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Wonk Week’s Healthcare Issue Area Deep Dive

Anne Dolan: Hi, everyone. Thanks so much for joining us today for our Healthcare Policy Deep Dive. My name is Anne Dolan. I am a Customer Success Manager here at Quorum, and I’ll be facilitating today’s discussion. So for today, the first half of our time will be a presentation from Suzanne Michelle Joy and Lisa Hawke with Holland and Knight. And the second half we’ll be joined by panelists, Julie Cantor-Weinberg, Jennifer Rosen, and Kimberly Davis for a Q and A I’ll plug right now that you can submit questions for our panelists by using the Q and A button over on the right-hand side of the Wonk Week platform. But with only an hour to cover the huge topic that is health policy we can jump right in.

So introducing you now from Holland and Knight, Suzanne Michelle Joy. Suzanne is a Senior Public affairs officer in Holland and Knight’s Washington DC office, and a member of the firm’s Public Policy and Regulation Group. Ms. Joy focuses on practice in healthcare policy and advocacy. I’m also joined by Lisa Hawke.

Lisa is a partner at Holland Knight’s Washington DC office, and also a member of the firm’s Public Policy and Regulation Group. And her practice focuses on federal relations and policy in healthcare, emergency medical services, and transportation issues. She provides strategic planning, advocacy, and legal assistance to clients on a broad range of legislative and regulatory matters.
So with that Lisa and Suzanne, thanks so much again, and I’ll turn it over to you.

Lisa Hawke: Great. Thanks Anne. I’m going to kick us off and then and cover really just a level set for all that’s happening in the healthcare space right now. Because there’s a lot of it. The last time I can remember it being this busy was Obamacare, really the enactment of Obamacare.

So with that let me start to provide some level sets and background, and then Suzanne is going to get into some of the wonky policy issues that are out there. Okay. Can you hit forward please?
So you’ve been hearing a lot about the Democrats very ambitious agenda with the election of President Biden, as well as the takeover of the House and Senate, albeit by a very slim margin. And they want to do all the things that they’ve been talking about. Climate change, physical infrastructure, meaning roads, and bridges, voting rights, human infrastructure.

I’m going to spend a little bit more time on this as is Suzanne, as we get further in. I’ve been doing this either on the Hill or off the Hill as an advocate for 30 something years, and I’ve never seen this much money flowing out of Washington, DC ever. It is just an enormous amount.

We used to think that talking about billions was a big number. Now, billions is small compared to the trillions of dollars that we’re talking about. But I did want to put it in context, particularly when you look at 2020 and the amount of revenues versus the amount of outlays. We certainly had a deficit going into the COVID pandemic.

But the amount of money that was passed throughout the course of the year for the COVID response was extraordinary and left us in a situation where the outlays almost doubled the revenues, leaving a $3 trillion deficit just for that particular year. And the public debt held $23 trillion.

These are astronomical numbers. And next. This is just a visual for what I just described showing the federal deficits or surpluses going back to 1971. And what in 2020 is the biggest that we’ve had, certainly since World War II.

And here you can see the debt. The deficits are, what we have for a particular year, whether there are enough revenues to cover the outlays. Debt is what’s held over a long-term basis. And as you can see again, these numbers are very high, and that is a backdrop for the political conversation that’s taking place on Capitol Hill with regard to the Democrats agenda, including healthcare. Next. I described this as the elephant in the room which is the, what the trustees of the Social Security Trust Fund and Medicare Trust Funds describe as a future insolvency, but for the Medicare program, Medicare Part A has been projected recently by the Social Security trustees to be insolvent within the next five years. That’s pretty significant. And is in the background minds of some of the Democrats who are concerned about adding additional outlays and responsibilities to a program that is not fully solvent. Next. Social security is even worse in terms of the projected.
And this is really the Baby Boom generation that you can see coming online with scheduled benefits. I’m the last of the baby boom. God only knows whether or not there’s going to, what is going to look like at that point, but everybody in Washington knows that these are issues. The question is if and when they get addressed.

