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Last Build Date: Wed, 26 Apr 2017 21:37:27 +0000


Health Policy’s Gordian Knot: Rethinking Cost Control

Wed, 26 Apr 2017 14:28:39 +0000

Medical spending has resumed its long-term rise. After several years of deceptive stability in the last, deep recession’s wake, health spending rose by 3.7 percentage points more than general inflation in 2014, then by 5.8 percentage points more in 2015, to a 17.8 percent share of the US economy. Not only does this spending rise threaten the United States’ fiscal stability and capacity to address other needs; it is undermining the promise of health care for all. To manage rising costs, insurers are hiking premiums, narrowing their networks, and raising deductibles and copayments, making purchase of coverage less appealing. Millions of Americans are thus eschewing subsidized coverage via the Affordable Care Act’s (ACA’s) insurance exchanges, choosing instead to pay the ACA’s tax penalty. And the skimpier coverage and scaled-back subsidies envisioned by congressional Republicans as an ACA replacement would add millions of people to the ranks of the uninsured. The central, intractable obstacle to long-term cost containment, we contend here, is the near impossibility of saying “no” to ever-more-expensive care that yields small marginal benefits. Public and private payers have made myriad unsuccessful attempts to surmount this barrier. We propose, instead, to circumvent it—through redirection of cost-control policy away from efforts to limit use of existing, low-benefit technologies and toward strategies for influencing the emergence of new technology. To this end, we urge: redesigning value-based payment to emphasize future rewards for tests and treatments that haven’t yet emerged, and varying the duration of intellectual-property protection so as to tie its rewards to therapeutic effectiveness. Why Don’t We Just Say ‘No’ Many factors influence health spending, including coverage expansion, the balance of bargaining power between payers and providers, and the aging of the United States’ population. But the persistent driving force behind rising medical spending is technological advance, fueled by health insurance’s promise of rich reward and unchecked by insistence that advances deliver clinical benefit worth their cost. Drug and device developers, clinical researchers, and their financial backers anticipate coverage for new tests and treatments with little concern for whether they add substantial therapeutic value, and they make research and development decisions accordingly. Once a new technology emerges, its developers are vested in pursuing its broad adoption. Hospitals, physicians, and others, in turn, commit to equipment and training that lock them into the new technology, even when the technology is merely a “me too” or marginal advance over existing clinical methods. Patients and their loved ones then come to expect the technology’s availability. The psychology of rescue makes it anguishing to say “no”—or to accept “no” as an answer—when care might save lives, however high its marginal cost. Medical ethics tightens this lock-in: Hundreds of years of Hippocratic tradition stand in the way of withholding care believed to do more good than harm. And both public and private payers risk charges of “rationing” if and when they push back. History underscores the difficulty of constraining access to existing, expensive technologies. Under both Republican and Democratic presidents since George H. W. Bush, the Centers for Medicare and Medicaid Services proposed, then backed away from, regulations that would make national coverage decisions under Medicare explicitly cost sensitive. Republican efforts to limit Medicare spending by reconceiving the program as a voucher scheme for purchase of private coverage have likewise been repeatedly stymied. Private insurers’ aggressive efforts in the 1990s to limit spending through tight administrative constraints on access to pricey treatments foundered in the face of the late 1990s consumer backlash against “managed care.” And the ACA’s misnamed “luxury tax” on high-cost health plans (really, a way to phase [...]

The MacArthur Amendment Language, Race In The Federal Exchange, And Risk Adjustment Coefficients

