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Modern HealthcareThe 115th Congress on the State of Healthcare

Sept. 24, 2018 | Special Supplement

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September 24, 2018 | Modern Healthcare Congressional Supplement 1

Cover photo: Getty Images

Thank you to the participating lawmakers for their commentaries on key issues affecting the state of healthcare. The viewpoints expressed by the contributors are published as a public service and do not re�ect the opinion of Modern Healthcare.

ContentsPage

2 Letter from Editor Aurora Aguilar

Senate

3 Sen. Roy Blunt (R-Mo.) Increasing funding to improve behavioral health

4 Sen. Shelley Moore Capito (R-W.Va.) States need to partner with Congress in opioids battle

6 Sen. Bill Cassidy (R-La.) We’re making progress on lowering prices for patients

7 Sen. Heidi Heitkamp (D-N.D.) Addressing challenges facing rural providers, �rst responders

8 Sen. Chris Murphy (D-Conn.) ‘Choose Medicare’ should be an option for all Americans

10 Sen. Rand Paul (R-Ky.) Association health plans open new coverage options

House of Representatives

11 Rep. Rosa DeLauro (D-Conn.) One thing President Trump must do to protect coverage

12 Rep. Ben Ray Lujan (D-N.M.) Medicaid buy-in would offer an attractive insurance option

14 Rep. Doris Matsui (D-Calif.) Let’s take additional steps to destigmatize addiction

15 Rep. Scott Peters (D-Calif.) Open, bipartisan process needed to �x insurance markets

16 Rep. Tom Reed (R-N.Y.) Lawmakers need to ful�ll their role as problem-solvers

18 Rep. Peter Roskam (R-Ill.) It’s time to modernize Stark law to re�ect changing times

19 Rep. Raul Ruiz (D-Calif.) Outdated infrastructure, policies hindering telehealth

20 Rep. Fred Upton (R-Mich.) Cures Act is delivering on promises to advance research

2 Modern Healthcare Congressional Supplement | September 24, 2018

Healthcare remains critical issue and Americans demand change

T HIS ISSUE IS INTENTIONALLY TIMED close to the

midterm elections this year. In just over a month, voters

will take to the polls to decide whether the Senate and

House will remain controlled by Republicans; if the GOP prevails

that would likely give new momentum to the campaign to repeal

the Affordable Care Act. Yet the number of people who continue to

be affected by rising premiums on the marketplace is marginally

low. Those who may be affected by Congress eliminating provisions

that prevent underwriting based on pre-existing conditions and

encouraging people to buy skimpy health plans is greater. Poll after

poll has shown that plans to lower drug prices, Medicare and Medicaid funding are top of mind

for voters. And while the U.S. adopting a universal health plan might seem unrealistic, look

no further than Alexandria Ocasio-Cortez’s primary win in New York to see that her stance on

healthcare supported her victory.

But let’s face it, Americans are fed up with the cost of healthcare, especially when compared

to what we get in return. At $3.4 trillion, healthcare spending is now 18% of the nation’s gross

domestic product. Americans are increasingly responsible for a bigger chunk of these costs.

Deductibles can soar as high as more than $6,000 for one person to more than $13,000 for a family

of four. Meanwhile, the U.S. claims the lowest life expectancy and the highest childhood mortality

rate among comparable developed nations.

As House Ways and Means Committee Health Subcommittee member Rep. Tom Reed

(R-N.Y.) states well in his op-ed (p. 16): “Failure to act is not fair to the people we were all sent to

Washington, D.C., to represent. In fact, it is inexcusable. While politicians talk, Americans suffer.

This is what is wrong with our politics today.”

The lawmakers and healthcare organization leaders who contributed to this special issue know

what’s at stake in the midterms and beyond. Our readers, high-level executives at hospitals,

healthcare systems, insurance companies and the vendors who serve them, are vigilant and well-

prepared for what’s to come. Similarly, our team in D.C.—bureau chief Virgil Dickson covering

rules and regulations and reporter Susannah Luthi covering Capitol Hill—is on guard and ready

to cover the role of healthcare issues in the elections and its aftermath. We hope to continue

to be your independent source to learn how to weather these changes and the responsibilities

of each of your sectors and committee appointments. To stay up to date, be sure to bookmark

ModernHealthcare.com for the latest industry news, analysis, research and data.

And please, feel free to share your feedback on this issue by emailing me at

[email protected].

Thank you for your continued readership.

By Aurora Aguilar

from the editor


The 115th Congress on the State of Healthcare

By

opioid epidemic, it will also dramatically reduce the amount of money spent treating other health concerns.

Stemming the number of individuals who become addicted in the �rst place is another top priority re�ected in this bill. That includes improving surveillance to gain a better understanding of where the problems are and where they are most severe, and ensuring the public understands the risks of taking opioids. The bill provides $476 million to the Centers for Disease Control and Prevention for opioid overdose prevention and surveillance, as

well as a public awareness campaign.The bill also addresses the needs of

infants, children and youth who have been affected by the opioid crisis. It provides $60 million to help states develop and implement plans of safe care for infants exposed to opioids at birth, and includes $40 million for prevention and treatment activities for children and families in, or at-risk of entering, the foster-care system.

Finally, simply reducing opioid prescriptions does not address the core problem—effective pain management. If patients with acute or chronic pain do not have reasonable access to non-addictive pain medications or alternative treatments,

it will be dif�cult to solve this crisis. The bill provides $500 million for research related to opioid addiction, pain management and addiction treatment as well as developing opioid alternatives.

The opioid epidemic has touched people of all ages, from every background, in communities across the nation. I’ll continue working with my colleagues to ensure we’re putting the right amount of resources in the right places to end this public health crisis.

A CROSS THE COUNTRY, OPIOID OVERDOSES AND DEATHS have surged in recent years. In 2017, opioid

overdose deaths hit a record high, taking the lives of 134 people every day.

Addressing the opioid epidemic has been a top priority for me and my colleagues on the Appropriations Committee’s Labor, Health and Human Services, Education, and Related Agencies Subcommittee. Since I became chairman of that subcommittee four years ago, we’ve increased funding to combat the epidemic by $3.5 billion, or nearly 1,300%.

To save lives, we must maintain a federal response that is up to the challenge we’re facing. The �scal 2019 Labor/HHS appropriations bill provides $3.8 billion for opioid-related programs. From researching opioid alternatives and expanding access to treatment and prevention programs, to providing critical services for children, this bill tackles the opioid crisis from every angle.

The bill includes $1.5 billion for state opioid response grants, which provide �exible funding for states to implement programs that best �t their needs. It also includes $130 million in targeted funding for rural areas, which often lack the same access to healthcare and support services found in urban or suburban areas.

Making sure people who are struggling with addiction can access effective treatment—including mental health services—is also essential to effectively addressing the opioid epidemic. To that end, the bill includes a $50 million increase for certi�ed community behavioral health clinics. If people are addressing their behavioral health issues, they are feeling better and sleeping better and are more likely to take the medications needed for other conditions. I think we will �nd that, as a result, expanding access to behavioral health won’t just allow us to make more headway in addressing the

By Sen. Roy Blunt

Increasing funding to address the ongoing opioids crisis and improve behavioral health

Sen. Roy Blunt (R-Mo.)

SERVING SINCE: 2011, now in his second term

HEALTHCARE-RELATED

COMMITTEES: Senate Appropriations Committee (chair of the Labor, Health and Human Services, Education and Related Agencies Subcommittee and member of the Agriculture, Rural Development, Food and Drug Administration, and Related Agencies Subcommittee)



programs to battle opioid abuse through federal drug programs. That’s a 1,275% increase over the past four years.

Equally as important, the Appropriations Committee has dedicated $1.5 billion for �exible state grants, and thanks to language I authored along with Sen. Jeanne Shaheen (D-N.H.), 15% of that dedicated funding goes to states with the highest opioid-related deaths. By targeting resources to where they’re needed most, we can make our efforts to �ght this epidemic more strategic and more effective.

In many of the other appropriations bills, we have worked to provide funding to address different aspects of the epidemic like education and job opportunities.

From healthcare to law enforcement, we are working to tackle the crisis from all angles.

In January, President Donald Trump signed the Interdict Act, legislation that will equip U.S. Customs and Border Protection of�cers with scanning devices and other technologies to detect synthetic opioids like fentanyl, protecting our communities from in�uxes of these deadly drugs.

As chair of the Appropriations Committee’s Homeland Security Subcommittee, I will ensure the funding is there to implement this bill.

This federal government is playing its part, but we all know that it’s local government and community leaders who know what works best for their cities and towns.

