Starting on January 1, Pennsylvania will employ a preferred drug list for its Medicaid program – a list that applies to both fee-for-service and managed care patients.

And as many as 150,000 of the state’s 2.8 million Medicaid beneficiaries may find themselves facing changes in their prescription drugs.

The purpose of the PDL is to save money – an estimated $85 million a year, according to the Pennsylvania Department of Human Services, which administers the state’s Medicaid program.

While physicians may submit requests to the state for exemptions for specific patients for specific purposes, those exemptions may be relatively uncommon:  the managed care plans that serve the vast majority of the state’s Medicaid population face daily fines starting at $1000 a day if their adherence to the new PDL falls below 95 percent.

Learn more about Pennsylvania’s new Medicaid PDL and how it may affect providers and patients in the Philadelphia Inquirer article “Nearly 150,000 in Pa. could be forced to change medications beginning on Jan.1.  Here’s why.”

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Should Medicare offer graduate medical education money for nurse practitioner and physician assistant training?

That was the subject of a recent inquiry by the U.S. Government Accountability Office.

In a new report inspired by concern over the current physician shortage and the belief that making greater use of nurse practitioners might help relieve that shortage, the GAO examined whether expanding Medicare’s graduate medical education (GME) program to include resources for the training of nurse practitioners and physician assistants was practical or possible.  As part of its research, the GAO reviewed current literature, interviewed officials of professional associations, and explored the financial and academic implications of a greater federal role in the training of nurse practitioners and physician assistants.

Read about what the GAO learned in its new report Views on Expanding Medicare Graduate Medical Education Funding to Nurse Practitioners and Physician Assistants…

While Congress’s decision this week to put off addressing the surprise medical bill challenge until next year has disappointed many, that decision did not reflect any lack of ideas for what to do.

At last count, various parts of Congress were considering four major surprise medical bill proposals:  one from the Senate Health, Education, Labor and Pensions Committee, one from the House Energy and Commerce Committee, one from the House Ways and Means Committee, and a compromise proposal from the Senate HELP and House Energy and Commerce committees.  Some have been around for some time while one emerged only in the past week.

The Commonwealth Fund has prepared a summary of the four proposals that includes a chart that compares where they stand on six major aspects of surprise billing legislation:

• The medical settings to which the legislation would apply.
• Whether they hold consumers harmless for surprise bills.
• Whether they ban balance-billing.
• How – or if – they establish standard rates.
• How they resolve disputes between insurers and providers.
• How they interact with existing state surprise medical bill laws.

Learn more from the Commonwealth Fund report “Update on Federal Surprise Billing Legislation: Understanding a Flurry of New Proposals.”…

A federal court has provided relief to hospitals that saw reduced Medicare payments for some outpatient services in 2019.

But that relief is only partial.

In response to a suit filed by several hospital groups, a federal court ruled that the Centers for Medicare & Medicaid services had illegally reduced Medicare payments for services provided in some hospital off-campus outpatient departments beginning on January 1, 2019 and ordered the federal government to repay the hospitals for the Medicare revenue they lost.  The reduced payments were part of a new Medicare site-neutral payment policy for outpatient services, and CMS has announced a plan for reimbursing affected hospitals for their losses.

At the same time, however, CMS announced that despite the court’s ruling, it will implement the same policy of reduced payments for outpatient care provided in some hospitals’ off-campus outpatient departments in 2020, and an effort by hospitals to persuade the court to ban this payment reduction was rejected by the same court that ruled against CMS on the 2019 payments.

Learn more about the ruling that CMS must reimburse  hospitals for lost payments in the Healthcare Dive article “Hospital group cheers CMS move to pay back outpatient payment cuts.”  Learn …

The Medicaid and CHIP Payment and Access Commission met for two days last week in Washington, D.C.

The following is MACPAC’s own summary of the sessions.

The Medicaid and CHIP Payment and Access Commission kicked off its December meeting with highlights from its forthcoming issue of MACStats: Medicaid and CHIP Data Book, due out December 18, 2019. MACStats brings together statistics on Medicaid and State Children’s Health Insurance Program (CHIP) enrollment and spending, federal matching rates, eligibility levels, and access to care measures, which come from multiple sources.

Later the Commission discussed a proposed rule that the Centers for Medicare & Medicaid Services issued in November, which—among other changes—would increase federal oversight of Medicaid supplemental payments. The final morning session addressed payment error rates in Medicaid, with a briefing on the annual Department of Health and Human Services Agency Financial Report (AFR). Fiscal year 2019 was the first time that the AFR incorporated eligibility errors since the Patient Protection and Affordable Care Act’s Medicaid eligibility and enrollment changes took effect in 2014.

After lunch, MACPAC staff summarized themes from expert roundtables convened in November, one to explore Medicaid policy on high-cost specialty drugs and another on the need for more …