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Second Opinion Podcasts

Learn about policy issues important to medical schools and teaching hospitals, with Atul Grover, M.D., Ph.D.

Appropriators Discuss FY 2016 Request for NIH, Preparedness, Title VII

February 27, 2015—The House Labor, Health and Human Services, Education, and Related Agencies (Labor-HHS) Appropriations Subcommittee Feb. 25 held the first hearing of the year to discuss the president’s fiscal year (FY) 2016 budget request for the Department of Health and Human Services (HHS). HHS Secretary Sylvia M. Burwell testified.

While there was bipartisan support for many priorities in the budget request, including the proposed increase for the National Institutes of Health (NIH), Subcommittee Chair Tom Cole (R-Okla.) noted the subcommittee will have limited resources due to the return of sequestration in FY 2016 and the Budget Control Act caps set in law. 

Given this context, he asked Secretary Burwell how she would prioritize the budget request. Burwell said the budget is a reflection of tough choices, but also described the fiscal climate of FY 2013 when government agencies were operating at sequester levels. During that time, she noted, NIH had the lowest number of research project grants in a decade. She also highlighted several recent public health challenges, including the Ebola outbreak, the influx of unaccompanied minors across the border, and the measles outbreak.

In light of these challenges, House Appropriations Committee Chair Hal Rogers (R-Ky.) also expressed concern about the budget context, adding, “we're facing a budget crunch that requires tough decisions in order to maintain continued investment in life-saving and breakthrough medical research, as well as prevention and treatment initiatives.”

House Appropriations Committee Ranking Member Nita Lowey (D-N.Y.) praised the budget’s investments in medical research at NIH, and for replacing sequestration. However, she cautioned that in the absence of a larger budget agreement and robust allocation for the subcommittee, the appropriations process would be “deeply imperiled.”

Subcommittee Ranking Member Rosa DeLauro (D-Conn.) echoed Lowey’s concerns, highlighting that after adjusting for inflation, the Labor-HHS budget has lost nearly $20 billion since 2010, translating to “less money for medical research, less money for public health, and less money for other critical priorities across the Labor-HHS bill.”

Rep. DeLauro added, “We must do better. We need to eliminate the sequester caps once and for all, and return to adequate levels of funding to support our nation’s health…We must invest in the NIH to accelerate breakthroughs against diseases like cancer… We must invest in public health, to strengthen our country in the fight against measles, meningitis, Ebola, and the obesity epidemic.”

Representative Lucille Roybal-Allard (D-Calif.) commended the administration for supporting the Health Resources and Services Administration (HRSA)’s Title VII health professions programs and for the newly proposed Title VII Health Workforce Diversity Program [see Washington Highlights, Feb. 6]. She said, “In today’s increasingly diverse population, HRSA’s Title VII health professions training programs have really been an invaluable tool in creating a pipeline of minority primary care professionals who overwhelmingly return to practice in diverse underserved areas.”

However, Rep. Roybal-Allard expressed concern that the new Health Workforce Diversity Program may not address the pre-high school pipeline as the Title VII Health Careers Opportunity Program (HCOP) does, and also had concerns about the administration’s proposal to eliminate the Title VII Area Health Education Centers (AHEC) program, despite proven success. 

Other discussion topics included the nation’s prescription drug abuse epidemic and the impact of the new electronic billing system beginning in October 2015, known as ICD-10, on small physician practices.


Alexandra Khalife
Legislative Analyst
Telephone: 202-828-0418


Energy and Commerce Health Subcommittee Hearing on President’s FY 16 Budget

February 27, 2015—Secretary of Health and Human Services (HHS) Sylvia Mathews Burwell testified at a Feb. 26 House Energy and Commerce Health Subcommittee hearing on the president’s fiscal year (FY) 2016 budget proposal [see Washington Highlights, Feb. 6].

