Industry trade groups believe big government can solve health care because they can’t. They are begging for help. There is a way the private sector can solve health care but plan sponsors would have to break the law in order to do so. So we need more laws…………
Payers, Plan Sponsors Hope for 2022 Telehealth, Drug Price Laws
December 23, 2021
Carriers and plan sponsors are taking stock of what federal policies deserve a fresh look as they work though tumultuous events like the pandemic and the telehealth boom. In the next year, major industry trade groups plan to push for policies including drug price reform and comprehensive telehealth regulation.
For the Alliance of Community Health Plans (ACHP), a trade group of nonprofit carriers, top priorities include changing Medicare Advantage risk adjustment rules to account for audio telehealth encounters, making some pandemic-era rules for telehealth permanent and passing drug price reforms. (ACHP also laid out more priorities in a Dec. 9 blog post.)
Meanwhile, the Purchaser Business Group on Health (PBGH), a health benefits management and policy group for large employers, also plans to lobby for drug price reform and comprehensive telehealth regulation. PBGH’s policy director, Shawn Gremminger, tells AIS Health, a division of MMIT, that plan sponsors also hope the Biden administration will take an aggressive stance against provider consolidation — which has reached unprecedented levels, according to a recent PwC analysis.
Drug pricing reform hit a major roadblock on Dec. 19, as Sen. Joe Manchin (D-W.Va.) said he would not support the Build Back Better Act (BBBA) in its current shape. Measures aimed at bringing down drug costs are more likely than many of the dozens of policies included in the bill to pass Congress as a standalone bill, but whether such a bill will be introduced remains an open question.
“It’s possible that Democrats will try to put something together in the new year,” Gremminger explains. “I don’t know that they’ve figured out what their plan is, but I have a hard time believing that they’re just going to give up entirely. I think they’re going to feel like they have to try to do something” on drug pricing next year. Both PBGH and ACHP backed the reforms included in the BBBA — in fact, they both pushed for the more aggressive H.R. 3.
In its latest form, the BBBA’s drug pricing provisions would allow the federal government to use international reference pricing to negotiate the prices of certain medications with pharmaceutical manufacturers; prevent drug prices from rising at a higher rate than that of inflation; restructure the Medicare Part D benefit design to lower beneficiaries’ out-of-pocket costs; cap the price of insulin; and repeal the never-implemented Trump-era rule that would have overhauled the prescription drug rebate structure in Medicare Part D.
Both groups also agree telehealth should be an area of focus for lawmakers next year. But because telehealth encompasses patient experiences ranging from physical therapy to specialist consultations to health coach check-ins, there is a vast range of policy ideas that have been introduced in Congress.
As of November, forty-four bills had been introduced by members of Congress from both parties and in both chambers to address telehealth issues, according to JD Supra. Many emergency policies were enacted by HHS to increase telehealth access during the pandemic, but they will expire with the public health emergency, which is currently set to end on Jan. 15, 2022. At the state level, the picture becomes even more complicated. According to the Kaiser Family Foundation, 37 states and D.C. enacted some sort of policy that expanded telehealth services during the pandemic.
TELEHEALTH EVANGELISTS AIM TO COMBAT SKEPTICS
“Unfortunately, we still have a little bit of outdated thinking in Washington when it comes to virtual care,” Ceci Connolly, president and CEO of ACHP, tells AIS Health. “And so all of us who believe in it and are seeing the benefits of it — we have an important job to do over the coming months and probably two years to really demonstrate why it is effective, why consumers love it so much, the ways in which it can reduce costs, and really answer some of the skepticism. The skepticism is a little bit of a hangover from pre-pandemic notions. But it’s incumbent upon the industry to really produce the compelling evidence that’s going to answer the skepticism.”
“There was such a proliferation of the availability and the use of telehealth during the pandemic,” Gremminger adds. “There were a lot of flexibilities made available under pandemic relief bills and administrative actions. We want to try to lock some of those into place, but make sure that we’re actually paying for quality on top. We continue to be very worried that you may see a rise in the use of telehealth without the accompanying savings. I’d say that the two main reasons for telehealth are 1) it provides access points which otherwise might not exist, but 2) it should be more efficient — when it’s clinically appropriate, you should be able to provide health care at a lower cost.”
In particular, Gremminger says PBGH hopes that Congress and the Biden administration will take actions to prevent providers from charging a facility fee for telehealth. Pay parity is another hot topic: Early in the pandemic, the Trump administration mandated that Medicare must reimburse most telehealth visits at parity with traditional visits; some states also have laws that create similar mandates.
“We think [parity] is inappropriate, at least as a broad goal,” Gremminger says. “Hospitals will do everything they possibly can to maintain their revenue. I think they look at telehealth not as an opportunity to bring down health costs for patients, but as an opportunity to bring down their own internal costs while maintaining the same revenue levels — which we just can’t abide.”
INTERSTATE LICENSURE REMAINS HOT TOPIC
Licensure for virtual care practitioners is another area of concern for payers. In normal times, most practitioners can’t care for patients across state lines even if they are fully certified in their home state. As recently as November, more than 20 states had waived licensure requirements for practitioners. Connolly hopes states will work together to create interstate compacts that allow providers to practice seamlessly across state lines. Similar interstate compacts already exist for the legal profession; lawyers admitted to one state bar can usually apply to be admitted to another to practice law in exchange for a fee. Payers have advocated for a federal licensure law for telehealth, but when asked about the prospects for such a law, Connolly said that might not be realistic.
“Right now, states control licensure — and, candidly, the fees that go with licensure,” Connolly says. “But we do think that the ability to set up those regional compacts is quite promising. We’re encouraging certain areas in the U.S. to pursue that path, which could probably go a little more smoothly [than a comprehensive federal licensure law] and open up some fantastic opportunities. Because we know that, for a certain number of people, it is simply a just-over-the-state-line kind of issue that they’re that they’re having to contend with.”
PBGH SETS SIGHTS ON REDUCING CONSOLIDATION
Gremminger also wants to slow down provider consolidation in the hope that it will arrest the growth of health care premiums.
“On the health systems side, we have efforts to deal with anti-competitive contracting practices by large hospitals and health systems,” Gremminger explains. “We have a bill that was introduced in the fall that we are really pleased about. We’re looking to work with the administration, who I think is very focused on this — issues around both market competition and consolidation among health systems.”
PBGH will push the administration to pursue policies like those that “empower the FTC to come down harder on potential mergers,” Gremminger continues. “We’ve been amazed to see continued, huge amounts of moves, even in the middle of this pandemic. I kind of hoped that the [provider] side would choose not to go there. But that’s not what they’ve decided to do — I think they’re really taking advantage of the kind of weak economic state in the health care system to try to take advantage and make more money.”
Contact Connolly via Tricia Busch at tbusch@achp.org and Gremminger via James Chisum at james@millergeer.com.
