repealed, and what the replacement and transition might be.
*In lieu of a newsletter on Monday the 26th, we will be putting out an early issue this week that focuses on what is next in Congress. The newsletter
will resume normal scheduling on January 9th.*
The House has adjourned for the holidays.
The Senate has adjourned for the holidays.
4. State Activities
5. Regulations Open for Comment
The House has adjourned for the holidays.
The Senate has adjourned for the holidays.
Sen. Grassley Urges Trump to Increase Importation of Drugs
On Dec 13, Sen. Charles Grassley (R-IA) urged President-elect Donald Trump to use agency authority to increase the importation of drugs from other
countries to help bring down the cost of drugs in the United States. He also suggested the Centers for Medicare and Medicaid Services (CMS) and the Food
and Drug Administration (FDA) could do more to help control drug prices. Grassley also said the Federal Trade Commission (FTC) needs to step up its
scrutiny of the pharmaceutical market.
Grassley noted Trump’s recent discussion with Time, in which the president-elect said he was going to bring down drug prices. In his letter,
Grassley said he shares those concerns, adding that a “lack of drug options in the marketplace, drug company anti-competitive behavior, regulatory backlogs
at the Food and Drug Administration (FDA), inefficient and ineffective government bureaucracies, and poor corporate decisions have all contributed to the
He cited Mylan’s EpiPen, Turing Pharmaceuticals’ AIDS drug Daraprim and Valeant Pharmaceuticals’ heart drug Isuprel as examples of extreme price spikes.
EpiPen’s 400 percent increase, from $52 to $600 since 2007, drew widespread consumer frustration. Grassley, who chairs the Senate Judiciary Committee, is
looking into Mylan’s classification of EpiPen as a generic, which cost Medicaid hundreds of millions of dollars in rebates.
Grassley asked the incoming administration to work with lawmakers on legislation to address anti-competitive behavior and reduce regulatory burdens.
Grassley also asked Trump to cooperate more fully with congressional requests than has been the case with the Obama administration, and noted that CMS and
the Justice Department would not testify at a hearing on Mylan and EpiPens that Grassley had planned.
Finance Republicans Seek Input on Future of Medicaid in Letter to Republican Governors Association
In a Dec. 13 letter,
Senate Finance Committee Republicans requested input from Republican governors on how to provide states with the flexibility to design and operate
innovative Medicaid programs in a fiscally responsible way. The letter, led by Chairman Orrin Hatch (R-UT), was sent to the Republican Governors
Association, and announced the committee will convene a roundtable discussion in January 2017 with state governors on the future of the Medicaid program.
“Even before the most recent expansion resulting from the Affordable Care Act (ACA), the Medicaid program was plagued by quality issues, states were
stymied in their attempts to utilize innovative solutions to improve patient care, and both federal and state Medicaid spending was growing at
unprecedented, and unsustainable levels,” the senators wrote. “We now find ourselves uniquely positioned to repeal the ACA, which was rife with failures
and the broken promise of lowering health care costs for the American people, and advance alternatives to it. … In addition, we recognize that we have the
opportunity to reflect on flexibilities that states have gained in recent years as well as the factors that inhibit states from pursuing innovations and
responding to the unique needs of their Medicaid beneficiaries. To that end, we will convene a small roundtable of Governors in January 17, to begin the
important dialogue regarding the future of the Medicaid program.”
The letter was signed by Senate Finance Committee Chairman Orrin Hatch (UT) and Senators Chuck Grassley (IA), Mike Crapo (ID), Pat Roberts (KS), Mike Enzi
(WY), John Cornyn (TX), John Thune (SD), Richard Burr (NC), Johnny Isakson (GA), Rob Portman (OH), Patrick Toomey (PA), Dan Coats (IN), Dean Heller (NV)
and Tim Scott (SC).
CMS Finalizes 2018 Obamacare Rules
On Dec. 16, CMS released the final 2018 notice of benefit and payment parameters, a major regulation that sets policy for the health care law’s exchanges
and other insurance programs.
