Inside the Beltway - October 2019 - NAPNAP

Inside the Beltway – October 2019

First Virtual Hill Day

For those of you who cannot join us in Washington, D.C. on Nov. 4 for our Capitol Hill Day, you can participate in our virtual Hill Day from your home or office. Look for a call to action email on Nov. 4 that links to our Hill Day campaign “asks.” It only takes a few minutes to click the link to our Advocacy Center to review and submit our pre-formatted letters to your federal elected officials via the electronic delivery system.

If you opted-out of past call to action emails, you can participate by visiting our Advocacy Center on Nov. 4 (or later that week) to take action on our Hill Day campaigns.

Telehealth: The Changing Landscape of Healthcare

Telehealth is the use of electronic information and telecommunications technologies to deliver virtual medical, health and education services. It is not a specific service, but rather a collection of means to enhance care and education delivery1. National utilization of telehealth grew by 53 percent from 2016 to 20172 and continues to rise. Consumer demand for convenience, as well as a move toward value-based care, has contributed to this trend. Many organizations are now offering telehealth options to employees as part of their medical benefits. Recently, Sam’s Club announced that it will sell bundled healthcare services that include telehealth to members in three states and may add mHealth services in the future. The packages will offer telehealth visits for only $1 each3. Amazon also announced in September that it has rolled out a virtual care clinic, offering telehealth and mHealth services to its employees in the Seattle area. After a trial period, it is anticipated to open the service to consumers4. These organizations join a long list of direct-to-consumer telehealth vendors.

As telehealth continues to grow, healthcare providers must learn to embrace this modality in order to remain competitive in the healthcare market. Maintaining the quality of care along with ensuring adequate reimbursement for services are key to advancing telehealth initiatives.

One of the most significant barriers to telehealth adoption is reimbursement. Federal reimbursement is centered on Medicare. Telehealth restrictions in the Medicare program include limitations on the type and geographic location of the originating site (patient location), limitations on providers who may bill for services via telehealth, and limitations on the services that may be billed. The Centers for Medicaid Services (CMS) has taken steps to allow for reimbursement of remote communication technology, chronic care management and remote patient monitoring as separate services from “telehealth”5 yet barriers remain. State Medicaid policies may be more accommodating than Medicare. However, each state establishes its own policies leading to significant variation in telehealth laws and regulations across the country5. As of May 2019, 50 states and Washington DC provide reimbursement for some form of live video in Medicaid fee for service;11 states provide reimbursement for store-and-forward; 21 states provide reimbursement for remote patient monitoring; 23 states limit the type of originating site; 34 states offer a facility fee; 39 states and DC have laws that govern private payer telehealth reimbursement and 14 states allow the home as an originating site6. Private insurance payors vary significantly in telehealth coverage. Limitations are based on the insured’s plan, visit type, provider type, form of telehealth (synchronous vs. asynchronous), patient location and use of a telepresenter.

Telehealth increases access to healthcare, improves health outcomes, reduces healthcare costs, and improves the efficiency of the healthcare system7. In order to encourage healthcare providers to embrace telehealth as an extension of the medical home, it is crucial to continue to advocate for improved telehealth reimbursement. Ensuring that healthcare providers are able to deliver the same high quality care to their patients via telehealth necessitates the investment of time and energy in advocacy for expanded telehealth reimbursement.



1 Center for Connected Health Policy, Retrieved from (September 30, 2019).
2 FAIR Health, FH Healthcare Indicators™ and FH Medical Price Index™: An Annual View of Place of Service Trends and Medical Pricing, A FAIR Health White Paper, April 2019.
3 Sam’s Club Includes Telehealth in New Bundled Health Program. mHealth Intelligence. Retrieved from (October 1, 2019).
4 Amazon Makes its Move: DTC Telehealth Service Opens for Employees. mHealth Intelligence. Retrieved from (October 1, 2019).
5 Telehealth Policy Barriers. Center for Connected Health Policy, Retrieved from (September 30, 2019)
6 State Telehealth Laws and Reimbursement Policies Report Spring 2019. Center for Connected Health Policy, Retrieved from (October 1, 2019).
7 Why are Telemedicine and Telehealth so Important in Our Healthcare System? California Telehealth Resource Center, Retrieved from (October 1, 2019).

Federal Regulators Propose E-Cigarette Restrictions as Vaping Illnesses Spread

The Food and Drug Administration proposed regulations Sept. 20 that would require e-cigarette products to prove they can be marketed in a way that protects public health before they can be sold to the public, following President Donald Trump’s Sept. 11 announcement that his administration was finalizing a ban on flavored e-cigarettes in response to a national outbreak of vaping-related illnesses. The proposed rule would require the FDA to consider risks and benefits for the whole population in deciding whether to authorize the sale of vaping products. The proposed rule would also require applicants to submit detailed and periodically updated marketing plans including intended audience and use of social media influencers.

