Tuesday, February 20, 2018

Brief Blog: Health Policy was 140 Pages of the 250 Page 2018 Budget Bill

Avoiding a long term government shutdown, the Hill passed a national budget bill of 250 pages on February 9, 2018.    The legislation is 250 pages(HR 1892).  There have been numerous summaries of various healthcare provisions.

Notable, I would say, is the raw fact that health care policy occupies 140 of the 250 pages (from 105 to 245).    

I've put the health care pages in the cloud here.

Many parts are nearly unreadable, because they amend existing law.  For example, the heavily debated and contentious funding of Children's Health (CHIP) looks like this:

Some tidbits and highlights after the break.

The 140 pages are impossibly to concisely summarize again but I've cherry picked a few legislative tidbits.  

SSA 1859 is a grab-bag of miscellaneous provisions, a new one  (S.50321, PDF page 34) requires CMMI to rollout a value based insurance design (VBID) demo "to all States" by 2020.   Hint for stakeholders and lobbyists:  If you really liked some CMMI program or other, you could ask Congress to tell CMMI to nationalize it in this way.

Major Medicare Advantage Sections

Section 50322 allows Medicare Advantage plans for "chronically ill" patients (in or outside of special needs plans) to include "supplemental benefits expected to improve health" which however are not necessarily "primarily health related benefits."  Don't look for these in Traditional Medicare.  I think you can by your MA patient a gym card under this, if it is "expected to improve health," but the range and scope of innovation may be more promising than that.    

Section 50323 improves MA telehealth benefits ( PDF p. 36).  These are services for which "Part B benefits are available" but not under Part B telehealth limits (1834m), via communications technology.    By November 2018, CMS shall solicit comments on what items and services these new benefits should be included, such as remote patient monitoring and other services (p. 37).  Notably, the benefits can be treated "as if" (at (a)(5)) they were benefits under the original Medicare program for accounting and reporting purposes, which if I understand, reduces a ton of paperwork that were demanded for historical "extra" benefits.
  • Medicare Nerd Three-Point Shot. I saw that the new law refers to "telehealth" and I imagined (and would have bet $20) that the old 2001 law probably referred to "telemedicine." But they both refer to "telehealth;" see SSA 1834(m).
  • If the 50323 benefits for MA plans are defined the same as old SSA 1834(m) but not under the extra constraints (such as telegeography), it's not obvious exactly what CMS is taking comment on.  

Major ACO Revisions, Starting With Telehealth

Section 50324 (p. 36-37) also allows broader telehealth in ACOs: the home may be an originating site and there are no other geographic restrictions, if the patient is in the ACO.   I think the point here is that the ACO gets a FFS reimbursement for the home-based office telehealth visit, whereas outside the ACO a health system could not get reimbursed because a home-based telehealth visit is outside of traditional Medicare telehealth.  There is also a section specific to individuals with stroke (50325, p. 39), without requiring they be in a rural health area, etc, but they must be in a hospital, mobile stroke unit, "or any other site" determined appropriate by the Secretary.  That's a big "or."
I believe that ACO beneficiaries are automatically assigned now based on records, but they would be able to "self-select" as part of an ACO under Section 50331 (p. 39-40).

In Section 50341 (p.41), ACOs can pay beneficiaries incentives of up to $20 under certain conditions. However, the HHS can't make any extra payments to allow this.

Other Legislative Points

While there's been great improvements in chronic care planning services, Section 50342 (p. 43) requires GAO to study if those payments overlap with other payments like hospice care services.

Section 50351 (p.45)  requires the GAO to study the effectiveness of medical synchronization programs to control polypharmacy under Part D.  

Section 50352 (p. 46), GAO to study impact of obesity drugs on health spending.   These are currently supplemental (not core) to Part D plans.

Section 50353 (p.47) is a general study of long term risk factors like smoking and obesity.

Section 50354 makes a lot of sense, giving Part D plans access to A/B data.

Section 50401 (p.48-51) provides a quirky transitional payment relative to home infusion therapy services, correctly a minor error in earlier law.  It ties directly to the DME External Infusion Pump LCD which is called out by name.  It takes 4 pages to explain this in law.

Section 50404 (p. 52) has to do with certain "holdover requirements" under Stark rules; it appears to cover payments that are ongoing if a lease has expired but the parties are acting as if it is still in place (not to be punished if corrected).  Otherwise after a lease expires, I infer that providing payments not under an active written contract might be statutory fraud.

Section 50411 "makes permanent the removal of the rental cap for DME for speech generating devices."  

Section 50412 increases the penalties for fraud and abuse.  For example, penalties that were "not more than 5 years" are now "not more than 10 years."

Diabetes strips have plummeted in price over several years and there have been concerns that the DME market has shifted to "off brand strips" and meters that may be less accurate.   Congress has required GAO to periodically study this shift.  Section 50414 (p.55) requires suppliers to have more brands of strips, I think, and puts more teeth into "anti switching rules" (you can't be forced to switch to a cheaper less accurate device).  There is for example a section here, "prohibition on influencing and incentizing."  

     > The government really cares about this section, because they've included a clause here that the Paperwork Reduction Act doesn't apply to it.


Not related to Medicare, Section 50502/510 (p.59) provides funding for "sexual risk avoidance education," which I think is "just say no" education, which must present and explain "the societal benefits associated with...self-regulation...and a focus on the future."  While there are countless terms for "doing it," here, for "not doing it" the legal term is called self-regulation.

For an April 2018 article on implementation of "self regulation" policy, here.

Foster Care

There are long sections on foster care.

Other Provisions

At 50902 (p.123), a Special Diabetes Program for Type I Diabetes is extended with $150M in a general section and what appears to be $150M in a second section for Indians.

Section 51003 (p.127) is a MIPS extension.

Section 51004 (p. 129) modifies cardiac rehab law at SSA 1861(eee)(4)(B) to include patients with stable chronic heart failure from NYHA Class II to IV, or "any additional" condition for which CMS determines cardiac rehab is appropriate.  

Section 51006 appears to upgrade the role of physician assistants (like nurse practioners) in hospice care.  Section 51008 (p.131) allows PAs, NPs, or CNS's to supervise cardiac and pulmonary rehab.

Section 51009 is a subtle tweak to radiation therapy payments.

Section 52001 (p.132) repeals the Independent Payment Advisory Board, IPAB.

If you win the lottery, how this affects your Medicaid status is detailed by Section 53103 (p.134).

Section 53104 (p.136) has to do with rebate law for line extensions of drugs and certain sole source drugs (I'm not sure, but this may be a "Martin Shkreli" type of law).

In Section 53105, a "Medicaid Improvement Fund" is dropped from $980,000,000" to "$0."   In Section 53106, a PFS update is dropped to 0.25%.    In Section 53115 (p. 140), a Medicare Improvement Fund is similarly dropped from $220,000,000 to "0."  One online source said that the M.I.F. was already made redundant by CMMI.

In Section 53107 (p.137), services of a "physician therapy assistant" are dropped to 85% of the otherwise applicable payment.

In Section 53113 (p.139), biosimilars are no longer excluded from certain Part D coverage gap rules, and in Section 53114, Part B and D subsidies are higher for high income individuals.  This alters law at SSA 1839.

In Section 53119, a Prevention and Public Health Fund is changed (PPACA S.4002) I suspect reducing dolalr values, as a pay-for.