Wed, 26 Apr 2017 02:47:26 +0000

For a number of days negotiations have apparently been underway with respect to an amendment to the Republican American Health Care Act (AHCA) that has been proposed by Congressman Tom MacArthur (R-NJ). A summary of this amendment became available on April 20, 2017 and was analyzed here. On the evening of April 25, the actual language of the amendment became available. As described in the summary, the amendment would repeal the enigmatic language included in a March 23, 2017 amendment to the AHCA that would have allowed states, beginning in 2018, to define the essential health benefits for purposes of determining premium tax credits (but not for other purposes). In its place the amendment would allow states to apply for waivers to “encourage fair health insurance premiums.” The Types Of Waivers Available States could apply for three different kinds of waivers. First, states could apply, for plan years beginning on or after January 1, 2018, waivers to set an age ratio “higher” than the 5 to 1 ratio established by the AHCA—or maybe the 3 to 1 ratio established by the Affordable Care Act. These higher rates would apply in the individual and small group markets. Presumably the section referenced in the MacArthur amendment is the provision of the ACA as amended by the AHCA, but the summary of the amendment released earlier said states could not set the ratio above 5 to 1. Unless “higher” means more favorable to older consumers, this amendment does not seem in accord with the summary. Moreover, although there has been a lot of discussion about whether 3 to 1 or 5 to 1, or something in between, is the appropriate age ratio, I do not recall arguments that it should be set above 5 to 1. This is pretty mysterious. There is nothing mysterious about the second type of waiver. States would be able, after January 1, 2020, to specify their own set of essential health benefits for all purposes in the individual and small group markets. As noted earlier, this does not only mean that states would be able to define what categories of benefits would have to be covered by insurers, but also the benefits—for example the kinds of drugs—that would have to be covered within each category. Since the ACA’s prohibitions of lifetime and annual limits and cap on out-of-pocket expenditures also only apply to essential health benefits, states granted a waiver would be able to define these protections as well. The changes to the lifetime and annual limits and to the out-of-pocket caps could potentially apply as well to large group and self-insured employer plans. The third type of waiver would allow states to permit insurers to engage in health status underwriting, but only under certain conditions. First, to obtain a waiver the state would have to operate a program under the AHCA’s patient and state stability fund to provide financial assistance to help high-risk individuals get coverage in the individual market, “provide incentives to appropriate entities to enter into arrangements with the state to help stabilize premiums” in the individual market (a reinsurance program), or participate in the recently added federal invisible high risk sharing program, which also essentially reinsures high cost cases. A state that implements one of these programs would be allowed, for any year beginning with plan year 2019 (or special enrollment periods beginning with plan year 2018) to permit insurers to impose health status underwriting on individuals who do not maintain continuous coverage (have a gap of at least 63 days in coverage in the preceding year), in lieu of the 30 percent of premium penalty provided by the AHCA. They could only do so for the duration of the enforcement period, which is generally of 12 months duration, not permanently. The provision does not actually require states to offer a high-risk pool through which individuals who are effectively excluded from coverage by very high health status underwriting could get coverage. A reinsurance program (which would be available in all states that [...]

Correcting Misconceptions About Invisible Risk-Sharing

Tue, 25 Apr 2017 15:11:18 +0000

On April 6, the House of Representatives added an amendment from Rep. Gary Palmer (AL) and Rep. David Schweikert (AZ) to the American Health Care Act (AHCA) before their recess. The amendment was drawn, in part, from the proposal in our previous Health Affairs Blog post. The proposal sparked a flood of media coverage, but many stories left much to be desired. Reporters and commentators repeatedly mischaracterized the program and some quoted individuals that clearly did not understand the mechanics of the program, which only deepened confusion. Some thoughtful discussions emerged that should influence the provision in any final bill. Our goal is to correct a few misconceptions and suggest a few changes that would improve such a program based on a comprehensive independent analysis conducted by actuarial firm Milliman. Goal of the Invisible Risk-Sharing Program The Invisible Risk-Sharing Program (IRSP) will stabilize the individual insurance market and lower premiums while concurrently providing guaranteed access to coverage and protecting those with pre-existing conditions. Different than a traditional high-risk pool, no one is declined coverage, enrollees with pre-existing health conditions get the same plans at the same lower price as a healthy individual, and those with pre-existing conditions are not segregated to higher cost and limited benefit high-risk pool plans. Several questions have been raised about IRSP and the amendment. We address a number below. Is There Enough Money Allocated? One issue that has been raised is that $15 billion allocated with the amendment may not be enough to fund the program through 2026. This would be true only if you assume states have no responsibility to contribute, that states will not find funding in the form of an assessment (the way Maine funded a large portion of their program), or that states will not use some of the other $115 billion allocated to the over the decade as they take over the program after 2020 as the amendment lays out. Milliman’s analysis of the most effective policy package to reduce premiums for the risk-sharing program carried a price tag at just over $3 billion per year. So at a minimum, the program could be fully federally funded for more than four years if the final bill reflects the model and before states would have to tap into the $115 billion Stability Fund or use other funding. To clear up any confusion about the devolution of such a program to states, the bill may benefit from a more explicit timeline to do so. Is This Program Too Complex For Insurers? The implementation of the Affordable Care Act (ACA) has been complex with a large amount of uncertainty, so we don’t believe this program is unduly complex. There are concerns that insurers may not want to participate as they have to prospectively cede individuals into the program and cede those individuals’ premiums to help pay for the risk sharing. While some insurers may be looking to game taxpayers and to do less work upfront, that’s not good for the program, patients, or the taxpayer. Of course, insurers will push to reduce their work and lobby for a straightforward taxpayer money transfer, but insurers gain with increased enrollment (up to 2 million according to Milliman depending on the program structure) and their losses are capped—but still there—for those with known pre-existing conditions or poor health at the time of enrollment. If the policy choice is to guarantee access to coverage but do so with the lowest premium rates for everyone and in the most cost-effective way for taxpayers, then that is the balance that invisible risk sharing provides—better and cheaper—for everyone. The IRSP is about directly subsidizing a policy choice — guaranteed access to those with pre-existing conditions. It is not about reducing insurers losses generally or providing general funding. Is Maine A Good Example To Predict A National Outcome? The risk-sharing program was modeled after a program in Maine that was passe[...]

