Applied Policy in the News

CMS said it seeks to prevent fraud, waste and abuse among both home healthcare companies and suppliers. Industry experts said competitive bidding is one way to fight that.

“The durable medical equipment category in general is viewed as a high-fraud or high-risk category,” said Simay Okyay McNutt, senior health policy manager at health policy and reimbursement consulting company Applied Policy. “It always has been and the way they define product categories and competitive bidding, in CMS’ eyes, is a way to combat fraud, waste and abuse and also control payment.”

Another concern for employers is legalities and ethics of the programs. In the presentation, Alison Falb, JD, vice president of health policy at Applied Policy, said that copay accumulators have been the subject of rulemaking and lawsuits. For federal regulations, the Affordable Care Act, Notice of Benefit and Parameters (NBPP) and a joint legislation from the Departments of Labor, Health and Human Services and the Treasury all apply.

Still, CMS must answer several key questions that will determine if and how practitioners will be able to bill the proposed DMHT codes, Simay Okyay, senior health policy manager for Applied Policy, told IHP.

Okyay said Digital therapeutic companies should also clarify the necessary documentation required to bill the new codes. CMS also must clarify the criteria DMHT and DMHT patients must meet to be eligible for the Medicare coverage, Okyay said.

To seek additional expert insights, First Report Managed Care connected with Gary Owens, MD, president of Gary Owens Associates (Ocean View, DE) and Alison Falb, health policy director at Applied Policy (Washington, DC). Dr Owens reported that “the way net cost is derived will determine formulary position. Follow the dollars. Plans need to find the best financial outcomes to maintain profitability.”

Ms Falb shared similar concerns stating, “There won’t necessarily be a one-size-fits-all approach. The [strategy] may change over time as more drugs have MFPs and new drugs enter the market…patient access to high list price and high rebate drugs may be retained, but there can also be negative impact on access to other drugs.”

A KFF poll revealed that only 25% of older adults know the Part D provision. This does not surprise Alison Falb, health policy director, Applied Policy, Washington, DC. “Older adults are likely less aware of this provision because of [its] complexity. Details about the rollout, which looks different in 2024 than in 2025, and explaining how cap can lead to savings makes messaging more complicated.” Edmund J Pezalla, MD, founder and CEO, Enlightenment Bioconsult, Wethersfield, CT, concurred. “The cap seems straightforward but [will be] difficult for people to understand until it happens.”

Alison Falb, health policy director, Applied Policy, Washington, DC, noted that changes to the Medicare Part D benefit under the Inflation Reduction Act change the incentives that promote this behavior regarding Part D plans. “Plans will be responsible for a greater share of costs, including once a beneficiary has met their out-of-pocket cap. This may lead to Medicare plans favoring products with lower list prices.”

AAR introduces two new members to its Board of Directors, discussing their experience in the health policy community and thanking Jim Eden for his service.

A coalition of medical societies and hospitals is supporting a new idea for boosting medical care in underserved communities: allowing medical schools in those areas to have a longer period of time to build up their residency programs.

Three small business owners told a Senate hearing Tuesday that Obamacare is riddled with problems that are leading to more expensive insurance policies, which is making it harder for companies to provide high-quality healthcare to their workers.

In the Bipartisan Budget Act of 2018 the Congressional Budget Office underestimated the amount Medicare would save due to changes in Medicare Part D. The savings come from an increase in the government mandated discount that drug manufacturers must offer enrollees in the Medicare prescription drug coverage gap. However, this could impact drug prices long-term as manufacturers account for the mandatory discount as they determine prices for their new drugs.