This Week in Healthcare Reform: June 25th, 2021

The Supreme Court hands down its latest Affordable Care Act decision; lawmakers focus on advancing critical telehealth legislation; an innovative partnership is announced to address rising generic drug prices; and, the pandemic swells Medicaid rolls.

Week in Review

SCOTUS Decision: Last week, the Supreme Court handed down its latest decision in a case challenging the Affordable Care Act (ACA).  It was the third time a lawsuit involving the law had found its way to the High Court, and the third time that justices upheld it.  This latest challenge argued that because Congress had zeroed out the individual mandate provision of the law in 2017, the law in its entirety must be struck down, given how interwoven the mandate was with the rest of the ACA.  Having, once again, survived this latest legal challenge, experts point to a handful of takeaways in the wake of the ruling, including what the future holds for the law.  For their part, opponents have  suggested that they’ll refocus their energies on how to address other issues in the healthcare space, like affordability.  Meanwhile, supporters of the law are turning their attention to how to expand it.

Telehealth Bills: Recognizing the importance of keeping in place key provisions that allowed for the expansion of telehealth services during the coronavirus pandemic, federal lawmakers have been working to advance a package of bills aimed at improving coverage beyond the COVID health crisis.  The driving concern is that the relaxation of restrictions governing when, where, and how telehealth can be used hinges on the continuation of the public health emergency.  One area in particular that has drawn increased legislative and regulatory focus is the use of audio-only telehealth.  A bill, introduced in the House, would remove geographic and originating site restrictions in order to ensure that Medicare beneficiaries’ homes can be used as originating sites for audio-only telehealth services.  Meanwhile, legislation has since been introduced in the Senate seeking to increase telehealth access for both Medicaid and the Children’s Health Insurance Program (CHIP).  Both bills would make permanent the expanded use of telehealth for programs serving some of the most vulnerable populations.  Separately, stakeholders have come together to urge the Centers for Medicare & Medicaid Services (CMS) to allow Medicare Advantage (MA) plans to include audio-only telehealth visits in their risk adjustment calculations.  These calculations are important, they argue, in that they affect the risk scores assigned to beneficiaries, which, in turn, reflects their overall health costs.  These risk scores ultimately impact reimbursement and benefit design.  Last year, CMS announced a policy change allowing diagnoses from video-based encounters to be used for risk adjustment calculations in MA.  However, as this change failed to include audio-only visits, MA plans have not been able to include this critical diagnosis information when they submit risk scores to CMS.  While telehealth use increased during the pandemic, failing to include audio-only encounters disadvantages already-vulnerable populations who are low-income, without broadband access, or uncomfortable with technology. 

Generic Rx Partnership: A growing collaboration involving key stakeholders from across the healthcare spectrum just added a pair of new partners to help in the ongoing effort to bring down the rising cost of generic drugs.  The newly-named CivicaScript initiative, a subsidiary of the hospital-owned nonprofit drugmaker, Civica Rx, announced last week that it had added health benefits company Anthem, Inc. and drug manufacturer Catalent as partners.  Since its launch, Civica Rx has grown to include over 50 health systems representing 1400 hospitals.  With Anthem now having joined the collective, the insurers backing CivicaScript represent 100 million covered lives.  The effort represents an innovative collaboration bringing together the experience and expertise of multiple healthcare stakeholders with operational line-of-sight into how the rising cost of generic drugs impacts consumers.  In making the announcement, CivicaScript officials said the initial plan is to focus on developing and manufacturing up to ten common, but pricey, generic drugs that are without sufficient market competition to drive down costs.  Those first generics could be available as early as next year.

Medicaid Enrollment: Over the course of the past year, enrollment in the Medicaid program hit an all-time high, with new data showing that between February of last year and January of this year the number of people in the program climbed by 9.7 million enrollees, pushing overall enrollment in Medicaid to nearly 74 million, an increase of more than 15 percent.  Additionally, an estimated 123,000 children joined CHIP during that period, an increase of 1.9 percent, putting enrollment in that program at around 6.8 million kids.  The boost in enrollment in both programs can be attributed to the pandemic, helped, in no small measure, by the additional federal matching funds to states for Medicaid included in the first coronavirus relief package passed by Congress last year.