Evidence on Payment Reform: Where Are The Gaps?

Tue, 25 Apr 2017 14:00:14 +0000

The US health care system is transforming how it pays for and delivers care. New payment models and benefit designs aim to promote and sustain improvements in health and care delivery, specifically focusing on better outcomes and lower costs. Supporting better payment policies is increasingly critical as rising costs affect the ability of individuals to afford coverage. However, the transition to new models is not easy. Published studies of payment reforms have shown mixed results, leaving providers, payers, purchasers, and patients uncertain about how to proceed. There is a strong consensus among health care stakeholders about the need for better evidence on the impact of payment reforms. Better evidence would give providers and the public more confidence in implementing payment and delivery reforms—and also knowing which ones to avoid. Evaluations can help stakeholders identify where to make necessary changes. In short, better evidence would ensure that we realize the promise of payment reforms to improve care and reduce costs. To accelerate the development of better evidence, the Duke-Margolis Center for Health Policy established the Payment Reform Evidence Hub, with support from the Laura and John Arnold Foundation and guidance from a multistakeholder expert working group. To support the Hub’s efforts, we built an inventory consisting of all the evaluations we could locate, 355 in total, of various payment reform initiatives implemented by commercial health plans, Medicare, Medicaid, and other state programs. The inventory has helped us assess the state of available evidence and identify gaps. What Specific Types Of Payment Reforms Need Better Evidence? We categorized the reports and results of payment reform evaluations using the categories of payment reforms developed by the Health Care Payment Learning and Action Network (LAN). LAN Category 1 is traditional fee-for-service (FFS) arrangements. The other LAN payment reform categories are: Category 2: Pay-for-performance initiatives, generally consisting of rewards or penalties built on top of the traditional FFS system (that is, FFS payment adjustments based on measures of quality or value). Category 3: Payment reforms based on a FFS infrastructure that includes some accountability for results at the level of a population of patients, generally either for episodes of care or for all services. These payments are divided into two subcategories. Category 3A includes accountable care organizations (ACOs) that share savings or losses based on quality and total spending performance for a population of patients on top of FFS payments but do not require any downside risk for the accountable providers. Category 3B payments include bundled payments for an episode of care with some downside risk, again in conjunction with FFS payments for the providers involved. Category 4: Population-based payments mainly tied to patients rather than services. This requires partial or full capitation with substantial adjustments for quality performance—a major change away from FFS. About 40 percent of evaluations of LAN Categories 2 – 4 address pay for performance and other Category 2 payments. About 60 percent focus on Category 3 and Category 4 payments. Of those, the plurality examine ACOs, a slightly smaller percentage focus on bundled payments or episode-based payments for procedures, and a very few look at Category 4 population-based payments not closely tied to FFS. This distribution is consistent with a 2016 LAN survey across a set of public and private payers. Figure 1. Summary of the Hub inventory of evaluations according to LAN payment category, with examples of each payment category shown in the right-hand column However, our findings raise questions about the overall rigor and diversity of the evidence presented in these studies. Of the private payer evaluations of Category 3 and 4 payments, 51 percent are “internal,” which meant they did not release details of how the refo[...]

