Federal budget continuing resolution battle derailed or delayed some telehealth extensions, physician fee increase, PBM reforms (updated 21 Dec)

December 19, 2024 | by

Updated for the final bill passed 21 December. It’s one day to the Friday 20 December shutdown deadline for the expiring Federal budget extension. How can this be? The continuing resolution (CR) that would extend Federal budgets to 14 March 2025 is running into severe headwinds in Congress. Conservative Republicans in both houses, plus President-elect Donald Trump, and DOGE co-heads Elon Musk and Vivek Ramaswamy have come out against the 1,547-page CR.

Nearly all legislators have NOT read it, to no one’s surprise. Instead of a clean CR that extends the budget, it’s hung like a Christmas tree with ornaments like provisions on health care (discussed below).  Among the ornaments: permitting year-round sales of E15 ethanol fuel (a really bad idea), $100 billion in badly needed disaster aid, the rebuilding of the wrecked Francis Scott Key Bridge in Baltimore–and, outrageously, a pay raise for Congress members, the concealment of information given to the House around the events of 6 January 2021 (Section 605), and the refunding of the Global Engagement Center (GEC) in the State Department that censored social media accounts! (Somehow the spending-free requirement requiring AM radio in all vehicles sold in the US, a linchpin of our national Emergency Alert System, was forgotten.) All of these should have been handled in discrete bills passed much earlier (or defunded as planned), reducing the CR to a manageable 100 pages or less. Why wasn’t it?

For context, the current 118th Congress ends on 3 January 2025. New Members will be sworn in on that date if not before (in the case of vacant seats). Control of Congress will remain with Republicans in the House and switch to them in the Senate. The 119th Congress is able to immediately address this on 3 January.

If the government shuts down after Friday–most of it is on vacation or out of session anyway–what continues are essential functions such as the military, government benefits, Medicare, the VA, and law enforcement. Non-essential employees won’t be coming into work. National parks, for instance, will be closed–but it is winter.

In healthcare, what was tossed on the tree at various points:

In telehealth, the American Telemedicine Association (ATA) applauded, perhaps too early, the following measures:

  • 2-year extension of Medicare telehealth flexibilities (Ed.–for geographic and originating sites plus types of providers)
  • 2-year extension of first dollar coverage of High Deductible Health Plans-Health Savings Accounts (HDHP-HSA) tax provision (Ed.–commercial coverage)
  • 5-year extension of Acute Hospital Care at Home program (Ed.–originally developed during the pandemic. The Hospital at Home Users group has a webinar at 4pm Thursday–direct link to registration– to discuss contingencies around delay or no extension. )
  • Allows cardiopulmonary rehabilitation services to be furnished via telehealth at a beneficiary’s home under Medicare in 2025 and 2026
  • 5-year extension of the Medicare Diabetes Prevention Program (MDPP) Expanded Model through 2030 and allows beneficiaries to participate virtually and in-person (Ed.–This consists of a one year course that promotes dietary changes, physical activity, and other behaviors to help people lose weight. Providers are paid both for sessions attended and weight loss outcomes. The big guns behind this are Teladoc, which has a lot riding on this, and Omada Health.)
  • Enacts the SPEAK Act which facilitates guidance and access to best practices on providing telehealth services accessibly

The Medicare physician fee schedule (Medicare PFS) has a 2.5% increase. This counteracts a 2.8% decrease enacted in November.

Bonuses to alternative payment models and a reauthorization of the SUPPORT Act for dealing with the opioid crisis.

PBM reforms. The bonuses would be paid for by transparency requirements for pharmacy benefit management (PBM) companies, including banning spread pricing in Medicaid and ensuring Part D plan sponsors delink PBM fees from the price of a drug. The PBM trade lobby charges that the delinking alone will increase premiums in Part D by $13 billion and benefit drug manufacturers.

Updated: Mario Aguilar in the STAT HealthTech newsletter reported the inclusion of a required GAO report on wearable devices: “Within 18 months, the government accountability office must produce a report on “(1) the potential for such devices to accurately prescribe treatments; (2) an examination of the benefits and challenges of artificial intelligence to augment such capabilities; and (3) policy options to enhance the benefits and mitigate potential challenges of developing or using  such devices.” I sent a few messages trying to figure out what exactly the deal is, but the language has been attached to telehealth legislation since at least May.”

FierceHealthcare 16 Dec, 16 Dec. Fox News  CBS News    

Update 21 December   A much-contracted and simplified bill was passed on Friday 0’dark:30 by first the House then the Senate for the presidential signature. The full text of the bill is here. The healthcare provisions included were in Division C, table of contents on page 91, and extended through 31 March 2025. Only three were extended–the rest have to wait for a bill or bills in regular order:

  • The Special Diabetes Program (Sec. 3102)
  • Telehealth flexibilities (Sec. 3207)
  • Hospital care at home (Sec. 3208)

More to develop when the 119th Congress convenes on 3 January.