So just to summarize the first year of the Biden presidency. The Biden administration and the Democrats, I think had a first, very good six months. They enacted the American Rescue Plan. It was on a party line vote but it was very popular with the public. COVID vaccines were looking pretty good, shots around the country. And then the infrastructure talks around roads, a $1.2 trillion roads and bridges was able to secure 19 Republican votes in the US Senate. So it was looking like that would move on a bipartisan basis and the president’s approval ratings were very high. And then what I describe as some summer storms that are overlaying the political atmosphere in Washington, DC, for to crisis ,vaccinations plateau, Delta variant comes onto the scene. Afghanistan. Inflation. And the president’s approval ratings start to plummet is a strong word. But I think given how quickly they went down is a fair one. Uncertain fall. So the Democrats were seeking a big win for the president and the Democrat agenda. They’re fighting amongst themselves right now.

But I think at the end of the day, they will succeed in getting one or both of these bills done that we’re going to talk about. Of note is that the Progressive’s have been very successful in leveraging their considerable weight, almost a hundred members within the Democratic caucus. And so what ended up happening is that the two bills, the bipartisan $1.2 trillion infrastructure, which is really for roads and broadband and bridges and things like that got tied to passage of this larger human infrastructure bill that you’ve heard about as $3.5 billion. The moderates on the Democratic side have certainly been publicly expressing some frustration over the size and the tying of those two together.

They just wanted to give the President an initial win around the $1.2 billion bipartisan infrastructure. And a number of these moderates are in swing districts and are concerned about maintaining their seat and the Democratic majority. Overlaying all of this is the debt ceiling. I will tell you that 10 years ago, no, no one outside of Washington, DC knew what the debt ceiling was, but now it’s become certainly a political football.

And the Republicans have said to the Democrats, if you’re going to spend without us you’re going to raise the debt ceiling without us in their vernacular. And the Democrats have said a lot of this COVID spending was yours too Republicans, so you should be, raising it with us. So that’s been a, that’s been a substantial stalemate until last week when the Republican leader, Mitch McConnell offered to the Senate Democrats, to Chuck Schumer, in the center to move on a short term debt ceiling through December to enable the Democrats to move the debt ceiling on budget reconciliation or a separate reconciliation matter. That’s just complicated talk in the Senate. Then there’s a whole bunch of continued uncertainty around COVID and Suzanne’s going to talk a little bit more about that.

Different people have different views, but it is my view that the Democrats are playing the long game and not the short game. They are viewing this as probably the best opportunity in many years that proceeded and that will follow to get major agenda items of theirs across the finish line. Expanding entitlements, addressing climate change while they can. And I think the progressives who sit largely in safe seats, want to get this accomplished whether or not the Democrats end up losing the House and or Senate next year. They want to have succeeded and I will tell you it’s a similar strategy in some ways to what President Obama did and really pushing to get the Affordable Care Act enacted in the first two years of his presidency. But the Democrats are bracing for substantial losses next year. And the 2020 congressional elections and sorry, 2022. And so they’re pushing very hard to succeed in getting some major legislative accomplishments right now before electioneering starts happening next year.

What’s on tap for the year end legislation? The answer is a lot. Normally we have a year end bill. This year we have a lot of year-end bills. So one the FY federal fiscal year 22 was just extended. Federal fiscal year started October one, but the appropriations process was not complete. So that got pushed to January. That will need to be done on a bipartisan basis. And it will start to add other elements of healthcare to it like the Medicaid territory. So we are just going to see the appropriations and what gets cycled through various different programs for healthcare. We will also see some, expect to see some Medicaid and or Medicare changes as well. People aren’t spending a lot of time talking about this, but the Senate has been working on a major public health and preparedness update on a bipartisan basis. They are still working on that language. The House has been working on CURES 2.0 and we’re seeing Senate developments around that.

