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APPLIED POLICY INSIGHT
Prior authorizations: a primer
Utilization management, including prior authorization requirements under which a provider must secure payer approval in advance of a prescription, procedure, or admission, allows payers to review the appropriateness of treatment before it is provided. This positions payers to flag inappropriate treatment options or redirect providers to less costly care. 

But prior authorization requirements can also put payers between providers and patients, limiting provider autonomy and sometimes leading to critical delays in treatment. Unsurprisingly, prior authorization has become one of healthcare’s most debated issues.

In the first of a four-part series on prior authorizations, we take a look at the arguments on both sides.
The 'Food as Medicine' movement,
it's not what social media might have you believe
As an appreciation for the impact of social determinants of health moves from academia to practical applications, many healthcare providers, payers, and policy makers are exploring the potential of “food as medicine.” 

From healthcare systems delivering medically tailored meals (MTMs) for patients with complex medical conditions to Medicaid programs subsidizing the purchase of fruits and vegetables through “produce prescriptions,” mainstream healthcare is recognizing the relationship between diet and health and addressing the socioeconomic barriers to nutrition access.

While grounded in science and good intentions, the food as medicine movement is not without its critics. The imprecise definition of the concept has left it open to misrepresentation and appropriation, sometimes with harmful consequences.   
Save the date:
NVHPF welcomes
John O'Brien, PharmD, MPH
President and CEO of
the National Pharmaceutical Council
in conversation on May 24
Invitations to Applied Policy Insight
and Northern Virginia Health Policy Forum subscribers are forthcoming.
We hope that you can join us.
Applied Policy's latest summaries
CMS Proposes FY 2024 Inpatient Payment Policies For Hospitals, Increasing Payment Rates, Advancing Equity, and Proposing Quality Reporting Changes 
CMS Increases Payments for Inpatient Rehabilitation Facilities in FY 2024, Proposes Changes to the Quality Reporting Program
For 2024, CMS Finalizes Changes Resulting in a 3% Increase in Plan Payments and Implements Inflation Reduction Act Provisions on Part D Benefit 
CMS Finalizes CY 2024 Policy Changes for Medicare Advantage and Part D Plans Impacting Plan Utilization Management, Patient Protections, and Health Equity
Applied Policy offers a summary of resources as the public health emergency comes to an end
It has been over three years since the Families First Coronavirus Response Act established the “continuous enrollment condition,” which provided states with extra federal Medicaid funding in exchange for maintaining enrollments for all Medicaid-enrolled individuals throughout the public health emergency (PHE). 

As the PHE comes to an end next month, 15 million or more enrollees could lose their Medicaid or CHIP coverage. In advance of what could be a historic shift in Americans' health insurance status, Applied Policy has compiled a summary of the Centers for Medicare & Medicaid Services' (CMS's) monthly calls regarding resources and updates on the unwinding of the continuous enrollment condition.
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:

  • Medicare Secondary Payer and Certain Civil Money Penalties (CMS-6061)
  • Misclassification of Drugs, Program Administration and Program Integrity Updates Under the Medicaid Drug Rebate Program (CMS-2434)
  • Strengthening Oversight of Accrediting Organizations (AO) and Preventing AO Conflict of Interest, and Related Provisions (CMS-3367
  • Medicaid Managed Care (CMS-2439)
  • Assuring Access to Medicaid Services (CMS-2442)
  • HHS Notice of Benefit & Payment Parameters for 2024 (CMS-9899)
  • Treatment of Medicare Part C Days in the Calculation of a Hospital's Medicare Disproportionate Patient Percentage (CMS-1739)

See all rules under OMB review here.
From the headlines
Insight joke of the month for April
Why did the cat go to the doctor?
April's podcast recommendation:
NEJM AI Grand Rounds
Launched in December, NEJM AI Grand Rounds was conceived as a forum for discussing the ethical and legal questions arising from the use of artificial intelligence in medicine. Since the program's inaugural episode, cohosts Arjun (Raj) Manrai, Ph.D. and Andrew Beam, Ph.D. and their guests have delved into the application of artificial intelligence in ophthalmology, genomics and cardiology, and radiology.

Manrai, an assistant professor of biomedical informatics at Harvard Medical School, and Beam, an assistant professor of epidemiology at the Harvard School of Public Health, bring a contagious enthusiasm and curiosity to their conversations with guests about how to integrate artificial intelligence within the healthcare system. It's not too late to get in on the beginning of what promises to be an important source for understanding a new frontier in healthcare.
Applied Policy, L.L.C., is a health policy and reimbursement consulting firm strategically located minutes from Washington, D.C.