Latest / CareTalk: Healthcare. Unfiltered. / 2024 Healthcare Policy Changes

Transcript

2024 Healthcare Policy Changes · CareTalk: Healthcare. Unfiltered.

• 0:00
  2024 has arrived, and with it a slew of new state laws and federal regulations that will affect health care in ways large and small, from restrictions on gender affirming care in West Virginia to a reduction of prior authorization requirements in Medicare advantage.
• 0:16
  We'll let you know what's in store.
• 0:18
  So will this year be a healthy, happy, and prosperous one for the healthcare system?
• 0:24
  Let's find welcome to Caretalk, America's home for incisive debate about healthcare, business and policy.
• 0:37
  I'm David Williams, president of health Business Group.
• 0:40
  And I'm John Driscoll, the president of Walgreens Health.
• 0:43
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• 0:55
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• 1:00
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• 1:08
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• 1:09
  David, what's all this about state regulations?
• 1:13
  I thought that healthcare was a federal thing, and all of the things that we needed to worry about were related to federal mandates, federal health care protections, new federal authorization, what's going on in the states, and is it really relevant to people's health care choices?
• 1:31
  John, what goes on in the states has been relevant in the past.
• 1:34
  The best example is probably Romney care in Massachusetts, which was the model for Obamacare nationally.
• 1:42
  Massachusetts bias, typical.
• 1:45
  Like, of course.
• 1:46
  Well, everything starts in Massachusetts, right? David?
• 1:49
  Come.
• 1:51
  You know, yes, at the time it was interesting.
• 1:54
  But if the best you can give me for state relevance is ancient mean, what are we talking about here?
• 2:02
  Do the states matter?
• 2:04
  So they can matter?
• 2:05
  So I think Romney care is the biggest example because Obamacare became the law of the land and really took things over.
• 2:11
  They sometimes talk about the states being the laboratory of innovation.
• 2:13
  We especially hear that on the republican side, you've got Medicaid waivers in place that allow states to experiment with various things.
• 2:20
  So, yeah, the states can be relevant.
• 2:22
  Now, having said that, John, I find myself in the painful position of having to agree with you, which I think your point is that in 2024, a lot took a look at all of what's going into effect in the states as we enter into 2024.
• 2:35
  I'll just run it down, John, and we can see if we think how significant it might be.
• 2:38
  But you're right.
• 2:39
  In general, it's not that big of a deal.
• 2:40
  Well, one thing that we've heard a lot about, at least in the popular press in the last year, has been about gender affirming care and bans on it, especially for minors.
• 2:49
  There's two states, that's West Virginia and Louisiana, where there's some bans going on for gender affirming care for are who are transgender.
• 3:01
  And it's interesting that these are not so absolute either.
• 3:05
  They require in some cases parental consent from both parents and sometimes to have one or two physicians to affirm that the patient really needs it.
• 3:14
  But it's not as extreme, actually, as some of the reproductive rights sides.
• 3:18
  That's probably the most significant thing, at least on the anti woke agenda.
• 3:22
  Now on the other side.
• 3:23
  But think about that, David.
• 3:27
  In many ways, the Republicans are really using the states typically to, not to be the laboratories of innovation, but laboratories to slow things down.
• 3:39
  And in the case of the somewhat obsessive focus on trans children, it appears that they are really injecting a lot of government oversight into what typically families have been able to or have been part of deciding on their own.
• 3:57
  It's a really interesting role reversal for the republican state legislators legislatures.
• 4:05
  And it's not just those two states where they relay pastorals.
• 4:08
  In other states, I think they've slowed down and tried to understand better what is going on around gender affirming care, but it's really much more part of a political agenda intended to divide than, I think, an informed conversation about healthcare, at least as of yet.
• 4:27
  It's just an interesting role reversal for a party that has historically talked about keeping government out and is now kind of actively trying to push government into health care decisions here and in women's health decisions like women's reproductive rights, that is completely inconsistent with where historically they've been on other issues.
• 4:50
  Well, that's fair, John, but these are the only two examples of new laws going into effect right now.
• 4:55
  The other ones are actually more toward the liberal side of things.
• 5:00
  So in New Jersey, pharmacists are now going to be able to provide self administered hormonal contraceptives without a prescription.
