On November 2, 2023, the Centers for Medicare & Medicaid Services (“CMS”) released the calendar year (“CY”) 2024 Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems Final Rule (“CY 2024 OPPS/ASC Final Rule”). The final rule with comment period finalizes payment rates and policy changes affecting Medicare services furnished in hospital
Current CMS Policy Priorities and Initiatives in Quarter 4
On October 17, 2023, CMS held their quarterly National Stakeholder Call to provide updates on recent accomplishments and how their initiatives advance CMS’ Strategic Plan. Administrator Chiquita Brooks-LaSure, kicked off the call by announcing the start of Medicare open-enrollment and how the entire agency is focused on educating beneficiaries on all 2024 benefits and encouraging people to renew their vaccinations which are available at no additional cost. Brooks-LaSure also revealed how for the first-time, high-cost prescription drugs will have a “catastrophic limit” in 2024. Dr. Meena Seshamani, the Director for the Center for Medicare explained that in 2024, Part D enrollees who reach what CMS calls “catastrophic fees” (the maximum threshold for paying out of pocket) will no longer have to pay a co-pay or out of pocket costs at the pharmacy. Dr. Seshamani also shared that beneficiaries taking insulin will not have to pay more than $35 for each supply of insulin products covered under part D and that people will not have to pay nothing out of pocket for recommended vaccines like shingles. CMS also spoke about the drugs selected for the Medicare Drug Price Negotiation program. CMS will have a patient-focused listening session on 11/15 for each selected drug to provide an opportunity for patients, beneficiaries, caregivers, and patient organizations can share relevant input for these selected drugs. Lastly, Dr. Seshamani shared that ACOs participating in the Medicare Shared Savings Program (MSSP) saved Medicare $1.8 billion in 2022. This is the 6th consecutive year that the program has generated overall savings, and the 2nd highest annual savings accrued for Medicare since the program’s inception.
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CMS releases updates to the ACO REACH model to advance health equity and increase participation
The Centers for Medicare & Medicaid Services (CMS) published new changes to the ACO REACH model to increase predictability for participating ACOs, protect against inappropriate risk score growth, and to advance health equity starting in performance year 2024 (PY2024). The ACO REACH model was created to deliver high-quality and coordinated care to patients while improving costs and health outcomes. Patients in a REACH ACO get help to manage chronic conditions, to receive more preventative health services, to receive care in more convenient ways like telehealth, and to better navigate the health system. When ACOs in the program achieve these goals of providing higher-quality care at a lower cost, they may be eligible to share in those savings. There are currently 132 ACOs participating in this model.
CMS Outlines Plan for Medicare Beneficiaries to Pay Prescription Drug Costs in Monthly Installments
On August 21, 2023, the Centers for Medicare & Medicaid Services (CMS) released draft guidance, pursuant to the Inflation Reduction Act (IRA), to implement the Medicare Prescription Payment Plan, a new program to help Medicare Part D beneficiaries more easily afford their out-of-pocket (OOP) costs for prescription drugs. The IRA, among other provisions aimed at lowering prescription drug costs for Medicare beneficiaries, requires, starting in 2025, that Medicare Part D plan sponsors offer beneficiaries the option to pay their OOP costs for prescription drugs monthly over a year instead of at the point of sale. Under the new program, referred to as the Medicare Prescription Payment Plan, Part D sponsors must pay the pharmacy the OOP cost-sharing that beneficiaries would have paid if they were not in the program. Part D plan sponsors then will bill beneficiaries monthly for their OOP responsibility.
CMS Proposes Transitional Medicare Coverage Pathway for Emerging Technologies
On June 21, the Centers for Medicare & Medicaid Services (“CMS”) issued a proposed notice with comment period outlining a transitional Medicare coverage pathway for emerging technologies through the national coverage determination (“NCD”) process in addition to several guidance documents that describe CMS’ approach to coverage reviews and evidence development, including the National Coverage Analysis Evidence Review and Clinical Endpoints Guidance: Knee Osteoarthritis.
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The 2024 Medicare Physician Fee Schedule Proposed Rule is Here: What you need to know
The highly anticipated 2024 Medicare Physician Fee Schedule (PFS) was released earlier this month packed with changes that the Administration hopes will advance health equity and expand health service access to underserved populations. Some of the proposed rules emphasize certain Medicare programs like the Biden-Harris Administration’s Cancer Moonshot initiative and the largest accountable care organization (ACO) program, the Medicare Shared Savings Program (MSSP). Additionally, the new rule highlights primary care and contains provisions that align with HHS’ Initiative to Strengthen Primary Care.
CMS Innovation Center Reports Data Challenges in Assessing Health Equity
On July 10, 2023, the Center for Medicare & Medicaid Innovation (CMMI or “Innovation Center”) released a White Paper, Assessing Equity to Drive Health Care Improvements, outlining their analysis and assessment of health equity incorporation in model designs and evaluations. CMMI supports the development and testing of innovative health care payment and service delivery models. These innovation models are designed to improve quality of care and patient outcomes while reducing or maintaining program costs.[1]
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Examining the Use of the Area Deprivation Index in Value-Based Care Models
The Centers for Medicare & Medicaid Services (CMS) has recognized that addressing health care disparities and achieving health equity should drive our nation’s top health priorities.[1] According to the CMS Framework for Health Equity 2022-2023, health equity is defined as, “the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes”. In order to eliminate health and health care disparities, there needs to be an effort to provide quality, equitable care to those in areas without access and availability to the services necessary to meet their health and social needs.
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CMS Announces New Demonstration Model Focused on Primary Care
On June 8, 2023, the Centers for Medicare & Medicaid Services (“CMS”) announced a new Center for Medicare and Medicaid Innovation (“the Innovation Center”) model focused on improving access to primary care and advancing care management and care coordination.
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Food is Medicine: Can Policymakers Come to the Table?
In 2021, 1 in 10 American households experienced food insecurity, an issue exacerbated by the COVID-19 pandemic.[1] Diet-related diseases such as diabetes, heart disease, and cancer are some of the leading causes of death and disability in the U.S. Each year in the U.S. there is an estimated $52.8 billion in excess health care costs as a result of adults experiencing food insecurity.[2] Since recognizing the influence of nonmedical factors such as socioeconomic status, education, and physical education on health, there have been a growing number of initiatives to address social determinants of health (SDOH) within the health care system. Food is medicine interventions are tailored to respond to the connection between food and health in order to help prevent, manage, or reverse diet-related disease.[3] Food is medicine interventions may include medically tailored meals, produce prescriptions, and medically tailored food packages. These interventions have been associated with decreased inpatient hospital admissions, decreased overall healthcare costs, increased medication adherence, and increased diet quality.[4] The concept of using healthy foods to reduce diet-related disease in the U.S. is increasing in popularity. There is bipartisan support for food is medicine initiatives to target food insecure and medically vulnerable populations.
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