So there, there’s a pretty strong bipartisan desire to do more on health care in terms of innovation and development beyond what’s happening with regard to the reconciliation legislation. And then as I said, we have the $1.2 trillion bipartisan bill and the $3.5 trillion infrastructure bill and the debt ceiling will have to get resolved.

The new deadline, so to speak for the Democrats to pass reconciliation legislation on a partisan basis is October 31. I suspect that will slip, but not really clear. I think you just need to go back. The precedent has indicated that in order to get the moderate votes in the Senate, that’s probably going to shrink down to 1.5, 2 billion, 2.2 billion somewhere in that neighborhood. And what are we talking about? We’re talking about $7.5 billion investments in just public health. Huge amounts of money going into home and community-based services, $10 billion for community health centers. The home and community-based services will probably end up being several hundred million dollars to try and keep grandma and grandpa out of nursing homes and assisted living facilities. Huge amounts of dollars for mental health and substance abuse. A massive investment with regard to maternal mortality and then building on the Affordable Care Act, extending the premium tax credit tax credits, expanding in non-expansion states. So the 12 states that didn’t expand under Medicaid, enabling those that remain uninsured to be covered in those states. Re-insurance pools, workforce, including more graduate medical education slots, medical schools in underserved areas, huge amounts of money in the . Legislation for teaching health centers, graduate medical education. Drug pricing reform. I’m not going to go into cause we have another panelist that’s going to. There’s also a, a huge effort, particularly on the part of Bernie Sanders to expand Medicare in terms of hearing dental and vision benefits, which is very expensive. And which people like Joe Manchin, Senator Manchin from West Virginia have pushed back on given what I was describing before in terms of the insolvency, pending insolvency, of the Medicare trust fund. And then there are other big programs out there like innovation, ARPA-H, which is like a DARPA on steroids for health to really expand the opportunity for cures and innovation.

So right now the Democrats are in the mode of shrink the $3.5 trillion and try and get the moderates and the Democrats the Progressives on board. I think it’s going to take them several months to get this done, but I do think at the end of the day, they’ll get it done. Something done.

Suzanne Michelle Joy: As Lisa said earlier, I’m going to walk through some of the more wonky details of some of the policy changes that are on the docket right now, as well as coming up in the next few months, rounding out the year. And I’m sure at the top of everyone’s minds, not surprisingly, not only in healthcare policy, but permeating, I think pretty much life as we know it these days is of course the COVID pandemic. But in the context, more of the health policy landscape and policy moving forward in the next couple of months, we separated it into two main buckets to keep your eyes out for.

The first is a potential and likely public health emergency extension. There’s been various rumors about, how long and when they would extend it. I think we all thought maybe a few months ago, optimistically things were winding down, but then we got hit with the Delta variant, which Delta is a whole other can of worms and really makes this look a little more uncertain. What we do know for certain is that the President, his administration have been abundantly clear that they would like to extend the public health emergency, at least through the end of this calendar year. But beyond that as a question, mark. I’ve heard from some people that they might extend all the way through next year, but that’s anything but confirmed. There’s a lot of rumors flying around. So we’re continuing to keep our ears to the ground, but I think a lot more information will be coming out in the coming weeks and months. One interesting thing to note is that statutorily the public health emergency must be extended on a 90 day timeframe. So I know that sort of has some people nervous because with it, of course comes a whole bunch of different flexibilities, not the least of which is tele-health, which has become booming as we’ll get into in just a second here. But the secretary must do that on a 90 day basis. Again, they’re trying to be a little more transparent with their intent is to continue through the end of this year. And I’m thinking they’ll probably do another long-term announcement sometime in the near term, but we don’t have that quite yet.

Turning to tele-health there are a few different angles to look at this with. One is definitely just an emergency waiver basis. There are quite a few flexibilities around state licensure, which we know is a big issue. And they’re working to address, on a more long-term basis kind of separately through Congress.

