This Week: Hearings scheduled on EpiPen…House and Senate have hearings on ACA-related issues…Negotiations continue on Continuing Resolution and Zika funding.

1. Congress

House of Representatives

House Energy and Commerce Committee Republican Leaders Send Letter to HHS OIG Concerning NIH Grant on Traumatic Brain Injury

On Sept. 15, Republican leaders of the House Energy and Commerce Committee sent a referral letter to HHS’s Office of the Inspector General regarding an NIH grant awarded for research related to traumatic brain injury. The grant was to be funded through a donation by the National Football League (NFL) to the Foundation for the National Institutes for Health (FNIH) as part of the Sports and Health Research Program (SHRP)—a public-private partnership with the National Institutes of Health (NIH). The SHRP was established for the purpose of supporting “research on serious medical conditions prominent in athletes and relevant to the general population.”

Earlier this year, media outlets and a subsequent report by the committee’s Democratic staff alleged the NFL attempted to inappropriately influence NIH decision-making related to this grant award. However, based on the information available to Republican committee staff, these reports failed to address critical questions related to the conduct of NIH that may have contributed to the controversy and delay in awarding this grant.

To ensure the integrity of NIH grant processes, prevent future breakdowns in NIH grant decision-making and advance the critical research related to head trauma and sports-related injuries, the committee leaders pose five questions for potential examination by the independent HHS watchdog:

1. Why didn’t the NIH require the NFL to pay pursuant to the terms of the agreement?
2. If the actions of the NFL or its advisers were clearly inappropriate, as the Democratic staff report concludes, why did NIH and FNIH engage with representatives of the League and perpetuate the impression that the dialogue was appropriate? If confronted with inappropriate conduct by a donor, what are NIH’s responsibilities to flag and address such behavior?
3. Did NIH adhere to the terms of the MOU regarding donor communications?
4. What are NIH policies for the control of non-public information, including information related to Notice of Grant Awards, as well as non-funded grant proposals? Were they followed in this series of events?
5. How does NIH evaluate conflicts of interest between applicants and donors in public-private partnership grant programs such as SHRP?

In the letter to the HHS OIG, the committee leaders concluded, “While this grant award has become an unfortunate distraction from the greater issue of improving the science of traumatic brain injury (TBI), given the significant public attention to these events, it is clear that a thorough and objective review by the HHS OIG is necessary. This review is important to the strength and integrity of the SHRP, as well as the independence of NIH decision-making.”

The letter was signed by Energy and Commerce Committee Chairman Fred Upton (R-MI), Oversight and Investigations Subcommittee Chairman Tim Murphy (R-PA), Health Subcommittee Chairman Joseph Pitts (R-PA) and Commerce, Manufacturing, and Trade Subcommittee Chairman Michael C. Burgess, M.D. (R-TX).

House Energy and Commerce Committee Holds Hearing on ACA

Republicans on the House Energy and Commerce Committee issued two strident reports ahead of its Sept. 14 hearing on the Affordable Care Act.

One report concludes that state-based exchanges are mismanaged because CMS has not conducted “robust oversight” and has not collected funds that were misspent. The report also charges that the agency is wasting tax dollars by “encouraging” state-based exchanges to shutter and join the federal exchange; just 12 of the 17 original state exchanges will be in operation next year.

The second report focuses on the failure of co-ops, of which only 6 of the 23 created by the Affordable Care Act survive.

For more information on the hearing, click here.

House E&C Committee Chairman Upton Claims to be Close on Cures Deal

House Energy and Commerce Committee Chairman Fred Upton said he may have a 21st Century Cures deal early this week. The biggest issue has been how to pay for the package, particularly since some of the original pay-fors in last year’s House-approved legislation have since been used.

If there is at least two-thirds support from the House, it could be fast-tracked under a suspension of the rules before the chamber leaves town this month. Upton said whether to pass the bill under suspension would be a leadership decision.

House Oversight Committee to Hold Hearing on EpiPen’s Pricing

On Sept. 21, Mylan CEO Heather Bresch will testify at a House Committee on Oversight and Government Reform hearing on EpiPen price increases. Subcommittee Chairman Chaffetz and Ranking Member Cummings said they will also examine ways to encourage greater competition for EpiPen and to speed up FDA’s approval of generic applications. Doug Throckmorton, FDA’s deputy director for the Center for Drug Evaluation and Research, will also testify. The Oversight committee will likely call more witnesses.