The budget blueprint includes a number of Medicare proposals of importance to academic medicine including a $16.3 billion reduction in Medicare Indirect Medical Education (IME) payments, a new proposal to equalize Medicare rates for services provided in off-campus hospital outpatient departments (HOPD) and other provider settings totaling $29.5 billion in savings, and a reduction of Medicare bad debt reimbursement saving $31.1 billion over ten years.

In her opening testimony Secretary Burwell outlined the administration’s “critical investments in health care, science and innovation, and human services,” accounting the increase of $4.8 billion in discretionary funding from FY 2015 appropriations as a commitment to “make the investments that are necessary to serve the millions of American people who count on our services every day, while laying the foundation for healthier communities and a stronger economy for the middle class in the years to come.”

Rep. Eliot Engel (D-N.Y.) expressed his strong concerns with the administration’s proposal to cut IME funding and emphasized the value of academic medical centers stating, “it requires significant funding and time to develop the infrastructure and expertise necessary to ensure quality care is available. How do we ensure stability for these academic medical centers and the patients they serve, if we put Graduate Medical Education funding at risk?”

Secretary Burwell replied, “we believe and hope that our proposal will not do that and meets the objectives of making sure we are training appropriate physicians for both primary care and specialties, when we don’t have as many as we should.”

Subcommittee Chair Joe Pitts (R-Pa.) opened the hearing recognizing the need for collaboration to refine the administration’s budget proposal stating, “if we are going to save and strengthen our safety net programs for the most vulnerable, we have to do better than the President’s budget. Both parties have to work together. You, we, and the President need to work together to save our entitlement programs and make them sustainable.”

Full Committee Ranking Member Frank Pallone (D-N.J.) applauded the administration’s recognition of the importance of research funding in the budget [see Washington Highlights, Feb. 6] stating, “I was pleased to see that the president’s budget included a funding increase of $1 billion for the National Institutes of Health (NIH). Investing in early stage basic research is one of the most promising ways that we can accelerate the discovery of new treatments and cures.”


Len Marquez
Director, Government Relations
Telephone: 202-862-6281

Courtney Summers
Legislative Analyst
Telephone: 202-862-6042


AAMC Comments on CMS Star Ratings TEP Report

February 27, 2015—The AAMC Feb. 25 submitted comments on the Centers for Medicare and Medicare Services (CMS) Measure Selection for Hospital Star Ratings technical expert panel (TEP) comment report. The TEP proposed nine measures for a future star ratings system on the hospital quality website, Hospital Compare.

The AAMC expressed concerns with the TEP’s goal of creating a hospital-level star rating score, noting that Hospital Compare covers a “wide range of conditions and procedures in the inpatient, outpatient, and emergency department settings” and that combining all of these “multiple dimensional aspects into a single summary score may be misleading and may not be representative of the aspects of care that is truly important for each consumer.”

The letter further recommends excluding measures under review in the National Quality Forum’s (NQF) sociodemographic status (SDS) trial period from the stars rating display (see related story). This exclusion would include the hospital level readmissions measures utilized in the Hospital Readmissions Reduction Program (HRRP).

Finally, the AAMC requests that CMS phase-in star ratings, starting with a subset of measures that can be used to compare performance across various types of hospitals.

The TEP report summarizes recommendations from the first of three planned meetings. The TEP’s next two meetings will focus on developing a method for converting each hospital’s summary score into a five star rating.


Scott Wetzel
Senior Specialist, Health Care Affairs
Telephone: 202-828-0495


CMS Proposes Adjustment for MA Star Rating to Account for Sociodemographic Factors

February 27, 2015—The Centers for Medicare and Medicaid Services (CMS) Feb. 20 released advance notice of methodological changes for calendar year (CY) 2016 to adjust Medicare Advantage (MA) capitation rates.

One proposal aims to modify the calculation of star ratings to account for plans that serve large populations of disadvantaged patients. Under the proposal, CMS would reduce the weight by 50 percent for seven of the 46 total measures where performance was associated to sociodemographic status (SDS) factors.

