1. Comments to CMS re: 2017 Draft Call Letter for Medicare Parts C and D
Every year, the Centers for Medicare and Medicaid Services (CMS) releases a draft of payment, performance and other rules that will apply to Medicare Advantage (MA) and Part D plans that choose to participate in the Medicare program in the following calendar year. Commonly referred to as the “Call Letter,” this document is first released in draft form, subject to public comment, and is finalized a few months later, usually in April. The 2017 Draft Call Letter was released on February 19, 2016 (see: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Advance2017.pdf).
The Center, in collaboration with several other advocacy organizations, submitted comments to the Call Letter. There are proposals that we support, and hope are finalized, and others about which we have concerns. Here is quick overview of some of these provisions:
- We have significant reservations about the methodology that CMS is proposing for adjusting Star Ratings for Medicare Advantage and Part D plans based on socioeconomic and disability status. We are concerned that despite the stated objective of ensuring that the Star Ratings accurately reflect quality, the proposed methodology might mask true differences in quality for these populations.
- On the one hand, we strongly support CMS’ proposal to enhance oversight of MA plan provider directories, including proposed data elements to be reported by plans. On the other hand, we urge CMS to do much more concerning the broader issue of MA enrollee access to providers, including how network adequacy is defined and monitored, particularly in light of a recent General Accounting Office (GAO) report that highlights regulatory shortcomings in this area. GAO recommends, among other things, that CMS “augment oversight of MA networks to address provider availability, verify provider information submitted by MAOs, conduct more periodic reviews of MAO network information, and set minimum information requirements for MAO enrollee notification letters.” Further, we are very disappointed that CMS has taken no further action to strengthen consumer protections surrounding MA plan mid-year provider network terminations.
- We applaud CMS for including strong, clear language reminding MA plans about their obligations to prevent illegal balance billing of Qualified Medicare Beneficiaries (QMBs) and dual eligible plan members.
- Among the Part D-related proposals, we urge caution in testing whether plan coverage determination timelines should be extended to improve clinical decision-making, particularly given that elsewhere in the draft Call Letter, CMS reports that the volume of cases auto-forwarded to the Independent Review Entity (IRE) by plan sponsors that have failed to process certain appeals in a timely manner “has been significant and sustained over the past several years.” In addition, we support CMS’ proposal to increase the specialty tier threshold for the first time since 2008.
The Center’s full comments can be found at https://www.medicareadvocacy.org/center-comments-on-medicare-advantage-part-c-and-part-d-payment-policies/.
2. Comments to Senate Finance Committee re: High Drug Prices
In the last year, pharmaceutical companies have increasingly come under the lens of public scrutiny and have provided an issue of debate for presidential candidates in the 2016 election cycle. The prime example of this development was seen last year as Turing Pharmaceuticals increased the price of 62 year-old Daraprim from $13.50 to $750 overnight. While perhaps the most famous case in recent memory, Turing Pharmaceuticals is not alone in pricing individuals out of treatment. In December 2015, the United States Senate Committee on Finance published a report entitled “The Price of Sovaldi and its Impact on the Health Care System.” While the Senate Finance Committee’s report is focused on one pharmaceutical company, it underscores the need for Congress to adopt policy that lowers the cost of prescription drugs across the board.
On January 21, 2016, Senators Wyden and Grassley issued a letter to the health care and patient community seeking feedback on potential avenues for legislative reform. On March 4th, 2016, in response to this letter, the Center submitted comments to the Senate Finance Committee. Asking Congress to view the rising cost of prescription drugs from the perspectives of older adults and people with disabilities, the Center addressed two of the questions posed by the Senate Finance Committee: (1) What role does the concept of “value” play in this debate, and how should an innovative therapy’s value be represented in its price? And (2) What tools exists, or should exist, to address the impact of high cost drugs and corresponding access restrictions, particularly on low-income populations and state Medicaid programs?
- For the Center’s comments to the Senate Finance Committee, see: https://www.medicareadvocacy.org/center-comments-on-prescription-drug-pricing-reform/.
 Andrew Pollack, Drug Goes From $13.50 a Tablet to $750, Overnight, N.Y. Times (Sept. 20, 2015), available at http://www.nytimes.com/2015/09/21/business/a-huge-overnight-increase-in-a-drugs-price-raises-protests.html?_r=0 (noting that Daraprim is used to treat a parasitic infection that may be life threatening for newborns, and patients with AIDS or certain types of cancer.)