However, that comes with a lot of different loopholes. Considering a lot of licensing is, regulated overseen, and enforced at the state level. Right now, That is lifted through these emergency waivers. So that’s a big difference. There’s also the site of service and geographic restrictions. So previously you had to be in an approved site of service for telehealth. It wouldn’t include for instance, the patient’s home, which I think is what we’ve all come to think synonymously with telehealth these days. And previously you could only access it if you were in certain geographic areas, designated as rural. So those have both been lifted, which has really allowed tele-health I think just explode. And it’s going to be hard to get the cat back in the bag, which we’ll talk about in a second. And another big piece of this is audio only technology. Now that one I would say is a little less certain to stay permanently. There’s definitely some pros, but also some cons in the minds of CMS and lawmakers in terms of abuse potentially. So those are what we have approved through emergency telehealth waivers. But the thing with those is they would go away at the end of the public health emergency, which is why they’re so intrinsically linked.

Congress, as we mentioned, is looking at several bills that would extend telehealth on a more permanent basis. Just one that I’ll mention as an example was CURES 2.0, which is picking up momentum. The sponsors say that they want to hopefully, we’ll see, pass it by the end of the year. But as Lisa said, there are lots of competing priorities. That would include the site of service and geographic restrictions, which are pretty major. And I would say are probably some of the more low-hanging fruit in terms of having decent public and congressional support behind them. So another close thing to pay attention to we mentioned that fraud and abuse are a concern with telehealth. The government accountability office has definitely shed a light on that and recommended more data before we make any decisions on a permanent basis. CMS has appeared to go that route in the most recent fee schedule. They’ve been adding hundreds of services in the past couple of years and are proposing to allow certain temporary codes to last a couple of more years so that we can collect more data on them. And then they’re also implementing provisions from the Consolidated Appropriations Act that would make more permanent changes for mental health services. So they’re using that as a, almost a test case. There are important restrictions, including a requirement that you would have to see the patient in person within the previous six months. So that’s receiving some feedback. And then there are also restrictions around documentation of requirements. The fact that you’d have to note that it’s an in-person or telehealth service and other things like that. So those are the big prongs on the telehealth front. I mentioned already the physician fee schedule, we are in prime annual rulemaking season.

Now there’s a lot packed into these. Thousands of pages of regulations, but just a few things to highlight here in terms of themes. A theme permeating pretty much across all of them is health equity. It’s a big, important theme in healthcare right now. You can’t escape it. And I think for good reason. One interesting piece of that is the fact that they’re really emphasizing the importance to collect more data on social determinants of health. But part of the discussion is also to stratify data or separate it into groups based on social determinants. And there’s a little less of a conclusive agreement on whether that’s a good idea or not some worry that could actually create different tiers of care. So something to pay attention to there. Another big theme is transitioning to digital quality measurement which they want to do completely by 2025. So we’re going to hit the work speed button there as well as transitioning to the fire standard, which is making sure that all the different EHR is in different systems can talk to each other.

And then, of course, continuing to mitigate and create flexibilities for the COVID pandemic through a variety of options, including reimbursing for COVID costs that aren’t accounted for, as well as making certain, I don’t want to say concessions, but adjustments, certainly to some of the quality reporting programs and just a couple of specific highlights in the rules.
The OPPS sort of went through the reversal of what’s been going on in the past couple of years, and they’re yanking back a bunch of codes from the outpatient setting and putting them back to inpatient over patient safety concerns. They say they want to implement a more gradual approach. So definitely an interesting reversal from what we were seeing under the Trump presidency, and then a fee schedule we’re bearing down on these up to 9% in total cuts.

