Life Science Compliance Update

May 19, 2017

Medicare Cuts in the Future of HACRP Hospitals

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As has been noted, CMS named 769 hospitals that will face Medicare payment cuts in fiscal year (FY) 2017 under the Hospital-Acquired Condition Reduction Program (HACRP), which for the first time considered rates of infection from antibiotic-resistant bacteria in its calculations. The HAC Reduction Program requires the Secretary of the Department of Health and Human Services to adjust payments to applicable hospitals that rank in the worst-performing quartile of all subsection (d) hospitals with respect to risk-adjusted HAC quality measures. These hospitals will have their payments reduced to 99 percent of what would otherwise have been paid for such discharges. In the FY 2017, HAC Reduction Program, hospitals with a Total HAC Score greater than 6.5700 are subject to a payment reduction.

CMS on HACRP

From Modern Healthcare: “Our goal is for all hospitals to improve,” and roughly half did improve enough to escape the bottom quartile, said Dr. Patrick Conway, the CMS' deputy administrator and chief medical officer. Federal data on quality measures released earlier this month by the Agency for Healthcare Research and Quality also showed that between 2010 and 2013, progress was made in reducing patient harm and preventing avoidable deaths, he said.

Reaction

The Advisory Board collected reaction from stakeholders. Some noted that hospitals cannot fully control antibiotic-resistant infections that occur in their facilities. Louise Dembry, a professor at the Yale School of Medicine and president of the Society for Healthcare Epidemiology of America, said, "The reality is we don't know how to prevent all these infections."

Moreover, some critics take issue with the way HACRP assesses penalties. Because the program penalizes the 25 percent of hospitals that perform worst overall, in some cases a hospital is penalized even though it has reduced its rate of avoidable complications. Nancy Foster, vice president for quality and patient safety at the American Hospital Association, said, "The HAC penalty payment program is regarded as rather arbitrary, so other than people getting upset when they incur a penalty, it is not in and of itself changing behavior"

Example from Emory

Three Emory-affiliated hospitals were fined for high rates of hospital-acquired conditions for fiscal year 2017. Emory University Hospital Midtown (EUHM) is being fined for the third consecutive fiscal year, and Emory Johns Creek Hospital (EJCH) for the second consecutive fiscal year. Emory University Hospital (EUH) is being fined for a second fiscal year, the first instance occurring in 2015.

But Emory’s response is worth considering. Director of Media Relations of Emory Healthcare Janet Christenbury wrote in a statement that the ratings inaccurately compared hospitals because they are “based on methodologies that often do not sufficiently take into account the differences in patient populations and the complexity of conditions that certain hospitals treat.”

Teaching hospitals, such as Emory’s Midtown facility, are unique because they conduct various common and complex procedures and provide clinical education and training to current and future medical providers, Christenbury said. Consequently, there is more data to report to CMS in comparison to other facilities that treat patients with limited specializations or more common conditions, Christenbury added.

March 17, 2017

Op-Ed in The Hill on Allowing Medicare to Directly Negotiate Drug Prices

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Dr. Rafael Fonseca, a Chair of the Department of Medicine at the Mayo Clinic in Arizona and Distinguished Mayo Investigator, recently wrote an editorial in The Hill, a Washington, DC, based newspaper focused on politics in Congress.

In the editorial, Dr. Fonseca opined that allowing Medicare to directly negotiate drug prices, as has been advocated by a variety of voices (both in and out of the industry), would actually hurt seniors’ access to new drugs.

Dr. Fonseca uses the Veterans Affairs (VA) as an example of what happens when government programs are allowed to negotiated their own drug prices. Currently, the VA pharmacy benefits program negotiates drug prices and pays far less for drugs than many other providers. In order to contain costs, however, the program does not cover many of the newest, most effective treatments.

According to the editorial, many of those drugs that are not covered are “newly approved drugs with no substitutes available.” According to an August 2016 report by Xcenda consultants, only three of the 25 most innovative drugs were available in the VA drug formulary. Compare that to 11 Medicare Part D plans that covered all 25. The majority of Medicare plans covered 21 of the 25 drugs. 

Dr. Fonseca believes that popularity and the “will” of the public will continue to force through “doing something” on prescription drug prices. He believes that there are “three essential things that we must understand about drug costs and how we can address the challenge,” before taking such a risk:

  1. Innovative treatments are expensive to develop. While the cost of some prescription drugs can be high, consider that it takes an average of more than $2.5 billion to bring a drug to market, according to the Tufts Center for the Study of Drug Development. By allowing the marketing of drugs earlier in the approval process, speeding up approvals for competing compounds, and reducing the costs to bring new treatments to market, the FDA could allow for more price competition without harming innovative and access to effective treatments.
  2. Innovative drugs offset other healthcare costs. Medicine has changed dramatically for the better, and mostly because of the new drugs clinicians have in their toolbox. A 2012 Congressional Budget Office study estimated that for every one percent increase in medication utilization, overall Medicare program costs fell by one-fifth of a percent.