E-cigarette maker Juul Labs said Oct. 17 that it would suspend all sales of its non-tobacco and non-menthol-based flavored pods pending reviews by the Food and Drug Administration, halting online sales after pulling flavored pods from retail outlets last fall. The company also said it would suspend all U.S. advertising and lobbying activities regarding the federal guidelines. Juul was also hit with its first wrongful death lawsuit Oct. 15, filed by a Florida mother who says her 18-year-old son died after respiratory complications caused by his use of the e-cigarette after he was exposed to the company’s advertising.

The Centers for Disease Control and Prevention reported Oct. 17 that the number of vaping-related fatalities continues to rise, taking 33 lives and making 1,479 people sick so far. The new cases – up from 26 deaths and 1,299 illnesses the preceding week – indicate that officials are no closer to getting the outbreak under control since it emerged as a public health threat in July. Among the 1,358 cases in which the CDC has age and gender data, 79 percent are under 35 years old with the median age of 23. Based on National Youth Tobacco Survey data, the CDC reported Oct. 3 that more than a quarter of high-school students used tobacco products in 2018, with the biggest increase coming in the use of flavored e-cigarette products. The report found that 27.1 percent of high school students and 7.2 percent of middle schoolers used tobacco products. Overall, the agency reported that 3.6 million teens said they used flavored e-cigarettes.

Courts Block Regulations as Administration Proposes New Immigration Limits

Several federal courts stepped in to block efforts by the Trump administration to make it easier to hold immigrant children and families in government custody and to deny permanent resident status to immigrants considered a “public charge” for receiving government assistance. Five separate federal judges blocked the Homeland Security Department’s “public charge” regulations between Oct. 11 and 14, with three imposing nationwide injunctions stopping the rule from taking effect as scheduled Tuesday Oct 15. The administration is expected to appeal the injunctions. The “public charge” standard was also applied by the State Department in a separate Oct. 10 regulation to green card and visa applicants outside the U.S. and is thought to be the basis for an as-yet-unseen Justice Department rule for deporting some legally present immigrants who receive public assistance.

Separately, a federal district judge on Sept. 27 rejected new regulations that would allow the government to hold children and their parents in detention for indefinite periods. Describing the government’s defense of its proposed new policy as “Kafkaesque” in some of its reasoning, Judge Dolly Gee said it was up to Congress, not the administration, to supplant the 20-year-old Flores Settlement Agreement consent decree that requires children to be held in state-licensed facilities and released in most cases within 20 days.

More recently, President Trump issued a proclamation Oct. 3 ordering federal officials to deny visas to immigrants if they cannot prove they have health insurance or the ability to pay for medical care once they become permanent residents. The order, which would become effective Nov. 3, is aimed at immigrants seeking to join their families in the U.S. Subsidized Affordable Care Act marketplace health plans would not be considered eligible coverage under the order, which is also likely to face legal challenges.

Trump also replaced acting Homeland Security Sec. Kevin McAleenan Oct. 11 after a tenure in which he reduced border crossings and managed major administration immigration policies but clashed with other senior officials and struggled to earn the President’s trust. The President has yet to name a replacement, and two of his apparent top choices – U.S. Citizenship and Immigration Services chief Ken Cuccinelli and Customs and Border Protection director Mark Morgan – were ruled to be ineligible, having not been formally nominated or confirmed by the Senate in their current positions.

Increase in Uninsured Children Raises Alarms

The U.S. Census Bureau reported Tuesday Sept. 10 that the number of Americans lacking health insurance grew last year, rising from 7.9 percent in 2017 to 8.5 percent last year, marking the first annual increase in the uninsured rate in nearly a decade. The data also showed that 425,000 fewer children had health insurance in 2018, the second year in a row that children lost coverage, with a total of 4.3 million children uninsured.

Saying “we can do better, and we must,” NAPNAP joined the American Academy of Pediatrics, the Children’s Defense Fund and other children’s health advocates in issuing a statement calling for comprehensive and immediate action by Congress and the Administration to “make it easier and more affordable for children and families to enroll – and stay enrolled – in coverage that meets their needs.”

Congress, Administration Make Little Progress on Year-End Spending Deal

With a short-term measure to fund government programs set to run out Nov. 21, congressional appropriators and White House budget officials appear no closer than they were in September to agreeing on a deal to fund agencies for the rest of fiscal 2020. Senate Appropriations Committee Chairman Richard Shelby (R-AL) said on Oct. 15 that negotiations remained in a “prolonged slump,” adding that without a breakthrough, lawmakers appeared headed toward another stopgap funding extension into mid-December.

The House passed a four-bill “minibus” spending measure (H.R. 2740) in June that included a $10 million increase in funding for statutory nursing workforce programs, plus an additional $20 million for a nurse practitioner fellowship initiative. The Senate has yet to advance its Labor-HHS-Education spending plan but proposed a $4 million increase for nursing education in a draft bill released in September.

Separately, there has been little progress in advancing legislation to renew the funding authorization for nursing workforce programs, which lapsed in 2015. The House Energy and Commerce Committee approved the “Title VIII Nursing Workforce Reauthorization Act of 2019” (H.R. 728) in July, but the full House has yet to vote on the bill. A Senate companion bill, S. 1399, has yet to be considered by the Senate Health, Education, Labor and Pensions Committee.