Take Wheeling, W.Va., for example. Folks in Wheeling are working to start a addiction

treatment center for pregnant women. Meanwhile, a local pharmacy has started a scholarship program for people who have completed recovery programs to help jump-start their college education or career training.

These are the kinds of partnerships and local efforts that, when combined with federal support, will truly help us to tackle this crisis.

We owe it to our families, friends and neighbors to continue the �ght.

States battling the opioid epidemic need partnerships with Congress in battle to �nd creative solutions

I T’S NO SECRET MY HOME STATE OF WEST VIRGINIA has been hit hard by the opioid crisis. In fact, the communities

in our state are feeling the consequences of the drug epidemic more than almost any other state in the country.

Recent statistics from the Centers for Disease Control and Prevention con�rmed that once again West Virginia has the highest rate of death due to drug overdose in the nation.

Nationwide, these statistics show there were more than 72,360 drug overdose deaths in 2017, and of those deaths, 49,068 involved opioids. That’s an increase from 2016, driven primarily by a continued surge in synthetic opioids, including fentanyl.

Each day in 2017, 134 Americans died because of this crisis.

The CDC estimates there are 200 drug overdose deaths every single day. That’s one person every eight minutes. Think about that. Every eight minutes, someone’s neighbor, friend or child dies of a drug overdose.

These statistics are devastating, but they don’t de�ne the West Virginia I know. The West Virginia I know is �ghting back. We are combating this epidemic head on through a wide range of creative and innovative strategies. And the �ght is being waged all across America.

That’s because we understand that it is going to take a coordinated, all-hands-on-deck, community-focused effort to �ght this epidemic. And while our local leaders are at the forefront of that �ght, Congress is by no means taking a back seat. In Washington, D.C., we are doing what we can to support and strengthen those community-led efforts across the country.

As a member of the Senate Appropriations Committee, I’ve worked hard to ensure the �scal 2019 Labor, Health and Human Services appropriations bill includes increased funding to combat the opioid epidemic that is ravaging my state and so many others.

In fact, the current bill provides more than $3.7 billion for

By Sen. Shelley Moore Capito

Sen. Shelley Moore Capito

(R-W.Va.)

SERVING SINCE: 2015, in her �rst term

HEALTHCARE-RELATED

COMMITTEES: Senate Appropriations Committee (chair of the Homeland Security Subcommittee and member of the Labor, Health and Human Services, Education, and Related Agencies Subcommittee; Military Construction, Veterans Affairs, and Related Agencies Subcommittee; and Commerce, Justice, Science, and Related Agencies Subcommittee)

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Hospitals have become epicenters of transformation, but their community mission will never change

Innovation has been a popular buzzword in healthcare for all the time I’ve been in the health policy �eld, and well before that. But what is meant by the term is fundamentally different today than it was decades or, for that matter, even a few years ago.

Where we have commonly thought of innovation in terms of the latest diagnostic scanning technology or a new surgical procedure that reduced recovery times and improved outcomes, now it has a much broader, game-changing meaning.

The rise of consumerism, the digital economy, precision medicine, predictive analytics, the increased use of arti�cial intelligence, and the acute awareness of healthcare affordability pressures—these are all serving as catalysts for change on a scale that we have not witnessed before.

While the media focus on large cross-sector acquisitions like CVS Health buying Aetna or new players like Amazon entering the healthcare arena, the major story is occurring in cities and small towns across the country as the local hospitals and health systems that have been cornerstones in their communities for decades are now epicenters of transformational change.

We’re calling this transition “Rede�ning the H,” referring to the iconic white-on-blue road sign that for decades has said “follow me” to have your medical needs met.

Hospital and health system leaders are well aware of the challenges before them and are reshaping their operations to meet patient needs and consumer expectations.

At the same time, unlike some other players entering the healthcare “space,” we will not compromise our values or whittle away at our obligation to care.

We are committed to ensuring that vulnerable and marginalized communities have the same access and opportunity as those who are much more privileged.

And we will work with lawmakers and regulators to ensure that this transformation occurs in a way that will protect the viability and sustainability of vital community health providers.

We know that the age of fee-for-service medicine is gradually, yet undeniably, giving way to value-based care. Hospitals have become organizations that reward value instead of volume, developing delivery methodologies that achieve greater ef�ciencies while using evidence-based practices, procedures and technologies to attain optimal outcomes.

The need for innovation, though, isn’t limited to the system’s shift to a pay-for-value orientation. Hospitals and health systems know that they can’t remain an analog service in a digital environment. Americans expect the convenience and �exibility that 21st century telecommunications capabilities make possible. Providers have heard the call and are working to meet this demand.

Hospital care is no longer con�ned to brick-and-mortar parameters. For example, hospitals have embraced the use of telehealth, strengthening communications between providers and patients, and improving the

patient experience. They are offering programs that monitor and care for patients at home.

And they are investing in technology to coordinate care and make access easier for patients. At the same time, we need to prepare our workforce to be more nimble and responsive to be successful.

This is not to say change isn’t challenging. Hospitals, unlike many others, cannot undergo

wholesale transformation. They will continue to provide the comprehensive healthcare services that communities require. They will continue to perform sophisticated surgery, diagnostics and therapeutics that are on the cutting edge of

science. In fact, the need for those services will continue to grow. They will maintain the capability to respond to disasters ranging from hurricanes to �u outbreaks. And they will continue to care for anyone who walks through their doors 24 hours a day, seven days a week.

“Rede�ning the H” can bring hospitals even closer to the communities and patients we serve. It is our opportunity to provide better care for more people in a way that ensures every hospital can play a leadership role as an anchor or access point for healthcare in their communities.

Rick Pollack President and CEO

American Hospital Association

“Rede�ning the H” can bring

hospitals even closer to the

communities and patients

we serve.

“

”To learn more about the American Hospital

Association, please visit www.aha.org

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good sign for American consumers.The administration has also taken action

to stop back-end rebates for drugs, which create a perverse incentive for companies to raise drug prices in order to gain formulary access. The CMS requested information from stakeholders on effectively ending the practice in Part D, and the Of�ce of Management and Budget is now reviewing a proposed rule concerning the safe harbor for pharmacy bene�t managers, which allows these rebates to occur.

The administration also effectively banned PBMs from using gag clauses to stop pharmacists from telling a patient when paying the cash price for a drug could be cheaper than using their insurance. I worked with my colleagues on the Senate Health, Education, Labor and Pensions Committee to pass legislation that would end gag clauses in the private market, and I hope to see the legislation passed and signed into law this year.

Our committee also tackled so-called “pay-for-delay” deals, where brand-name drug companies pay generic-drug makers to stay out of the market. While manufacturers of small-molecule brands and generics must report these deals to the Federal Trade Commission, currently, biologics and biosimilars—the most expensive drugs on the market—do not. The committee passed a bill to �x this, which will save taxpayers roughly $100 million over the next 10 years and get cheaper biosimilars to patients faster.

These are strong steps that will help lower healthcare costs for patients—and we’re just getting started.

HEALTHCARE COSTS ARE TOO HIGH. Families are grappling with double- and triple-digit increases in

health insurance premiums and rising out-of-pocket expenses. A growing percentage of our nation’s gross domestic product is consumed by healthcare costs—far more than other developed countries. We need solutions.

To advance the conversation, in May, I released a nine-page white paper of ideas to make healthcare affordable again.

To get healthcare costs under control, we must restore market forces and equip patients to be involved in their care. That means empowering the doctor-patient relationship, which bene�ts not just the patient’s health, but also the patient’s pocketbook. Currently, practice, laws and regulations work to keep the power and money surrounding healthcare decisions in the hands of bureaucrats, lawyers and lobbyists. That is wrong. As a doctor, I know that giving power to patients creates a healthcare system that is aligned with patients’ health and �nancial interests.

President Donald Trump and HHS Secretary Alex Azar understand the incentives in our healthcare system are not aligned with the interests of patients. That’s why the administration has moved to implement policies included in my white paper.

As I proposed, when a sole-source generic-drug manufacturer exists, U.S. buyers should be able to buy that drug on the international market, as long as the supply chain and facility are certi�ed safe by the U.S. Food and Drug Administration. The FDA recently announced it would form a working group to explore this policy, and that’s a

By Sen. Bill Cassidy

We’re making progress on lowering prices for patients, especially on costly drugs, and we’re just getting started

Sen. Bill Cassidy, M.D. (R-La.)