News and deal roundup, 5 March: Oscar Health’s $1.4 billion IPO, telehealth expansion in Congress, what people *really* do during a telehealth visit

March 5, 2021 | by

What a difference a month makes in a blazing healthcare market. ‘Neoinsurer’ Oscar Health went public on Tuesday, selling over 37 million shares at $39 each, reaping an eyeblinking $1.44 bn. While shares took a tumble on Wednesday and Thursday, closing at just above $32, the valuation of the company could be anywhere between $7.92 and $9.5 bn (calculating in options and the like). Quite a difference from the estimate in early February, which was a modest–and as now we know, totally sandbagged–$100 million [TTA 9 Feb]. A lovely payday for their backers and all at Oscar who had stock grants, indeed.

As we’ve seen from recent IPOs, they have all been underestimated (e.g. Signify Health’s $100 million filing transubstantiated into $561 million). The downward glide slope in share price is typical. Whether it will rise will depend very much on strong results for this quarter, half year, and full year as Oscar presses harder into the competitive Medicare Advantage, exchange, and small group markets. How they, and all the other payers do, will be dependent on health policy permutations and emanations from the DC Swamp. CNBC, TechCrunch, FierceHealthcare

Speaking of the DC Swamp, telehealth expansion is enjoying real traction in Congress and with Health and Human Services (HHS). The chair of the House Health Subcommittee, Rep. Anna Eshoo (D-Calif.) has called for many of the flexibilities on payments and locations granted temporarily during the pandemic’s liberalization of coverage to be made permanent. These affect Medicare and other types of Federal payments. [Review of the 2021 Medicare Physician Fee Schedule re telehealth here]  They expire after the public health emergency (PHE), extended in January to end of April, so a clock is ticking, quickly.

The basics are that Congress must pass legislation that removes restrictions on geography (currently rural only) and permits the patient home to be used as a ‘distant site’. Advocates also want to add to Medicare telehealth coverage hospice and home dialysis care, more types of eligible care providers such as physical therapists and other allied health professionals, and audio-only (telephonic) consults. Others are pushing for reinstating HIPAA compliance for telehealth platforms.

The Telehealth Modernization Bill that covers most of the above was introduced on 23 February in both the Senate and House, in a rare show of both bipartisanship and bicamerality. (Excluded: telephonic consults, HIPAA compliance) Rep. Eshoo’s remarks were made during last Tuesday’s Committee on Energy and Commerce Health Subcommittee hearing.

HHS is also backing this, based on HHS’ Office of the Inspector General’s recent statement praising the expansion of telehealth. Recognizing that concerns have been raised about ‘telefraud’, IG Christi Grimm noted that they have been vigorously prosecuting fraudulent claims [TTA 2 Oct 20] with telehealth being used in a broad sense for billing other goods and services such as medications and durable medical equipment. FierceHealthcare, Healthcare Dive, ATA News 26 Feb

Speaking of telehealth visits, what do the patients do during them? This Editor had filed away, waiting for an opportune moment to share it, a surprising study by DrFirst, a mobile telehealth and communications platform. It was conducted online during the Pits of the Pandemic (June 2020). It may not surprise you that most patients weren’t fully engaged in the process. Bored, isolated, mostly male patients–73 percent men, 39 percent women–multitasked and distracted themselves during the virtual visit by: 

Surfing web, checking email, texting – 24.5%
Watching the news, TV, or movie – 24%
Scrolling through social media – 21%
Eating a snack or a meal – 21%
Playing a video game – 19%
Exercising – 18%
Smoking a cigarette – 11%
Driving a car – 10% (!!!!)

And the best….Having a “quarantini” cocktail or other alcoholic beverage – 9.4%

Reasons for consults were unsurprising: annual checkup – 38%, mental health therapy – 25%, and specialist visits (e.g., dermatologist, hematologist, or oncologist) – 21%.  N=1,002 US consumers. 44% of Americans Have Used Telehealth Services During Coronavirus Pandemic but Some Admit Not Paying Attention. Also Advisory Board blog.

Medicare dis-incentivizes home health care in ACA’s name (US)

July 4, 2014 | by

When it comes to home health care, the C in CMS (Centers for Medicare and Medicaid Services) should perhaps stand for ‘contradiction’. According to recent reports appearing in the pre-holiday ‘dead zone’ of late last week, CMS has decreed that it must save, as part of a four-year plan under ACA, $58 million (0.3 percent) in fiscal 2015 (starting 1 Oct) from home health agencies which were formerly touted as a great way to save money. To put this in perspective: in 2013, Medicare paid about 12,000 home health agencies $18 billion to provide services to 3.5 million patients. In the US, Medicare has always had more restrictive rules for home and community-based services (HCBS); state-administered (but Federally subsidized) means-tested Medicaid still pays for the vast majority of long-term care (well over 60 percent, according to another Federal agency, Housing and Urban Development [HUD]), which strikes many observers as one pocket to another. So where are the contradictions?

  • Conundrum #1: CMS has emphasized post-discharge, post-acute care as part of reducing acute care costs, exemplified in the penalty for 30-day same-cause readmissions. Nursing home expenditure is at least three times more costly than in-home LTC (a conservative estimate used by HUD).
    • But CMS plans to cut Medicare home health funding in total so fewer people may receive it at all or less of it even if needed. What will be their alternative, and the effect on outcomes? (more…)