The 465-page rule outlines changes to the ACA risk adjustment
model, standardized plan benefits and special enrollment periods among other topics.
For more information, click here.
CMS Drops Medicare Part B Proposal
The Obama administration has decided to drop its controversial test of new ways of paying for often costly drugs in Medicare Part B. The proposal, aimed at
reducing drug spending, spurred a heavy lobbying campaign against it, and sharp criticism from Congress.
The Part B drugs are administered by physicians and include costly medications for cancer and other diseases.
CMS Unveils New Quality Sites for Rehab Facilities, Long-Term Care Hospitals
On Dec. 14, CMS unveiled new Compare websites for both Inpatient Rehabilitation Facilities (IRFs) and Long-Term Care Hospitals. The new websites
will allow the public to compare metrics for more than 1,100 rehab facilities and 420 long-term care hospitals across the country. Measures that will be
reported on the websites relate to patient pressure ulcers and unplanned readmissions within 30 days of discharge.
For more information, click here.
Signup Period for Health Insurance Extended Through Dec. 19
The deadline to sign up for Obamacare coverage starting Jan. 1 has been extended for four days, until Dec. 19, amid high volume on the HealthCare.gov
website and the call center. Nearly 1 million people have left contact information to hold a place in the signup line, HealthCare.gov CEO Kevin Counihan
HHS Finalizes Rule to Protect Abortion Providers From State Defunding
On Dec. 14, the Obama finalized a rule on the Title X program that is designed to shield abortion providers against state defunding efforts. The regulation
would ban grant recipients from prohibiting family-planning providers if the basis for those decisions is not related to their ability to administer
services. The Title X program provides funding for a broad array of family planning services, including STD screening and treatment, but funding is not
used to pay for abortions.
According to HHS, 13 states since 2011 have taken actions to restrict participation by family planning providers in Title X because they provide abortions.
Planned Parenthood has often been the subject of defunding actions at the state level and in Congress.
However, abortion rights supporters acknowledged the final rule may be short-lived. Republican sources have already said the incoming Trump administration
can quickly undo this rule. Republican lawmakers next year are also expected to act quickly to cut off Planned Parenthood’s federal funding.
CMS Announces New Medicare-Medicaid ACO Model
On Dec. 15, the Centers for Medicare and Medicaid Services (CMS) announced the Medicare-Medicaid Accountable Care Organization (ACO) Model, a new
initiative designed to improve the quality of care and lower costs for beneficiaries who are dually eligible for Medicare and Medicaid. Through the model,
CMS intends to partner with interested states to offer ACOs the opportunity to take on accountability for both Medicare and Medicaid costs and quality for
In current Medicare ACO initiatives, beneficiaries who are Medicare-Medicaid enrollees may be attributed to ACOs. However, Medicare ACOs often do not have
financial accountability for the Medicaid expenditures for those beneficiaries. The Medicare-Medicaid ACO Model will allow Medicare Shared Savings Program
ACOs to take on accountability for the quality of care and both Medicare and Medicaid costs for Medicare-Medicaid enrollees.
CMS is accepting letters of intent from states that wish to work with CMS to design certain state-specific elements of the model. The model is open to all
states and the District of Columbia that have a sufficient number of Medicare-Medicaid enrollees in fee-for-service Medicare and Medicaid. CMS will enter
into participation agreements with up to six states with preference given to states with low Medicare ACO saturation. Once a state is approved to
participate in the model, a request for application will be released to ACOs and health care providers in that state.
For more information on the Medicare-Medicaid ACO Model, including a fact sheet, click here.
OASIS-C2 Approved by OMB for Home Health Quality Reporting Program
On Dec. 9, CMS received approval for the OASIS-C2 form, developed to accommodate new data being collected for the Home Health Quality Reporting Program in
support of the Improving Medicare Post-Acute Care Transformation Act (IMPACT Act). Effective Jan. 1, 2017, HHA providers and vendors will begin using the
OASIS-C2 in submitting assessments.
The guidance manual for OASIS-C2 is available here.
