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APPLIED POLICY INSIGHT
Prior authorizations and the U.S. healthcare system
The contradiction has become a cliche in health policy: In study after study comparing healthcare across high-income countries, the U.S. consistently ranks lowest in key health metrics, despite outspending all other countries whether measured in terms of per capita expenditures or as a percentage of gross domestic product.

Less frequently discussed is the fact that, despite the nation’s outsized expenditures, physicians in the U.S. are more likely than those in other high-income countries to report that restrictions on coverage resulted in difficulties accessing medication or treatment for patients.

At first glance, such findings support concern on the part of patient advocates and public health officials about access to care. When considered in the context of expenditures and outcomes, they point towards another issue—providers frustrated by what they perceive as efforts to control healthcare spending at the expense of their autonomy.

In the second installment of our series on prior authorizations, we consider how prior authorizations have become a persistent feature of healthcare in the U.S., particularly among commercial insurance plans.
Understanding UPICs
Applied Policy has previously reported on the work of Recovery Audit Contractors (RACs), a group sometimes characterized as "bounty hunters." This month, we turn our focus to the "detectives" within the Center for Medicare & Medicaid Services' (CMS's) audit and recovery program—the Unified Program Integrity Contractors (UPICs). 

While the RACs focus on improper payments in Medicare fee-for-service programs, the UPICs have a more specifically defined mission across a wider territory. UPICs are charged with finding, preventing, and proactively deterring fraud, waste and abuse in Medicare Parts A and B, Durable Medical Equipment (DME), Home Health, Hospice, Medicaid, and the Medicare-Medicaid data match program.

Essentially deputized by CMS, UPICs exercise a wide degree of latitude in conducting their investigations. They are authorized to make site visits unannounced, conduct interviews with any interested parties, and request medical records and other documentation for review.

Importantly, UPICs are allowed to extrapolate loss from small but statistically significant sample sizes. This means that even their seemingly most innocuous records request can be consequential.


Applied Policy names
John Voorhees as COO
This week, Applied Policy announced the promotion of John Voorhees to Chief Operating Officer, effective immediately. Voorhees, who has been with Applied Policy for nine years, has held both policy consulting and managerial responsibilities in his role as the company’s Senior Vice President.

Jim Scott, President and CEO, said this promotion is an acknowledgement of John’s importance to the company and of the role he has been serving in for the last few years.

Prior to joining Applied Policy in 2014, Voorhees spent 11 years at the Centers for Medicare & Medicaid Services (CMS), where he was Senior Advisor to several of the Agency’s most senior leaders, including the CMS Administrator, Chief Operating Officer, and the Medicare Beneficiary Ombudsman. 

As CMS’s Chief Administrative Officer, Voorhees oversaw the Agency’s annual award of more than $900 million in contracts and development of the Agency’s strategic plan. As Senior Advisor to the Chief Operating Officer, he was recognized for his work in helping the Agency enroll 24 million Medicare beneficiaries during the implementation of the Medicare Modernization Act.

Reflecting upon his tenure with Applied Policy, Voorhees said, “Before I joined, Jim Scott told me it would be the hardest job I’d ever have. And he was right. But it’s been a wonderful experience. Every day I learn something new, and I get to work with an amazing team. I’m looking forward to what we can achieve in the next nine years.” 
Register for NVHPF's May 24 event
Negotiating Drug Prices:
What Should CMS Do Next?
The Centers for Medicare and Medicaid Services (CMS) is facing a critical deadline in its effort to implement the Medicare Drug Price Negotiation Program, created by the Inflation Reduction Act of 2022 (IRA). Under the Program, CMS will negotiate directly with drug manufacturers to lower the price of certain high expenditure single-source brand-name Medicare Part B and Part D drugs.

The first ten drugs selected for negotiation will be announced by September 1, 2023, and the prices set by CMS for these drugs will go into effect in 2026. CMS is in the process of making pivotal decisions to implement this landmark change in Medicare drug pricing. The Agency has solicited public comment on its process for the first year of the Program, including how it will collect and use data for negotiation.

John O’Brien, Pharm.D., MPH, President and Chief Executive Officer of the National Pharmaceutical Council (NPC); Jason Spangler, MD, Chief Executive Officer of the Innovation and Value Initiative (IVI); and Monét Stanford, Pharm.D., Director of Policy, Association for Accessible Medicines; will join the Northern Virginia Health Policy Forum on Wednesday, May 24th from 12:00 to 1:00pm ET to share their insights on the decisions before CMS regarding this critical process, the impact those decisions may have, and their outlook on the next steps for CMS.
Reflecting upon the PHE:
Applied Policy team members remember where
they were as the world shut down
On January 31, 2020, U.S. Health and Human Services Secretary Alex Azar announced the declaration of a public health emergency (PHE) in response to the Novel Coronavirus (2019-nCoV).

Assured that the Trump administration was “working to keep the risk low,” most Americans paid little attention. For many, the death of Kobe Bryant in a helicopter crash the week before was of more interest than a virus concentrated on the other side of the world.

It was hard to imagine the changes that would come.

