What Does This Mean?
On October 3, President Trump signed an (EO) to “protect and improve Medicare by building on those aspects of the program that work well, including the market-based approaches in the current system.” The EO does not trigger any immediate policy changes – instead it directs the Secretary of the U.S. Department of Health & Human Services (HHS) and other agency heads to undertake certain rulemaking procedures and to produce reports within specified timeframes.
What Will the EO Do?
Broadly, the EO focuses on expanding access to Medicare services by reducing regulatory barriers and increasing beneficiary access and choice. The EO includes a rejection of Medicare-for-All and lays out areas for Medicare improvement, including more plan choice, improved network adequacy for Medicare Advantage (MA) plans, faster adoption of new technology and breakthrough products, and a reduction in fraud, waste, and abuse.
How Might This Impact Pharmacy Practice?
ASHP was pleased to see the inclusion of a provision to remove regulatory barriers that “limit professionals from practicing at the top of their profession.” The EO directs the HHS Secretary to propose regulations that would “eliminate burdensome regulatory billing requirements, conditions of participation, supervision requirements, benefit definitions, and all other licensure requirements of the Medicare program that are more stringent than applicable Federal or State laws require and that limit professionals from practicing at the top of their profession.” This language suggests that HHS hears ASHP’s arguments that failing to fully and effectively engage pharmacists is a poor use of clinician resources. At minimum, it could be used to further justify the inclusion of pharmacists on healthcare teams. It does not, however, make legislative changes that would be needed to give pharmacists Medicare provider status.
It is important to note that the EO language is vague, which provides HHS with great flexibility in implementing it. For instance, the EO proposes to eliminate only those barriers that “are more stringent than applicable Federal or State laws.” It is unclear exactly which regulations would be targeted – will HHS consider only those regulations affecting Medicare providers, or will they read the provision broadly to include regulations limiting pharmacist participation on the healthcare team? Further, should HHS interpret the EO’s direction to “eliminate burdensome regulatory billing requirements” to mean the types of changes to incident-to billing it proposed in the , then pharmacists could face reimbursement challenges. ASHP will continue to actively engage with HHS in an effort to expand and enhance the pharmacist’s role on the healthcare team.
Other sections of note in the EO include deal with reimbursement more broadly:
Clinician Neutral Payment: The EO directs HHS to “conduct a comprehensive review of regulatory policies that create disparities in reimbursement between physicians and non-physician practitioners and propose a regulation that would, to the extent allowed by law, ensure that items and services provided by clinicians … are appropriately reimbursed in accordance with the work performed rather than the clinician’s occupation.” Again, this language is vague and open to interpretation, but the idea is that payment will be tied to the service rather than varying based on the clinician providing the service. This could potentially incentivize NP and PA billing at the expense of pharmacists providing incident-to services. It could also significantly impact overall reimbursement for healthcare teams, particularly in outpatient clinics.
Site Neutral Payment: The EO also doubles down on HHS’s plans to expand site neutral payment, directing HHS to “ensure that Medicare payments and policies encourage competition and a diversity of sites for patients to access care.” ASHP will continue to oppose site neutral reimbursement policies that ignore care quality and undermine care coordination efforts.
Payment Parity Report: The EO directs the HHS Secretary to coordinate with the Council of Economic Advisors to create a report on “approaches to modify Medicare [fee-for-service (FFS)] payments to more closely reflect the prices paid for services in MA and the commercial market…”. Medicare FFS reimbursement is significantly lower than the payment rates for MA and commercial plans. Payment parity between Medicare FFS and MA and commercial plans would require substantial increases to Medicare FFS reimbursement.
What’s Next?
As noted above, the EO does not provide detail on how the new policies will be implemented. Instead, those decisions will be left to HHS and other regulators. There are a number of questions HHS will need to address regarding the removal of regulatory barriers, including:
- Which regulations will HHS target?
- How will HHS determine which current regulations go beyond what is required by State and Federal law?
- Will HHS focus only on Part B eligible providers or will it expand its review to include pharmacists?
The timelines for agency action vary by policy proposal – but most provisions require action within one year (by October 3, 2020). ASHP will review the proposed regulatory rules as they are published and update members accordingly.