This story has been updated with a clarification.
Buried in the spending deal that congressional negotiators announced on Tuesday are several nuggets that should be of interest to hospitals, home health providers and pharmaceutical companies. They won't have any immediate impact but could lay the groundwork for significant policy changes.
Congress is seeking answers from the CMS about its requirement that home healthcare agencies provide face-to-face certifications by a physician before the agency will cover in-home care for Medicare and Medicaid beneficiaries. The spending deal asks the agency to detail in its 2016 budget request how that requirement has prevented fraud, increased access to healthcare and affected costs for the Medicare and Medicaid programs. It also calls on the agency to present a plan for how the face-to-face certification requirement can be simplified.
Congress also wants the CMS to provide an analysis within 90 days of how “rebasing” is affecting home healthcare agencies. Providers have estimated that the payment changes will amount to a 14% cut (PDF) by 2017.
“It basically is a definitive, bipartisan statement to CMS that Congress is concerned about these two issue areas in home health,” said William Dombi, vice president for law at the National Association for Home Care and Hospice.
The budget deal also addresses concerns about critical-access hospitals. In recent years, the Obama administration has proposed eliminating critical-access designation for facilities that are within 10 miles of each other. That would result in lower Medicare and Medicaid payments for those hospitals. Currently there are more than 1,300 critical-access hospitals nationwide. Congress wants the CMS to produce a report within 90 days of enactment of the budget deal looking at how the 10-mile rule would affect access to healthcare providers in rural communities.
“There's been a lot of concern about the president's proposal, particularly from rural hospital advocates,” said Eric Zimmerman, principal at McDermottPlus Consulting. “Ten miles is sort of an arbitrary number.”
Congress is also expressing concern about the 340B program, which requires that drugmakers give rebates on certain outpatient drugs to hospitals that serve large numbers of low-income and uninsured patients. Congress authorized funding in the last fiscal year for the U.S. Health Resources and Services Administration to create a website documenting drug prices under the 340B program. The spending deal orders HRSA to provide a briefing to the House and Senate appropriations committees by March 3 on its progress.
“There are concerns that HRSA has been unable to demonstrate that the 340B program benefits the most vulnerable patients,” the spending deal states. “In order to best serve the public need, the program should examine its ability to ensure patients' access to 340B savings for outpatient drugs.”
In October, the Pharmaceutical Research and Manufacturers of America, the industry's trade group, filed suit again to strike down a 2014 rule by HRSA that allows safety net hospitals to obtain discounts when purchasing so-called orphan drugs when using them to treat non-orphan conditions or diseases through the 340B program. The drug industry has also raised questions about how 340B providers use savings generated by the program.
Safety Net Hospitals for Pharmaceutical Access, which represents facilities that benefit from the 340B program, expressed support for the website. “We are very pleased to see the drug ceiling-price website moving forward and we look forward to HRSA's update on the project,” the organization said in a statement. “Healthcare providers need to know they are not being overcharged by manufacturers.”
PhRMA, meanwhile, has complained that participating hospitals don't use the 340B savings for the patients who qualify them for the program. The law, however, allows hospitals to use the funds for general purposes.
A previous version of this story did not adequately specify which part of the legislation is supported by the Safety Net Hospitals for Pharmaceutical Access.
Jaimy Lee contributed to the reporting of this story.
Follow Paul Demko on Twitter: @MHpdemko