SERVING SINCE: 2015, in his �rst term

HEALTHCARE-RELATED

COMMITTEES: Senate Health, Education, Labor and Pensions Committee (Children and Families Subcommittee and Primary Health and Retirement Security Subcommittee); Senate Finance Committee (chair of Social Security, Pensions and Family Policy Subcommittee; member of Health Subcommittee); and Senate Veterans’ Affairs Committee

Cassidy is a gastroenterologist

overdose epidemic on children and families. Among them is legislation that would expand resources for �rst responder training and access to the opioid overdose reversal drug naloxone, as well as require HHS to issue best practices for recovery housing facilities.

While this legislation is a good step in providing additional resources to rural and tribal communities struggling with this national emergency, Congress must continue to build a united front that expands access to treatment, family support services, and evidence-based evaluations of children experiencing trauma—which is why it’s so important that my provisions to tackle the consequences of childhood trauma were included in this bill.

While we’re addressing the urgent threat posed by opioids and methamphetamines, we can’t let other aspects of rural healthcare deteriorate. As co-chair of the Senate Rural Health Caucus and as the spouse of a family physician, I know that doctors, nurses and community providers are key components of delivering high-quality, affordable healthcare in these small towns and townships.

Back in February, my bipartisan bill to strengthen rural healthcare delivery systems

passed out of a U.S. Senate committee. Introduced alongside U.S. Sen. Pat Roberts (R-Kan.)—my co-chair on the Senate Rural Health Caucus—our bill would allow state of�ces of rural health to continue receiving the critical support they need through 2022 to bolster the rural health workforce and increase affordability of local clinics and hospitals. It recently passed the Senate by unanimous consent, and it accompanies a recently passed �ve-year extension of rural Medicare “extenders,” which will continue to strengthen important rural healthcare operations.

We still have lots of work to do. I’ll keep �ghting to improve and expand healthcare services in North Dakota and across the country—regardless of ZIP code.

A PPROXIMATELY 20% OF AMERICANS live in rural areas. In North Dakota, that number is much

higher—around 50%.Rural communities are the backbone of

my state and have always been economic drivers for important industries like agriculture. But as someone who represents a largely rural state in the U.S. Senate, I also recognize that these areas, across the country, face unique healthcare challenges due to their isolated locations.

That’s why I’ve long been working to craft bipartisan solutions to make healthcare more affordable and accessible for rural populations.

Right now, it’s no secret that the ongoing addiction crisis is casting its shadow on small towns, farms and tribal areas, where prevention and treatment options are historically hard to come by. I’ve heard story after story about how North Dakota families and communities are being ripped apart due to drug abuse. And at seven listening sessions across my state over the past two years, I’ve heard from community leaders, treatment experts, law enforcement of�cers and �rst responders who are on the front lines of the rural drug abuse crisis and need additional help.

We simply can’t ignore the trauma young people are exposed to and the massive burden placed on our rural healthcare providers. It’s clear that childhood exposure to trauma—such as the opioid abuse by a parent—can often lead to severe health and behavioral complications that can detrimentally impact children throughout their lives. We need a strong plan that gives additional attention to rural and tribal communities. Otherwise, we’ll see an entire generation of young people crippled by this crisis.

In April, a U.S. Senate committee passed bipartisan, comprehensive legislation to combat opioid and substance abuse. Several items I fought for were included in the bill, including six provisions to address the ripple effects of the

By Sen. Heidi Heitkamp

Opioid abuse epidemic poses unique challenges for providers, �rst responders in rural communities

Sen. Heidi Heitkamp (D-N.D.)

SERVING SINCE: 2013, in her �rst term

HEALTHCARE-RELATED

COMMITTEES: Senate Agriculture, Nutrition and Forestry Committee and the Senate Indian Affairs Committee

Heitkamp also serves as co-chair of the Senate Rural Health Caucus





WHEN PEOPLE ACROSS THE COUNTRY go to cast their ballots this November, they’re

going to be voting on healthcare. Poll after poll shows that healthcare is the No. 1 issue on the minds of voters this fall.

For the past two years, much of the action around healthcare in Washington, D.C., has been focused on saving the Affordable Care Act and its many protections, especially for people with pre-existing conditions. And while Republicans may have failed in their attempts to repeal the law outright, they continue to do damage to the healthcare system through deliberate sabotage, driving up costs and putting the coverage gains and guaranteed protections of the ACA in jeopardy.

Democrats have rightly focused most of our attention on �ghting off these attacks. But as our party seeks to win over voters this fall, we’ve also laid out a variety of forward-looking health policy proposals, so that we have a menu of options to debate when we’re back in charge.

“Medicare for all” may command much of the attention (and the breathless pearl-clutching from the right), but Democratic ideas range from full single-payer systems to broad expansions of Medicaid, and plans to let Medicare negotiate drug costs.

My contribution to the discussion is the Choose Medicare Act, a bill I introduced with Sen. Jeff Merkley (D-Ore.), that will let people of all ages buy a Medicare health plan if they want to, and let any business buy in to Medicare for its employees.

The Choose Medicare Act would offer a new Medicare plan on all state and federal

exchanges, and people could use their existing ACA subsidies to help pay for it. Employers could also choose to select this Medicare plan instead of private insurance to cover their employees. Choose Medicare builds on the existing network and low administrative costs of the program, and it would help save even more money by allowing Medicare to negotiate drug prices.

Having Medicare as an option will force private insurance companies to be more competitive, bringing down costs for everyone. It also tests the idea that Medicare is the right bene�t for everyone by allowing consumers and businesses to choose for themselves.

I believe that, given the choice between a private insurance plan and Medicare, the majority of people will choose Medicare. A recent Kaiser Health Tracking Poll con�rms it: three-quarters of Americans supported a Medicare buy-in, including 6 out of 10 Republicans.

Candidates running in 2018 are embracing Medicare buy-in plans as an on-ramp to universal coverage—and not just in safe blue states or districts. Candidates promoting Medicare buy-in plans can be found in Massachusetts and California, but also in swing districts in places like Texas and South Carolina.

There’s no denying that if I were designing a healthcare system from scratch, I’d build a “Medicare for all” type of system. But opening up Medicare to anyone who wants to buy in to it will help us build on the system we have and brings us one huge step closer to affordable coverage for everyone.

‘Choose Medicare’ should be an option for all Americans, to ensure coverage and boost competition

By Sen. Chris Murphy

Sen. Chris Murphy (D-Conn.)

SERVING SINCE: 2013, in his �rst term

HEALTHCARE-RELATED

COMMITTEES: Senate Health, Education, Labor and Pensions Committee (Primary Health and Retirement Security Subcommittee and Employment and Workplace Safety Subcommittee) and Senate Appropriations Committee (Labor, Health and Human Services, Education, and Related Agencies Subcommittee)

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PAs Can Help Drive Healthcare Forward, But Outdated Laws Are Holding Them Back

In discussions about healthcare, there are two ubiquitous subjects: cost and access. Everyone from patients to providers to legislators are driven by the fact that healthcare should be accessible and affordable for all. These issues are exacerbated by the growing physician shortage—which data from the Association of American Medical Colleges shows could be up to 120,000 physicians by 2030. It is no wonder that hospitals and other healthcare organizations have embraced PAs (physician assistants) on their healthcare teams for over �fty years.

PAs are medical professionals who diagnose illness, develop and manage evidence-based treatment plans, prescribe medications, and often serve as a patient’s principal healthcare provider. With thousands of hours of medical training, PAs practice in every state and in every setting and specialty—and they’re enhancing access to affordable care.

Hospitals and health systems that employ PAs already know their immense value. PAs provide high-quality, inexpensive, patient-centered care with excellent outcomes. Research published in the Journal of Clinical Outcomes Management compared different staf�ng models at community hospitals: one with a provider group of three physicians and three PAs; the second with nine physicians and two PAs. The data showed that the quality indicators were equal between the two groups, but the cost of care was far less in the provider group with more PAs—illustrating two key bene�ts of hiring PAs.

Plus, patients love their PAs. A Harris Poll found that 93 percent regard PAs as trusted healthcare providers, 92 percent said that having a PA makes it easier to get a medical appointment, and 91 percent believe that PAs improve the quality of healthcare.

Over the past few decades, the PA profession has grown exponentially, with more than 123,000 PAs currently practicing in the United States. In fact, the profession is expected to grow signi�cantly faster than average for all occupations—37 percent by 2026, according to the Bureau of Labor Statistics. And as we inch closer to 2030 and the physician shortage worsens, the growing PA workforce is well-positioned to increase access to care—especially in rural or underserved areas.

But right now, the healthcare industry can’t make the most of what this expanding segment of healthcare providers has to offer.

