 | | | | | | Did someone forward this newsletter to you? Sign up here to get it in your inbox. In today’s issue: - Exclusive: A new coalition is launching to push Medicare Advantage reforms focused on prior authorization, sidestepping the more politically fraught fights.
- Home health and hospice providers are scrambling after the Trump administration imposed a six-month freeze on new Medicare enrollments as part of a broader anti-fraud crackdown.
- The Supreme Court is set to consider whether it will hear drugmakers’ constitutional challenge to Medicare’s drug-negotiation program after a string of lower-court losses.
Good afternoon, this is Health Brief. As predicted, Wednesday’s Senate Appropriations panel hearing, at which Marty Makary had been set to testify about the FDA’s budget, has been postponed after he resigned Tuesday. What’s next on your FDA bingo card? Hearing some wild names being floated as the next nominee — what have you got? Send any tips, documents or intel to megan.wilson@washpost.com, or message me on Signal at megan. 434. |  | | Prior authorization is likely to be the next front in the debate over Medicare Advantage reforms. (Pablo Martinez Monsivais/AP) | | | |  | The Lead Brief | A new initiative called the Coalition to Improve Medicare Advantage is launching this week, and betting that the next phase of the Medicare Advantage debate will involve supporters of the program being able to admit it needs fixing. Scott Styles, executive director of the coalition’s parent organization, Alliance for Medicare, tells me that he’s launching the effort to tackle one of the most pernicious problems: insurers’ use of prior authorization. Styles, once an insurance industry lobbyist, acknowledges that newly introduced legislation to address the issue — though bipartisan — may not have a chance of passage this Congress because of the election-year slowdown, but he hopes to set it up for future success through meetings with key lawmakers and staff on Capitol Hill and coordinating the advocacy efforts of the coalition’s members. Members of the coalition include the American Medical Rehabilitation Providers Association, several post-acute care providers such as ScionHealth and PAM Health, and other health systems. “Although Medicare Advantage offers benefits, its current form can also create obstacles, confusion and delays,” said Anthony Misitano, president and CEO of PAM Health. “As it stands, it isn’t the best fit for everyone.” Medicare Advantage now covers 35 million people, more than half of all Medicare beneficiaries, and remains popular among older Americans who value the supplemental benefits offered by private plans and other perks of the program. But its explosive growth has also produced mounting scrutiny over opaque coverage decisions and increasingly aggressive utilization management practices such as prior authorization. → That criticism has intensified enough that major insurers have begun promising changes, making voluntary commitments with the Trump administration to streamline the prior authorization process and reduce the number of services or medications that trigger a prior authorization request. The administration has also been making its own moves, on Wednesday, announcing its own coalition of organizations spanning the health industry — including insurers, providers and digital health developers — to work on streamlining and simplifying the prior authorization process. It follows on a proposed rule issued last month that would implement electronic prior authorization requirements for medications in federal health programs. Major insurers have touted initial progress on their pledges, noting they have reduced the volume of these requests by 11 percent since making the commitments last summer. AHIP, a major insurance industry group, cites its own data showing that almost all prior authorization requests in Medicare Advantage were ultimately approved. However, a new survey of doctors on the topic of prior authorizations released Wednesday by the American Medical Association showed that more than 30 percent of clinicians believe the pledges by insurers will result in meaningful change. Nearly all of the physicians surveyed said that prior authorizations delayed necessary care or negatively impacted patient outcomes. Doctors say they complete an average of 40 prior authorizations per week, and a majority said that patients will often abandon treatment entirely after encountering the roadblocks. | | | | | | Strategy File | → That’s where the Coalition to Improve Medicare Advantage comes in. Although regulators and industry are making an effort to improve the process, legislative action may be needed to help cement and expand on some of the reforms. The coalition is initially focused on a bipartisan measure recently reintroduced in the House and Senate that would implement stricter requirements for prior authorization requests — in addition to curbing retroactive care denials and strengthening coverage of long-term care and rehabilitation hospitals. Major hospital and post-acute care groups have already lined up behind the bill, saying that misuse of the prior authorization process is “one of the greatest pain points in the U.S. health care system.” Insurance plans haven’t come out in opposition to the legislation, though some industry interests tell me they’re still reviewing its implications. → The coalition is deliberately avoiding the policy fights related to coding intensity and overpayments that typically occur in the Medicare Advantage debate, instead framing itself around the “patient experience” and continuity of care. This could make it easier for policymakers, who have until recently been hesitant to offer criticism of the Medicare Advantage program, for fear of angering insurers and older Americans who like their coverage. “If you look at, especially how the Republican conference has changed since 2003, almost all those members that were involved in [Medicare] Part D are gone now,” said Styles, who worked as a top aide Rep. Pete Sessions (R-Texas) earlier in his career. “They were the ones that were really overly protective of Medicare Advantage.” “What we’re seeing now is you have a whole new group of members. A lot of them are physicians that have had direct experience with Medicare Advantage, and so they understand some of the issues,” he added. “They’re still very