The CONNECT for Health Act suggests the future isn’t too remote

A new piece of legislation would increase the use of telehealth and remote patient monitoring (RPM) in the Medicare program. The Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act, a bipartisan piece of legislation, is aimed at cutting health care costs while improving care outcomes. The bill is premised on the belief that telehealth is the future of medicine and that the quality of care can be greatly improved, in a cost effective way, through better contact between patients and providers.

Provisions

The CONNECT for Health Act would loosen current restrictions on Medicare reimbursement for telehealth and RPM services. Specifically, the legislation would allow certain providers to use telehealth and RPM without many of the current 42 U.S.C. §1834(m) limitations, which include originating site restrictions, geographic limitations, restrictions on store and forward technologies, limitations on distant site providers, and limitations on covered codes. The act would also permit providers to use telehealth and RPM in alternative payment models without most of the Section 1834(m) restrictions. The act would allow RPM of certain patients with chronic conditions, permit more facilities to serve as originating sites, and enable telehealth and RPM to be considered basic benefits in Medicare Advantage, without most of the Section 1834(m) restrictions.

Response

According to an Avalere study, the bill could save as much as $1.8 billion over the next ten years. The American Medical Association (AMA) has expressed its support for the bill, noting that it stands to strengthen physician-patient relationships and improve care access while maintaining patient safety. The bill was introduced by Senators Brian Schatz (D-Hawaii), Roger Wicker (R-Miss), Thad Cochran (R-Miss), Ben Cardin (D-Md), John Thune (R-SD), and Mark Warner (D-Va). The Senators praised the advances of health information technology and the promise of telehealth, noting the importance of the opportunity to bring together improvements in technology with the prospect of better care quality.

Do voters really care about health care reform?

In April of last year, the Atlantic told readers that this question would be “the most decisive question” of the upcoming 2016 presidential election: “Will you take away my health insurance?” On February 2, 2016, the House of Representatives, voting mostly along party lines, failed to override President Obama’s veto of the latest attempt to repeal the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) in the form of the Restoring Americans’ Healthcare Freedom Reconciliation Act (H.R. 3762). Yet, while attacks on reform efforts are usual rhetoric for Congressional Republicans as well as most of the GOP presidential candidates, a recent study by the Kaiser Family Foundation shows that voters’ interest in health reform as an issue in the presidential primary race is not as strong as some had predicted. Does this mean that voters do not care about health reform as much as we thought? Further, will this trend continue once the primaries are over and the Republican and Democratic candidates go head-to-head?

Kaiser study

A Kaiser Tracking Poll released in January of 2016 revealed that the ACA does not “rank highly as an issue for voters in the presidential primaries.” While the general cost of health care ranked as the third most important issue—with 28 percent of voters stating that that issue would be “extremely important” to their presidential vote—the ACA specifically ranked eighth overall, with 23 percent of respondents stating it was extremely important to their vote. Other issues ranking above the 2010 health reform were terrorism (38 percent), the economy and jobs (34 percent), the federal budget deficit (28 percent), and gun control (27 percent). Moreover, when respondents were asked to choose the single most important issue in the presidential race, only 4 percent chose the ACA.

CNN poll

A less specific question asked in a recent CNN poll ranked health care in general as the third most important issue in the election. When asked how important, on a scale of extremely important to not that important, a list of issues would be in the upcoming election, 35 percent stated health care would be extremely important, 41 percent said it would be very important, and 18 and 6 percent considered it moderately important or not that important, respectively. The poll also revealed that only 39 percent of respondents were aware of President Obama’s recent veto to the ACA-repealing legislation and that opinions are steady and almost evenly split when it comes to satisfaction with the ACA, with 44 percent having an unfavorable view and 41 percent favoring the reform.

Candidates’ opinions

Current Republican front-runners for the presidential nomination, including Senator Ted Cruz (R-Texas), Senator Marco Rubio (R-FL), and Donald Trump, have expressed their intentions to repeal the ACA, if elected. Yet, there is no one replacement plan that all the candidates agree on. While Cruz and Rubio both voted in favor of the recent attempt to repeal the ACA through H.R. 3762, Trump’s views on the reform have been vague. Beyond “bashing the current law” and promising that “everybody’s going to be taken care of” and “the government’s [going to] pay for it,” Trump’s particular stance on health reform is unknown. The lack of a solid position on this issue for the popular candidate has GOP leaders concerned.

On the Democratic side, while former Secretary of State Hillary Clinton has promised to make general improvements in health care costs, she supports a continued implementation of the ACA. Her sole democratic opponent, Bernie Sanders (D-VT), has indicated that, if elected, he intends to pursue replacing the ACA with a “Medicare for all” single payer system.

As the votes for and against the override of the President’s veto of H.R. 3762 show, it appears that support for health care reform is split between party lines. However, in terms of the current presidential candidates, the views on health care reform are not as uniform. Because of the unique circumstances of the current presidential primaries, it may not be clear to what extent health care reform will be a major deciding issue for the race until the primaries are over and the Democratic and Republican nominations are decided.