CMS Releases Its Person and Family Engagement Strategy
On Dec. 13, CMS released its Person and Family Engagement Strategy, one of the six goals outlined in the
CMS Quality Strategy
. The goal of the PFE Strategy is to create a new health care system that proactively engages people and caregivers in the definition, design and delivery
of their care.
The PFE Strategy will serve as a guide for the implementation of person and family engagement principles and strategies throughout CMS programs. This
strategy will expand the awareness and practice of person and family engagement by providing the following goals and objectives:
Actively encourage person and family engagement along the continuum of care within the broader context of health and well-being in the communities in
which people live.
Promote tools and strategies that reflect person and/or family values and preferences and enable them to actively engage in directing and self-managing
Create an environment where persons and their families work in partnership with their health care providers to develop their health and wellness goals
informed by sound evidence and aligned with their values and preferences.
Develop meaningful measures and tools aimed at improving the experience and outcomes of care for persons, caregivers and families. Also, identify
person and family engagement best practices and techniques in the field that are ready for widespread scaling and national integration.
For more information,
CMS Releases Interim Final Rule for Medicaid Dialysis Facilities
On Dec. 13, CMS released an
interim final rule requiring new disclosures for Medicare dialysis facilities that help
patients pay their premiums either directly or through a nonprofit charity or other third-party payer. CMS also announced it will pilot its pre-enrollment
verification system for special enrollment periods in all federally facilitated marketplace (FFM) states and counties starting in June 2017.
Fifty percent of new applicants will be randomly selected for the pilot, which will include all special enrollment categories. Applicants in the
pilot—which was first announced in September—will still be able to apply and select a plan, but their enrollment will be pended until the consumer submits
documentation proving eligibility. Applicants will have 30 days to provide the information. Once the document has been provided, the FFM will send the
application to the issuer, and coverage can begin once payment is received. CMS will train navigators and other enrollment assisters as well as agents and
brokers on how to help consumers, and will add instructions to HealthCare.gov.
CMS plans to evaluate the impact of pre-enrollment verification on the risk pool using data on 2017 claims that will become available in the spring of
2018, and will also look at how the pilot affects enrollment and other metrics on an ongoing basis.
CMS Releases Final Medicare Outpatient Observation Notice
On Dec. 9, CMS
posted the final Medicare Outpatient
Observation Notice after withdrawing a notice the agency said was posted prematurely earlier in the week.
The final notice, required under the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act, is a standard form that hospitals
and critical access hospitals must provide to beneficiaries who receive observation services to let them know they are receiving outpatient care and have
not been admitted to the hospital. The final notice also lays out the potential consequences for beneficiaries of receiving outpatient care.
Hospitals have 90 days to implement the new notice and must provide it to beneficiaries under observation starting March 8.
Former Pharma Executives Charged in Price-Fixing Case
The Justice Department has charged two former senior executives with Heritage Pharmaceuticals for their roles in alleged conspiracies to fix prices for
certain generic drugs. Former company CEO Jeffrey Glaze and Jason Malek, the company’s former president, were also accused of rigging bids and allocating
customers for an antibiotic and a diabetes drug. The company ran its antibiotic scheme from as early as April 2013 until at least December 2015 and fixed
prices for the diabetes drug between April 2014 and December 2015, DOJ said.
Attorneys General to Sue Heritage for Collusion in Generic Market
Nearly two dozen state attorneys general have named New Jersey-based Heritage Pharmaceuticals and other companies in a lawsuit accusing them of conspiring
to increase generic drug prices.
The officials, including New York Attorney General Eric Schneiderman, accuse the companies of committing significant harm to the nation’s health care
system by artificially increasing the price for the antibiotic doxycycline hyclate and glyburide, an oral diabetes medication, according to a complaint
filed under seal in U.S. District Court in Connecticut.
The suit also accuses Aurobindo Pharma USA, Inc.; Citron Pharma, LLC; Mayne Pharma (USA), Inc.; Mylan Pharmaceuticals, Inc.; and Teva Pharmaceuticals USA,
Inc., of colluding with their competitors at “industry dinners,” “girls’ nights out,” lunches and parties, and through numerous and frequent telephone
calls, emails and text messages.
