12/18/2024

Breaking News: Telehealth Expansion, Medicare, and PBM Reforms Included in Proposed Federal Spending Bill

The Ohio Hematology Oncology Society (OHOS) is excited to inform our members about significant provisions included in the proposed federal spending bill that could profoundly impact the future of cancer care. These reforms address critical issues affecting both hospitals and practices while safeguarding cancer patients’ access to high-quality care.  Below is a summary of some of the key provisions:

Medicare Updates

Medicare Physician Fee Schedule Relief

• Partial Relief from Fee Cuts: The Medicare physician fee schedule cuts would be mitigated by a 2.5% increase, offsetting significant decreases that were previously scheduled.

• GPCI Floor Extension: The 1.0 Geographic Practice Cost Index (GPCI) floor would be extended through 2025, maintaining stable reimbursement for underserved and rural areas.

• APM Incentive Payments: Advanced Alternative Payment Models (APMs) would see an extension of incentive payments through payment year 2027, albeit at a revised rate of 3.53%. This extension also maintains 2023 Qualifying Participant (QP) thresholds through 2027.

Telehealth Flexibilities

• Telehealth services would continue to receive robust support, with flexibilities extended through 2026, including provisions exempting telehealth services from high-deductible health plan requirements for an additional two years.

Future Coverage for Multi-Cancer Early Detection Tests

• Starting in 2029, Medicare would provide coverage for multi-cancer early detection tests, a groundbreaking step in expanding early detection capabilities.

PBM Reforms: A Landmark Victory

Pharmacy Benefit Manager (PBM) reforms are a centerpiece of this proposed bill, delivering long-overdue accountability and transparency:

• “Any Willing Provider” Contracts Codified: PBMs and plan sponsors would be required to contract with any willing provider under reasonable and relevant terms and conditions.

• Banning Spread Pricing in Medicaid: The harmful practice of spread pricing, where PBMs retain a portion of drug costs, would be prohibited in the Medicaid program.

• Prohibition on Percentage-Based Rebates: PBMs would no longer take a percentage of drug prices as rebates, a significant step toward fair pricing.

• Mandatory Reporting Requirements: PBMs would need to annually disclose comprehensive data, including:

  • Net and gross drug pricing

  • Drug spending

  • Rebate details

  • Formulary placement rationale

  • Benefit designs incentivizing the use of PBM-affiliated pharmacies

• Enhanced Audit Rights for Part D Sponsors: Medicare Part D plan sponsors would gain stronger audit rights to ensure compliance and fairness.

• Full Rebate Pass-Through: Starting 30 months from now, PBMs would be required to pass 100% of drug discounts and rebates to employers and health plans regulated under ERISA.

OHOS Advocacy at the National and State Levels

These national reforms represent a critical opportunity to protect access to quality cancer care, but we need your help to make them a reality. OHOS is calling on all members to reach out to their congressional representatives to express support for this important spending package.

Let’s Make This Happen

This spending bill is a game-changer for seniors and cancer care. It has overwhelming support nationwide, but we need to ensure it becomes a reality. Now is the time to act—contact your congressional representatives and urge them to support this package. Together, we can protect the future of oncology care and keep making a difference!