Now I say that with a caveat because there’s general consensus that hopefully, Congress will act to just wave the PayGo cuts. This means that you have to basically pay for legislation as you go. As we were saying with the trillions going out the door, that comes with a cost but usually Congress waves that, but at the last minute, so that’ll be another interesting year-end battle.
2% is going to be the Medicare sequestration, which is set to resume on January 1st. And then we have a temporary 3.75% payment boost that was basically created to mitigate some of the coding changes that went into effect a couple of years ago, which would add new codes that essentially distribute more of the money to people that would typically build primary care services.
And therefore it would cut into specialty services. So that was a hugely contentious issue. Right now that policy is still on the books but Congress last year, created a little bandaid with a little 3.75% boost across the board to everyone, especially because of the pandemic. Right now there’s a huge effort underway to extend that 3.75% that is gaining quite a bit of steam amongst Congress.
So we’ll see if they act on that as well. One other thing I’ll note here is that there was an effort to bundle critical care services with global surgical codes. The impact there is that they’re trying to, basically, if you’re operating on the same patient and then you have an additional service, they’re trying to include that in the bundle. But the question is, are those two services really related?
And it could really have major financial impacts across the industry. We’ve talked to multiple providers and hospitals that say could slash into their profits to the point where they can’t continue. So a lot of pushback from the provider community and something to watch for in the final rule.

And the two final rules are expected in November. Another big issue on the regulatory front is price transparency. You all probably saw the surprise billing second interim final rule came out not last week, but the week before. So we’re coming up on the two-week mark and it caused quite the stir because it said that basically the median payment rate which was supposed to serve as one of the elements, or at least according to Congress when they passed it, CMS is basically saying that is now the benchmark de facto, and that providers have to prove that if it is not if it should not be the benchmark and they have to come with data and documentation to prove it.

So a lot of pushback, the insurers are happy. The providers are not. So setting up definitely an interesting kind of another thing to watch out for the next few months. And then the other thing I’ll mention here is that it is an interim final rule. So it’s supposed to go into effect on January 1st. That doesn’t give us a lot of time.

So we’ll see how many changes they’re able to negotiate there. But definitely, this is a hot area for policymaking in the next few months with all these changes set to go into effect January 1st, for the most part. So definitely something to keep on your radar. And then finally provide relief funding as Lisa was mentioning, there are trillions of dollars going out the door, and provide relief funds for hospitals and other providers of health services are no exception.

We just had the fourth traunch announced. What sort of separates this traunch from some of the previous ones is number one, that it includes a separate entire pool of money for rural health funding. And the fact that they’re not, you as a provider, do not have to be in a rural area as long as you treat rural patients.

So that is unique. And the other thing I’ll mention there is that they’re going to give additional funds to providers who both see high Medicaid, CHIP, and Medicare populations. So a lot of government-sponsored plans and underserved communities traditionally as well as smaller providers, but they are not releasing those definitions in advance.
They’re collecting the applications, deciding where to draw the line, and then distributing the money. So those applications are due October 26. Payments are going out in December for the most part. So again, another very important issue rolling out in the next couple of months. And just one other mention here is that for the first reporting period for the phase one funds where you have to report that you spent the money appropriately due to Delta and other reasons, other natural disasters, CMS did allow a 60 day grace period. So providers now have until the end of November, but I think once they get that data that will shed a lot of light on the level of scrutiny and fraud and abuse concerns that have been permeating the conversation up until now. So that is it. I think we’re handing it back to you, Anne, for the panelists. But I put Lisa’s and my emails up here. So if anyone has questions, feel free to reach out. And I think we’re also planning to hang around. So we’re looking very forward to the panel.

Anne Dolan: Great. Thank you so much, Suzanne and Lisa as well. Now we’ll invite our full panel to join us, so Julie Cantor-Weinberg, Jennifer Rosen, and Kimberly Davis.
I’ll start with some brief introductions. So first Julie Cantor-Weinberg is the Principal Consultant at Prime Therapeutics where she participates in direct federal lobbying in Congress and before regulatory agencies. Jennifer Rosen is the Director of State Affairs for the Alzheimer’s Association and the Alzheimer’s Impact Movement. She currently directs the association’s 50 state gubernatorial and state legislative engagement strategy, analyzes key policy trends, and manages state policy development. And Kimberly Davis. Kimberly is the Director of Political Programs and Federal Affairs at Johnson and Johnson, where she manages and oversees the J&J PAC, grassroots, and political compliance areas. Additionally, she has responsibility for relationship building with members of the Congressional Hispanic. Thank you all so much for being here. So I’ve got a couple of questions for each of these panelists as we get started. Again, folks joining us, please feel free to chime in with questions in the chat, but we’d love to start with Julie because I know that Lisa plugged this earlier. Julie would love for you to share with us a general summary of what’s happening in the world of drug pricing currently.

