November/December 2022 Industry Updates
CMS, HHS Expand Access to Behavioral Health, Whole-Person Care
The US Department of Health and Human Services (HHS) and Centers for Medicare & Medicaid Services (CMS) announced on November 1, 2022, the expansion of access to cancer screening coverage, dental care, and behavioral health care through the Calendar Year 2023 Physician Fee Schedule (PFS) final rule.
Through accountable care organizations (ACOs) the innovation and coordinated care in the Medicare program will also be promoted through the PFS final rule.
“Access to services promoting behavioral health, wellness, and whole-person care is key to helping people achieve the best health possible,” said CMS Administrator Chiquita Brooks-LaSure. “The PFS final rule ensures that the people we serve will experience coordinated care and that they have access to prevention and treatment services for substance use, mental health services, crisis intervention, and pain care.”
By allowing behavioral health clinicians such as marriage and family therapists and professional counselors to offer general as opposed to direct supervision of the Medicare practitioner, CMS hopes to make it easier for Medicare beneficiaries to get behavioral health services.
According to CMS, opioid treatment programs that use telecommunications with patients to initiate treatment with buprenorphine will be paid by Medicare and these programs can also bill for opioid use disorder treatment services provided through mobile units.
Furthermore, policies are being finalized by CMS to pay for clinical psychologists and licensed clinical social workers to furnish integrated behavioral health care as part of a primary care team.
To strengthen whole-person care CMS is working on the following:
- expanding and enhancing accountable care by finalizing changes to the Medicare Shared Savings Program;
- reducing barriers and expanding coverage for colon cancer screening such as reducing the minimum age for screening from 50 to 45 years;
- finalizing payment for dental services that are integral to covered medical services; and
- payment rates for 2023.
“Together, we are building a stronger Medicare program,” said Deputy Administrator and Center for Medicare Director Meena Seshamani, MD, PhD. “No matter who you are, or what diagnoses you have, these changes will help ensure that Medicare treats the whole person—caring for physical health, behavioral health, and social needs that are integral to health—and ensuring access to the high-quality care all people deserve.” —Samantha Matthews
Real-Time Prescription Benefit Check Lowers Out-of-Pocket Costs
Real-time prescription benefit (RTPB) recommendations reduced out-of-pocket costs for patients, especially for those prescribed high-cost medications. Researchers published their findings in JAMA Internal Medicine.
“Rising drug costs contribute to medication nonadherence and adverse health outcomes,” said Sunita M Desai, PhD, affiliated with the NYU School of Medicine, and coinvestigators. “[RTPB] systems present prescribers with patient-specific out-of-pocket cost estimates and recommend lower-cost, clinically appropriate alternatives at the point of prescribing.”
Researchers conducted a cluster randomized trial in which providers in a large, urban, academic health system implemented RTPB recommendations for adults treated in the outpatient setting. The study was conducted from January 13, 2021, to July 31, 2021, and researchers carried out analyses between August 20, 2021, and June 8, 2022, using electronic health record (EHR) data.
After providers entered a prescription in the EHR, the RTPB system recommended lower-cost alternatives which included different medications, prescription lengths, and pharmacy options. The prescriber was then free to choose the initial prescription or one of the recommended alternatives.
Out of 867,757 total outpatient prescriptions, there were 36,419 (4.2%) with alternative options. The RTPB intervention yielded out-of-pocket costs of $39.90 for a 30-day supply, compared to $67.80 for patients whose prescriptions were not run through the system.
Of note, RTPB recommendations reduced out-of-pocket costs by 11.2% overall (95% CI, -15.7% to -6.4%) and 38.9% for high-cost drugs specifically (95% CI, -47.6% to -28.7%).
The intervention did not affect rates of 90-day supply, and mail order pharmacy use was similar between groups, at “9.6% and 7.6% in the intervention and control groups, respectively (adjusted 1.9 percentage point increase; 95% CI, 0.9 to 3.0).”
“This cluster randomized clinical trial showed that RTPB recommendations led to lower patient out-of-pocket costs, with the largest savings occurring for high-cost medications. However, RTPB recommendations were made for only a small percentage of prescriptions,” study authors concluded. —Maria Asimopoulos
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