July Was a Busy Month for Centers for Medicare and Medicaid Services (CMS)

CMS and The Affordable Care Act

The U.S. Court of Appeals Fifth Circuit heard oral arguments in landmark Texas v. U.S., challenge to the Affordable Care Act (ACA). The appeals court is reviewing a federal trial court’s December 2018 decision invalidating the ACA by determining the individual mandate to be unconstitutional. In a compelling argument the justices compared the components of the ACA to a game of Jenga in which the entire system, comprised of interdependent parts, could easily fall apart if a single piece is removed. If the lower court’s ruling is upheld and the ACA invalidated, the result may cause millions of Americans to lose health coverage. Those approaching Medicare eligibility would be disproportionately impacted, since pre-existing conditions increase with age. Over 31 million individuals, ages 55-65, have a pre-existing condition for which they could be denied health coverage. The impact of cost shifting to workers compensation, in the absence of health care coverage, is a threat to property and casualty insurers. the result may also impact claim settlements involving Medicare Secondary Payer recovery, including conditional payments owed to CMS and the allocation of future medical treatment and costs to protect Medicare from future liabilities.

CMS Coverage Guidelines for Acupuncture

In response to the Opioid Crisis, Medicare considers adopting coverage guidelines for acupuncture for the treatment of chronic low back pain. The Centers for Medicare & Medicaid Services (CMS) announced on July 15 that it proposes to cover acupuncture under section 1862(a)(1)(E) of the Social Security Act (the Act), with the support of the Agency for Healthcare Research and Quality under section 1142 of the Act.

CMS has established criteria for research studies and clinical trials to assess the effectiveness of acupuncture for the treatment of chronic low back pain; all studies must be approved by CMS and address the following research questions: 1) Does the use of acupuncture for the treatment of chronic low back pain decrease pain and/or increase function? 2) Does the use of acupuncture for the treatment of chronic low back pain decrease the use of other continuing medical treatments and services (e.g. opioids)?

CMS is seeking comments on their proposed decision and particularly interested in comments that address current studies of acupuncture in the Medicare population. Care Bridge International inquired of acupuncture organizations in Florida, their knowledge of this CMS development and any current research in treating chronic low back pain among the larger constituency of Medicare beneficiaries living in Florida. We will continue to monitor this development and keep you informed.

CMS and Big Pharma

In addition to the Fair Drug Pricing Act which passed the Senate Health, Education, Labor and Pensions (HELP) Committee last month, on July 25 the Senate Finance Committee voted 19-9 to advance the Prescription Drug Pricing Reduction Act, a bipartisan deal to lower drug prices. The combined effect of these bills would simultaneously require that drug manufacturers not only lower drug prices but also disclose and justify any planned drug pricing increases to control the escalation of drug costs over time. The CBO expects the financial impact to represent a savings to taxpayers of $100 Billion and Lowers Medicare Beneficiaries’ Out-of-Pocket Costs by $27 Billion and Premiums by $5 Billion over the next 10 years. The effect of these initiatives should also impact the methodology used by the CMS Workers Compensation Review Center (WCRC) for MSA approval, and a significant reduction in Part D prescription drug costs in MSAs should be realized within the next two years. We will continue our advocacy with CMS to drive improvements in Part D prescription drug allocations for MSAs and keep you updated.

Happy Birthday, Medicare and Medicaid!

July 30, 2019 marked the 54th Birthday celebration of Medicare and Medicaid, critical healthcare safety nets serving the poor, disadvantaged, disabled and elderly in our country.