For more information, click here.

Moderate Democrats Write Concerns to CMS About Medicare Drug Demo

On Sept. 9, a group of moderate House Democrats wrote a letter to Acting CMS Administrator Andy Slavitt expressing concerns with the Obama administration’s controversial Medicare Part B prescription drug demonstration project. “We appreciate that [HHS and CMS] have listened to the myriad concerns raised about this proposed demonstration. We ask that you fully address these concerns,” the Democrats wrote.

This letter comes as the administration is expected to release the final rule to authorize the demonstration. The group says they do not like the wide scope of the demonstration, are frustrated that there was little input from stakeholders and warn that 60 days is not enough time to successfully educate Medicare beneficiaries.

The letter was signed by Democratic Reps. Ami Bera (CA), Brad Ashford (NE), Collin Peterson (MN), David Scott (GA), Grace Meng (NY), Joyce Beatty (OH), Kyrsten Sinema (AZ), Scott Peters (CA) and Suzan DelBene (WA).

Senate

Senate Homeland Security and Governmental Affairs Holds ACA Hearing to Look at Exchange Stability

On Sept.15, the Senate Homeland Security and Governmental Affairs Committee held a hearing concerning the stability of exchanges. Witnesses included: The Honorable Mary Taylor, Lieutenant Governor and Director, Ohio Department of Insurance, State of Ohio; J.P. Wieske, Deputy Commissioner, Office of the Commissioner of Insurance, State of Wisconsin; Nick Gerhart, Commissioner, Iowa Insurance Division, State of Iowa; and The Honorable Mike Kreidler, Commissioner, Office of the Insurance Commissioner, State of Washington.

For more information on the hearing, click here.

Bipartisan Legislation Introduced in House and Senate to Require Transparency in Rx Drug Price Increases

U.S. Sens. Tammy Baldwin (D-WI) and John McCain (R-AZ) and U.S. Rep. Jan Schakowsky (D-IL) today introduced the FAIR Drug Pricing Act. The bipartisan and bicameral Fair Accountability and Innovative Research (FAIR) Drug Pricing Act is supported by AARP; the Campaign for Sustainable Rx Pricing; The Medicare Rights Center; Consumers Union; Doctors for America: Drug Price, Value, and Affordability Campaign; Families USA and the Center for Medicare Advocacy, Inc.;and Public Citizen.

The FAIR Drug Pricing Act would require drug manufacturers to notify the U.S. Department of Health and Human Services (HHS) and submit a transparency and justification report 30 days before they increase the price of certain drug products by more than 10 percent. The report will require manufacturers to provide a justification for each price increase; manufacturing, research and development costs for the qualifying drug; net profits attributable to the qualifying drug; marketing and advertising spending on the qualifying drug; and other information as deemed appropriate. The bill will not prohibit manufacturers from increasing prices but it will, for the first time, give taxpayers notice of price increases and bring basic transparency to the market for prescription drugs.

The legislation is in response to price increases of EpiPen, Gleevec and insulin, among others.

2. Administration

CMS Sends MACRA Rule to OMB

On Sept. 15, CMS sent its MACRA rule to the White House’s Office of Management and Budget (OMB) for review. CMS is required by statute to finish the rule, which will reshape its payment and bonus policies for doctors, by November. On Sept. 8, CMS announced flexibility in its quality reporting programs under MACRA, which take effect Jan. 1.

CMS Blog Releases New Data From the Hospital Readmissions Reduction Program

In a Sept. 13 blog post, CMS released new data to show the successes of the Hospital Readmissions Reduction Program. The program adjusts payments for hospitals with higher-than-expected 30-day readmission rates for targeted clinical conditions such as heart attacks, heart failure and pneumonia. According to the new data, since 2010:

• All states but one have seen Medicare 30-day readmission rates fall.
• In 43 states, readmission rates fell by more than 5 percent.
• In 11 states, readmission rates fell by more than 10 percent.