Fearing that prosecutors might one day catch on, many of these communications were done in person or via text to avoid creating a record. Heritage is
accused of being the ringleader, according to the court filings.
The U.S Justice Department on Wednesday charged two Heritage executives with conspiring to fix prices on generic drugs. Jeffrey Glazer, a former chief
executive officer of Heritage, and Jason Malek, an ex-president, are preparing to plead guilty and cooperate with investigators.
The criminal charges and the civil suit stem from a sweeping two-year investigation into the pricing of generic drugs. The investigation began in
Connecticut. Aside from Schneiderman, the attorneys general participating in the suit are from Connecticut, Delaware, Florida, Hawaii, Idaho, Iowa, Kansas,
Kentucky, Louisiana, Maine, Maryland, Massachusetts, Minnesota, Nevada, North Dakota, Ohio, Pennsylvania, Virginia and Washington.
Read the complaint
Supreme Court Declines to Hear Apotex v. Amgen
On Dec. 12, the U.S. Supreme Court declined to hear a challenge to an
appeals court ruling that effectively gave brand drugmakers an additional six months of marketing protection from inexpensive biosimilars.
Apotex had asked the high court to reverse the Federal Circuit’s July ruling that the company had to wait until it received FDA approval of its biosimilar
to Amgen’s Neulasta before it could give Amgen the required 180 days’ notice of its intent to launch the copycat drug. Apotex had argued it could file that notice earlier so that it could
launch the drug immediately following FDA’s approval.
However, the Supreme Court could still weigh in on the issue, which will affect how quickly cheaper versions of some of the most expensive drugs could
reach patients. The Supreme Court must still decide whether to take up Sandoz v. Amgen. In that case, Sandoz asked the Supreme Court to overturn an
identical decision from the Federal Circuit.
solicitor general weighed in and said the high court should take up Sandoz v. Amgen and overturn the Federal
Circuit’s decision that the 180-day notice must come after FDA approves the biosimilar.
Amgen also asked the Supreme Court to reverse the appeals court’s decision that biosimilar makers do not have to engage in a patent-sharing process with
branded biologic makers. The solicitor general said that part of the Sandoz v. Amgen ruling should stand.
4. State Activities
Arkansas: CMS Approves Governor’s Proposed Medicaid Expansion Changes
On Dec. 7, Arkansas Gov. Asa Hutchinson said that the Obama administration has approved most of his proposed changes to the state’s Medicaid expansion program. Though CMS did not grant all of the governor’s more conservative requests for the program, it will allow the state to charge premiums and
require certain recipients to look for a job. CMS did not approve Hutchinson’s proposal to provide assistance to all businesses that provide health
insurance to their workers.
California: California Exchange Extends Enrollment Deadline
California’s Obamacare exchange is pushing back the deadline to enroll in coverage starting in the new year, citing an increase in demand. The new signup
deadline for Jan. 1 coverage is midnight on Dec. 17, two days later than the original Dec. 15 deadline. State exchange officials said more than 25,000 new
enrollees chose plans on Monday and Tuesday, nearly double the 13,000 people who selected plans during the same dates last year.
More than 153,000 new customers have selected Obamacare plans in California since enrollment began six weeks ago. Those figures are not included in CMS
enrollment updates for HealthCare.gov states. In the 39 states using the federal enrollment website, more than 4 million people selected plans between Nov.
1 and Dec. 10. Most states set Dec. 15 as the deadline to enroll in coverage starting Jan. 1, although some did not. For instance, the deadline in
Massachusetts is Dec. 23.
In other news, California alone accounts for nearly a third of the adults who could lose Medicaid coverage if the ACA is repealed. The Kaiser Family
Foundation (KFF) analysis,
which relies on Medicaid enrollment by state in 2015, shows nearly 3.5 million California adults have become newly insured through the expansion effort.
That is a significant portion of the statewide Medi-Cal population of more than 13 million, and far more than any other state.
