Effects of Insurance Marketplace Uncertainty

Even as Senators continue to consider “Graham-Cassidy,” the latest Affordable Care Act (ACA) repeal legislation, insurance markets are already reacting to uncertainty and instability brought about by persistent GOP efforts to upend the post-ACA insurance landscape. Between the Trump Administration’s ongoing refusal to commit to long-term funding of the ACA’s cost-sharing reductions (CSRs) and legislative overtures to repeal key portions of the ACA, premiums have increased, insurers have exited state exchanges, and access to health care coverage has been compromised. Continue Reading

MACRA Update: How to Prepare for Changes in MIPS

As we reported last month, CMS’ proposed rule updating MACRA’s Quality Payment Program (“QPP”) for CY 2018 would extend and expand exceptions that would allow many practitioners to avoid participating in its Merit-based Incentive Payment System (“MIPS”) during next year’s performance period. In particular, the proposed rule would increase the low-volume threshold for MIPS-participation from $30,000 to $90,000 and present additional opportunities for advanced alternative payment model participation. In 2017, approximately 800,000 practitioners were exempted from MIPS-participation and CMS estimates that an additional 134,000 would be exempted under the proposed rule, leaving less than 40% of eligible practitioners subject to MIPS participation in 2018. Continue Reading

CMS Aims to Nix Obama-Era Payment Models

In a proposed rule published Tuesday, August 15, 2017, the Centers for Medicare & Medicaid Services (CMS) announced its intention to roll back a handful of payment models introduced under the Obama Administration. If implemented, the rule would cancel the Episode Payment Models (EPMs) and Cardiac Rehabilitation (CR) Incentive Payment Model, each currently set to begin next year. The rule would also cut the number of mandatory participation locations in the Comprehensive Care for Joint Replacement (CJR) Model from 67 to 34. Continue Reading

ACA Cost-Sharing Reductions– A Momentary Reprieve and Ongoing Doubts

The Future of CSRs – A Tale Told in Tweets. In follow-up to our May 5, 2017 blog post, “ACA Cost-Sharing Reductions: An Uncertain Future,” on August 16, 2017, the Trump Administration made an announcement (Announcement) that it will continue to fund cost-sharing reduction (CSR) payments to insurers in accordance with the CSR provisions in the Affordable Care Act (ACA) for the month of August. The Announcement did not include any commitments to fund CSR payments in September or anytime thereafter. Continue Reading

MACRA Quality Payment Program Update

On June 20, 2017, CMS released its proposed rule updating MACRA’s Quality Payment Program (“QPP”) for CY 2018. At over 1,000 pages, the rule might not do much to simplify the already complex requirements of the QPP; however, it would expand and extend the flexibility offered by CMS to practitioners in the 2017 performance period into the 2018 performance period, potentially reducing the program’s immediate burden. Nevertheless, as CMS’ ramp-up to full implementation of the program continues, practitioners should use any flexibility offered in the 2018 performance period as an opportunity to prepare for the imposition of potentially more onerous requirements in the 2019 performance period. Continue Reading

Recent Department of Justice Crackdown on Fraud and Abuse

As reported by the New York Times in an article dated July 13, 2017, in an effort to crack down on fraud and abuse, and with a particular focus on opioids, the Department of Justice (“DOJ”) is charging 412 individuals for collectively defrauding the government of around $1.3 billion. Of the individuals implicated, approximately one-third are being accused of opioid-related crimes. These crimes include billing Medicare and Medicaid for drugs that were never purchased, collecting money for fake treatments and tests, and exchanging prescription drugs for money. The fraud and abuse prosecutions are spread across more than 20 states, which include California, New York, Florida, and Texas. Continue Reading

Part VIII: BCRA – What Is Dead May Never Die

In Part VII of our blog series, Very Opaque to Slightly Transparent: Shedding Light on the Future of Healthcare, we described the Better Care Reconciliation Act of 2017 (“BCRA”), the Senate GOP’s latest Obamacare repeal and replace legislation. While the Senate GOP leadership had hoped to vote on this bill as soon as this week, the sudden announcement on July 17th by Senators Mike Lee (R-UT) and Jerry Moran (R-KS) of their opposition to BCRA has effectively killed the legislation as written. With Senators Susan Collins (R-ME) and Rand Paul (R-KY) having previously voiced their refusal to support BCRA, the bill simply lacks sufficient votes to pass or even be voted on by the full Senate. In response to this development, Senate Majority Leader Mitch McConnell issued the following statement: Continue Reading

More Telemedicine Food for Thought: Exception Five to the Haight Act’s In-Person Examination Requirement

In our July 10, 2017 post regarding telemedicine prescribing, we wrote about the seven exceptions to the Haight Act’s requirement that a provider and patient have an-person visit before a prescriber/practitioner can prescribe a controlled substance for his/her patient. As we concluded in the post, the current exceptions are so narrowly focused that they are of limited utility to telemedicine providers and practitioners. Continue Reading

Giving Telemedicine More Room to Breathe: Recent and Pending State and Federal Actions in the World of Online Prescribing

On October 18, 2008, the Ryan Haight Online Pharmacy Consumer Protection Act of 2008 (the “Haight Act”) came into law as the federal government’s first attempt to address the public health risks associated with online pharmacies – such risks including the dispensing of drugs (including addictive drugs to be used recreationally) without a valid prescription, and the dispensing of adulterated drugs, counterfeit drugs, and/or expired drugs, all of which could result in significant harm to individuals who may have been looking for an easy way to obtain prescribed medications at a lower price. Continue Reading

Part VII: The Senate’s Response to the American Health Care Act

Caveat: As of the date of this writing, there are indications that revisions to the Better Care Reconciliation Act of 2017 (“BCRA”) are in the works and may be issued as soon as Friday, June 30, 2017. If a revised BCRA is issued, there will be a new CBO report generated with respect to the revised bill. We will continue to watch the progress of the BCRA and, as a result, we will post to this blog additional blog posts regarding BCRA revisions, if any, and the BCRA’s advancement through the Senate, if any.

In Part VI of our blog series, Very Opaque to Slightly Transparent: Shedding Light on the Future of Healthcare, we outlined the “Macarthur Amendment” to the American Health Care Act (“AHCA”), which led to the bill’s narrow passage in the House on May 4, 2017. Almost 50 days later, on June 22, 2017, Senate Majority Leader Mitch McConnell released a “discussion draft” of the Senate’s response: the BCRA. While in large part similar to its House counterpart, there are some important changes, outlined below. Continue Reading

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