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A look at what will impact the managed care industry next year.
With an election year just about upon us, there are a number of changes coming from the current administration that are going to impact the managed care industry in 2020. Changes in allowable benefits, home health, hospice carve-ins, and new CPT codes for remote home monitoring are just a sample of these.
There are an additional set of fundamental changes coming from the administration affecting clinicians related to payment models. For example, earlier this year, CMS announced five new primary care payment models designed to incentivize the entire healthcare system to transition to value-based care, especially for patients with complex, chronic, and high-need conditions.
Here are eight policy changes that could make a huge impact in 2020.
1. Medicare for All
Michael Abrams, managing partner of the global healthcare consulting firm Numerof & Associates, a global healthcare consulting firm based in St. Louis, says there will be no ignoring Medicare for All in 2020.
“It’s already a hot policy topic among presidential candidates, and I suspect the debate around its potential pros and cons will only continue to intensify; some arguing that the significant expansion of healthcare coverage is worth the incredibly expensive price tag, and others arguing there’s no way today’s providers will be able to respond to its ramifications,” he says.
2. Stark Law
Emily Felder, senior policy advisor and counsel with D.C.-based Brownstein Hyatt Farber Schreck, a lobbying firm specializing in healthcare, notes HHS is rewriting the rules for the Stark Law, or physician self-referral, and will issue a proposed rule later this year. That will set up 2020 as the year to debate the proposed changes and a broader discussion about the role of Stark in managed care.
CMS Administrator Seema Verma has called Stark “outdated” and said while it makes sense in a fee-for-service (FFS) system to prevent inappropriate financial incentives, it doesn’t apply the same way to managed care and value-based systems.
“Changes to Stark will be largely positive for two reasons,” Felder says. “One, the administration is aware that the 30-year-old law needs to be updated and adapted for today’s evolving system, and two, there is commitment and action to make it reflect the intent of the law. The administration sees these changes as part of the larger ‘Regulatory Sprint to Coordinated Care.’”
3. Price transparency
John Nicolaou, healthcare expert at PA Consulting, a global healthcare consultancy with U.S. offices in New York, says the price transparency regulation proposal, started by executive order earlier in the year, and now part of a CMS proposed rulemaking, is currently in comment period.
“This would require hospitals to publish gross and negotiated rates for services in an accessible format, including commonly used ‘bundles’ of services,” he says.
Robbie Hughes, founder and CEO of Lumeon, a digital health company leveraging Care Pathway Management, based in Boston, expects that heading into 2020 there will be more movement around Trump’s order on price transparency, aimed at lowering rising costs of care by showing prices upfront to patients.
“The executive order describes the concept of price transparency as the means to creating a ‘shoppable’ experience-the idea that there could be packages of care at understandable, logical prices,” he says. “Not only will this force providers to package their care into ‘shoppable’ products for consumers, but it will also ultimately drive down prices through market forces.”
The ideas in this executive order will likely be reflected in a bigger policy package that will need bipartisan support and approval from both houses in Congress.
“Nobody will disagree on making it easier and more affordable for Americans to consume healthcare,” Hughes says. “The challenge I anticipate we’ll see is around industry agreement on an approach that ensures the consumer sees the benefit of reduced healthcare costs.”
4. International reference pricing for therapies paid for by Medicare
Both political parties have proposed plans that involve some form of reference pricing, and a recently released study by the Senate Ways and Means Committee found some therapies may cost fourfold more in the United States than other comparator countries.
Meg Alexander, managing director, reputation and risk management practice for Syneos Health, a healthcare research organization based in Morrisville, North Carolina, says some reference pricing proposals, such as the version posed by the administration, may enable payers to more closely “manage” certain drug categories. However, reference pricing could also deliver several un-intended consequences that may have the opposite effect of making drugs affordable and accessible for Americans.