• 5:08
  As you may recall, last year, as we had discussed it, there is an over the counter contraceptive that's being offered now, but it's one that doesn't have a hormonal component to it.
• 5:20
  So it's maybe considered not as effective.
• 5:22
  So there's one state that's trying to press the boundary a little bit there.
• 5:26
  I'm not sure how big of an impact that will have.
• 5:29
  Now in California, there is a move to actually increase the minimum wage in the healthcare sector to push it up toward 18 or $25 an hour by 2028 in the urban areas and 2033 in the rural areas.
• 5:42
  Now, I know there's a lot of complexity to this, which I probably don't understand completely, but the idea that you're going to have a higher minimum wage in health care, it just, to me, just sort of adds to health care is already too expensive.
• 5:54
  Let's make it even more expensive by increasing the cost of the biggest component of healthcare, which is labor.
• 6:02
  You're just way too critical here, David, not surprisingly.
• 6:07
  Look, we have a real healthcare staffing problem in America, and we've got a broken system to support a fair minimum wage.
• 6:15
  And so I think what happened in California is the unions got together with a lot of popular support.
• 6:23
  So the people who are providing essential caregiving should not be paid less than they can survive on, so they can really focus on doing their jobs well.
• 6:32
  I actually think this is a modest positive, in spite of your skepticism, because it will help us recruit more people to healthcare and allow more health care and labor as a percentage of the total dollars.
• 6:45
  While very high entry level labor costs the folks who are making seven dollars to fifteen dollars an hour, it's actually a relatively modest amount of the total dollars involved in health care.
• 6:57
  And there's no one who's getting their bed camp band cleaned or who needs their relatives taken care of in a custodial way that doesn't think that people should be able to be paid a fair wage.
• 7:09
  I think this is progress.
• 7:11
  So, John, let's take our huge earnings from California and drive up the left coast there, right through Oregon, where nothing much is going on this year to Washington. Now they're taking a different approach towards staffing.
• 7:23
  Instead of pumping up the wage, they've got another thing which they say the hospitals have to establish staffing committees.
• 7:29
  This sounds very Kremlin esque.
• 7:32
  And then they have to have staffing plans that they approve and they have to file those with the state.
• 7:36
  And then if they fall below 80% compliance, they have to make correction, they have a corrective, accurate plan, and if not, then they could be fined up to $50,000 a month per hospital.
• 7:46
  So that's the other approach used on the left long term Kremlin watcher.
• 7:51
  I'm sure this is encouraging for you, David, because it gives you something to kind of poke fun at, but I actually think that the staffing problem, this is a little bit missing the point.
• 8:03
  The reason why we aren't getting the staffing that we need is there has been a pretty sizable increase in demand and not enough of a sizable increase in the people who can staff these jobs.
• 8:18
  And so the risk is, without some amount of intervention or standards, that people will not get the care they need.
• 8:26
  And there's nothing more scarier than being that person in pain or in Cris in a room trying to push the button to have a nurse or a nurse's aide or a doctor come to your side and knowing that it may not happen because they don't have enough staff.
• 8:39
  Now the staffing crisis is tied to a broken immigration process.
• 8:46
  Fact that we have way too many sick people and people getting older every day who are naturally going to age with some form of chronic illness.
• 8:54
  And we only produce the same amount of nurses and doctors every year, even though we have a disproportionate, increasing number of people who are chronically ill.
• 9:02
  But having said that, I don't know how you can argue that there shouldn't be some standards for staffing.
• 9:08
  I mean, are you inhumane?
• 9:09
  David, I was thinking of a new name for you.
• 9:13
  I'm going to take John Driscoll off and call you Thomas Hobbs Driscoll.
• 9:16
  It's like, yeah, it's like everything is terrible.
• 9:20
  We have enough resources.
• 9:21
  John, I'll leave you with.
• 9:22
  We do not want your life to be nasty, british and short.
• 9:25
  Yeah, it's too late for short now, John.
• 9:28
  The last one I'll leave you with, and I'm sure there's more to this one than I know, but I think this is not going to be the basis.
• 9:34
  This is like the opposite of Romney care.
• 9:36
  It's not going to be the basis of a national healthcare reform, which is that in Pennsylvania they have now introduced medical assistance coverage for pasteurized human donor milk.
