Workforce
The win: The Pediatric Subspecialty Loan Repayment Program (PSLRP) was authorized by the CARES Act legislation; however, it is not yet funded. The Resident Physician Shortage Reduction Act (H.R. 1763/S. 348) made progress, with 240 co-sponsors.
Context: Pediatric rheumatology fellowship slots are filled around 50% of the time, while adult rheumatology fellowship slots must turn away applicants. The final COVID-19 package of 2020 repealed the cap on Medicare support for graduate medical education (GME) instituted by the Balanced Budget Act of 1997 and added 1,000 new Medicare-funded GME full-time equivalent residency positions, beginning in fiscal year 2023. The PSLRP legislation addresses the pediatric workforce shortage by providing funds for loan forgiveness when certain metrics are met.
Telehealth: Parity & Access
The win: The CMS and commercial insurance companies increased reimbursement for telehealth visits to match those of in-person visits during the public health emergency (PHE). Many states followed suit and increased telehealth reimbursement in Medicaid and some state-regulated health plans.
Context: Prior to 2020, telehealth was a novelty practiced by few providers. As in-person visits plummeted during the PHE, providers quickly learned and implemented procedures to treat patients virtually. Prior to the pandemic, reimbursement was quite low for telehealth, despite acuity and providers’ cognitive efforts. The CMS, followed by commercial insurers, increased reimbursement for audio-visual telehealth visits—and, later, audio-only visits—to match in-person visits.
The CMS recognizes that telehealth is here to stay when this PHE is over. It has begun to add additional services to the list of covered services for telehealth for post-pandemic treatment.
Utilization Management & Reimbursement: Step Therapy, Prior Authorization & DXA Scans
The wins: Regarding step therapy, H.R. 2279 has 157 bipartisan co-sponsors and the companion Senate bill, S. 2546, has 18 bipartisan co-sponsors. Regarding prior authorization, H.R. 3107 has 280 bipartisan co-sponsors. Regarding DXA reimbursement, H.R. 2693 and the companion bill S. 283 have bipartisan support.
Context: Step therapy is a burden for providers and patients. This legislation requires Employee Retirement Income Security Act (ERISA) health plans to allow for reasonable overrides for physicians to be able to use certain medications. The prior authorization legislation will protect patients in Medicare Advantage plans that delay or deny access to care. It also supports reporting back to the CMS how often Medicare Advantage plans approve or deny medications and services. Funding for DXA reimbursement is at an all-time low. This legislation will set a $98 floor for DXA reimbursement.