supportive, they have high penetration in their districts — but they understand there have to be some changes made because they’ve seen it in their own practices.” A majority of the sponsors of the legislation championed by the coalition, called the Medicare Advantage Improvement Act, are physicians, including Reps. John Joyce (R-Pennsylvania) and Sen. Roger Marshall (R-Kansas). The legislation “seems to be more along the lines with what they see as some of the problems without really being too heavy-handed with the plans.” What to watch: A key leverage point that advocates often use to get their favored bills included in larger legislative vehicles often hinges on being able to show their proposals can save the government money. While actuaries at the Congressional Budget Office haven’t yet scored the Medicare Advantage Improvement Act, it’s not clear that it could be used as an offset in a spending bill. → However, Styles tells me that offering savings data may be more nuanced. He’s making the argument that if older Americans don’t have timely access to medical services or access to post-acute care, it could increase the overall cost of care to the system when the patient ends up in the ICU. “We’re going to continue to look at some of the data and share that with folks on the Hill, within CBO, whoever wants to listen to us,” Styles said, to talk about “if these policies were implemented, could they actually have savings … health savings down the line.” | | | | | | Executive Health Brief | The Trump administration is temporarily pausing new home health and hospice providers from enrolling in the Medicare program, a key revenue source that the industry worries could have negative impacts on patients in rural or underserved areas. The six-month nationwide moratorium on new Medicare is part of an effort by the Centers for Medicare and Medicaid Services to tamp down on fraud. “We’re shutting the door on fraud — preventing new bad actors from entering Medicare while we aggressively identify, investigate and remove those already exploiting them,” said CMS Administrator Mehmet Oz. “This is about protecting patients, restoring integrity and safeguarding taxpayer dollars.” The Trump administration has been publicly focused on states run by Democratic governors, including California and Minnesota, but the announcement on Wednesday includes details about heightened oversight in several GOP-led states, including Georgia, Ohio, Nevada and Texas, that are considered at higher risk for fraud. The National Alliance for Care at Home, an industry group representing hospice and home care providers, and its members have been asking federal officials not to take this step — arguing that a nationwide moratorium could disrupt ongoing state oversight efforts, prevent providers from expanding services and threaten telehealth access for hospice patients. Jennifer Sheets, the group’s chief executive, told me that she’s already talked to CMS officials about the move, which was announced Wednesday in a Federal Register notice set to publish later this week. She said the moratorium didn’t come as a surprise because the administration had long been stating its intent to impose one, but also that she’s now working to ensure that CMS uses the six months to “design an effective, targeted integrity response that does not impact compliant providers.” “That’s what I really worry about here,” said Sheets, who said she plans for the industry to engage with the administration and lawmakers on Capitol Hill in the coming months. “We’ve already got an industry that is holding on by thread in some scenarios.” She says that fraud in the home health industry is a problem that needs to be addressed, but the moratorium wouldn’t provide the solution. Regulators seeking to root out fraud should look at data relating to beneficiaries instead of the surface-level invoice data, she said. “Unfortunately, these criminals are not stupid … so their bills are beautiful — they’re completely clean. So, go a layer deeper. If you look at things like mortality on hospice, what they would find is — in these fraudulent providers — no one ever dies on hospice. That’s a red flag,” she said. Earlier this year, the National Alliance for Care at Home sent a letter to Centers for Medicare and Medicaid Services head Oz detailing ways to strengthen program integrity, building on a December letter from the alliance and fellow industry group LeadingAge that outlined additional proposals, including strengthening oversight of new entrants and holding Medicare contractors accountable. During the moratorium, CMS said it plans to “intensify targeted investigations, deploy advanced data analytics, and accelerate the removal of hospice and [home health agency] providers from the Medicare program that are suspected of committing fraud.” By pausing enrollments nationwide, the agency said, it will prevent bad actors from evading detection by moving to another state. | | | | | | Litigation Report | For your calendar: The Supreme Court is slated to discuss Thursday whether it will hear drugmakers’ legal challenges to Medicare’s drug negotiation program. Six companies — AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Johnson & Johnson’s pharmaceutical arm, Janssen Pharmaceuticals, Novartis and Novo Nordisk — have asked the high court to rule on whether the program is unconstitutional. They’ve all argued that the program, enacted within the Inflation Reduction Act during the Biden administration, violates their free speech and due process rights protected by the Constitution. But every company has lost their lower-court legal challenges and appeals. Andrew Twinamatsiko, the director of the Center for Health Policy and the Law at Georgetown University Law Center, is bearish about the Supreme Court accepting the cases in this term. He points out: There has been no dissension among lower courts on these rulings — which would have made the Supreme Court more likely to step in — and there are still ongoing lawsuits from Teva Pharmaceuticals and the industry’s main advocacy group, the Pharmaceutical Research and Manufacturers of America. It should also be noted: The Justice Department in January filed a brief with the Supreme Court defending the drug negotiation program, urging the high court to reject the legal challenge. | | | | |
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