Julie Cantor-Weinberg: Oh, wow. That is really all tied up to macro reconciliation politics. It is not all the same people that are. The problem, if you’re Democratic leadership and trying to get majority votes. Senator Manchin is all in on direct government negotiation, Senator Sinema is not. And you had five House moderates vote in committee against HR 3, which is the Pelosi drug pricing bill.

Direct government negotiation polls off the charts. The other issue is that CBO scored it as saving $450 billion with a B over 10 years. So the Dems need this money to take care of other priorities. Pharma is working really hard against this. There are a lot of bipartisan policies and HR 19, which is the Republican bill. Things would have been bipartisan. For years. The Democratic bill as was discussed has government negotiation. It’s really a price-setting based on an international price index of several OECD countries. It’s unlikely that the Senate Finance Committee will go with this international reference pricing.

News bombs have leaked about their using some kind of domestic reference pricing. We don’t know if that’s VA drug pricing. The VA has a very narrow formulary compared to part D plans. So we’re going to see what that means. It could mean a whole bunch of things, and they may also punt and leave a lot of the issues to the secretary. HR 3 and the Senate in the last Congress, the Grassley – Wyden bill agreed to unimposing inflationary rebates. The Republican bill and the House and Senate bills all agree on modernizing the Part D benefit, although exactly how the numbers fall different, but Part D is the only major benefit with no maximum catastrophic. I think MedPAC says about 483 seniors with one prescription, get into the catastrophic where they’re paying 5% of a very large number. So lots of moving pieces. Lots of very strong Democratic support for addressing drug pricing by repealing what’s called the non-interference clause and letting the government negotiate instead of companies like the PBM I worked for doing it or letting us after the government has, but whether or not we’ll be able to get there is still up in the air and maybe at the hands of the enigmatic Kristin Sinema, as well as the four or five moderates in the House who said we are for a different skinny down version of it. And the Progressives are saying, we don’t want to go skinny. We want big.

Anne Dolan: Thanks so much, Julie, for providing all the details of places where drug pricing fits into that turning it now to Jennifer, healthcare is more than just those hospital visits. So from your perspective, what are the pieces of the healthcare debate in conversation that could use some more attention?

Jennifer Rosen: Sure. A little bit of a loaded question, I think. But we knew this before COVID hit but the pandemic has really shined a light on how we address the needs of vulnerable populations who require long-term care and where the shortfalls are. And, just this morning, actually I saw a Kaiser Family Foundation event notification come through my inbox and it was for an event that’s focused on age-ism and health care and when the pandemic hit and the shutdown first occurred March 2020, for months, we heard about states local federal officials, governors, chartering planes the president getting PPE to hospitals and frontline healthcare workers, which was so important. It took months and months of us, of the association, really banging on doors to get any officials to focus on the needs of long-term care facilities and getting PPE and testing supplies to these facilities.

And at that time that’s when 40% of all COVID deaths at that time were occurring in long-term care all the way through 2020. And I, for me just looking at long-term care, how this nation is financing long-term care where oversight is, what the needs are. I always refer to long-term care providers as partners in care, and they’re not the big, bad guys. It’s not their fault that the pandemic swept through these facilities, the way that it did, but we’re not really as a nation addressing long-term care holistically. And I think that right now is really, it’s like the fifth wheel and we need to do better. State and local and federal governments need to come together.

Right now long-term care is primarily historically fallen to state governments. And we’ve seen through the pandemic that can’t be the case any longer. We need holistic solutions and there’s gotta be more federal and state engagement and ownership. We’ve got to look at the workforce issues. We’ve got to look at Medicaid and financing. State Medicaid budgets can’t handle the growth and long-term care costs any longer. So we need to figure that out. For me, I will say that’s where I have felt for a while now. And it’s just grown over the past couple of years of the pieces of the healthcare discussion that we as a nation need to just look at more holistically.

