We take a look at how the midterm elections affect healthcare.

View as webpage.

hpw - topbar hpw - topbar - diag hpw - topbar xce

Nov. 9, 2018


Forward to a Friend



View Archived Issues


Pass the Popcorn: Political Theater on Healthcare Issues


The midterm elections on Tuesday yielded the result many poll watchers had been expecting: the Democrats reclaimed the House of Representatives, the Republicans held the Senate, and everyone still cannot stop talking about our President. Nancy Pelosi (D-CA) is expected to re-assume her role as Majority Leader, though there are rumblings of discontent among her party colleagues.

The elections will have healthcare consequences, on both the federal and state levels. Below, we describe briefly how the change in power might affect healthcare.

House Jurisdiction of Healthcare Policy
In the House, Rep. Frank Pallone (D-NJ) will become Chairman of the Energy and Commerce Committee, of which its Health Subcommittee has jurisdiction over the health sector broadly, including private and public health insurance (Affordable Care Act [ACA], Medicare, Medicaid, Children’s Health Insurance Program [CHIP]), the Department of Health and Human Services (HHS), biomedical research and development, mental health, and the 340B drug discount program.

Fate of the ACA
Republican efforts to repeal and/or replace the ACA through legislation are likely doomed in the near term.

House Democrats will certainly advance refinements, such as reinsurance, but any changes will need to be approved by the Republican Senate, a dynamic that will likely elude major revisions.

Democrats in House leadership positions have indicated they will be investigating actions of the Trump Administration they view have weakened healthcare, such as withdrawing insurance-exchange reinsurance payments, shriveling ACA outreach efforts, partially supporting Republican attorneys general in a lawsuit against the ACA, and imposing Medicaid work requirements.

While House Democrats are unlikely to advance major healthcare legislation, they will be able to send bills to the Senate that draw distinctions between Republicans and them leading up to the 2020 elections.

340B Program
Republicans spent a good portion of the 115th Congress exploring how to constrain the rapidly expanding 340B program through a series of hearings. However, those efforts will likely be for naught, as shrinking the reaches of the drug discount program is likely not a priority for Democrats.

Drug Pricing
Many Democrats have supported removing the “noninterference clause,” the provision in the Medicare Modernization Act that banned negotiations between the Centers for Medicare & Medicaid Services (CMS) and pharmaceutical manufacturers on drug prices and prevented the government from developing its own formulary or pricing structure. In his American Patients First blueprint, President Trump also considered the cost-saving potential of the federal government negotiating drug prices with the industry, so it would not be unfathomable for Trump and House Democrats to partner together on this issue. However, the Republican-controlled Senate would likely impede such a radical departure from free-market activity.

Medicaid Expansion
Four red (Republican) states had Medicaid expansion on ballots Tuesday: Idaho, Montana, Nebraska, and Utah. Voters supported the measures in 3 of the 4 states, while they voted it down in Montana. With voters in those 3 states supporting expansion, 37 states have now acted to expand Medicaid. (The state legislature approved Medicaid expansion in Montana in 2015 but instituted a legislative sunset for the end of June 2019.)


Barcelona Bound? Join Xcenda at ISPOR Europe 2018


November 10–14, 2018 | Barcelona, Spain

Xcenda’s global HEOR team is excited to join nearly 5,000 attendees from around the world at ISPOR Europe 2018 in Barcelona, Spain. Timely topics such as global market access strategy and prospective studies are just a part of our focus, and we look forward to learning more about your most current challenges.

Stop by booth #314 to meet our team and explore how we can provide the local expertise you may need to reach your global goals.

Learn more >



HPW Rebuild


Xcenda is pleased to present the following guest post, written by Laura Simpson, Assistant Director at the American Autoimmune Related Diseases Association (AARDA), highlighting how step therapy, the insurer utilization-management tool, inhibits patient access to therapies for autoimmune diseases.