California: Sen. Hernandez Reintroduces Drug Pricing Legislation
California Sen. Ed Hernandez, who chairs the Senate Committee on Health, recharged his fight against rising drug prices by reintroducing legislation for
the 2017-18 session that would require pharmaceutical companies to provide advance notification of their price increases. The Democrat pulled his previous
effort, S.B. 1010, from consideration in August after
amendments had watered down the legislation too much.
The details of the new version, S.B. 17, have not been hammered out, but the previous version would have required drugmakers to warn health insurers and
state programs in writing if they planned to raise drug prices by 10 percent or more, or if a drug was going to cost more than $10,000 for an annual course
Louisiana: State Prisons to Enroll Ex-Inmates in Medicaid Beginning Jan. 1
In January, as part of the state’s Medicaid expansion program, seven state-owned prisons will begin automatically enrolling prisoners in Medicaid on the
day they are released. Implementation of the enrollment program will start roughly six months after expansion took effect under Democratic Gov. John Bel
Edwards. Louisiana is among a handful of states—including Ohio and Massachusetts—that have inmate Medicaid enrollment programs in place. The Louisiana
Department of Health said it will also identify high-need inmates and assign them case managers to make sure they receive sufficient medical or
Oregon: Gov. Brown Trying to Secure Medicaid Waiver Before Trump Takes Office
Oregon Gov. Kate Brown is attempting to get CMS’s approval for a Medicaid waiver that would extend the state’s coordinated care organizations program
before Trump takes office. The waiver would extend Oregon’s system for coordinated care organizations, which is scheduled to sunset next year.
Vermont: Vermont Receives Start-up Funding for All-Payer Waiver
On Dec. 15, CMS issued a notice officially outlining the amount of start-up Medicare funding Vermont will receive for its all-payer waiver, which was
approved in October and will begin in January. The state will get $9.5 million to help achieve the health outcomes and financial goals under the model. The
waiver aims to contain health care cost growth across Medicare, Medicaid and private insurance. Vermont will seek to limit annual cost growth to 3.5
percent per capita.
To read the CMS notice, click here.
Washington: Letter Urges Republican Lawmakers Against Dismantling Obamacare
Washington state Gov. Jay Inslee and insurance commissioner Mike Kreidler are urging Republican lawmakers not to pursue efforts to dismantle Obamacare or
make cuts to Medicaid and Medicare. In a letter sent to
House Majority Leader Kevin McCarthy, Inslee and Kreidler say that “it would be a moral outrage to repeal the health care policies that are so beneficial
to millions of Washingtonians without providing an alternative system to make sure all our families continue to have access to affordable care.” McCarthy
recently requested feedback from state officials on Congress’s Obamacare repeal efforts.
5. Regulations Open for Comment
CMS Releases Proposed Rule on Fire Safety Requirements for Dialysis Facilities
On Nov. 3, CMS announced a proposed rule to update Medicare
fire protection guidelines for certain dialysis facilities to ensure that patients are protected from fire while receiving treatment in those facilities.
The new proposed guidelines apply to all dialysis facilities that do not provide one or more exits at grade level from the treatment area level. CMS
previously updated the requirements to include dialysis facilities located adjacent to industrial high-hazard occupancies; however, as dialysis facilities
are not permitted to be located in such areas, the requirement specific to such geographically located facilities will be removed.
The rule adopts, for certain dialysis facilities, updated provisions of the National Fire Protection Association’s (NFPA) 2012 edition of the Life Safety
Code (LSC), as well as provisions of the NFPA’s 2012 edition of the Health Care Facilities Code in order to bring CMS’s requirements more up to date with
current fire safety standards. The LSC is a compilation of fire safety requirements for new and existing buildings, and is updated every three years.
The proposed rule addresses construction, protection and operational features of dialysis facilities to provide safety for Medicare beneficiaries from fire
and smoke. Some of the main requirements laid out in the rule include:
Doors to hazardous areas must be self-closing or must close automatically.
Alcohol-based hand rub dispensers now may be placed in corridors to allow for easier access.
A fire watch or building evacuation is required if the sprinkler system is out of service for more than 10 hours.