Overall, readmission rates fell by 8 percent nationally between 2010 and 2015. Across states, Medicare beneficiaries avoided almost 104,000 readmissions in 2015 alone, compared to if readmission rates had stayed constant at 2010 levels. That means Medicare beneficiaries collectively avoided 104,000 unnecessary return trips to the hospital. Cumulatively since 2010, the HHS Assistant Secretary for Planning and Evaluation estimates that Medicare beneficiaries have avoided 565,000 readmissions.

For more information, click here.

QIOs Restart Reviews of Short Inpatient Hospital Stays

On Sept. 12, the Quality Improvement Organizations (QIOs) restarted reviews of short inpatient hospital stays after CMS said the contractors completed re-training on the two-midnights hospital admissions policy. The audits had been on hold since early May.

CMS also said the Beneficiary and Family Centered Care QIOs finished a second review of all hospital short-stay claims that had been previously denied, and the contractors reached out to providers affected by the temporary audit suspension prior to CMS’s lifting it.

The two-midnight hospital admissions policy says providers must expect that beneficiaries will remain hospitalized for at least two midnights for doctors to admit them. Otherwise, the stay should be considered outpatient and paid at the lower outpatient rate. In early May, CMS temporarily paused the QIOs’ initial patient-status reviews after hospitals told the agency there were procedural problems—such as not having enough time to implement education and improvement activities between rounds of audits and delays in hospitals’ receiving review results.

In a notice posted on the QIO website, CMS said that the QIOs have also initiated provider education on the two-midnight policy in addition to finishing their own re-training on the policy. “CMS will continue its oversight efforts by re-reviewing a sample of BFCC-QIO completed claim reviews each month, monitoring provider education calls and responding to individual provider inquiries and concerns,” the agency said.

IRS Issues Report: $1.7 Billion Paid in Fines for Individual Mandate in 2014

Nearly $1.7 billion in individual mandate fines were paid through about 8.1 million tax returns in 2014, the first year the ACA’s penalty was enforced, according to an IRS report on 2014 individual income tax returns published Aug. 31. The average penalty paid was $210, the IRS said. In 2014, the fine for lacking minimum essential coverage equaled 1 percent of household income capped at the annual premium of the national average bronze-level exchange plan, or $95 per adult and $47.50 per child up to $285, whichever was higher.

More than 13.3 million Americans also claimed an exemption from the individual mandate. “The total premium tax credit was taken on 3.1 million returns on the Form 8962, for a total of $11.2 billion,” the IRS said. “Also on Form 8962, 3.4 million returns had an APTC totaling $12.0 billion. When the PTC and APTC were reconciled, 1.5 million returns received the net premium tax credit ($1.0 billion) and 1.8 million returns had to repay excess advance premium tax credit ($1.4 billion).”

When broken down by adjusted gross income brackets, the IRS found that Americans who made between $15,000 and $20,000 noted the most premium tax credits on their returns, for $1.6 billion across nearly 470,000 returns. Those people also received the most APTCs, at $1.5 billion across nearly 460,000 returns.

Those taxpayers fell slightly higher than the 2014 federal poverty level for a single person, which was $11,670, and just below the poverty line for a family of four at $23,850.

However, those with adjusted gross incomes of $50,000 or more—the income ceiling for subsidy eligibility started at $46,680 for a single person—had to repay the most in excess APTCs, at $691 million among more than 380,000 returns. While the $15,000 to $20,000 bracket filed the most returns with individual mandate penalties, those in the $50,000 and higher bracket doled out the highest amount for the fee at $694 million.

3. State Activities

Alabama: State Lawmakers Provide Medicaid Another Short-Term Funding Fix

Alabama has temporarily solved its Medicaid budget shortfall. Gov. Robert Bentley signed a bill providing $120 million to Medicaid over the next two years. The money will come from a bond issue from BP’s $1 billion oil spill settlement with the state. Alabama’s Medicaid program, which requested $785 million for 2017, estimates that it needs about $865 million in 2018 and $895 million in 2019.

California: Report Finds California Officials Still Lack Oversight on Mental Health Spending

According to the Little Hoover Commission—a state watchdog—California officials still have not taken steps to better track how $2 billion a year in voter-approved funding for mental health programs is spent, despite a critical audit 19 months ago flagging issues. Proposition 63—known as the Millionaire’s Tax—is supposed to support mental health programs, but state officials are not sure the money is being used appropriately and effectively. The audit cites weak financial reporting and limited oversight of revenue as main issues. “Twelve years and $17 billion later the state still can’t handily show the impacts of this funding, how it is spent or who is helped,” the report said.