Report Card: Access Restrictions for Those With Autoimmune Diseases


A new report card tool launched in October by the Let MI Doctors Decide initiative is helping to shed light on the challenges faced by autoimmune patients when insurers place restrictions on access to treatment for their illnesses.

The report card is based on new research from Emory University that evaluated Michigan’s largest 25 health plans on the level of access restrictions they impose on treatments for 5 key autoimmune diseases—Crohn’s disease, multiple sclerosis, psoriasis, psoriatic arthritis, and rheumatoid arthritis. The restrictions include health insurance practices such as step therapy, which delays coverage of prescribed treatment by requiring that patients first try several drugs before covering the doctor-recommended medicines. According to the report card, nearly a quarter of the top 25 health plans evaluated received a failing grade for their access restrictions on treatment for the 5 diseases, and the vast majority received a grade of just a “C.”

Other key findings of the research include:

  • Patients suffering from psoriatic arthritis and rheumatoid arthritis appear to face the most treatment-access restrictions among the 5 conditions evaluated
  • Medicare plans impose far greater access restrictions on medicines for autoimmune diseases analyzed than private, commercial coverage
  • Among employers, plans covering federal employees imposed far greater access restrictions than other private and public employers in Michigan for all 5 autoimmune diseases

The report card is just the latest resource from Let MI Doctors Decide, launched last year to raise awareness about step therapy and to provide resources assisting doctors and patients to navigate the practice.

“Step therapy not only compromises patient health by delaying treatment, it also places burdens on health care professionals and our health care system as a whole,” said Virginia Ladd, President and Executive Director of AARDA, which led the launch of Let MI Doctors Decide. “This report card reveals just how pervasive access restrictions like step therapy have become for certain patient communities, and also demonstrates why these restrictions need to be limited.”

To learn more about Let MI Doctors Decide and explore its resources on step therapy, visit www.LetMIDoctorsDecide.org.

HPW Rebuild


Why Does HHS Write Like It’s Running Out of Time?


Yesterday, CMS issued a proposed rule to streamline the Medicaid and CHIP managed care regulations so states can better design, develop, and implement Medicaid and CHIP managed care programs tailored to each state’s local needs and populations.

In 2016, CMS issued a final rule that was a comprehensive rewrite of the Medicaid and CHIP managed care regulations to try to better align managed care rules with other healthcare coverage programs. CMS has since received stakeholder feedback that those regulations were unnecessarily prescriptive and added costs and administrative burden to state Medicaid and CHIP programs. The agency also formed a working group with state Medicaid directors to create a consensus framework for review and to prioritize areas of concern.

CMS believes the proposed rule released yesterday would streamline the 2016 managed care regulatory framework. As such, CMS proposes to revise the following areas:

  • Setting actuarially sound capitation rates
  • Pass-through payments
  • State-directed payments
  • Network adequacy standards
  • Quality Rating System (QRS)
  • Appeals and grievances
  • Requirements for beneficiary information
  • CHIP

Enrollment in Medicaid managed care was 54.6 million in 2016, representing 68.1% of all Medicaid enrollees. The swelling popularity of Medicaid managed care requires programs are optimally coordinated among state and federal governments and the commercial insurers administering the plans.

Public comments are due by January 14, 2019. The proposed rule was issued with an accompanying press release and fact sheet.


Hoping for Busy Badgers: CMS Approves WI Medicaid Requirements


Last week, CMS approved a waiver from Wisconsin to require that eligible enrollees engage in a “community engagement” and undergo a health-risk assessment to qualify for Medicaid. However, drug test requirements were not included as essential for coverage. It is estimated that the time from approval to implementation will be at least a year.

Medicaid members affected by the demonstration waiver are largely limited to non-pregnant, non-disabled, non-elderly childless adults with incomes of up to and including 100% of the federal poverty level. As of September 30, 2018, there were 148,156 childless adults enrolled in Wisconsin Medicaid, representing 12.53% of the state’s Medicaid population.