In a follow up release, CMS explained that they sought “to provide relief to plans serving large numbers of dual or LIS [low-income subsidiary] beneficiaries while (they) conduct additional research into what is driving the association.” CMS also stated that this adjustment was an interim step, and is considering additional changes to measures affected by patient SDS characteristics.

Adjustment for SDS in performance measures has been a widely discussed issue. The National Quality Forum (NQF) is currently running a trial period to see the impact of adjusting for SDS for certain measures. In a letter to CMS about a star rating system for hospitals (see related story) the AAMC asked the agency to exclude those measures that are under review in the NQF’s SDS trial period. The AAMC argued that performance for these measures would be inaccurately portrayed without an appropriate SDS adjustment.

Comments on the CMS MA plan proposal are due March 6.


Scott Wetzel
Senior Specialist, Health Care Affairs
Telephone: 202-828-0495


CMS Issues Final HHS Notice on Benefit and Payment Parameters for 2016

February 27, 2015—The Centers for Medicare and Medicaid Services (CMS) Feb. 20 issued a final rule on benefit and payment parameters included in the Affordable Care Act (ACA, P.L., 111-148 and P.L. 111-152). The rule sets forth 2016 payment parameters and provisions related to the risk adjustment, reinsurance, and risk corridors programs; cost-sharing reductions; and use fees for federally facilitated exchanges.

Most notable in the final rule, the Department of Health and Human Services (HHS) clarifies that insurance coverage is required to include substantial coverage of inpatient hospital services and physician services to meet the ACA’s minimum value (MV) threshold, which is consistent with recently published CMS guidance.

The MV threshold, designed to protect enrollees from substandard coverage and financial liability for substantial unanticipated health care expenses, requires coverage of at least 60 percent of expected costs for an enrollee. 

Previously an MV calculator created by HHS was certifying plans as meeting the 60 percent coverage standard, despite plans having minimal inpatient hospital coverage. If employer coverage is certified as meeting the MV threshold, then employees are not eligible to receive subsidies to buy insurance through the online marketplaces.  The final rule clarification of the “minimum value” necessary to meet the 60 percent standard furthers the ACA intent of deterring employers from offering inadequate coverage to their employees.

The final rule also: 

  • Codifies network adequacy requirements so that qualified health plans on the Federally Facilitated Marketplaces must offer provider contracts to at least one essential community provider in ten provider categories (including hospitals) in each county within the service area, where a provider in that category is available;
  • Finalizes a proposal to reduce the maximum annual limitation on cost-sharing for self-only coverage in 2016 to $2,250 for individuals with a household income between 150-200 percent of the Federal Poverty Level (FPL); and $5,450 for individuals with a household income between 200-250 percent of the FPL; and
  • Amends the special rule for network plans to clarify that issuers have the option to count cost sharing for out-of-network services toward the annual limitation on cost sharing.

Furthermore, the rule finalizes standards for the open enrollment period for the individual market; essential health benefits; quality improvement strategies; the Small Business Health Options Program (SHOP); guaranteed availability; guaranteed renewability; the rate review program; the medical loss ratio program; and other ACA health insurance marketplace reforms. 

Most regulations are effective April 26, 2015, except for amendments to regulations pertaining to Essential Community Providers, enrollment of employees under SHOP, and reporting of federal and state taxes, which are effective January 1, 2016.


Ivy Baer, J.D., M.P.H.
Senior Director and Regulatory Counsel
Telephone: 202-828-0499

Allison M. Cohen, J.D., LL.M.
Senior Policy and Regulatory Specialist
Telephone: 202-862-6085


MACPAC Discusses Future of CHIP, Behavioral Health Related Issues

February 27, 2015—The Medicaid and CHIP (Children’s Health Insurance Program) Payment and Access Commission (MACPAC) Feb. 26-27 met to discuss the short and long-term options for children’s health care coverage, behavioral health related care, and future policy considerations for shared savings in Medicaid.