Connecticut: ConnectiCare Sues State Insurance Department, Threatens to Leave Obamacare Exchange

Health insurer ConnectiCare is suing the Connecticut insurance department and threatening to leave the Obamacare exchange because regulators declined to consider its third revision to its rate increase averaging nearly 27 percent. The new request was made after the state insurance department had already approved an average rate increase of 17.4 percent for 2017. ConnectiCare covers about 48,000 individuals on the exchange, which has already seen the departure of UnitedHealth Group and the collapse of Connecticut’s co-op plan.

Massachusetts: Report Finds Health Care Costs in the State Grew More Than Expected

According to a new report, health care expenses totaled $57 billion in Massachusetts in 2015 and health care costs are growing faster than what state officials had hoped for. The Center for Health Information and Analysis said in its annual review of Massachusetts’s health care system that total costs rose by 3.9 percent over the previous year. This is higher than the 3.6 percent growth benchmark set by a commission established by the state’s 2012 cost containment law. While costs exceeded state officials’ expectations, they grew more slowly in the state than the rest of the country in 2015.

Click here to see the report.

Oregon: Oregon Health Authority Releases Quarterly Legislative Report

An Oregon Health Authority report to the state legislature finds the state Medicaid program’s coordinated care organizations are cutting emergency department visits and preventable hospital visits. For example, avoidable ER visits have declined by 50 percent since 2011. However, more improvement is necessary on measures related to substance abuse and smoking cessation. The report also finds the CCOs performed well enough to receive bonus payments based on a set of 17 quality measures. In 2015, all but one of 16 CCOs earned all of the quality bonuses for which they were eligible. The remaining CCO received 60 percent of eligible funding. The bonuses totaled $168 million last year.

Vermont: Burwell, Gov. Shumlin Meet to Discuss Pending All-Payer Waiver

On Sept. 14, Vermont Gov. Peter Shumlin met with HHS Secretary Sylvia Burwell to discuss the state’s pending all-payer waiver, which would control rates paid to hospitals and providers to limit health care cost growth. The demonstration would cover Medicare, Medicaid and private insurance regulated by the state’s Green Mountain Care Board. Officials discussed the source of timing and funding during the meeting. Gov. Shumlin said he is “cautiously optimistic” that his administration will make the deal happen and he expects to have a decision in the next couple of weeks.

4. Regulations Open for Comment

IRS, Treasury Release Proposed Rule on QHP Benchmarks

The IRS and Treasury Department, in a proposed rule released July 6, proposed to alter how qualified health plan (QHP) benchmarks are determined so that they account for the costs of pediatric dental benefits. If finalized, the rule would go into effect for the 2019 plan year.

Although pediatric dental care is one of the 10 “essential health benefits” that plans are required to cover under the Affordable Care Act (ACA), several plans do not include such coverage, and consumers instead buy stand-alone dental products. Meanwhile, the marketplace determines the amount of tax credits a family can receive to cover the cost of coverage based on the second-cheapest silver-level plan.

However, as the proposed rule said, “because qualified health plans that do not offer pediatric dental benefits tend to be cheaper than qualified health plans that cover all ten essential health benefits, the second lowest-cost silver plan (and therefore the premium tax credit) for taxpayers purchasing coverage through a Marketplace in which stand-alone dental plans are offered is likely to not account for the cost of obtaining pediatric dental coverage.”

Treasury and IRS added that the existing rules “frustrate” the goal of making all essential health benefits affordable to those receiving premium tax credits, so the administration wants to update its interpretation to ensure all 10 services are addressed.

“Consistent with this interpretation, the proposed regulations provide that for taxable years beginning after December 31, 2018, if an Exchange offers one or more silver-level qualified health plans that do not cover pediatric dental benefits, the applicable benchmark plan is determined by ranking (1) the premiums for the silver-level qualified health plans that include pediatric dental benefits offered by the Exchange and (2) the aggregate of the premiums for the silver-level qualified health plans offered by the Exchange that do not include pediatric dental benefits plus the portion of the premium allocable to pediatric dental benefits for stand-alone dental plans offered by the Exchange,” the proposal said.