To the detriment of patients, other providers and health systems, PAs practice under some of the most restrictive state practice laws and regulations. The most sti�ing requirements dictate how PAs and their collaborating physicians work together, including where and how often a physician must consult with each PA, and with how many PAs a physician can collaborate. Over time, these outdated requirements have made it dif�cult for PAs to practice at

the top of their education and experience, and dif�cult for hospitals, health systems and physicians to fully deploy these critical team members.

PAs, physicians, and other members of healthcare teams should be empowered to make decisions at the practice level, where the skills and experience of every team member are well understood. The reality is, every medical setting may experience unique challenges—one may treat more patients affected by a chronic condition, such as diabetes, whereas another practice may treat a larger proportion of elderly patients with a higher prevalence of co-morbidities. In any case, enabling this type of decision making at the practice level allows healthcare teams to better harness the time and talents of each clinician—ultimately increasing their ability to meet patients’ needs in a cost-effective manner.

Experts are coming to the same conclusion. A June 2018 study conducted by the Hamilton Project, an economic research group and think tank within the Brookings

Institution, concludes that removing barriers to PA care would alleviate healthcare shortages

and improve ef�ciency and productivity in the delivery of healthcare—without adverse effects on patient outcomes.

Practices and health systems need the ability to build a care team that meets the needs of

their patients. And the many restrictive laws and regulations currently in place simply don’t

allow for that.

The American Academy of PAs is committed to modernizing laws and regulations affecting PAs, and putting decisions about practice where they belong—at the practice level. It’s time to put patients �rst by allowing healthcare teams to determine how they can best care for their patients.

Healthcare in the United States is constantly evolving as we adapt to advancements in technology, changing patient needs, and emerging health threats. PAs have the versatile skill set and the rigorous education needed to help move healthcare forward and ensure access to affordable, high-quality care for all. Let’s make the most of America’s PAs.

Jonathan E. Sobel , DMSc, MBA, PA-C, DFAAPA, FAPACVS

President and Board Chair,American academy of PAs

To learn more about AAPA, please visit www.aapa.org




insured plan. Prior to the Labor Department issuing

its �nal AHP rule this past June, outdated administrative guidelines forced small businesses and the self-employed to remain in the high-cost small group and individual markets—yet another government barrier to businesses growing and hiring more workers.

Unfortunately, the new rule maintains state regulation, and AHPs are additionally subject to federal laws such as the Employee Retirement Income Security Act, HIPAA and parts of the ACA, which means AHPs will still not achieve the cost savings that multistate large corporate plans do.

While the Labor Department did a great job putting forward this rule, more needs to be done so these plans can more easily operate nationwide and achieve the size and scale necessary to be a viable option for as many businesses as possible.

In particular, Congress will need to change the law to allow legitimate associations that have health plans to operate across state lines, ensuring AHPs have the same exemptions from state regulations large corporations already get—to help groups such as National

Federation of Independent Business and the Chamber of Commerce—reach the necessary economies of scale.

I also believe Americans should be able to access AHP coverage through individual membership in a broad array of organizations like the National Ri�e Association, Costco or even eBay.

Such freedom has the potential to be transformative, and I will continue �ghting to help more Americans gain access to affordable group coverage.

L OOKING TO “BIG GOVERNMENT” FOR ANSWERS to skyrocketing healthcare costs may be some politicians’

solution, but that only results in giving the American people more frustration and fewer options—along with still-expensive healthcare.

Throughout 2017, I worked directly with President Donald Trump and his administration on a pro-patient, pro-family, and pro-worker reform proposal that �ips the status quo script and returns power to the American people to �nd the healthcare coverage that best meets their needs at a price they can afford.

Known as association health plans, or AHPs, this alternative allows small businesses and self-employed individuals to join together to be considered as a large group for the purpose of offering health insurance as an employee bene�t, similar to a single large employer plan. AHPs allow thousands or even millions of Americans to join together to achieve better negotiating power with large insurance companies, decrease administrative costs, and get more comprehensive bene�ts.

Last October, President Trump of�cially paved the way to allow more people to join AHPs through an executive order entitled “Promoting Healthcare Choice and Competition Across the United States.”

That’s exactly what this effort is all about: providing more choices in a way that is allowed under current law but has for decades gone underutilized due to government barriers created through a closed process.

Our reform expanded the types of groups that can band together to form AHPs, and it empowered self-employed Americans who have no other employees to �nd family coverage through a large-group AHP, including a self-

By Sen. Rand Paul

Association health plans open new coverage options, but Congress needs to take steps to level the playing �eld

Sen. Rand Paul, M.D. (R-Ky.)

SERVING SINCE: 2011, now in his second term

HEALTHCARE-RELATED

COMMITTEES: Senate Health, Education, Labor and Pensions Committee (chair of the Children and Families Subcommittee and member of the Employment and Workplace Safety Subcommittee)

Paul is an ophthalmologist

children born with life-threatening conditions and individuals living with chronic diseases. Women were denied coverage because they had a C-section, or were a survivor of domestic abuse. People like Melissa were afraid to follow their dreams, lest their new insurer deny them coverage.

In many ways, junk plans represent the failed healthcare system that the president is trying to take us back to. Junk plans are not bound by the ACA’s medical-loss ratio, allowing insurers to raise their pro�ts and commissions. They can use loopholes and �ne print to avoid covering illnesses. For example, some junk plans cover emergency room visits, except on weekends.

Nor is the president’s sabotage making healthcare cheaper. By expanding junk plans and repealing the individual mandate, premiums could increase 18% in nearly every state’s ACA exchange, according to the Urban Institute, while costing the federal government $28 billion over the next decade, according to the Trump administration.

Clearly, we cannot afford to be going backward, something with which the American people agree. According to the Kaiser Family Foundation, 64% do not want to see protections for pre-existing conditions overturned.

Neither did the president, based on what he promised voters. During the 2016 campaign, he said with regards to these protections, “I want to keep pre-existing conditions. I think we need it.” Now the president can and must protect the 130 million Americans like Melissa with a pre-existing condition. All he needs to do is stop the sabotage.

DURING THE INITIAL FIGHT FOR THE AFFORDABLE CARE ACT, I met Melissa Marottolli. Only

28 years old at the time, she told me her story of dealing with Stage 4 lung cancer and how having a pre-existing condition was “killing” her. She feared losing her job or changing careers, because that would result in her being denied medical coverage.

As an ovarian cancer survivor myself, her story still inspires me. No one should be punished for bad luck. And there are 130 million Americans with pre-existing conditions who would struggle to get quality, affordable health insurance, if not for the protections in the ACA.

It is imperative for President Donald Trump to protect those millions of Americans. And he can. He only needs to stop sabotaging the ACA.

Since taking of�ce, President Trump has advanced a number of policies to undermine the ACA: curtailing outreach, repealing the individual mandate and stopping cost-sharing payments that lower insurance costs for lower-income Americans. He and congressional Republicans also repeatedly attempted to repeal it outright.

Then in July, the president signed an executive order expanding the availability of junk plans—short-term health insurance plans that among other things circumvent the ACA’s protections for pre-existing conditions. It followed his June endorsement of a lawsuit by 22 states to overturn the protections in court.

The sabotage is wrongheaded. Before the ACA, insurance companies could deny coverage or gouge people. We are talking about

By Rep. Rosa DeLauro

The one thing President Trump must do to protect 130 million Americans from losing their health coverage

Rep. Rosa DeLauro (D-Conn.)

SERVING SINCE: 1991, now in her 14th term

HEALTHCARE-RELATED

COMMITTEES: House Appropriations Committee (ranking member of the Labor, Health and Human Services, Education, and Related Agencies Subcommittee and member of the Agriculture, Rural Development, Food and Drug Administration, and Related Agencies Subcommittee)

DeLauro is chair of the Congressional Food Safety Caucus and co-chair of the Congressional Ovarian Cancer Caucus and the Congressional Baby Caucus





New Mexico to talk with community leaders, the labor and business communities, health advocates, healthcare providers and insurers about Medicaid buy-in. Tough questions were put on the table and not everything had an immediate answer.

With the acknowledgment that “healthcare is complicated” con�rming what I know as a member of the House Energy and Commerce Committee’s Health Subcommittee, there are tough questions we need to work through. Should reimbursement rates go up? Sure. Should the cost of prescription drugs go down? You bet. Do we need to think about network adequacy and federal waivers and a whole lot more? Yes. But what’s not complicated is that too many sick people are unable to afford a trip to the doctor. That’s why smart people are invested in making this happen.