A Good Deal For Eliminating Hepatitis C: Saving Money And Lives

Mon, 24 Apr 2017 15:00:54 +0000

The conundrum of hepatitis C is well known. The virus kills more than 20,000 Americans each year, more, according to Centers for Disease Control and Prevention, than the other 60 infectious causes of death combined. A cure is in hand, but is out of reach for many because it costs tens of thousands of dollars per patient. The problem is most acute in state Medicaid programs and prisons, where 700,000 people need treatment but only 20,000 a year will get it. The price controls some have asked for would make treatment affordable, but would also be likely to chill innovation in pharmaceutical companies, the very innovation that benefits society by producing such remarkable drugs. A recent consensus committee of the National Academies of Sciences, Engineering, and Medicine proposed a novel strategy to improve access to hepatitis C medicines. Their report recommends that the firms producing the hepatitis C treatments compete to license their patent to the federal government for use in neglected patients, such as Medicaid beneficiaries and prisoners. Such a deal would protect the innovator companies’ market share in the lucrative private markets, while allowing the government to save billions of taxpayer dollars and reach more poor patients. How Would The Deal Work? Every year roughly 20,000 Medicaid beneficiaries receive hepatitis C treatment. After the mandatory Medicaid discount, these medicines cost about $40,000 per patient. Thus, under the status quo over the next 12 years about 240,000 Medicaid patients will receive treatment, generating roughly $10 billion in revenues for manufacturers. Since these revenues are earned over a 12 year period their worth in today’s dollars is roughly $6.5 billion. Pharmaceutical firms should be indifferent between being paid $6.5 billion today rather than $10 billion over a 12-year period. Currently there are five pharmaceutical firms competing to provide hepatitis C treatment to patients. So the $6.5 billion in projected revenue in the Medicaid market would be split among these competitors, each expecting to earn about $ 1.3 billion. Therefore, if the government offered a deal to any one of the five firms to license their patent for Medicaid patients for $2 billion, they should jump at the offer. If the firm accepts the offer, they expect to gain $1 billion relative to the status quo. If they decline and one of their competitors accepts the offer, then they stand to lose all their Medicaid revenue as they would have to compete against a much cheaper generic. From a fiscal and financial perspective, both taxpayers and drug companies benefit. Under the status quo, taxpayers would foot the entire $10 billion bill for hepatitis treatment through state and federal taxes. With the deal, taxpayers only pay $2 billion to license the patent. Estimates of the production costs of these drugs suggest that the government would need another estimated $140 million for supplying the licensed product to about 700,000 patients. The overall savings to the government from this deal are in the billions of dollars. From a public health perspective, nearly half a million more patients will receive curative treatment, dramatically lowering the death toll from the disease. Increase in access to curative treatment will also forestall the spread of hepatitis by reducing the number of new infections. Overall this deal, combined with other measures, can help eliminate the scourge of hepatitis C. The deal achieves the dual goal of reducing costs and improving access to treatment while preserving incentives for innovation. It involves a voluntary transaction between a patent holder and the federal government, at a price agreeable to both parties. The voluntary nature of the process guarantees the drug company reasonable compensation — the patent holder always has the option to walk away from the transaction if the price is not right. In addition, the deal is limited to the least lucrative market segme[...]