In Other News…

Executive Order Calls for Review of Practice Barriers in Medicare
President Trump issued an executive order Oct. 3 that calls on the Secretary of Health and Human Services (HHS) to propose regulations to “eliminate burdensome…supervision requirements” and “all other licensure requirements…that are more stringent than applicable Federal or State laws require and limit professionals from practicing at the top of their profession.”  The order also direct the Secretary to conduct “a comprehensive review of regulatory policies that create disparities in reimbursement between physicians and non-physician practitioners,” proposing regulations that would “ensure that items and services provided by clinicians…including nurse practitioners, are appropriately reimburse in accordance with the work performed rather than the clinician’s occupation.”

The wide-ranging order directs HHS to move toward using market-driven rates for traditional Medicare and to look at “rewarding care through site neutrality,” though a federal court told the administration its most recent attempt at site-neutral payment for some hospital outpatient clinic visits was unlawful. The order contrasts Trump’s health care vision with Democrats’ calls for a greater government role in health care, with the President, promising to defend the private insurance system and decrying “Medicare for All” as a socialist takeover that would ruin Medicare for seniors.

Separately, NAPNAP and other nursing, physician assistant, and patient advocacy groups met Sept. 20 with senior staff for the Centers for Medicare and Medicaid Services to discuss the Medicare Payment Advisory Commission’s recent recommendation to eliminate Medicare “incident-to” billing for NPs and PAs. The CMS staff were interested in the idea of adding a modifier to claim forms to identify incident-to services but had questions about the impact that the policy change would have on clinical practice suggested meeting again with other agency staff.

Courts Question Work Requirements for Medicaid Enrollees
During oral arguments Oct. 11, a three-judge federal appeals court panel sounded doubtful about the Trump administration’s policy of allowing states to impose work requirements in a pair of cases involving Medicaid waivers for Kentucky and Arkansas. All three members of the D.C. Circuit Court of Appeals repeatedly said Trump administration officials neglected to consider that people would lose health insurance under the new rules, noting that state Medicaid waivers must fulfill the basic purposes of the program of providing vulnerable residents with health coverage. Administration attorneys argued that requiring low-income people to work could help them get private health plans, freeing up funds for additional Medicaid services.

A federal judge has also blocked work requirements in New Hampshire, and the administration is also being sued to stop new rules from going into effect in Indiana. On Oct. 17, Arizona state health officials told the Centers for Medicare and Medicaid Services that they would delay “until further notice” implementation of the state’s work requirements in part because of ongoing litigation that halted similar programs in other states.

Meanwhile, Tennessee officials on Sept. 17 released a first-in-the-nation proposal to cap federal funding for its Medicaid program and phase out its open-ended entitlement in exchange for new flexibility. While officials called the draft proposal a “block grant” the state would receive a federal share based partly on average enrollment during 2016, 2017 and 2018, increasing on a per-capita basis if future enrollment grows beyond the average. State officials also want authority to limit which prescription drugs are covered and modify rules related to uncompensated care payments to hospitals.

Drug Pricing Reform Moves Toward House Vote
House Democrats pushed Speaker Nancy Pelosi’s sweeping plan to lower prescription drug costs through three committees in six days, hoping to have the full House pass it by the end of October. The House Ways and Means Committee approved the “Lower Drug Costs Now Act of 2019” (H.R. 3) Oct. 22 on a party-line vote, with Republicans continuing to object to the measure’s plan to have federal officials negotiate prices for high-cost drugs.

A week earlier, both the House Energy and Commerce Committee and the House Education and Labor Committee approved the bill separately Oct. 17, also along partisan lines. The original proposal was amended to expand from 25 to 35 the list of drugs whose prices could be subject to federal negotiation. In a partial analysis, the Congressional Budget Office projected that the bill would save the government $345 billion over a seven-year period when the negotiation threshold was 25 medicines. The CBO also estimated that drug makers would lose up to $1 trillion in potential revenue over a decade, which could reduce research and development and result in eight to 15 fewer new drugs being launched.

The Senate Finance Committee approved the bipartisan “Prescription Drug Pricing Reduction Act” (S. 2543) Sept. 25, which would add an out-of-pocket maximum for Medicare beneficiaries, penalize drug companies if the prices for their drugs rise faster than inflation, and require pharmacy benefit managers to disclose information on the discounts they negotiate.

White House Issues Order on Vaccine Improvement
President Trump issued an executive order Sept. 19 intended to improve processes for manufacturing influenza vaccines, including a more focused effort toward a “universal” flu vaccine. The order calls for reduced reliance on current egg-based flu vaccines, and an approach to modernizing the development process – from expanding capacity for alternative flu vaccines, such as newer cell-based vaccine technology, to the development of newer, more broadly protective vaccine candidates that don’t have to be reformulated every year. However, the order didn’t indicate how this aggressive program would be funded, noting that its implementation would be “subject to the availability of appropriations.”  The order included instructions to agencies including the departments of Defense and Veterans Affairs to take steps toward buying flu vaccines produced with “faster, more scalable, and innovative technologies.”

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