Anne Dolan: Thanks so much, Jennifer. And now turning to Kimberly on, on the same conversation, thinking about not just long-term care, but the full spectrum of services that we need as, collectively to stay healthy. Could you share some examples of sustainable partnerships and programs that we can be thinking about to enhance health?

Kimberly Davis: Thank you. And I think I do want to say one of the things that Suzanne said, which I thought was extremely important was this concept of telehealth and how across the spectrum, that has been a game-changer during this pandemic. So if you think about where we were last March and how people thought they could access care and where we are today are two very different things, whether it’s in the neuroscience space or dermatology or anything else. So that, while it doesn’t answer the partnership question, I felt like that needed an important shout-out for the people in the webinar that looking at what Congress says about it. And then how states implement the same is something that may very much change the face of healthcare. And then when Jennifer mentioned long-term care, it’s that same concept. How are people inside of long-term care facilities or other places getting that access to care? So one of the notes that I had that I thought was so spot on Suzanne, looking at the public health emergency, looking at that every 90 days, but really thinking about for people all over the country, let alone the world, how telehealth and telemedicine will change that space that we live in.

And relative to the partnership question, I feel like what we have seen at J&J in particular, and I know is true for many of my colleagues in the healthcare space is people really going back to their communities and looking at associations or small group practices or in Philadelphia, black doctors against, oh, I can’t, I’m not going to get it right. But it was like the Black doctor COVID consortium or other places where we’ve started to see communities of like-minded people coming together to either get folks excited about or aware of access to vaccines, what things look like in that space. Because I think, again, going back to my whole belief that on March 13th, 2020, we were a bunch of individuals, but as the collective country came to a pause, we all started to come together and think about what we needed to do to get us to the next space and the things we saw with states and local government and Congress all coming together and trying to work in a bipartisan manner to move us forward are things that for our company and I’m sure for others on the line have made us rethink the way we look at health care and how we deliver health.

Julie Cantor-Weinberg: One quick comment. And thanks, Kimberly, and I think Suzanne mentioned this Prime has really deep analytics capability on the fraud waste and abuse front. We use artificial intelligence and while I think a lot of people think telehealth is great, my family uses it, we have seen an increase in fraud, waste, and abuse during the pandemic because of increased telehealth. I think as we look to make that permanent, we were going to need to figure out the balance.

Anne Dolan: Thanks, Kimberly, as well as Julie for that. Obviously, as you think about that, this idea of, telehealth and all of its implications, I have a question for the panel at large is could speak to are some of the impacts on providers here? We know what it means to log in and access your care personally. Thinking through what are the implications there that we should be thinking about? What resources or services do we need to ensure it will be successful on their provider end? I see Lisa is on, maybe take it away to start.

Lisa Hawke: Yeah. One of the big challenges is for providers that are close to borders of states, right? Where you have a need to cross state lines, you have a number of major medical centers sitting right on the border of two or three, or in some instances, four states. And so you have providers who want to be able to provide services but aren’t licensed in the state next door. And so I think that’s a critical issue that Congress needs to take on as part of the telehealth revolution to enable greater access to care that isn’t just limited to particular state borders.

Suzanne Michelle Joy: I’ll add to that kind of wrapping some of the things we’ve already talked about today. I think one of the reasons people really like telehealth is that it’s an equalizer of access and it really helps to reach some of those underserved communities. And I think it’s really seen as a tool in the arsenal of an ability to do that But some of the concerns that have come up, I very briefly mentioned audio only, not everyone has access to broadband, especially rural communities, especially underserved communities. Not everyone has access. Although a lot of us have our iPhones glued to our hands, not everyone does. And so I think, but then at the same time, Julie brought up the fraud and abuse issue, which I think is equally important.