The Payment Reform Landscape: For Employers, Keep Pushing Ahead

Fri, 21 Apr 2017 17:45:58 +0000

With all the tumult in Washington, D.C. surrounding health care reform, it is hard to know which reforms will be prioritized at the federal level and whether provider payment reform will still be a central focus. But in some corners of the health care Marketplace, efforts to implement payment reform continue, building on experimentation to better understand how to increase value. These efforts are coming from private employers, other large purchasers of health care, and the health plans that act as their agents. While employers are sure to be affected in many ways by changes to federal health care laws, much of the cost and quality conundrum that has troubled our health care system for decades can be influenced by ongoing payment reforms and benefit design efforts in the private sector. As of 2015, employer-sponsored insurance covered nearly 56 percent of the US population, or 147 million people. And employers will continue to cover more Americans than the Affordable Care Act’s 20 million no matter what happens in Washington over the next few years. Because they cover more people than Medicare and Medicaid combined, employers could have a great deal of power over health care system reforms. But they need to use it. Employers can leverage their influence through aligned sourcing, a term that we at Catalyst for Payment Reform use for speaking with one voice on priority issues when it comes to the buying of health care. If employers and other health care purchasers work together to demand change from health insurance companies, they can bring their purchasing power to bear on the issues that keep them awake at night. Here are the issues that many employers and other health care purchasers tell us should be prioritized in the coming year. Maternity Care For most purchasers, maternity care is a high cost and practiced by providers without sufficient adherence to evidence-based guidelines. According to the Centers for Disease Control and Prevention, cesarean deliveries remain persistently high at 32 percent of births, far above the goal of 10 percent that the World Health Organization says makes medical sense. Cesarean deliveries are not only more expensive than vaginal deliveries, but they lead to worse outcomes for mothers and babies. At the same time, the Leapfrog Group reports good news related to the drop in the rate of early elective deliveries, which occur when women by choice and without medical necessity deliver babies before they are full term. This rate has plummeted to less than 2 percent from 17 percent in 2010. A combination of public reporting efforts on these rates, quality improvement initiatives, and decisions by payers not to pay for them, has had a significant impact. Similar headway could be made in reducing the cesarean rate for low-risk births by changing how we pay health care providers for labor and delivery services. Purchasers can encourage health plans to change the relative amounts we pay for cesarean and vaginal deliveries so that it is not so relatively lucrative to deliver babies by cesarean compared to vaginal deliveries. Reforms to how health plans pay for deliveries can also make a difference. For example, the use of bundled payments can encourage providers to collaborate and provide care more efficiently. In addition, purchasers can push health plans to find ways to incorporate lower-cost, high-quality alternative providers into the mix, such as certified nurse midwives, laborists, and free-standing birth centers. Pharmacy Traditional strategies, such as formulary management, step therapy, and use of generics, continue to play a role in managing pharmacy costs but are inadequate to address the ever-rising costs of drugs. Despite recent news coverage and political attention focused on products such as Harvoni (medication used to treat hepatitis C) and EpiPens (epinephrine injection used to treat severe allergic reactions), the overall increase in drug co[...]

As MACRA Implementation Proceeds, Changes Are Needed

Fri, 21 Apr 2017 16:20:36 +0000

The Medicare Access and Chip Reauthorization Act (MACRA) is the product of four years of work that included input from multiple stakeholders and was signed into law on April 16, 2015, following broad bipartisan support in Congress. Implementation of MACRA began on January 1, 2017. The legislation, as originally conceived, had three fundamental goals. The first goal was to repeal the Sustainable Growth Rate (SGR) physician payment formula, a major cause of uncertainty and instability for more than a decade. The legislation did that. The second goal was to stabilize physician payments to give providers relief from the annual, and at times more frequent, threats of substantial cuts to their reimbursement. The legislation technically stabilized payments, although due to the modesty of payment updates, physicians are likely to see their inflation-adjusted income drop substantially over the next several years. The third and much more difficult goal was to move to a better, more stable payment system that wouldn’t have policy makers back at the table in a few years discussing the same issues. For most analysts, this means transitioning away from traditional fee-for-service (FFS) into what has become a catch-all term, “alternative payment models” (APMs). Fundamentally, MACRA attempts to achieve this transformation by making FFS increasing unattractive, while simultaneously developing and implementing APMs for providers to transition into. The fundamental infrastructure for the future Medicare physician payment system, according to MACRA’s Quality Payment Program, includes two payment options. The Merit-Based Incentive Payment System (MIPS) is a complex pay-for-performance system based on traditional FFS. The other option, participation in an Advanced APM, is in reality not currently an option for the majority of providers. Therefore, the main issue currently confronting providers in MACRA is that, despite considerable flexibility for 2017, when full implementation arrives, MIPS will make FFS untenable at a much faster pace than the development and implementation of viable APMs. This means that, unless something changes, a large number of providers will be pushed out of FFS and over the cliff before they have a safe place to land. There are essentially two ways to address this problem. One is to make MIPS less onerous. The other is to greatly accelerate the development and implementation of viable APMs. Policy makers should consider doing both. MIPS And The Burden Of Performance Measurement Physician practices face an enormous administrative and financial burden just to report on health care performance measures. This burden predates MACRA, and the legislation actually streamlines some of the reporting burden by combining three previously separate reporting requirements (Physician Quality Reporting System, Value-Based Payment Modifier, and Meaningful Use) into MIPS. However, physicians and their staff currently spend, on average, 785.2 hours ($40,069 per physician) annually simply tracking and reporting quality measures for Medicare, Medicaid, and private health insurers. In spite of the substantial time diverted from patient care and the money ($15.4 billion—roughly the amount of government spending each year on graduate medical education) that could be used for other purposes, most physicians feel that the current measures do not help them improve the care they provide. According to an October 2016 analysis of the current misalignment of health quality measures, the Government Accountability Office concluded that: “Although hundreds of quality measures have been developed, relatively few are measures that payers, providers, and other stakeholders agree to adopt, because few are viewed as leading to meaningful improvements in quality.” Making this huge investment in measure reporting with very little return in quality improvement is wholly inconsist[...]

