Telehealth, PBM reform legislation among health care issues pending in DC

In a divided government, a bipartisan legislative accomplishment “is a hard-to-achieve prize,” but some legislation relating to health care still has a chance of getting through Washington in the current Congress.

That was the word from Nick Bath, partner at Manatt Health, during a webinar this week about the legislative, regulatory and industry trends shaping health care. Here are some areas to watch.

Pharmacy benefit manager reform legislation

The Pharmacy Benefit Manager Transparency Act 2023 is aimed at helping drive down costs for seniors by holding PBMs accountable for the use of anti-competitive business practices. The Congressional Budget Office estimates that the legislation would reduce the federal deficit ty $740 million over the next 10 years.

The Senate Committee on Commerce, Science and Transportation voted to send the bill to the full Senate for a vote.

Bath described the bill as “one of the few areas of bipartisan possibility.”

Medicare Part D drug price negotiations

Bath gave an update on Medicare Part D drug price negotiations. In March, the Centers for Medicare and Medicaid Services released guidance detailing how it would conduct the first year of Medicare Part D drug price negotiation under the Inflation Reduction Act.

Beginning with 10 Part D drugs for 2026, CMS must select the single-source drugs or biologics with the highest Medicare expenditures, with certain exceptions. The manufacturers of the selected drugs are then required to negotiate a “maximum fair price,” which will be made available to pharmacies and other dispensers for Medicare beneficiaries.

Sept. 1 is the deadline for the Department of Health and Human Services to publish the first list of selected drugs subject to negotiation.

Telehealth policy trends

COVID-19 transformed the telehealth landscape and telehealth continues to be used even as the pandemic winds down, said Jared Augenstein, Manatt Health managing director.

In 2021, 30 million Americans conducted about 106 million telehealth visits, he said. Telehealth usage now represents about 40% of behavioral health visits, 10% of primary health care visits and less than 5% of specialty care visits. Almost half of all behavioral health care is being delivered virtually today.

Significant policy changes in response to the COVID-19 public health emergency accelerated the implementation, adoption and widespread use of telehealth services across the health care industry. However, not all policy changes will continue permanently, he said.

Telehealth flexibilities expected to continue include:

• Expansion of covered services.
• Allowing patients to receive care from any location.
• Allowing additional provider types to deliver telehealth.
• Elimination of in-person exams before receiving care via telehealth.
• Allowing providers to offer hybrid care models.

Telehealth flexibilities expected to narrow when the public health emergency ends May 11 include:

• Coverage of services that involve more physical touch or are higher acuity – such as inpatient and emergency department-level hospital services or specialized therapy evaluations.
• Coverage of a broad range of services offered only via audio.
• Enforcement discretion that enabled the use of non-HIPAA compliant telehealth technologies such as FaceTime.

Some telehealth flexibilities are yet to be determined, Augenstein said. They include:

• Cross-state licensure flexibilities and exceptions.
• Laws and rules pertaining to telehealth-only providers.

Telehealth payment parity also is a key issue for the states, Augenstein said, with more than 20 states implementing laws requiring insurers to cover and pay for telehealth services at parity with in-person services when clinically appropriate.

Susan Rupe is managing editor for InsuranceNewsNet. She formerly served as communications director for an insurance agents' association and was an award-winning newspaper reporter and editor. Contact her at [email protected]. Follow her on Twitter @INNsusan.

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Susan Rupe is editor in chief, magazine, for InsuranceNewsNet. She formerly served as communications director for an insurance agents' association and was an award-winning newspaper reporter and editor. Contact her at [email protected].