Eligible BadgerCare (Wisconsin-specific terminology for Medicaid) enrollees will need to perform 80 hours per month of “community engagement activities,” meaning time spent at a job, in school, in job training, or doing volunteer work. However, exemptions do exist—those: 1) with children; 2) over 50 years old; 3) with disabilities; 4) who are medically frail; or 5) who are a primary caregiver, will be exempted from the activity requirement. If beneficiaries do not meet the 80-hour requirement for an aggregate 48 months (ie, total time not working cannot exceed 4 years), they will lose coverage for 6 months.

Similar to commercial payers, Wisconsin also will require the eligible BadgerCare applicants to disclose certain health behaviors such as excessive drinking, tobacco use, and lack of exercise. Those with “riskier” behaviors may be charged higher premiums; individuals with “approved” answers will be charged a lower monthly insurance premium compared to their counterparts.

Joining Indiana, Arkansas, and New Hampshire, Wisconsin is the fourth state to receive approval to operate a community-engagement program; given CMS’ stance, expect more states to consider submitting an application.


Tarheel of an Idea: Medicare Reference Pricing for State Employees


To reduce costs and improve transparency, North Carolina announced a proposed plan that would index insurance payments for state employees’ and teachers’ healthcare to Medicare rates beginning in 2020. The state hopes to save $300 million per year, and health plan members to save approximately $60 million, if the proposed plan is finalized. The proposal would move the plan from the Blue Cross and Blue Shield of North Carolina’s (Blue Cross NC) commercial network of providers with their proprietary fee schedules to a reference-based payment system linked to a percentage of Medicare rates to pay providers for services.

The North Carolina Medical Society and the North Carolina Healthcare Association, among other local provider associations, oppose the plan, noting the potential negative impact on patients’ access to quality care, particularly those located in rural areas already reeling from recent hurricanes.

North Carolina would be the second state, behind Montana, to shift to payment based on Medicare rates. If the plan does move forward, other states could follow suit.


MIP-PY! Positive Payment in Year 1


This week, CMS released year 1 performance data for clinicians participating in the Merit-based Incentive Payment System (MIPS) under the Quality Payment Program (QPP). Overall, MIPS-eligible clinicians did well in the inaugural year of the program; 93% earned a positive payment adjustment in 2017; of those, 22% earned an additional adjustment for exceptional performance.

However, some differences emerge when results are broken down by special status. For example, 19% of small practices received a negative payment adjustment compared to only 5% of all MIPS-eligible clinicians who received a negative payment adjustment. Over 70% of small practices still earned a positive payment adjustment.

Although the results appear generally positive for the first year, it is important to keep in mind that the metrics for positive payment are more attainable in the initial years as clinicians get acquainted with the program. CMS expects payment adjustments will be more distributed in future years as the performance threshold gradually increases.

To assist clinicians with growing pains, CMS has made the commitment to continue providing no-cost technical support for all clinicians as well as customized support for small and rural practices and clinicians who received negative payment adjustments. CMS has done well so far with providing assistance, reporting a 99.8% customer satisfaction rate from clinicians and practice managers. For additional details on the performance data, check out the recent CMS blog post and infographic.


Information Buffet (AKA, Other Stuff That Caught Our Attention)


We kept running into stories we wanted to bring to your attention, so here’s a quick hit list of other news we thought you should know:

  • During an appearance at a value-based care summit, HHS Secretary Alex Azar said the Administration would “revisit” mandatory models it had previously scrapped in cardiac care, and he said the time had come for “exploring new and improved episode-based models in other areas, including radiation oncology.”
  • CMS issued a proposed rule, “Patient Protection and Affordable Care Act (PPACA): Exchange Program Integrity,” the purpose of which is to safeguard taxpayer dollars by ensuring people are accurately determined eligible for premium subsidies they receive through the exchange. See the accompanying press release and fact sheet.
  • Coherus BioSciences announced the Food and Drug Administration (FDA) approved UDENYCA (pegfilgrastim-cbqv), its biosimilar of Amgen’s NEULASTA (pegfilgrastim), for patients with cancer receiving myelosuppressive chemotherapy. UDENYCA is the 14th biosimilar to obtain FDA approval, and the second FDA-approved biosimilar of NEULASTA, following the FDA’s approval this past June of Mylan and Biocon’s FULPHILA (pegfilgrastim-jmdb), which has since launched.
  • The FDA held a public hearing on November 5 regarding the future format of the National Drug Code (NDC). Recognizing that a change to NDC length and/or format will be necessary when the FDA runs out of 5-digit labeler codes, the FDA said it held the public hearing to receive input from stakeholders on how to maximize the benefit and minimize the impact in advance of any forthcoming change.
  • International management consulting firm Oliver Wyman released its 2018 Consumer Survey of US Healthcare, which explored why only a small minority of consumers have tried new healthcare options that offer patients convenience and low cost.


It’s that time again...open enrollment for the insurance exchanges. As we have done each year, we will compare weekly enrollment in the current and previous years for the 39 exchanges that use the HealthCare.gov platform for the 2019 benefit year, including the federally facilitated exchanges, state partnership exchanges, and some state-based exchanges.

Comparison of 2018 and 2019 Weekly Open Enrollment Snapshots for HealthCare.gov



  Cumulative Enrollment After 1 Week


– Tweet by Jason Ukman, Managing Editor, statnews, November 7



65% vs 44%, 44%, 47%


A Cato 2018 Health Care Survey of 2,498 Americans found 65% favor regulations that prohibit insurance companies from refusing to cover, or charging higher premiums to, people with pre-existing conditions, while 32% oppose.

However, support plummets when Americans are faced with likely consequences of these regulations. Support drops 20 points to 44% in favor and 51% opposed if pre-existing condition protections limited people’s access to medical tests and treatments. Similarly, 44% would favor and 50% would oppose if these regulations harmed the delivery of high-quality healthcare. Support drops 18 points to 47% in favor and 48% opposed if these regulations limited people’s access to top-rated medical facilities and treatment centers.

Source: Cato Institute 2018 Health Care Survey, November 5


ISPOR Europe 2018

November 10–14 | Barcelona, Spain
Are you Barcelona bound? Xcenda’s global HEOR team is excited to join nearly 5,000 attendees from around the world at ISPOR Europe 2018 in Barcelona, Spain. Timely topics such as global market access strategy and prospective studies are just a part of our focus, and we look forward to learning more about your most current challenges. Stop by booth #314 to meet our team and explore how we can provide the local expertise you may need to reach your global goals. Learn more


Count on Health Policy Weekly for an at-a-glance view of legislative and regulatory developments and news that impacts the healthcare industry.


Jennifer Snow
Vice President,
Reimbursement and
Policy Insights,

Scott Shields
Associate Director,
Health Policy



Amy Grogg, PharmD
Senior Vice President | Commercialization Solutions | AmerisourceBergen Corporation

Kristine Flemister, PharmD
President | Xcenda

Tommy Bramley, PhD, RPh
President | Lash Group

Stacie Heller
Vice President | Government Policy | AmerisourceBergen Corporation

Rita Norton
Senior Vice President | Government and Public Policy | AmerisourceBergen Corporation

Ana Stojanovska
Vice President | Commercial Consulting | Xcenda


Isabell Kang | Jenna Kappel | Jennifer Le | Scott Shields


Laurie Kozbelt | Ellen Olson | Tia O’Brien


Nov. 9, 2018


Forward to a Friend



View Archived Issues



Connect with AmerisourceBergen:   AmerisourceBergen.com   I  AmerisourceBergen Insights  |   LinkedIn   I  Twitter  

Connect with Xcenda:   Xcenda.com   I   LinkedIn   I  Twitter