Currently, CMS is using the 2000 edition of the LSC to survey dialysis facilities for health and safety compliance. With this proposed rule, CMS is
adopting provisions of the 2012 edition of the LSC and provisions of the 2012 edition of the Health Care Facilities Code, to bring CMS’s requirements more
up to date, and align dialysis facility fire safety requirements with the codes CMS uses to survey other healthcare facilities.
CMS Releases Proposed Notice With Changes to Medicaid National Drug Rebate Agreement
On Nov. 7, CMS issued a proposed notice announcing changes that would be made to the Medicaid National Drug Rebate Agreement (NDRA) for use by the
Secretary of the Department of Health and Human Services and manufacturers under the Medicaid Drug Rebate Program. The NDRA is being updated to incorporate
legislative and regulatory changes that have occurred since the agreement was published in February 1991, as well as to make editorial and structural
revisions, such as references to the updated Office of Management and Budget (OMB)-approved data collection forms and electronic data reporting. There is a
90-day comment period for this proposed notice that will end on Feb. 7, 2017.
For more information, click here.
Comments Due on IMPACT Act Cross-Setting Quality Measure
On Nov. 4, CMS announced that public comments are due Nov. 17 on a cross-setting post-acute care measure under the Improving Medicare Post-Acute Care
Transformation Act of 2014 (IMPACT Act) to further develop and refine
the percentage of residents or patients with pressure ulcers that are new or worsened and language modifications being explored with the term “Pressure
Injury.” CMS seeks feedback on potential updates to measure specifications and items used to calculate the quality measure. Visit the Public Comment webpage
for more information.
CMS Issues Interim Final Rule to Delay Inclusion of U.S. Territories in Definitions of States and United States
CMS published the Covered Outpatient Drug Final Rule with Comment Period in the Federal Register on Feb. 1, 2016. As part of that
final rule with comment, CMS amended the regulatory definitions of “States” and “United States” to include the U.S. territories (American Samoa, the
Northern Mariana Islands, Guam, the Commonwealth of Puerto Rico and the U.S. Virgin Islands) beginning April 1, 2017. However, the agency said those
territories could not be ready to implement the program by this date.
Therefore, CMS issued an Interim Final Rule with comment period that delays the inclusion of the territories in the definitions of “States” and “United
States” from April 1, 2017, until April 1, 2020, which is effective on Nov. 15, 2016. There is a 60-day comment period that will end on Jan. 17, 2017.
For more information visit theCovered Outpatient Drugs Policy page on Medicaid.gov.
CMS Issues Proposed Rule for Medicaid Managed Care Plans
CMS has issued a new proposed rule detailing regulations for pass-through payments to providers from Medicaid managed care plans. The guidance builds on
the Medicaid managed care rule finalized by the Obama administration in May.
Read the proposed rule
here. It is scheduled to be
in the Federal Register on Nov. 22.
CBO Releases New Volume of Deficit Reduction Options
The Congressional Budget Office (CBO) recently laid out several ACA-related policy changes in its new volume of deficit reduction options. The policy that would save the most, or more than $1.2 trillion
from 2017 through 2026, is a repeal of all the ACA coverage provisions, which includes the Medicaid expansion, ACA subsidies, employer and individual
mandate, Cadillac and other taxes, and market regulations such as coverage of pre-existing conditions, benefits and age rating.
CBO projects the repeal would increase the number of uninsured Americans by about 23 million over the same time frame. CBO separately looked at the impact
of repealing the individual mandate, and found it would reduce the federal deficit by $416 billion through 2026. Eliminating the mandate would also
increase the number of uninsured Americans by about 17 million, and would increase premiums in the individual market by about 20 percent.
CBO and the Joint Committee on Taxation also looked at what would happen if Congress stripped the 40 percent tax on high-cost plans, and instead
implemented limits to the tax treatment of employer-sponsored coverage. The GOP’s Better Way plan as well as HHS Secretary-nominee Tom Price’s (R-GA)
health reform proposal and other GOP plans all propose a similar policy, but will face strong opposition from employer and labor groups.