New Mexico is rich in history and culture, but as a rural state with its fair share of health challenges, it often needs to think outside the box to help families. This Medicaid buy-in effort is the result of some of the smartest health policy minds in the country and a �erce grassroots engagement to protect Medicaid

expansion—stories were sent to my of�ce from New Mexicans who make just too much money to qualify for Medicaid coverage yet not enough to piece together real insurance options on the exchanges.

This bottom-up approach to solving policy problems motivated the State Public Option Act, a bill I introduced with my colleague Sen. Brian Schatz of Hawaii and legislators who encompass the full spectrum of the Democratic Party. From Sen. Bernie Sanders of Vermont and Elizabeth Warren of Massachusetts, to Reps. Beto O’Rourke of Texas and Andre Carson of Indiana, this concept is gaining traction with Democrats who, one day, hope to offer universal health coverage to all Americans.

Currently, 14 states across the country are considering a Medicaid buy-in option. Healthcare is a right, plain and simple.

WHILE CONGRESSIONAL REPUBLICANS have spent the 115th Congress repeatedly

attacking a law that protects tens of millions of Americans, the New Mexico state Legislature took a bipartisan step forward by approving a measure to study how a Medicaid buy-in program could strengthen healthcare in the state.

The concept is simple: allow states to open their Medicaid programs to anyone, regardless of income. People who chose to buy in to the Medicaid program would have access to Medicaid’s bene�t package and provider network.

Though the Affordable Care Act and Medicaid expansion cut New Mexico’s uninsured rate by half, as many as 1 in 10 New Mexicans still remain uninsured. Over 12,000 more are enrolled in high-deductible health plans, which encourage people to forgo needed care.

I believe that Medicaid buy-in could provide a more affordable coverage option for those struggling to pay premiums and deductibles right now and in my state help the more than 180,000 uninsured get coverage. It could also help insulate New Mexicans from the Republican-caused turmoil at the federal level. This could be replicated across the country.

New Mexico families already bene�t from and know Medicaid. The program serves as the foundation of the state’s healthcare system and provides comprehensive coverage to over a third of the state’s residents. Introducing an option for individuals and families to purchase Medicaid would increase competition and give consumers more choices. In addition, people in the individual insurance market can experience “churn” as their income changes and they move between Medicaid and the private insurance market. The opportunity to purchase Medicaid could help minimize the disruption that consumers currently face when their circumstances change.

Recently, former CMS acting Director Andy Slavitt visited

By Rep. Ben Ray Lujan

‘Healthcare is a right, plain and simple.’ Medicaid buy-in would offer an attractive option to guarantee coverage

Rep. Ben Ray Lujan (D-N.M.)

SERVING SINCE: 2009, now in his �fth term

HEALTHCARE-RELATED

COMMITTEES: House Energy and Commerce Committee (Health Subcommittee)

Lujan is also chair of the Democratic Congressional Campaign Committee

SPONSORED CONTENT

Improving Outcome Measurement in Behavioral Healthcare

There is general consensus that meaningful healthcare system reform requires a focus on increasing value for patients, typically de�ned as health outcomes achieved per dollar spent. While the transition from a fee-for-service to a value-based model has been underway for many years, effective implementation in the behavioral health discipline has proven to be slow or non-existent. Fortunately, there are some notable exceptions of providers utilizing clinical outcome assessments and comprehensive patient satisfaction data to improve care and demonstrate clinical value.

Earlier this year, The Joint Commission provided a strong and promising model toward increasing value for patients, requiring residential and outpatient psychiatric care providers to implement standardized outcomes assessments of their choosing and to speci�cally utilize the results in the provision of care. Payers are likewise increasingly expecting behavioral health providers to demonstrate evidence-based value and prioritizing providers who do. However, concerns over potential disruptions of patient care and clinical progress due to an externally mandated, “one size �ts all” approach from uncoordinated payers and regulators strongly suggests that providers are those best positioned to re-shape and spearhead improved public quality reporting with patient-reported outcomes.

Inadequate ReportingRegulatory agency interests in population health currently drive publicly reported measures of quality. However, these measures are often inadequate or inapplicable to behavioral health settings, as they neither address the immediate interests of patients nor re�ect the true clinical purpose of behavioral health treatment.

While suicide is a leading cause of death in the U.S, it is not represented in any publicly reported outcome measures. Nevertheless, even a basic measure of suicide rates within inpatient programs, despite low frequency, would align more closely than currently used and largely inapplicable measures such as in�uenza vaccine rates or tobacco cessation.

“Practice-Based Evidence” vs. “Evidence-Based Practices”Practice-based evidence is gleaned from real-world clinical practice and observation – assessed and measured at the treatment facility level, allowing patients, providers, and payers to identify best treatment practices. Doing so avoids the pitfalls of highly controlled, evidence-based trials, �delity concerns relative to such programs, and provider or payer biases when interpreting treatment results, while honoring the philosophy of data-driven, patient-centric care.

“Did the patient get better?”How we pay for healthcare, risk-adjust patient mix, and provide care are all critical components of the healthcare discussion. In the raucous conversation, the simple parameter, “Did the patient get better?” seems to have been lost. For the patient and the community that supports them, getting better is all that matters.

Capturing patient-reported outcomes is a reasonable solution that combines the transparent reporting of practice-based evidence with the patient’s perspective on symptoms, severity, functioning, or quality of life. To be sure, this “simple” concept has a complexity not yet fully explored

by all stakeholders. Reasonable challenges are driven by what to measure and how. These are fair concerns as clinical outcome measures have potential consequences rooted in extending or declining ongoing care, readmissions, reimbursement, accreditation, or federal regulation.

Beginning the journey Rather than mandate a single set of measures for all providers, we must provide incentives for patients, providers, and payers to work together to identify desirable clinical outcomes. We must provide a marketplace full of clinically relevant measures and allow a publicly driven rating system to develop, while providers and researchers work to improve the means and methods of measurement. Providers must take the lead in conscientiously assessing patients, evaluating care, and transparently reporting the results.

Demonstrating clinical outcomes, satisfaction, and publicly reported measures Universal Health Services, the largest provider of freestanding behavioral health hospitals in the U.S., treating approximately 500,000 patients annually, has in

recent years dramatically increased its investment in and utilization of a wide variety of respected

assessment tools across its network of over 200 facilities. Doing so has greatly enhanced its ability to capture, benchmark, and utilize clinical outcomes and patient satisfaction data to improve clinical care. In 2017, UHS measured outcomes across 571 distinct

treatment programs, with results revealing that approximately 75% of patients reported

statistically meaningful improvement from admission to discharge and over 85% at 45-day post-discharge.

You can manage only what you measureValuing this data-driven approach, we encourage further collaboration and engagement from all stakeholders to promote increased use of behavioral health outcomes to improve treatment. We must start somewhere. Patients deserve it.

Johan Smith heads Mental Health Outcomes, a leading consultancy specializing in the design and implementation of custom outcomes measurement for behavioral health programs.

Johan Smith Vice President, Health Informatics

Mental Health Outcomes, LLC.

To learn more about Mental Health Outcomes, LLC., please visit www.mho-inc.net




of physical, mental and substance abuse treatment, and expanded support for families of people living with mental health issues. Eight states now have such clinics; because of the original Excellence Act that I co-authored, they’ve been able to hire more addiction specialty staff and successfully expand recovery services to more patients.

Without this sustained investment, the care for people with a mental illness in our country is more likely to remain an exhausting and frustrating process of isolated, cyclical visits to emergency departments. When this happens, we are reminded that mental illness affects families and communities—the parents, siblings, grandparents, children and friends of patients are all integral to supporting their treatment, care and recovery. And when a patient is hospitalized, there inevitably follows a sequence of events that results in confusion for providers, families and patients about what information can be shared under the federal HIPAA privacy law.

If we want to support the recovery of patients, providers need the best tools to engage with a patients’ family and communities of support. That is why I included a provision in the 21st Century Cures Act requiring HHS’ Of�ce for Civil Rights to conduct education and awareness efforts on patient and family rights under HIPAA. A year later, this has resulted in the education of over 3,000 health policy

lawyers, a strategy to conduct outreach to healthcare providers, and a funding opportunity to establish a Center of Excellence for Protected Health Information Related to Mental and Substance Use Disorders.

What people still don’t realize is that HIPAA does actually allow for information sharing when it is in the patient’s best interest. We need to make sure that clinicians know that they can and should work a patient’s loved ones into their care and recovery, just as we would if the patient had a disease like cancer.

These legislative actions are only part of the larger solution. Expanding treatment will be most effective when a patient suffering from a mental health disorder can ask for and receive assistance from supportive communities without stigma.