Since 1991, the nation's cancer death rate has dropped by 25 percent, according to a recent report by the American Cancer Society. Some cancers, like chronic myelogenous leukemia, are no longer a death sentence; metastatic melanoma, previously a death sentence, can now sometimes be controlled such as was done for President Carter. Hepatitis C can be cured with a short course of pills; and today the life expectancy of HIV patients is about the same as the general population. It is important to remember that today's drug treatments are, often, enormous advances in disease treatment. 

3. Price controls will kill innovation. The United States is the engine of innovation in healthcare, producing roughly half of the world's new drug treatments in the past decade. But the current proposals could threaten patient access and the development of future treatments. Health care economists John A. Vernon and Joseph A. Golec found that price controls imposed in the EU between 1986 and 2004 not only reduced R&D spending, they also "resulted in about fifty fewer new drugs and about seventeen hundred fewer scientists employed in the EU." Rather than feasting on the goose that lays the golden eggs, we should be looking for ways to grow more geese.

Conclusion

There is no denying that Medicare and other government-funded programs are facing a serious funding crisis and that changes to the programs are long overdue. However, it is important to review history and not make the same mistakes that have already been made in attempting to resolve the issue. Instead, Dr. Fonseca believes that “Medicare beneficiaries should have more freedom to choose the coverage and services that best meet their individual needs and preferences.”

March 15, 2017

MedPAC Considers Revised Approaches to Part B Drug Payment

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In mid-January, the Medicare Payment Advisory Commission (MedPAC) met and discussed a revised approach to clinician payment for Medicare Part B drugs. Under the new approach, the average sale price plus 6 percent (ASP + 6) payment methodology would be changed to include a variety of reforms including consolidated billing codes, an inflation limit for price increases and additional manufacturing reporting of ASP. The Commission also discussed a parallel policy which contemplates the start of a bidding program for Medicare Part B drugs.

Staff Presentation

MedPAC’s staff presented a policy approach to Part B drug reform that mirrors the approach to Part B physician payment reform under MACRA. There would be two tracks for Part B drug reimbursements: (1) an updated version of the current ASP +6 payment methodology or (2) and updated version of the Medicare’s competitive acquisition program (CAP) that MedPAC staff refers to as the Drug Value Program (DVP).

ASP + 6 Redesign

The improved ASP system would: feature new requirements for manufacturer reporting of ASP data; modify the add-on payment for drugs during the period prior to ASP data becoming available; implement an inflation cap on drug price increases similar to the Medicaid program; and utilize consolidated billings codes. Further, the current ASP + 6 add-on payment would be phased down over time to encourage DVP enrollment.

DVP Program

The DVP program would be created from lessons learned from the CAP program and would give the Secretary authority to use private vendors to negotiate prices and offer providers shared savings opportunities. The DVP would: be voluntary; include multiple vendors; and allow providers to share in savings that Medicare received on the drug’s purchase price. The DVP will be different from the CAP because vendors would be able to utilize a formulary with an exceptions and appeals process. Further, drug prices would not be able to exceed ASP.

Commissioner Discussion

ASP Redesign

Commissioners were largely supportive of the ASP redesign, though several expressed reservations about specific components of the proposals. Commissioner Amy Bricker (Express Scripts) noted that manufacturers should not be offered Part B reimbursement if they did not report ASP prices. Commissioner Paul Ginsburg (The Brookings Institution) noted that the Commission needed to consider the effects of the sequester, while Commissioner Kathy Buto pointed to possible complications with respect to the inflation limit surrounding beneficiary cost sharing implications.

Some Commissioners expressed “severe reservation” about grouping drugs together under a billing code due to concerns over “practical challenges” for how the drugs would be classified and intense stakeholder pushback. Commissioner Bricker, however, felt that there should be no exceptions for the consolidated billing as there will always be winners and losers in any market. Most, if not all, of the commissioners seemed to agree that biosimilars could be grouped with their reference because the FDA decided that the drugs were not meaningfully different.

DVP Program

With respect to the DVP, Commissioner Jack Hoadley stated it would make sense to have only a few vendors so that they would be able to consolidate buying power and negotiate good prices. Commissioner Brian DeBusk, on the other hand, commended staff for leaving flexibility in the DVP program design to encourage a variety of entities to bid on being a vendor. Overall, the Commissioners were largely supportive of the DVP. They agreed that it essentially amounted to an early form of government negotiation for prescription drugs. Commissioner Pat Wang believes that the DVP is “very much worth trying to detail out.”

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