Highlight on Vermont: New all-payer model grows out of state Medicaid budget crisis

For months, Vermont has been struggling with how to pay for its Medicaid program as reported costs have far outstretched allotted budgets. Instead of reducing benefits for all of the newly insured enrollees in Vermont’s health care programs, Governor Peter Shumlin announced a new payment system entirely, one that he claims will transform its health care system from one that rewards fee-for-service, quantity-driven care to one that rewards quality-based care that focuses on keeping Vermonters healthy.

All payer model. This new all-payer model is described by Shumlin as an agreement between the state and CMS that enables the three main payers of health care in Vermont–Medicaid, Medicare, and commercial insurance—to pay for health care differently than the traditional fee-for-service reimbursement. In an all-payer model, Vermonters will continue to have the same choice of providers as they have today under Medicare, Medicaid, and commercial insurance. Benefits will not be reduced and by changing the payment structure, Medicare beneficiaries may have access to, and coverage for, new services not currently covered by Medicare.

In Vermont’s proposal, the all-payer model will require commercial insurers and Medicaid to pay the same way Medicare will be paying for health care under its Next Generation program. All involved payers will approach health care payment to accountable care organizations in a common way and all payers will provide doctors and other health care professionals the flexibility they need to lead health care delivery change. Maintaining the same set of rules, standards, and methods of payment across payers will drive efficiencies in the system. The all-payer model builds off current federal and state health care reform efforts that have value-based payment components.

Outlined to the public on January 25, 2016, Shumlin and the Green Mountain Care Board released an outline or term sheet detailing the new all-payer system. The state is focusing on three main health goals: increasing access to primary care, reducing the prevalence of chronic diseases, and addressing the substance abuse crisis. The term sheet lays out plans to curb expenses by setting a 3.5 percent spending target and 4.3 percent spending cap, with a commitment that “Medicare will grow more slowly in Vermont than nationally.” These financial targets, the term sheet notes, are based on health care services in Vermont’s Medicare, commercial, and Medicaid shared savings programs today, mostly hospital and physician services.

“From Day 1, reforming the way doctors and other medical providers are paid has been a priority of my administration,” Gov. Shumlin said. “This is the only way we will curb the rising cost of health care that gobbles up money faster than Vermonters can make it. Today is the beginning of the rubber hitting the road on cost containment. Our success will mean better health outcomes for Vermonters and the end to health care costs rising faster than our economic growth.”

Investments in infrastructure. To curb spending, Vermont is planning to incorporate old and new ways of making health care more affordable. By investing in the state’s current infrastructure, Shumlin plans to expand the Services and Supports at Home (SASH) program, which already has a track record of saving money while keeping seniors in their home and out of hospitals. Another program Vermont intends to continue with is Medicare participation in the Blueprint for Health, Vermont’s nationally recognized initiative transforming primary care, which has also already demonstrated success. The state also proposes to add Medicare participation in the Hub and Spoke opiate addiction treatment program.

The state is currently in the process of finalizing negotiations of the terms of the all-payer model with the federal government. The information and terms released by Vermont do not represent the final state plan.

FDA approval of new hepatitis C drug may temper drug prices

Patients with hepatitis C have gained a new treatment option, which may help curb the rising cost of drugs treating the virus. The FDA has approved Zepatier® with or without ribavirin for the treatment of chronic hepatitis C virus infections in adult patients. Previously, the FDA gave Zepatier a breakthrough therapy designation, which is a program designed to expedite the development and review of drugs intended to treat a serious condition after preliminary clinical evidence indicates that the drug may demonstrate substantial improvement over currently available therapy.

Growing competition among hepatitis C drugs may help to stabilize the increasingly high prices for these products. Merck stated that including Zepatier in treatment options for patients with chronic hepatitis C virus (HCV) provides the U.S. “with an unprecedented opportunity to significantly reduce the burden of [the virus.]” Merck has set a list price for Zepatier of $54,600 for a 12-week regimen, which it believes to be in the range of net prices for other 12-week antiviral regimens used to treat HCV. Merck anticipates that its competitive pricing and its comprehensive access strategy to seek broad coverage “will help broaden and accelerate patient access to treatment and move us closer to our shared goal of reducing the burden of chronic HCV in the U.S.”

Compared with the prices of treatments from Gilead Sciences Inc., an early competitor in the market for oral hepatitis C drugs, like Sovaldi® being sold at $1,000 per pill ($84,000 for a single course of treatment) and single-tablet regimen Harvoni® with a list price of $94,500, Zepatier is expected to be a welcome addition to the market. In December 2015, the Senate Committee on Finance found, through its own investigation, a revenue-driven pricing strategy behind Sovaldi, which caused Medicare and Medicare to spend more than $5 billion on Sovaldi and Harvoni in 2014. Financial statements showed U.S. sales of the drugs through public programs and private payers totaling $20.6 billion after rebates in the first 21 months following Sovaldi’s introduction to the market.