The rule aims to create the ranking by adding the premium for the lowest-cost silver plan that does not include a pediatric dental benefit to the premium for the cheapest stand-alone dental plan, and the premium for the second-cheapest silver plan without pediatric dental benefits to that of the second-lowest stand-alone dental plan. The second-cheapest amount from this combined ranking would be the taxpayer’s applicable benchmark plan premium, the rule said.

CMS Releases Proposed Mandatory Bundled Payment Program

On July 25, CMS proposed new models to mandate bundled payments for cardiac care. This is the agency’s second program requiring providers to accept set payments for an episode of care. CMS also proposed extending its existing mandatory bundled payment initiative for hip replacements to other hip surgeries.

CMS clarified that under the new Medicare physician payment system starting in 2018, both mandatory bundled payment models could qualify as Advanced Alternative Payment Models, which would allow participating physicians to be excluded from a new proposed quality reporting program and instead receive a lump-sum payment from Medicare.

The agency also announced a new initiative to encourage hospitals to increase cardiac rehabilitation, in hopes of improving patient outcomes and reducing readmissions.

To see the proposed rule, click here. CMS will accept comments on the proposed rule until 5 p.m. on Oct. 3.

IRS Publishes Draft Regulations on Reporting of Catastrophic Health Coverage

The Internal Revenue Service (IRS) published new draft health coverage reporting regulations in the Federal Register on Aug. 2. The new draft regulations call for the health insurers that sell catastrophic medical insurance to report any catastrophic coverage they have provided to the enrollees and the IRS on Form 1095-B. The rule would first apply to the coverage in effect in 2017—issuers would then send out the first catastrophic plan 1095-B forms in early 2018.

Catastrophic plans are higher-deductible, lower-value plans that insurers can sell to people under 30, and to people of any age who earn too much to qualify for ACA exchange plan premium subsidies. The new draft regulations also call for the government agencies that offer Basic Health Plans—which are similar to managed Medicaid programs for people who earn too much to qualify for Medicaid—to report Basic Health Plan coverage to the IRS.

A third piece of the draft regulations clarifies that an employer providing two or more types of coverage that come under the minimum essential coverage rules would just have to report the richest form of coverage.

Comments on the draft regulations are due by Oct. 3.

UNOS Proposes Changes to Liver Transplant Policies

The United Network for Organ Sharing (UNOS) is proposing changes to the geographic regions for liver transplants to better match organ supply with demand and make access more equitable. Currently, there exists a wide variation in a transplant candidate’s chance of receiving an organ in a timely way, based on where the patient lives and the location of the transplant hospital where they are listed. Some patients may not get organs until they are much sicker than are patients awaiting transplants in different regions.

HHS Proposes Updates to Title X Rules

On Sept. 2, HHS proposed to preclude Title X grant recipients from using criteria in their selection of family planning providers that are unrelated to the ability to deliver services effectively.

Since 2011, 13 states have attempted to restrict participation by family planning providers in Title X based on factors unrelated to their ability to provide services. The Title X program provides funding for certain family planning services, including STD screening and treatment, but funding is not used to pay for abortions. Although Planned Parenthood is not mentioned by name in the proposed rule, it has often been the subject of defunding actions by states and Congress.

In the proposed rule, HHS said the effects already felt by the restrictions in many states justify the department’s rulemaking. HHS said grant recipients that do not provide services directly would also be required to follow the updated standards when choosing subrecipients.

HHS also proposed that a tiered structure governing how funds are distributed would not be allowed unless it can be proven that a provider in a top tier delivers Title X services more effectively than a lower-tier provider. According to the Guttmacher Institute, a research organization that supports reproductive rights, four states have a priority system for distributing family planning funds, which often disadvantages family planning centers.

CMS Proposes Changes to Risk Adjustment in 2018 Marketplace Rules

On Aug. 29, CMS issued the proposed annual Notice of Benefit and Payment Parameters for 2018, which outlines additional steps to strengthen the Health Insurance Marketplace. CMS is issuing this rule earlier in the calendar year in order to provide more certainty to the Marketplace as it continues to mature.