ADDICTION IS A MEDICAL CONDITION. This is a fact, yet despite our efforts to bring mental

illness out of the shadows, the misconception that a substance use disorder is a re�ection of a character �aw remains.

Recently, the Harvard T.H. Chan School of Public Health and Politico released a poll showing that 37% of respondents believed that opioid addiction is a sign that someone has a personal weakness. This poll reiterates the �ndings of a 2014 study from the Johns Hopkins Bloomberg School of Public Health led by Dr. Colleen Barry, chair of the health policy and management department and co-director of the Center for Mental Health and Addiction Policy Research. As Barry stated, “The American public is more likely to think of addiction as a moral failing than a medical condition.”

Congress has the ability—and the responsibility—to play a larger role in destigmatizing all addictions, including opioid use disorders, as part of our work to improve the behavioral healthcare system.

While the House-passed opioids package, HR 6, took steps to expand treatment for individuals with a substance use disorder, it did so with a unilateral focus on opioid use disorder. If we are truly going to address the root causes of the opioid epidemic, we need to look at the entire spectrum of care. That means updating our systems to integrate behavioral and physical healthcare while funding services for patients who need crisis care as well as prevention and early intervention services.

Substance use disorder is not limited to opioids, and addiction can co-occur with other mental health conditions like depression, eating disorders and schizophrenia. Therefore, changes need to be made across the system. If not, we are only legislating from crisis to crisis.

The Excellence in Mental Health and Addiction Treatment Expansion Act, HR 3931, takes a more holistic approach by expanding funding for certi�ed community behavioral health clinics. These clinics cover a broad range of mental health services, including 24-hour crisis care, increased integration

By Rep. Doris Matsui

Addiction is a medical condition, not a moral weakness. We need to take additional steps to reinforce this fact

Rep. Doris Matsui (D-Calif.)

SERVING SINCE: 2013, now in her third term

HEALTHCARE-RELATED

COMMITTEES: House Energy and Commerce Committee (Health Subcommittee, Environment Subcommittee and Communications and Technology Subcommittee)

Matsui is also co-chair of the Congressional Caucus to Cure Blood Cancers and Other Blood Disorders as well as the Congressional High Tech Caucus



By

government and higher out-of-pocket costs for everyone. Congress should reauthorize and make permanent federal reinsurance programs to protect insurers against the costliest medical claims.

Insurers currently don’t know what will happen with cost-sharing reduction payments from month to month, and that leads to higher premiums. President Trump ended cost-sharing reduction payments and as a result, premiums across the country have spiked. Congress should end the uncertainty and work together to ensure consistent funding for the payments over time. To keep insurance available and premiums

down (and reduce risk in markets), we need to encourage young, healthy people to buy insurance. Congress could authorize an automatic enrollment system that would provide basic primary-care, catastrophic illness or injury coverage for young individuals who do not purchase insurance.

There can—and should—be conversations about what the future of healthcare looks like. There will continue to be real differences on policy and ideology, but Congress should seek common ground and �xes that are not purely partisan. Long-term stabilization that’s necessary to drive down costs requires a

concerted effort from both parties. These are solutions that members of both parties can

support, and they should be the starting point for a bipartisan, open process to protect what is working in our healthcare system and �x what isn’t. Maybe then, instead of playing games with people’s healthcare, Congress could stop trying to revive partisan bills, and instead build on our healthcare system.

Bipartisanship is key to insurance market stabilization and lasting healthcare reform

“REPEAL AND REPLACE” was President Donald Trump’s main policy objective for nearly a

year, yet he had no better plan for what an alternative healthcare initiative would look like.

Americans were outraged, and made their outrage known. As a result, the Republican replacement bills—and later, the repeal-only bills—failed to pass Congress.

Many months later, the healthcare market is still not stable. While my Democratic colleagues and I are thankful the previous measures failed, that doesn’t mean we should do nothing.

The Affordable Care Act was not perfect—nor was it intended to be that way. Full repeal or failure of the current system would take us back to a time when an unexpected illness would bankrupt a family and emergency rooms were full of parents seeking basic care for their children. Instead, everyone should welcome the opportunity to make necessary adjustments to the framework of our current system. When we do, the �xes must be bipartisan.

I strongly believe that with certain reforms and a recommitment to policies that work, we can improve the individual market and make healthcare more affordable. These include making federal reinsurance programs permanent, providing long-term funding for cost-sharing reduction payments, and �nding ways to boost the participation of young, healthy enrollees in the marketplace.

Without federal reinsurance programs, insurers with sicker enrollees would have to charge higher premiums to all their customers to stem their �nancial losses. That means larger subsidies being paid by the federal

By Rep. Scott Peters

Rep. Scott Peters (D-Calif.)

SERVING SINCE: 2013, now in his third term

HEALTHCARE-RELATED

COMMITTEES: House Energy and Commerce Committee (Environment Subcommittee) and the House Veterans’ Affairs Committee (Technology Modernization Subcommittee and the Oversight and Investigations Subcommittee)



coverage and create more options for consumers.

While no one in the caucus got everything they wanted, we recognized the importance of working together to reduce the suffering of our fellow Americans caught in this healthcare debacle.

We also believe that this proposal should be paid for and stand ready to work to �nd agreeable offsets within federal healthcare spending. Potential offsets could include: Recapture premium tax credit overpayments; encourage use of generic drugs in Medicare Part D; speed up brand-name drug discounts in Medicare Part D as seniors approach the coverage gap, or “donut hole”; create a bundled-payment system for post-acute care in Medicare; reduce Medicare payment for bad debt; and accelerate competitive bidding in Medicare Advantage.

In response to our plan, Larry Levitt, a health policy expert at the Kaiser Family Foundation, said: “Overall, I think it would keep insurers in the individual markets and reduce premiums. And I think it would avoid the potential of coverage losses, while also risking a modest loss in coverage from repealing the employer mandate.”

We realize how many Americans desperately need and deserve a solution to their rising premiums. We are fully committed to continue working toward a bipartisan solution and urge President Donald Trump and our colleagues in the House and Senate to come together to break

the gridlock in Washington on healthcare policy and help the people they represent.

Now more than ever, we as a nation need to move past petty political games. We are better than this. The American people deserve the solutions and leadership the Problem Solvers Caucus is providing.

REPUBLICAN LAWMAKERS DO NOT WANT TO remind people about two things: rising healthcare

costs and the failure to repeal the Affordable Care Act—which has essentially led to the collapse of the insurance market. On the other side of the aisle, Democrats are content with doing nothing and blaming Republicans for the dismal state of healthcare today.

Failure to act is not fair to the people we were all sent to Washington, D.C., to represent. In fact, it is inexcusable. While politicians talk, Americans suffer. This is what is wrong with our politics today.

While this news is unfortunate, it is not surprising given the strong convictions held on both sides and what shows up as deep divisions in our political discourse. My colleagues in the Problem Solvers Caucus, a group of Republican and Democrat House lawmakers, which I lead on the Republican side, foresaw the looming double-digit insurance premium hikes more than a year ago.

So, the Problem Solvers Caucus decided to sit down, listen and learn from their colleagues on the other side. What came out of this was the very �rst and only bipartisan plan to �x skyrocketing health insurance premiums.

Some key ideas that resulted from our work: Bring cost-sharing reduction payments under the congressional oversight and appropriations process, but ensure they have mandatory funding; create a dedicated stability fund that states can use to reduce premiums and limit losses for providing coverage—especially for those with pre-existing conditions; repeal the 2.3% medical-device tax, since the costs of the tax are passed on to consumers, again contributing to higher healthcare costs; provide technical changes and clear guidelines for states that want to innovate on the exchange or enter into regional compacts to improve

By Rep. Tom Reed

Lawmakers need to ful�ll their role as problem-solvers to address the soaring cost of healthcare and health insurance

Rep. Tom Reed (R-N.Y.)

SERVING SINCE: 2011, now in his fourth term

HEATHCARE-RELATED

COMMITTEES: House Ways and Means Committee (Health Subcommittee) He is also co-chair of the bipartisan congressional Problem Solvers Caucus, a group of 24 House Republicans and 24 House Democrats who meet weekly to discuss some of the most contentious issues facing the country

Reed is co-chair of the Congressional Diabetes Caucus

SPONSORED CONTENT

How to Improve America’s Behavioral Healthcare System Repeal Medicaid’s IMD Exclusion and Open Access to Treatment

In September we observe both National Recovery Month and National Suicide Prevention Awareness Month to educate Americans that effective behavioral healthcare treatment can help those struggling with mental health and substance use disorders live healthy, satisfying lives.

