Updates from CMS and BCBS IL
Senate Looking at High Pharmaceutical Prices Again
The Senate may soon consider another attempt at limiting Medicare’s exposure to increasing pharmaceutical prices. After proposed legislation failed to materialize a few years ago, Senator Ron Wyden, chairman of the Senate Finance Committee, is working on updating a previous bill to limit prescription drug price increases for Medicare patients.
The renewed effort comes amid news that the FDA has approved the first new drug to help manage Alzheimer’s in almost twenty years. The drug, Aduhelm, is set to cost $56,000/year despite having limited clinical trial support for its effectiveness. Wyden called the price “unconscionable” during a Senate Finance Committee hearing
In related news, an analysis from the Medicare Payment Advisory Commission (nonpartisan agency of the legislative branch) showed that Medicare’s Part D prescription spending grew by 26% from 2013 to 2018. The increase outpaced inflation during the same period by roughly three times. Further, the analysis pointed to higher drug prices, not increasing prescription usage, as the primary culprit behind the spending surge. Review the complete study here. http://www.medpac.gov/docs/default-source/reports/jun21_medpac_report_to_congress_sec.pdf?sfvrsn=
Historically, rapid increases in spending generally lead to more calls for government intervention. However, passage of any bills from Senator Wyden’s committee will depend on bipartisan support. A bill in the House that would give Medicare the power to negotiate drug prices has floated around for some time, but has little chance of passing the evenly divided Senate.
Providers can help limit spending in this area by reviewing their patients’ prescriptions to ensure cost-effective options, including generic prescriptions or alternative therapies such as lifestyle changes, are used whenever appropriate.
New Vendor to Handle Blue Cross and Blue Shield of Illinois’ Overpayment Review
BCBS IL recently announced a change in their overpayment claim review department. Digital intelligence and consulting firm, EXL Health, will take over BCBS IL’s complex claim review process starting with claims filed on July 1st. Be on the lookout for overpayment notifications, and corresponding appeal directions, coming directly from EXL and not BCBS IL, or their previous vendor, EquiClaim. BCBS IL will still perform the actual overpayment recoupments when necessary
Mental Health Services Not Recovering to pre-Pandemic Levels
A CMS analysis shows that mental health services during the first seven months of the COVID-19 pandemic dropped significantly, and unlike many other areas, has yet to recover. Specifically, CMS’ data found 34% fewer mental health services were performed in the middle of 2020 than the same timeframe in 2019, which calculates to 14 million fewer services for children under age 19. This coincides with a notable rise in mental health issues across all ages, as well as an increase in drug-related mortalities.
In response, CMS started an initiative to enroll eligible, but currently uninsured children in Medicaid and CHIP, to provide more opportunities for them to find necessary care. Providers can assist the effort by performing mental health screenings and counseling uninsured patients or their parents about their options on healthcare.gov, which can guide them to selecting ACA Marketplace or Medicaid plans.