CBO Outlines Choices, Challenges for Capping Medicaid Spending
The Congressional Budget Office (CBO) outlined choices Republicans have to cap Medicaid spending and said the potential 10-year deficit reductions range
from $370 billion to $680 billion, depending on the design of the policy.
CBO estimates that caps on spending per enrollee, with spending growth based on the Consumer Price Index for urban consumers plus 1 percent, would save
$370 billion over a decade, while using block grants that peg inflation to the same growth rate would cut spending by $486 billion. If the government used
block grants and limited spending increases to the CPI-U, the deficit reduction would equal $680 billion.
Republicans in Congress and the incoming administration say they want to make changes to Medicaid that reduce federal spending, but they have yet to work
out the details. Some had expected House Republicans’ Medicaid task force to recommend legislative changes to Medicaid, but the task force chair recently
said the group will not make recommendations. Seven states have stopped plans to expand Medicaid while Republicans work out program reforms.
Short of legislative changes to allow block grants or per-capita caps, the Trump administration could let states cut Medicaid eligibility and benefits or
make trade-offs between exchange and Medicaid coverage.
CBO’s biannual report on options for reducing the deficit lists the main policy questions that
Republicans would need to answer if they cap the federal share of Medicaid financing.
GAO Report Identifies Challenges for Small, Rural Practices in Value-Based Payment Models
Based on a review of literature and interviews with 38 stakeholders, GAO identified challenges faced by small and rural physician practices when
participating in Medicare’s new payment models. These models, known as value-based payment models, are intended to reward health care providers for
resource use and quality, rather than volume, of services. The challenges identified are in five key topic areas:
Financial resources and risk management
Health IT and data
Population health management care delivery
Quality and efficiency performance measurement and reporting
Effects of model participation and managing compliance with requirements
For example, GAO found that some of these practices have small budgets, making it harder for them to invest in the training and technology they need to
participate. GAO also found that not all of these practices have access to organizations that can help them share staff and IT systems.
For the full report, click here.
GAO Report Finds More Action Necessary on Prescription Drug Labels for Blind or Visually Impaired Individuals
Over 7 million Americans are blind or visually impaired and may have trouble reading the labels on prescription drug containers. In a new report on
prescription drug labels, GAO found that some pharmacies can provide accessible labels in audible, braille and large print formats but dispense very few
prescriptions with these labels. GAO also found that the National Council on Disability has conducted limited activities to inform pharmacies and the
public about best practices for accessible prescription drug labeling. GAO recommended that NCD assign responsibility for conducting those activities, and
evaluate its efforts to raise awareness of best practices.
For the full report, click here.
GAO Report Finds Most States Not Meeting Newborn Screening Goals
Each year, more than 12,000 newborns are diagnosed with conditions that can cause severe disability or death if not treated quickly. To screen for such
conditions, health care providers collect blood samples from newborns and send them to labs for testing.
According to a new GAO report, states face barriers to timely screening—such as issues with sending samples to labs—that can delay treatment. Most states
had not yet met their goal to screen 95 percent of blood samples within seven days of birth by 2017, although some have improved screening time. For
example, one state expanded courier service so all rural hospitals can get their samples to the lab more quickly.
For the full report, click here.
GAO Tests Enrollment for the 2016 Special Enrollment Period
GAO was asked to test marketplace enrollment and verification controls for applicants attempting to obtain coverage during a special enrollment period
(SEP). A new report describes the results of GAO attempts to obtain subsidized qualified health-plan coverage during the 2016 SEP in the federal
marketplace and two selected state-based marketplaces—California and the District of Columbia.
To perform the undercover testing of enrollment verification, GAO submitted 12 new fictitious applications for subsidized health-insurance coverage outside
of the open enrollment period in 2016. GAO’s applications tested verifications related to a variety of SEP triggering events. The federal and state-based
marketplaces approved health-insurance coverage and subsidies for 9 of 12 of GAO’s fictitious applications.
GAO did not make any recommendations to HHS. For the full report, click here.
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Charlie Iovino, Vice
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