There has never been a better time for these annual reminders than now.

In 2016, more than 20 million people in the United States had a substance use disorder (SUD), and 89 percent of individuals who needed treatment did not receive it. Meanwhile, the Centers for Disease Control and Prevention reported this past June that suicide is a leading cause of death in the United States and that nearly 45,000 died by suicide in 2016.

Millions of Americans are suffering and have lost their way. Often when we learn someone has died by suicide or from substance misuse, we wish we could do something—and then we move on.

We can no longer take this approach.

Facing these alarming statistics, we need to do all we can to help our families, friends, neighbors, and fellow citizens �nd their own road to recovery.

The good news is we live in a country with �rst-rate behavioral healthcare providers, health systems, and treatment programs to offer that help. Now we need to do more to expand access to those clinicians and services.

The most effective way to improve access to behavioral healthcare treatment is for Congress to repeal the outdated and burdensome Institutions for Mental Diseases (IMD) exclusion in Medicaid. Since 1965, Medicaid’s IMD exclusion has prevented bene�ciaries between the ages of 21-64 — the same age group affected most severely by our nation’s current opioid and suicide crises — from accessing short-term, acute care in psychiatric hospitals or SUD treatment facilities.

For millions of Americans living with suicidal thoughts and SUD, including alcohol use disorder, recovery often starts with a short stay in an inpatient facility, where behavioral healthcare providers can help move patients through the behavioral healthcare continuum. Unfortunately, the IMD exclusion limits access to this life-saving �rst step.

The federal government has chosen to address our country’s need for mental health and SUD services primarily through grant funding for years. To be sure, those federal dollars have provided help to those who need it. Today, though, we see federal grants for mental health and SUD services as a temporary solution to a permanent problem. Simply put: this method is not working.

Repealing the IMD exclusion would expand access immediately by leveraging existing payment mechanisms and avoiding the long delays associated with time-limited

grant programs. NABH is one of many stakeholder groups that support repealing the IMD exclusion, including the President’s Commission on Combating Drug Addiction and the Opioid Crisis, governors, state Medicaid directors, law enforcement of�cials and of�cers, mental health and substance use treatment advocates, and healthcare providers and professionals.

As I write this op-ed, the Senate is preparing to vote on its opioid legislation package, which could include a measure that addresses the IMD exclusion. The House has already done so, when it partially repealed the IMD exclusion for SUD in the SUPPORT for Patients and Communities Act (H.R. 6) that the House passed in June.

We applaud Congress for taking steps in the right direction. Still, we will continue to advocate for policymakers to repeal the IMD exclusion entirely. Only when Congress removes access barriers to behavioral healthcare treatment will we have true parity with medical-surgical care, which the Paul

Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act promised to every

American a decade ago.

As Congress considers ways to address our nation’s deadly opioid crisis and high suicide rate, we recommend that policymakers and their staff read Pathways to Care: Treating

Opioid and Substance Use Disorders, a new white paper from NABH Director of Quality

and Addiction Services Sarah A. Wattenberg. Pathways identi�es the major challenges facing the addiction treatment system today and maps out how we can make the most of the quality clinicians, health systems, and treatment programs we have to help

those who need services desperately. Please visit www.nabh.org/pathways to learn more.

We remain hopeful that the United States has the behavioral healthcare providers and resources to end the opioid crisis and help lower the rate of suicide. In urging Congress to repeal Medicaid’s IMD exclusion and applying the lessons from Pathways, there are actions we can take today to make a real difference for those struggling with mental health and SUD.

Lives depend on it.

Mark Covall President and CEO,

National Association for Behavioral Healthcare (NABH)

To learn more about NABH, please visit www.nabh.org


National Association for Behavioral Healthcare

Access. Care. Recovery.

By

In an era when we are now pushing our providers to work closely together to bring down costs, and in many cases share in the savings they create, we need to update the laws to ease the burden on providers and give the CMS more �exibility to approve waivers to providers who enter into these high-value arrangements.

Through bipartisan support, the Health Subcommittee is speaking with healthcare professionals across the country to identify unnecessary regulations that must be met at the cost of patient care. Working together, we can �nd a balance to maintain

a system of accountability for providers that makes sense while protecting patients and providing quality care at a reasonable cost. The goal of the subcommittee in evaluating the Stark law is simple: better care for Medicare patients.

Our nation—in fact, our world—has seen signi�cant technological advancements over the past 40 years; it’s now time for our laws to catch up to the modern-day tools at our disposal in order to ensure we use these tools responsibly without hindering progress.

Regulations are often well-intended, and there is value to smart regulation for patient and provider protection. However, new regulations year after year have a compounding effect. Healthcare is

constantly changing, and we need to review these rules as technologies and care delivery models change.

Hearings we’ve held on Stark law modernization and achievements through the Medicare Red Tape Relief Program offer members of the Ways and Means Health Subcommittee the opportunity to work together to �nd solutions that improve healthcare quality and safety.

THE HOUSE WAYS AND MEANS COMMITTEE’S HEALTH SUBCOMMITTEE recently held

a hearing titled “Modernizing Stark Law to Ensure the Successful Transition from Volume to Value in the Medicare Program.” Its purpose was to evaluate the Stark law within the context of our modern-day, technological advancements and learn from healthcare professionals what steps need to be taken to sustain a more advanced system of healthcare that will provide higher-quality care at lower costs.

The Stark law is a 1980s-era policy originally intended to protect Medicare bene�ciaries from excessive costs and other potential harms that could result from physician referrals of patients to other providers with whom they have �nancial ties. However, we’ve seen this law driving up costs and creating additional, unnecessary regulatory burdens for healthcare providers.

Named after former Democratic Rep. Pete Stark of California, who sponsored the initial bill, the Stark law was, and in many ways still is, necessary to ensure patient safety and act as a safeguard against wasting taxpayer dollars. The law essentially prevents physicians from making referrals to entities that provide certain services if they have a �nancial stake in that entity, thus eliminating unnecessary services that could raise healthcare costs.

Over time, however, we’ve seen the web of regulations born out of the law become nearly impossible to navigate without legal assistance. The Stark law has become so complex and burdensome that healthcare providers, legislators and even the bill’s original sponsor have called for repealing the law in its current form, which has veered from the original intent.

By Rep. Peter Roskam

It’s time to modernize the Stark law as new payment models, technologies require regulatory �exibility

Rep. Peter Roskam (R-Ill.)

SERVING SINCE: 2007, now in his sixth term

HEALTHCARE-RELATED

COMMITTEES: House Ways and Means Committee (chair of the Health Subcommittee)

Roskam also serves on several healthcare-related caucuses, including the Congressional Primary Care Caucus and the Bipartisan Congressional Task Force on Alzheimer’s Disease



provider, who tells Tony he needs to see a dermatologist. Right now, Tony would have to �nd a dermatologist—who could be hours away—and take an entire day to get the care he needs.

Telehealth, on the other hand, could connect Tony with a dermatologist via videoconference in that same exam room, who could then work with Tony’s doctor to help screen for cancer and manage treatment.

That’s the ideal scenario—but there are many obstacles that get in the way. First, Tony’s clinic may not have adequate broadband internet. Second, Medicare does not cover remote patient monitoring or “store and forward,” which are necessary for transmitting personal health data. Third, community health workers are not an approved telehealth “practitioner” under Medicare. And fourth, Medicare typically does not allow providers to bill for multiple visits by a patient in one day.

Bottom line, outdated policies and insuf�cient infrastructure mean individuals like Tony are going without the care they need.

To overcome these barriers, we need a robust, coordinated plan that facilitates the expansion of telehealth services. Medicare should reward—not punish—telehealth’s ef�ciency and affordability. Regulations should help doctors access their patient’s medical records. And public investment should enable hospitals to purchase technology that saves money for patients and providers.

Telehealth is the future of medicine. It is an opportunity to expand healthcare access to improve patient outcomes, and the government must be an active partner to pave the way for this transformation. Telehealth has spread its wings; intelligent policy and smart investment will help it soar.

YOU’RE BUTTERING YOUR TOAST when your vision starts to blur. You shake it off and think

nothing of it, but �ve minutes later when you reach for your keys, you struggle to lift your right arm. That’s when you realize you could be having a stroke, and immediately call 911.

Every minute counts in this scenario and can be the difference between a full recovery and permanent loss of function or death. In the future, if you have an elevated risk of a stroke or heart attack, you could have access to a mobile app paired with a wearable sensor that can detect a stroke or heart attack and activate emergency medical services immediately—all before you even notice any symptoms. That’s the power of telehealth.