Loathing And Loving As A Pathway To Meaningful Health Care Reform

Fri, 21 Apr 2017 11:30:27 +0000

The Republicans are having trouble reaching consensus on a plan to replace the Affordable Care Act (ACA), and the Democrats understandably are not inclined to help. Searching for areas of agreement at this point seems like a waste of legislators’ valuable time. Perhaps a more productive approach would be for each member of Congress to ask, “What do I want so much that I would be willing to accept something I really loathe in exchange?” Here are two suggestions. Fee-For-Service Medicare Versus Medicare Advantage What Speaker of the House Paul Ryan (R-WI) and some other congressional Republicans presumably want for Medicare is premium support—a system in which traditional fee-for-service (FFS) Medicare is treated as just another health plan that competes on a leveled playing field with Medicare Advantage plans. Democrats seemingly would like for the Medicare program to be placed on firm financial footing, rather than dealing with annual Trustees’ reports announcing the wavering date when the trust funds will be exhausted. Both sides know that the simplest way to provide a sound financial foundation for the Medicare program, although not the most efficient, is to raise payroll taxes for Part A (possibly adding a means-tested out-of-pocket premium) and increase income taxes and premiums for Parts B and D. Republicans like the privately administered Medicare Advantage health plans and loathe tax increases. Democrats love the traditional government-administered FFS Medicare plan but probably have noticed that FFS Medicare is bleeding market share to Medicare Advantage plans. As part of the trade, astute Democrats might propose a change in the Medicare entitlement legislation such as tiered cost sharing and reference pricing that cannot be overridden by Medigap coverage that would give traditional FFS Medicare more flexibility to compete with Medicare Advantage plans. The question is whether both sides love or loathe premium support more than they love or loathe tax and premium increases. Proposing such a tradeoff would force them to decide. Tax Deductibility Versus Premium Assistance The second issue is premium assistance. The federal government currently provides billions of dollars in premium assistance—to the wealthy. Ryan and some other congressional Republicans presumably want to limit or even eliminate the tax deductibility of health insurance premiums, especially for wealthy people. Let’s lay aside the irony that in this case it’s the Republicans—the party that usually is blamed for favoring the rich and despising tax increases—who are trying to raise taxes on the wealthy. The Democrats say they want to ensure that there are adequate subsidies for low-income people to have meaningful health insurance. When the government favors some goods and services over others by allowing them to be purchased with pre-tax dollars it’s called a tax expenditure. The tax deductibility of health insurance premiums is the largest tax expenditure in the federal budget—more than $216 billion in 2016. The deduction is inflationary and worth nothing or next to nothing for poor people. It’s welfare for the well-to-do. The Democrats have been in a tight spot on this one ever since then presidential candidate Barack Obama vilified John McCain (R-AZ) for proposing a limit on the tax deductibility of premiums during the 2008 campaign, but they now could score a twofer by helping the Republicans get rid of the regressive deduction on the condition that the resulting tax revenue is used to provide premium subsidies to people who really need them—primarily young, healthy, poor, working people who the Republicans could characterize as self-employed entrepreneurs. As part of the deal, the Republicans could negotiate more flexibility on ACA regulations they blame for making premiums more expensive, such as “esse[...]