Beginning in 2017, the proposed policies will take steps to strengthen the risk adjustment program. First, the rule proposes updates beginning in 2017 to better reflect the risk associated with enrollees who are not enrolled for a full 12 months. Second, beginning in 2018, the rule proposes to use prescription drug utilization data to improve the predictive ability of CMS’s risk adjustment models. Third, also beginning in 2018, the rule proposes to establish transfers that will help to better spread the risk of high-cost enrollees, a change that would improve the risk-sharing benefits of the program.

In addition to the improvements to risk adjustment, the proposed rule contains other provisions to improve the Marketplace consumer experience and strengthen the individual and small group markets as a whole. The proposed rule would give consumers additional tools for assessing the networks of competing plans; broaden availability of this year’s new standardized plan options by accommodating state cost-sharing rules; and create consumer protections for consumers enrolling through the direct enrollment channel. The proposed rule would also create multiple child age bands that address instances in which consumers could face large premium changes after turning age 21; amend the guaranteed renewability regulations to provide additional flexibility for issuers to remain in an insurance market in certain situations; and codify several special enrollment periods that are already available to consumers in order to ensure the rules are clear and to limit abuse. It also seeks information on a number of suggestions offered by issuers, consumers, providers and others on further improving the risk pool, such as additional changes to special enrollment period policies or outreach; clarifying coordination of benefit rules between Medicare, Medicaid and the Marketplace; and providing greater certainty on the amount of user fee revenue spent on education and outreach.

To see the proposed rule, click here.

5. Reports

GAO Report: Better Information Necessary on Direct Care Workers

In a new report, GAO finds there is better information needed on nursing assistants, home health aides and other direct care workers. Millions of elderly individuals and persons with disabling conditions rely on long-term services and supports (LTSS) to help them perform routine daily activities, such as eating and bathing. Direct care workers are among the primary providers of LTSS.

In the report, GAO examined federal and state data available on the paid direct care workforce and actions HRSA has taken to develop information and projections on this workforce. GAO analyzed data on paid direct care workers’ demographics, compensation and benefits. GAO recommended that HRSA take steps to produce projections of direct care workforce supply and demand and create methods to address data limitations in order to do so.

To see the full report, click here.

GAO Report: Exchanges Still Vulnerable to Fraud

In a new report, GAO found Obamacare insurance marketplaces approved coverage for each of the 15 fictitious applications the agency submitted for 2016, including for six fake applicants that previously obtained subsidies but did not file required federal income tax returns. This happened despite CMS’s saying that in 2016 it would halt subsidies to enrollees who received financial assistance in 2014 but never filed a tax return. GAO also found that 10 of 11 fictitious enrollees kept subsidized coverage even though it sent fake documents—or none at all—to resolve coverage application discrepancies. GAO submitted the fake applications through the federal exchanges in Virginia and West Virginia as well as through California’s state-based exchange.

GAO Report Finds Generic Drug Prices Under Part D Have Declined Overall

GAO recently released a report finding that about 22 percent of generic drugs billed to Medicare Part D had at least one price increase of 100 percent or more between 2010 and 2015. Forty-five drugs had a price increase of 100 percent or more between the first quarter of 2010 and the first quarter of 2011, while the price of 103 drugs were similarly raised between the first quarter of 2014 and the first quarter of 2015. Nearly 50 of these large price increases were 500 percent or higher, and 15 were 1,000 percent or higher. In contrast, at least 50 percent of the 1,441 generic drugs that were on the market during the entire study period experienced a price decrease from one year to the next.

But the “extraordinary” price hikes of 315 generic medicines over the five-year period moderated the overall decline in cost of generic drugs during this time, the report found. Overall, generic drug prices in Medicare Part D fell rapidly in the first half of the study period, but then declined moderately thereafter.

To see the full report, click here.

JAMA Study: Choosing Wisely Recommendations Did Not Change Overuse of Cancer Medicines

According to a new JAMA Oncology study, Choosing Wisely campaign recommendations aimed at reducing overuse of newer and expensive anti-nausea and vomiting medications in cancer patients had only a short-term effect on doctors’ prescribing behavior.

The results suggest that voluntary measures are not creating change and steps such as financial incentives may be needed to reduce unnecessary and wasteful use, the study authors, led by William Encinosa of AHRQ, said. Examination of health insurance type and health plan design might also be useful, as the study found some evidence that these factors can affect the likelihood of overuse.