• 9:46
  So I'm sure there's a story behind that.
• 9:47
  I just don't know what it is.
• 9:49
  Don't have much to work with you there. David.
• 9:52
  What's the most important?
• 9:54
  Well, can you explain what that whole thing is?
• 9:56
  I don't probably, I don't know.
• 10:00
  I'm sure it's important and related to being able to feed breast milk to baby, and it must have been some shortcoming somewhere in the system in Pennsylvania, which doesn't surprise me.
• 10:09
  David, let's stick to something we know about.
• 10:11
  How about what's going on with Medicare part d?
• 10:13
  Prior authorization. Okay.
• 10:16
  I'm going to force you to go federal because I do think people ought to be aware that whether it's marketing or prior auth or advertising, that people the feds are watching and CMS is listening, and things are going to change this year.
• 10:29
  Yeah, fair enough. All right.
• 10:30
  So John, let's start with the misleading marketing part, because one of the things that happens is around the open enrollment season.
• 10:35
  We talked about this on previous editions of CareTalk.
• 10:39
  You see all these tv ads and it looks like the federal government is doing something.
• 10:43
  And it's like, well, wait a know, what is this actually being advertised and what are they using this Medicare logo for? And so on.
• 10:49
  So there's some rules where the tv ads now have to talk about specific Medicare Advantage plans.
• 10:55
  They can't just talk in general.
• 10:57
  They're not allowed to mislead or misrepresent with a Medicare logo or language.
• 11:02
  And then their policy is being reinstated against predatory behavior, giving that the health plans themselves more ability to monitor agents and brokers, which is where a lot of the abuses actually come from.
• 11:14
  So there's some cracking down on misleading advertising.
• 11:18
  I think the fundamental problem is that when people like my 90 year old mother and I don't know how old your parents are, but presumably they're not frozen in age, who have grown up with a fee for service Medicare view and think of all of Medicare as Medicare fee for service as opposed to managed care or part d, which is the drug benefit.
• 11:39
  And that phrase is thrown around Medicare offers you when really it's Medicare managed care advantage or Medicare managed care like a Humana or a united.
• 11:50
  I think there's genuine confusion there.
• 11:52
  And what came up in the congressional hearings is that a lot of people thought they were just signing up for an enhanced version of what they already had, as opposed to a completely different program, one being open access fee per service, largely covered, but with lots of copays, deductibles and limits, and the other managed care, which is insured, smaller networks, more covered, but from a narrower set of providers.
• 12:23
  And that can be really confusing, particularly given the incredibly dense, almost impossible to understand text on the disclosures that CMS has actually signed off on.
• 12:35
  The federal government has signed off on that no one can really understand.
• 12:39
  And so I think actually it's a legitimate gripe that people are loosely using that word Medicare, when really it's a very different program.
• 12:47
  Now I would put that as a different category than the predatory salespeople, some of your friends, David, who are involved in running some of these brokerages that have not always hired the right people, and some folks who frankly are individual salespeople who've made a living out of signing people up and not worrying about what they're signed up for.
• 13:11
  And I think both of them are really important categories, particularly as Medicare Advantage becomes, as the companies become bigger marketing and sales machines, because to your point, depending on the time of year and what you're watching, all you'll see is ads for joining Medicare Advantage.
• 13:27
  So I actually think this is the federal government doing the right thing and trying to make sure people understand what they're signing up for and making sure that they don't sign up for anything they don't really want.
• 13:38
  So, John, the big change here is actually in prior authorization, and prior authorization is one of the tools that Medicare advantage and other managed plans use on the commercial side as well.
• 13:51
  And there have been complaints that this is a process that's been used to sort of deny care, ration care and so on.
• 13:57
  So the requirements are to streamline this process.
• 14:01
  Step back a second, Dave.
• 14:02
  Maybe explain how prior authorization works and why it can sometimes be a barrier to care, because I'm not sure everybody understands kind of what it is and how it's used in the range of ways that it's implemented.
• 14:15
  So prior authorization, it actually isn't a misnomer.
• 14:18
  It's something that's supposed to be done prior to care being delivered.
• 14:22
  And it's an authorization to have that care delivered and then presumably to be paid for to be reimbursed.
• 14:29
  So it could be used often it's used for drug therapy.
