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Editor's Note: This is a complimentary research note published by Healthcare Policy analyst Emily Evans. CLICK HERE to get COVID-19 analysis and alerts from our research team and access our related webcasts. |
POLITICS
It was like that time your beautiful first cousin from Alabama, under threat of being grounded for life, was forced to go to the prom with your mom's best friend's son, an avid Warhammer fan from Poughkeepsie.
The awkward pairing of Donald Trump and health policy was restored momentarily on Friday when the president released, or said he would release, four new Executive Orders on drug prices.
These Executive Orders travel a well worn path. One will allow for importation of drugs from Canada; another for 340B discounts earned by Federally Qualified Health Centers on Epi-pens and insulin to be passed on to patients; a third to eliminate manufacturer rebates in Medicare Part D plans; and a final one, still unreleased, to tie Medicare drug prices to an international index.
Stop me if you have heard this before.
These orders say more about the White House's inability, despite years of trying, to develop a coherent health care policy than it does about the dog-eared proposals themselves.
You can draw a straight line from that deficiency to the very reason the president poll's numbers suffer: competency.
The health care policy apparatus led, at least in theory, by HHS Secretary Alex Azar, has been plagued by intra- and inter-agency disagreements. Azar, a former pharma executive has favored measures to end the Medicare drug rebate system that subsidized Part C premiums.
CMS Administrator Seema Verma opposed the move because Medicare Advantage premiums would rise, limiting growth in enrollment and opportunities for more reforms. Azar has been skeptical drug price increases could be limited by international competition but the White House political shop disagrees.
Normally, policy differences like these, when they do occur, are hammered out behind closed doors. Not in the Trump administration. Chaos is king. Unfortunately, on Capitol Hill and elsewhere in Washington, the lack of harmony within the administration is perceived as indecision and ineptitude. The original efforts now repeated in Friday's Executive Orders stalled in 2019.
The Executive Order proposals all have some merit, now and when they were first considered. The 340B program and the Part C rebates create such distortions in the market, the price of a drug is merely theoretical.
The U.S. role as the R&D lab for the world's drug supply is approaching its natural limit.
Had the policy differences been reconciled within the administration in 2018, the Trump administration could be well on its way to restructuring the dysfunction pharmaceutical policy. Now, these Executive Orders are little more than an effort to change the subject and revive what was once a priority for many Americans.
POLICY
For all it's policy awkwardness, the Trump administration is not without its sensible reforms.
Eschewing the conventional wisdom that protected the brick and mortar health care institutions for decades, CMS has made transforming telemedicine to merely medicine a priority with long lasting implications.
Even before the COVID-19 outbreak, CMS had implemented expansions of the Medicare benefit to permit greater use of telemedicine in Medicare Advantage plans. The pandemic allowed them to extend liberalization of the benefit to traditional Medicare.
Critical reforms permitting a visit to originate from anywhere, like a patient's home, and not constrained by rural geography or technology format created a massive expansion of telehealth visits between March and June.
There is broad concensus that many emergency provisions should be retained and the next iteration of COVID-19 relief is considered the most likely vehicle for accomplishing that.
However, an outline circulated last week and originating from Majority Leader McConnell's office indicates "[t]elemedicine reimbursement policies are extended through the end of 2021."
Such a temporary extension, likely due to CBO scoring considerations, may come as a disappointment until you recall Congress' time honored year-end routine of extensions that have for decades made the temporary permanent.
We do believe that the Office of the Inspector General's enforcement discretion regarding use of non-HIPAA platforms like Facetime and Skype is not likely to endure.
The discretionary nature of the OIG's position and genuine provider concerns about privacy have already permitted EHR platforms like Epic and MDRX to displace early and temporary use of popular apps. Another provision that may get tossed is one allowing a virtual visit to initiate a patient-doctor relationship, limiting telemedicine visits to established patients.
The wording of the McConnell outline suggests the most critical provision will remain, at least for now. Reimbursement of virtual visits on a parity basis with in-office visits is a predicate for continued expansion of the service and uptake by providers.
A negative for $TDOC for certain but a positive for health care as a whole.
POWER
Not that we needed more evidence but the COVID-19 pandemic has reminded us of the old political campaign maxim, "tell your story or someone will do it for you."
Telling the story of the COVID-19 outbreak has been very data dependent; good and bad; accurate and misleading; stale and real time.
Everything from sketchy websites of unknown provenance, media outlets, academic institutions and mercifully, state health departments, have moved quickly to establish dashboards of downloadable data.
The State of Florida produces a county-by-county report totalling 2400 pages as well as case line data on 400,000 people tested positive for SARS-CoV-2.
AWOL from the great COVID-19 data obsession is the Federal Government, whose IT shortcomings spilled out into public view last week during a turf battle between HHS and the CDC over hospital capacity.
It would be easy to blame the Trump administration for the miserable communication of a compendium of data points from CLI Emergency visits to testing to hospital occupancy. The truth is, IT procurement at the federal - and arguable the state and local - level has been a mess for years.
Procurement law, policy and systems were designed for an era when governments bought stuff; machinery, buildings, paperclips. It was not designed for the 21st century where procuring Software as a Service was the most pressing request.
The CDC, charged with collecting and reporting hospital capacity, struggled to complete the task, even on a week lag. HHS, which is responsible for distributing Remdesivir, needed information in real time. To get over the quagmire, HHS ordered hospital to report data to HHS, causing the CDC to take their marbles and go home. It appears they have now worked things out but not before conspiracy theories were woven into the tale.
The Federal Government is slowly coming up the curve on data availability, providing those with a welcoming mind greater insight into the disease spread and impacts.
Unfortunately, it comes too late for the credibility of the Trump administration and its pandemic fighting reputation.