“For example, some reference pricing proposals involve vendor ‘middle men’ for drug management, increased payer management strategies, and could involve a flat physician administration fee for therapies offered under Medicare Part B,” she says. “This may translate into fewer physicians offering such therapies due to administrative and reimbursement hassles; thereby leading to American patients potentially struggling to find doctors to administer the medicines they need.”
5. ETC model
Bryan Becker, MD, chief medical officer for DaVita Integrated Kidney Care, a Fortune 500 healthcare provider based in Denver, Colorado, says following an executive order signed in July- Advancing American Kidney Health-the Center for Medicare and Medicaid Innovation (CMMI) announced voluntary and mandatory payment models, though the details of the voluntary models, which have some general features that mirror the primary care payment models, have not been released yet.
“The mandatory model, otherwise known as the ESRD Treatment Choice [ETC] model, would take effect in 2020,” he says. “The ETC as proposed extends to half of the Hospital Referral Regions [HRRs] in the country and includes the patients in the dialysis clinics in those HRRs and the nephrologists who work with patients in those clinics.”
The claims from both nephrologists and clinics will be adjusted based on home and transplant rates for chronic kidney disease stage 4/5 or ESRD Medicare FFS patients in areas identified by CMS as an ETC region.
6. The rising cost of insulin
Sami Inkinen, CEO and founder of Virta Health, a San Francisco-based health tech company specializing in type 2 diabetes reversal through nutritional intervention, believes in 2020, there will be policy changes roll out to help address the rising cost of insulin, which the FDA Commissioner Scott Gottlieb, MD, has called unacceptably high for a decades-old drug.
“Insulins are biologic drugs, and they will be regulated as such for the first time in 2020. The transition will spur generic competition in the insulin market and impact costs,” Inkinen says. “The shift has been long planned, but it comes amid growing public outrage and media stories focused on patients having to ration their insulin, travel abroad to buy cheaper insulin, and make choices between buying insulin or putting food on the table.”
HHS is aggressively pushing forward with new requirements to hasten the adoption of interoperable electronic health records and utilizing brand new legal authorities to do so. In its February 2019 Interoperability and Patient Access proposed rule, CMS requires all Medicare, Medicaid, and federal exchange plans to share claims data information electronically with enrollees.
“While this is an important policy objective to further the administration’s goal of giving patients access and control over their own data, it could create a burden for plans to operationalize this new rule and ensure it complies with data safety standards,” Felder says. “This rule is set to be finalized by the end of the year, and plans will be charged with implementing it in 2020.”
8. Lowering drug prices
Lee Barrett, executive director and CEO of Electronic Healthcare Network Accreditation Commission, the nonprofit standards development and healthcare accreditation company, says to the extent to which managed care companies manage drugs, as well as other healthcare service delivery, the current focus on bringing drug costs under control is relevant.
House Speaker Nancy Pelosi’s bill to lower prescription drug prices would save Medicare $345 billion over 10 years, according to a preliminary analysis from the nonpartisan Congressional Budget Office.
The main thrust of the plan would allow Medicare to negotiate lower prices on up to 250 of the most expensive drugs-including insulin-per year and apply those discounts to private health plans.
“If Medicare were to move in the direction of the Pelosi proposal, in which drug prices would be indexed against foreign prices and the government would negotiate prices downward, we would expect that drug prices in the commercial market would fall as well,” Barrett says. “While a political agreement on an approach to lowering drug prices will be difficult, we think there is a reasonable chance that drug manufacturers and PBMs [pharmacy benefit managers] will be squeezed considerably in 2020, and managed care organizations, like other payers/controllers of care, should benefit.”
This past summer, the Trump administration dropped the proposed drug rebate rule aimed at PBMs, then introduced a plan to import drugs from Canada. As the public is still searching for a solution, 2020 will undoubtedly see more discussions about how to reel in drug prices.
Keith Loria is an award-winning journalist who has been writing for major newspapers and magazines for close to 20 years.