Without congressional action, federal support for CHIP expires at the end of fiscal year (FY) 2015. The commissioners reaffirmed their recommendation from the June 2014 Report to Congress to extend federal funding for CHIP for a transition period of two years [see Washington Highlights, June 20, 2014] and agreed to send a letter to Congress emphasizing the importance of extending CHIP funding immediately in a manner that reduces administrative, state, and family burdens.

The commissioners also discussed long-term issues to improve exchange coverage for children, including: the family glitch, affordability of exchange plan premiums for children, affordability of exchange plan cost sharing for children, pediatric dental benefits for children with exchange coverage, and benefits for children with exchange coverage.

The first day concluded with a staff presentation on issues related to Medicaid behavioral health enrollees. Approximately 13 million enrollees, almost a fifth of the Medicaid population, have a behavioral health related diagnosis. Approximately $170 billion total is spent on these enrollees, accounting for half of all Medicaid expenditures. The commission plans to delve further into the types of services this group is utilizing, identify which interventions have been successful, and break down behavioral health related costs for subgroups within Medicaid.

The second day included a joint presentation by Mark McClellan, M.D., Ph.D., senior fellow, Brookings Institution, and Alan Weil, editor-in-chief, Health Affairs, to discuss various shared savings opportunities under Medicaid. The presentation followed their 2013 Health Affairs articles “Moving Forward On Medicaid Reform: Shared Savings In Medicaid, And How To Do It” and “Promoting Cooperative Federalism Through State Shared Savings.” The presenters advocated for a more standardized Medicaid program that moves away from a system of waivers, with additional focus on national cost and quality outcome metrics. 


Scott Wetzel
Senior Specialist, Health Care Affairs
Telephone: 202-828-0495

Jason Kleinman
Program & Policy Specialist, Government Relations
Telephone: 202-903-0806


On The Agenda

March 3: House Labor-HHS Appropriations Hearing on NIH Budget
8:30 a.m.; 2358-C Rayburn House Office Building
The House Labor, Health and Human Services, Education, and Related Agencies (Labor-HHS) Appropriations Subcommittee will hold a hearing to discuss the budget for the National Institutes of Health (NIH). NIH Director Francis Collins, M.D., Ph.D., is scheduled to testify and will be accompanied by: National Institute of Allergy and Infectious Diseases (NIAID) Director Anthony Facui, M.D.; National Institute of Mental Health (NIMH) Director Tom Insel, M.D.; National Institute of General Medical Sciences (NIGMS) Director Jon Lorsch, Ph.D.; National Institute on Drug Abuse (NIDA) Director Nora Volkow, M.D.; and National Heart, Lung, and Blood Institute Director Gary Gibbons, M.D.  

March 5: Senate HELP Hearing on Health IT Transformation
10 a.m.; 430 Dirksen Senate Office Building
The Senate Health, Education, Labor & Pensions (HELP) Committee will hold a hearing to discuss health information technology (HIT) and specifically electronic health records Witness testimony will be made available on the committee’s website.

March 5: E&C Health Subcommittee Hearing on 340B Program
10 a.m.; 2123 Rayburn House Office Building
The House Energy and Commerce Subcommittee on Health will hold a hearing to examine the 340B drug pricing program. Witness testimony will be made available on the subcommittee’s website.

March 5-6: MedPAC Meeting
Time: TBD; 1300 Pennsylvania Avenue, Washington, D.C.
The Medicare Payment Advisory Commission (MedPAC) will hold a public meeting and will solicit comments on the agenda via its website.


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Washington Highlights, a weekly electronic newsletter, features brief updates on the latest legislative and regulatory activities affecting medical schools and teaching hospitals.

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For More Information

Dave Moore
Senior Director, Government Relations
Telephone: 202-828-0559