Unfortunately, outdated policy and a lack of political will is holding back the widespread deployment of telehealth. Barriers include insuf�cient federal funding for telehealth infrastructure, inconsistent licensing requirements, lack of broadband internet in rural communities and needless bureaucracy. There is no silver bullet to solve these challenges, but the potential for telehealth to improve the lives of individuals in rural and underserved areas necessitates that we try.

I represent California’s 36th Congressional District, which is one of the most economically and geographically diverse in the country. Before I was elected, I worked as an emergency medicine physician, and I saw how physician shortages, lack of health literacy and proximity to a hospital determined a patient’s access to healthcare. Telehealth can bridge those gaps.

Take one example: Tony, a retired farmer who is on Medicare, has a new and suspicious lesion on his face. A community health worker refers him to a primary-care

By Rep. Raul Ruiz

Outdated infrastructure, federal policy holding back the power of telehealth to improve access to care

Rep. Raul Ruiz, M.D. (D-Calif.)

SERVING SINCE: 2013, now in his third term

HEALTHCARE-RELATED

COMMITTEES: House Energy and Commerce Committee (Communications and Technology Subcommittee and Environment Subcommittee)

Ruiz is chair of the Congressional Hispanic Caucus healthcare task force and a member of the Congressional Telehealth Caucus

Ruiz is an emergency medicine physician





Advancing Innovative Neurotechnologies Initiative, which supports a more dynamic understanding of brain functions; and the Regenerative Medicine Innovation Project, which aims to accelerate the �eld of stem cell science.

Cures provided the FDA with new authorities and also established an FDA Innovation Account so of�cials can concentrate on a broad range of goals including patient-focused drug development to incorporate the patients’ perspective, advancing new therapies to transform the way drugs are developed, modernizing drug-testing trial design, and development of methodology to use real-world evidence in the process, and more.

Cures also focuses on reforming our nation’s mental health system, which is why we worked so hard to include the Helping Families in Mental Health Crisis Reform Act in the bill.

And, amid our country’s opioid crisis, Cures provides $1 billion for states to �ght the epidemic at the local level through the end of 2018. We’re now focused on ensuring that this funding continues, and more.

Currently, we are looking at how the Cures implementation is progressing. We’re curious to �nd out how, exactly, it is changing the medical innovation ecosystem and what tweaks can be made to ensure we’re always putting patients �rst. When FDA Commissioner Dr. Scott

Gottlieb and NIH Director Dr. Francis Collins testi�ed in late July before the Energy and Commerce Committee’s Health Subcommittee on the continuing rollout of this law, they reminded us just how Cures is already having a monumental impact on health and healthcare delivery.

More than a year after it was signed into law, Cures is proving its worth. We look forward to continued engagement with patients, stakeholders and other lawmakers.

THE 21ST CENTURY CURES INITIATIVE began with the spark of an idea: What could we in Congress

do to ensure that life-saving drugs and devices move to market in the fastest and safest way possible? That spark was the start of a multiyear journey that took us from Michigan to Colorado, the halls of Congress to the Oval Of�ce.

And after listening, gathering stakeholder feedback and drafting and re-drafting legislation, the �nal product was what some called the most meaningful legislation we passed in the 114th Congress. While it was enacted into law in late 2016, we’ve only begun to see what it can do to advance cutting-edge healthcare and promote the nation’s overall health.

When a bipartisan group of lawmakers including myself and my partner in this effort, U.S. Rep. Diana DeGette (D-Colo.), gathered in the White House to sign the 21st Century Cures Act—also referred to as Cures—into law, it marked a momentous occasion. We not only had made needed reforms to the Food and Drug Administration and National Institutes of Health in order to encourage more ef�cient and safer approvals, we also had boosted research at the NIH, funded new mental-health programs, and appropriated money to states to �ght the ongoing opioid epidemic.

More speci�cally, Cures is boosting four major innovative initiatives at the NIH: the Beau Biden Cancer Moonshot, which works to accelerate progress in cancer prevention and screening; the Precision Medicine Initiative, which is a long-term research endeavor aimed at understanding how a person’s genetics, environment and lifestyle can help determine the best approach to prevent or treat disease; the Brain Research through

By Rep. Fred Upton

Delivering on promises of the 21st Century Cures Act to advance medical research and improve the nation’s health

Rep. Fred Upton

(R-Mich.)

SERVING SINCE: 1987, now in his 16th term

HEALTHCARE-RELATED

COMMITTEES: House Energy and Commerce Committee (Subcommittee on Health)

Upton also serves on several healthcare-related caucuses: the Bipartisan Disability Caucus, Bipartisan Problem Solvers Caucus and Congressional Addiction, Treatment and Recovery Caucus

SPONSORED CONTENT

Patients First Policy solutions that address misaligned incentives in supply chain and lower costs for patients

A troubling but familiar scene is playing out in pharmacies across the country. A patient walks in to pick up a prescription, but walks out empty-handed.

It simply costs too much.

Today, scientists and researchers are advancing a new era of medicine with the promise of new cures and better treatments. But those medical breakthroughs are only truly meaningful if they reach patients and help them get healthier.

America’s biopharmaceutical companies are proposing fresh policy solutions that would shake up the status quo, address misaligned incentives across the supply chain and solve for what patients are most concerned about: rising out-of-pocket costs for their medicines.

Last year, spending on medicines grew 0.6 percent, and net prices grew just 1.9 percent. That’s because our industry gives steep discounts off of a medicine’s list price to entities in the supply chain, like insurers and pharmacy bene�t managers (PBMs). These rebates and discounts added up to $150 billion last year, and that total has been growing every year. But all too often those savings are not being applied to help lower patients’ out-of-pocket costs for their medicines. Instead, insurers, PBMs and others use those funds to pad bottom lines, lower premiums or �ll other holes in their budgets. And because those funds are based on a percentage of a medicine’s list price, the entire supply chain has incentives to want higher list prices.

Our system needs to solve for these misaligned incentives that hurt patients. That is why we are proposing policies that would prohibit PBMs and others along the supply chain from having their compensation calculated as a percent of the list price of a medicine. Instead, they should be paid a fee based on the value of their services. This would require signi�cant change for our members. But it is worth it to make sure patients get access to the medicines they need at a cost they can afford.

Second, patients should have access to negotiated savings that PBMs and insurers receive. Recently, UnitedHealth and Aetna announced they will start sharing some of the rebates they negotiate. This is a step in the right direction. And, we know it works. For example, a recent analysis found that sharing a portion of negotiated rebates with seniors suffering from diabetes could reduce total health care spending by $20 billion over the next decade.

And pharmacists should have the tools available to help patients save money. We need to put an end to gag clauses that prevent pharmacists from telling patients it could be cheaper to buy a medicine out-of-pocket than through insurance. Some states have taken action to prohibit these gag clauses, but more work needs to be done.

We need policies that turn our system on its head and ensure patients share more of the discounts our member companies offer - whether it’s from rebates or commercial plans, Part D, 340B, Medicaid, and the list goes on.

Third, our members are already entering into new payment arrangements with insurers to be paid based on how well a medicine works for patients. In exchange for taking that risk, companies may negotiate preferred formulary placement for those medicines, which come with lower copays and coinsurance. This would help us move to a system that measures what matters most to patients, like how quickly they can get back on their feet after an illness.

Fourth, we need to ensure that 340B – a program designed to help vulnerable or uninsured patients access prescription medicines at safety-net facilities– works as it’s supposed to. Even though hospitals are getting huge discounts on medications, according to GAO data, fewer than half of hospitals surveyed provide those discounts to low-income,

uninsured patients when they �ll prescriptions at pharmacies. Of those that do, some said they still

charge patients more than the hospitals paid for that same medicine. We must �x this program, and we’re encouraged that the Administration is considering more improvements.

Some look at the challenges in our health care system and assume we have to choose

between innovation and affordability. That’s a false choice. We can choose to put patients over politics.

Lawmakers can pursue new policy ideas that are as innovative as the cures and treatments our scientists and researchers are developing

every day. And we can have a future where patients never have to walk out of a pharmacy empty-handed. America’s biopharmaceutical companies are ready to make that a reality.

Stephen J. Ubl is president and chief executive of�cer of the Pharmaceutical Research and Manufacturers of America (PhRMA), which represents America’s leading biopharmaceutical research companies.

Stephen J. Ubl President and CEO

Pharmaceutical Research and Manufacturers of America (PhRMA)

To learn more about PhRMA, please visit www.phrma.org


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kdriscoll

Sticky Note

Should read : For nearly(not over).

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