A New Attempt Emerges To Bridge GOP Divisions On AHCA (Updated)

Thu, 20 Apr 2017 19:57:16 +0000

April 21 Update: New Aid For State Formulary Review At REGTAP On April 17, 2017, CMS announced that it would be turning the job of drug formulary review for qualified health plans over to state regulators in the thirteen states that have plan management responsibility.  On April 19, CMS offered at its website (registration required) a seminar on the qualified health plan (QHP) application review tools for prescription drugs that the states may use for these reviews. The EHB Category and Class Drug Count Tool, which is new for the 2018 QHP review period, reviews drug lists to ensure that QHPs comply with essential health benefit requirements. EHB regulations require that health plans cover the greater of one drug in each USP category or class or the number of drugs in each USP category or class covered by the state’s EHB benchmark plan. The Formulary Review Suite reviews the drug list of each plan to ensure that the plan’s benefit design or benefit design implementation (including marketing practices) does not discriminate on the basis of age, expected length of life, present or predicted disability, quality of life, or other health conditions.  Non-discriminatory formulary outlier review identifies plans that have unusually low numbers of drugs that are not subject to prior authorization or step therapy requirements in twenty-seven USP categories and classes.  Non-discriminatory clinical appropriateness review analyzes the availability of drugs associated with nine conditions—bipolar disorder, breast cancer, diabetes, hepatitis C, HIV, multiple sclerosis, prostate cancer, rheumatoid arthritis, and schizophrenia. Both tools include RxNorm Concept Unique Identifiers to provide normalized names and unique identifiers for drugs. These help a regulator determine, for example, whether a generic drug is the equivalent of a branded drug. The seminar also covered the appropriateness of justifications that insurers may offer where questions arise under drug formulary review.  It may, for example, be appropriate for a health plan to cover some drugs under the medical rather than the pharmaceutical benefit if they are injectable.  It would not be appropriate for an insurer to cover a drug only through its exceptions process, since that would be essentially the same as not covering it at all. Original Post On April 20, 2017, a one-page summary of amendments to the American Health Care Act proposed by Congressman Tom MacArthur (R.N.J.) surfaced. It is dated April 13, 2017 and has been presumably been under discussion for a week. It is reportedly a compromise between House Republican moderates, represented by MacArthur, and more conservative members of the Republican Freedom Caucus. It could be considered when Congress returns from its spring recess on April 27. Congress will have to enact a bill to fund the federal government as soon as it returns and it is hard to imagine that it will also try to enact legislation to amend the Affordable Care Act. Reportedly, however, President Trump would like something to happen during his first 100 days in office, which end on April 29. It is also far from clear at this point, though, whether the AHCA as thus amended can pass the House. It will likely face an even harder time in the Senate, where it would have to garner at least 50 Republican votes and find some way of getting past the Byrd rule, which limits reconciliation legislation to provisions that affect the revenues or outlays of the United States more than incidentally. What’s In The Amendment? Reinstating EHBs The proposal would first “Reinstate Essential Health Benefits as the federal standard.” This would presumably remove the confusing amendment to the American Health Care Act adopted in late March that would have required states to define the essential health benefits pa[...]

GrantWatch: Call For Blog Submissions

Thu, 20 Apr 2017 16:52:01 +0000


GrantWatch, Health Affairs Blog’s section on health philanthropy, brings you news and views of what foundations are funding in health policy and health care.

We seek blog posts from foundation staffers and grantees, as well as commentators on health philanthropy. We would like to hear about innovative initiatives funded by foundations, results of foundation-funded projects, changes in funding priorities (and why), and suggestions of what foundations could and should be funding but are not.

We are looking for original posts—not previously published elsewhere.

And we are particularly interested in candid posts examining both the successes and challenges of foundation initiatives. This information helps the fields of philanthropy and health policy. Posts about more than one foundation are also desirable.

Blog posts considered by GrantWatch need to go beyond what is in a typical press release or e-alert—that is, bloggers need to provide some context about the broader problem being addressed. Self-promotional tones should be avoided.

Posts can be as short as 600 words, but please try to avoid a word count exceeding 1,500 words.

Read three examples of GrantWatch posts: “A Funder Collaborative To Integrate Oral Health Into Primary Care Sets the Bar,” by Brenda Sharpe; “Could Foundations Have Mounted A Better Defense Of The ACA?” by Michael Booth; and “New Initiative Explores The Intersection Of Education And Mental Health,” by Nathaniel Counts and Paul Gionfriddo.

Are you up for the challenge? Here are the guidelines for submitting a post.