In 2013, the American Society of Clinical Oncology in conjunction with the American Board of Internal Medicine Foundation’s Choosing Wisely campaign, issued recommendations to discourage overuse of expensive antiemetics in patients with low risk of chemotherapy-induced nausea and vomiting. They are recommended for patients on those types of chemotherapy that have a high risk of causing nausea and vomiting, not for all patients on chemo.

A review of 678,220 privately insured adults receiving chemotherapy before and after the recommendations found that overuse of these drugs decreased for the first six months after the recommendations, but then rose to even higher levels than before the recommendations.

A complementary editorial outlines four additional steps that could be taken to decrease overuse, including suggesting CMS revise its coverage policy to align more closely with clinical practice guideline recommendations.

JAMA Paper Performs Historical Analysis on Sugar Industry-Funded Research

A new paper published in JAMA Internal Medicine analyzed more than 1,500 pages of newly unearthed internal documents from the Sugar Research Foundation, shedding light on industry-funded studies that downplayed sugar’s role in cardiovascular disease in the 1960s. University of California at San Francisco researchers suggest the documents show that the industry-backed research “successfully cast doubt about the hazards of sucrose while promoting fat as the dietary culprit in [culinary heart disease].”

NFIB Survey: Cost of Health Insurance is Top Concern for Small-Business Owners

According to a survey from the NFIB Research Foundation, small-business owners say the cost of health insurance is their top concern, as it has been for 30 years. About half—52 percent—of small-business owners surveyed listed it as a top concern, which is unchanged from four years ago.

NFIB fought Obamacare to the Supreme Court in 2012, and President and CEO Juanita Duggan said the plan has failed in its central promise, that is, in providing a solution to the cost problem. More severe problems for small-business owners include unreasonable government regulations, federal taxes on business income and uncertainty over economic conditions, respectively.

Kaiser Survey: Employer-Based Plans See Modest Increase in Average Premiums

According to an annual survey from the Kaiser Family Foundation, premiums for employer-based health insurance continued to increase modestly this year, partly because of an ongoing shift toward high-deductible plans. The average premium for family coverage increased by 3 percent this year, reaching $18,142. This is below last year’s increase (4 percent) but still higher than the inflation rate (1.1 percent) and wage growth (2.5 percent). But deductibles continued to skyrocket for workers. The average deductible for single workers in 2016 is $1,478, a 12 percent increase over last year. Since 2011, the average deductible for individual workplace coverage has increased by almost 50 percent.

Employers’ increasing preference for high-deductible plans has helped keep down premium growth. Since 2011, family premiums have increased by 20 percent. By contrast, they spiked by 31 percent in the prior five-year period, and by 63 percent in the five years before that. This year, 29 percent of workers were enrolled in a high-deductible plan with a savings component such as a health reimbursement arrangement. That is up from 20 percent two years earlier. In addition, just under half of workers are now enrolled in a broad network PPO plan, down from 58 percent in 2014.

Kaiser’s survey, conducted with the Health Research & Educational Trust, included 3,110 employers with at least three workers.

To see the full survey, click here.

National Academies Report: U.S. Needs New Elder Care Strategy

According to a new report from the National Academies of Sciences, Engineering and Medicine, the next administration needs to take immediate action to better support elderly patients and their caregivers as the U.S. population ages and family caregivers face increasing challenges. HHS should head up this effort by developing a national strategy in collaboration with other federal agencies that would help the health care system and increase workplace support for family caregivers.

CMS should develop, test and implement provider payment reforms that will encourage health care providers to engage with family caregivers. The strategy should suggest federal policies that would provide economic support to working caregivers. Further, CMS and the U.S. Department of Veterans Affairs should develop ways to ensure that family caregivers are identified and supported. The report also calls on states to develop their own caregiver support programs.

The report expresses concerns about the country’s dependence on family caregivers. The need for caregiving is rapidly increasing, as the pool of potential family caregivers is shrinking, the report says. However, it says research demonstrates that interventions to support caregivers can significantly improve care and the quality of life for caregivers and patients.

These policy changes will carry new costs, some of which may be offset by reductions in use of nursing homes, emergency rooms, home health and inpatient hospital care. However, the savings are unlikely to support all of their recommendations, the report notes.