• 14:33
  So before you're getting an expensive drug, they may require you to have that authorized before you're going to have, let's say, a surgery, they might want to confirm that you actually have a condition that's going to benefit from the surgery and so on.
• 14:48
  So it's used for medical treatments.
• 14:50
  It's also used for drug therapies.
• 14:53
  And sometimes it slows things down. Right.
• 14:55
  Because if you need something now and there's a wait of a week or two or a month that's going to delay or really it's going to be sort of to say justice delayed is justice denied.
• 15:07
  And it could be similar here in terms of health care.
• 15:11
  So the streamlining of it is to say, okay, you can do it, but you can only use it to confirm that there is the presence of actually diagnoses or other criteria that say that's medically necessary.
• 15:22
  And then they're making it so that when you shift from one managed care plan to another, one Medicare Advantage plan to another, your prior authorization stays with you.
• 15:31
  So you don't have, let's say if I'm getting a new plan as of today, I don't have to get a new prior authorization for at least three months.
• 15:37
  And also I don't have to renew that prior authorization.
• 15:40
  Let's say if I'm on a drug, if I still have the condition, I don't have to renew it every 30, 60, 90 days or even every year, as long as the treatment is still medically necessary.
• 15:49
  And then they have to make sure that the policies are actually consistent with those guidelines under traditional Medicare.
• 15:54
  So the question of all of this is whether by reducing the use of prior authorization, are you making Medicare Advantage more like regular Medicare, and therefore, are you losing some of the cost advantage of it?
• 16:09
  I think that's really the big question.
• 16:11
  I think what's hard for people to recognize is that in many ways, the promise of managed care, lower cost for the same amount of dollars or less, less dollars than you would spend in fee for service, depends on using less expensive treatments.
• 16:28
  An x ray before an MRI, a less expensive generic drug before a branded generic, everyone can kind of, most people can get their heads around.
• 16:35
  Well, that makes sense.
• 16:36
  But when you're the person whose doctor has suggested something, it's irksome, but it often does add to a lower cost trend.
• 16:47
  The challenge is in some ways by ineptly managed prior authorizations, which some managed care companies have done, in some cases, really does slow down care.
• 17:00
  And to your point, care delayed can be care denied, and it isn't always the case.
• 17:04
  And it's a judgment call.
• 17:06
  And what I think is really interesting about these regulations is they're trying to both manage the fact that managed care does work and does provide, in many cases, better outcomes in total.
• 17:18
  But in individual cases, it can create real problems and friction for patients and doctors.
• 17:23
  So it's trying to remove the friction while maintaining the value.
• 17:26
  So I actually think this is a pretty interesting, again, effort on the part of the federal government to do the right thing.
• 17:32
  So I think in many cases, David, it's good that the states are staying out of the big things and that the feds are starting to improve them.
• 17:40
  So, John, last question for you.
• 17:42
  Do you think that 2024 is going to be a big year for state and federal health care laws?
• 17:48
  No, I think that it's going to be a big year for state and local posturing about health care.
• 17:56
  Your budy Trump has claimed that he's got a brand new health care plan, even though he was in office for four years and ran for a year or so before that and came up with zero.
• 18:05
  I think that there's a lot of posturing around some of the cultural agendas.
• 18:11
  I think the one place where you're going to see a lot of interest in health care and politics is around women's right to choose and access to essential medical care and reproductive freedoms.
• 18:21
  And I think that's going to be one of the defining political issues of the year, and it is very much related to health care.
• 18:28
  But I think a lot of the rest of the stuff is going to be small ball, but you're going to hear a lot of noise about it.
• 18:32
  But I think it's going to be small ball. What about you?
• 18:34
  I'd have to agree with you there, John, and I will go back and also further agree that reproductive rights is going to be a big issue in the elections, and it's likely to play well for the Democrats.
• 18:46
  Anything that the Republicans do around the edges there is likely to, by raising additional interest, is actually going to turn more people against them.
• 18:54
  And with that, I'll say that's it for yet another episode of Care Talk, the first one of 2024.
• 19:00
  We're looking to many more good ones.
• 19:02
  I'm David Williams, president of health Business Group.
• 19:05
  And I'm John Driscoll, the president of Walgreens Health.
• 19:08
  Happy New Year, everyone.
• 19:09
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• 19:11
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