The PHE came to an end last week—1,196 days and more than 1,100,000 American lives later. As we move forward into a new relationship with COVID, some Applied Policy team members paused to reflect upon where they were as a new reality unfolded at the beginning of the pandemic and the lessons they hope we never forget.
On March 9 2020, I was on a plane flying back to New Orleans when I got a text letting me know that the first case of COVID in Louisiana had just been diagnosed in the New Orleans VA hospital ED that I managed. Was it a coincidence 1.5 million good friends had been in town the week before for Mardi Gras? Over the next week 14 New Orleans residents had died of COVID. Despite 40 years of work as an emergency physician, multiple overseas military deployments (both combat and peacetime), the next year or so would come to be the worst experience of my professional life

William Rogers, MD
Chief Medical Officer
I was living in Northern Virginia with my family. I had just gotten back from a trip to Spain at the end of February when the first news coverage of COVID hitting Italy and Spain started to air. My dad even told me I had to shower before he would hug me when I got home. I thought we were lucky to not catch it and bring it home.  

Little did we know that was just the beginning. Since then, I moved to Denver, Colorado; got married; and became a corgi mom. I never thought I would be a “work from home” professional, but COVID changed that too. I am glad for it because I get to keep doing what I love to do while living where I want to live for the time being. Even though we all want to move past “the COVID years,” I don’t want to forget them. We found how fragile and how resilient we can be, we found joy in the smaller things, we remembered the value of connecting with each other in person again. I hope those lessons stick around.

Simay Okyay McNutt
Health Policy Manager
At that time, I lived in Hawaii and worked in a healthcare trade association representing providers across the healthcare continuum. I remember looking with our team members at COVID-19 case counts – six positive cases in the United States on January 31st – and thinking there was no way this would turn into a major pandemic. Little did I know. Over the coming years, I worked over many sleepless nights, long days, and incredible uncertainty to support providers’ efforts to mitigate and respond to the pandemic. But the fact that we are here today is a testament to the incredible sacrifices our health care workers, community stakeholders, and public leaders made to keep our communities safe. 

Patrick Harrison
Health Policy Director
I had flown down to New Orleans, Louisiana, to visit my fiancée who had been stationed in Stennis, Mississippi, for about six months. Our wedding was scheduled for May 22, 2020. We ended up getting married in a backyard in Slidell, Louisiana, on April 10, 2020 with a Navy Chaplain officiating and our families watching on Zoom.

Meghan Basler
Health Policy Associate
CMS releases final rule for 2024 qualified health plans, strengthening network adequacy standards, and expanding consumer access
CMS holds office hours on the end of the PHE
The end of the public health emergency on May 11 ushered in many changes in healthcare. Enhanced federal Medicaid matching funds are currently being phased out and will end on December 31, 2023, along with virtual supervision flexibility. Nursing home and hospital COVID reporting requirements will end on April 30, 2024. The extension of the Acute Hospital of Care at Home waiver will end on December 31, 2024. Most Medicare telehealth flexibility provisions will end on December 31, 2024.  

On April 25, Will Harris, Senior Advisor at the CMS Office of the Administrator, led a CMS office hours session to help providers, facilities, and Medicare beneficiaries navigate these and other changes. 
Applied Policy at MDMA
From left: Dan Waldmann from MDMA with CMS officials Tamara Syrek-Jensen, Jason Bennett, and Carol Blackford.(Simay Okyay McNutt photo)

Applied Policy team members attended the annual Medical Device Manufacturers Association meeting in Washington, D.C., April 26-27. The event included discussions of changes coming to DME in future rulemaking and an update on the proposed rule on transitional coverage of emerging technologies. 
Celebrating Earth Day
From left: April Gutmann, senior health policy associate; Marlowe Galbraith, health policy associate; and Emma Hammer, health policy associate, take part in Earth Day activities.
Applied Policy is proud of its team members, proud of its waterfront office on the Potomac, and proud to be active members of the Alexandria, Virginia, community. So, it only made sense for us to pitch in for Earth Day cleanup sponsored by our neighbors at the Torpedo Factory.
On our calendars
Under review/On the docket
Applied Policy is paying particular attention to the following rules under review at the Office of Management and Budget:

  • Transitional Coverage for Emerging Technologies (CMS-3421)
  • Omnibus COVID-19 Health Care Staff Vaccination (CMS-3415)

See all rules under OMB review here.
From the headlines
Insight joke of the month for May
Why did the Dalmatian go to the ophthalmologist?
May's book recommendation:
Taking Care: The Story of Nursing
and its Power to Change our World
As we join in observing National Nurses Month, we are happy to recommend Taking Care: The Story of Nursing and its Power to Change our World by Sarah DiGregorio.

In a heartfelt and exceptionally well-researched tribute to what she describes as "a thread running through all human history," DiGregorio examines both the evolution of the nursing profession and the challenges it faces today.

Publisher's Weekly described Taking Care as striking an "expert balance between the big picture and intimate portraits of individual caregivers."

DiGregorio doesn't shy away from nursing's more difficult topics, including sexism, classism, compensation, and the moral injury that contributes to burn-out and the current nursing shortage.

And, with due respect to Florence Nightingale, DiGregorio is quick to dismiss with historical oversimplification. She believes that nursing has infinite origin stories and is not exclusive to one time or culture. For DiGregorio, "The history of nursing argues that nursing belongs to everyone."
Applied Policy, L.L.C., is a health policy and reimbursement consulting firm strategically located minutes from Washington, D.C.