So again, I think all these arguments have merit. And what we need to do is we’re in an information collecting phase right now. That’s what CMS is doing. And I think we need to look at where some of these policies are most effective. And I think one of the interesting things, too, with the mental health little test case that we’re doing here, that six-month requirement, it does, help to prevent fraud and abuse. But on the flip side of that, what, if you’re having an episode and it, you don’t, especially now with Delta, you don’t want to go and you don’t feel safe going in to see a provider, or you just haven’t in the past six months. This could be a way to really get rid of the backlog for mental health services that have so built up over the pandemic.
So I think we really have to think about these, billing requirements that came with good intentions but could also be a barrier, especially to people that really need these services. So just those competing, elements wanted to paint a picture of that.

Kimberly Davis: Suzanne, and I also want to add, and again, I’m sure folks know this, that this is, telemedicine is not new or telehealth is not new. And we used to only think of it as rural and you couldn’t get somewhere to do this. And again, this whole concept of what has opened up to people who could be in urban centers or rural centers, or all sorts of things. I’m not as familiar with the waste fraud and abuse piece of it. But what I know is that studies have definitely shown access to care for people has gone through the roof in terms of helping people with, again, everything from dermatological needs to mental health needs to pediatric needs to you name it. So if we can figure out how to make it work, I really do think it changes the trajectory of healthcare in our country. And we will see that benefit not only across generations but across communities.

Jennifer Rosen: To that point too, during the pandemic, we started utilizing really for the first time in a much larger way, telehealth options as a way to train direct care staff in these nursing homes regarding infection control in real-time. And having experts, almost that kind of concept of doing grand rounds in a hospital where you follow a doctor and they work through case by case. That’s what we started doing with nursing homes during the pandemic. And so that’s something that we’ve learned and a model that we want to really explore and and it helps us to get to those rural facilities where you don’t have trainers nearby or onsite. So I think that’s a great point.

Anne Dolan: Building on that idea, Jennifer of training the workforce and giving your healthcare providers what we need. We know that workforce shortages in healthcare professions were something that was on our radar and worrisome pre-pandemic. And of course, now we know that many healthcare workers are continuing to leave the profession.
What policy solutions might help address these shortages?

Jennifer Rosen: Yeah, this is a really big one. And I don’t think people are quite scared enough yet that it’s going to hit really hard really soon. And it’s going to become apparent. For a long time we’ve seen healthcare shortages be discussed in a very specific silo at state and federal level. And that is just within health policy discussions and unlike other workforce development initiatives or a need to grow in other industries addressing shortages when we’ve had manufacturing or working on oil rigs where you see a much larger voice at the table coming up with solutions, state by state or the national level, you haven’t seen that in the healthcare scope.

And so I think what I think we really need to make sure that we’re focusing on as a nation, the federal level also state by state, is that we’re expanding this discussion that this discussion is including the governor’s office. It’s including not just the health agency and the legislative committees with health jurisdiction, but also education and the state department of education, licensure, labor, state labor departments. It is time now. Conversation grows and it’s gotta be blown up and it’s gotta include everybody because there’s no easy solution. We talk about recruitment and retention strategies, of course increasing pay for healthcare workers. For those who were working in direct care roles, it’s not a very high-paying job. So that’s a challenge, very hard jobs, but low wages. We talk about training and access to training. A lot of kids coming out of high school don’t really think of this as a career and how do we change that thought and that trajectory and that open those doors of opportunity and how do we create incentives within a career path within these roles to grow? And we’re working, we’re thinking, there’s, of course, the standard loan forgiveness programs, but it’s gonna take a lot more, it’s going to take a lot, raising interest and awareness much younger to much younger generations, high school and community college and up.

Anne Dolan: Yeah, thanks so much, Jennifer and I’m realizing now, too, as you’re speaking that, we were talking about everything that’s on the table when it comes to reconciliation and what we could include, and I’m now realizing, what we didn’t see on that slide was, workforce development or any of those other pieces for that, long-term sustainable solution there.
Knowing what continues to be top of mind for all of us is vaccines and COVID vaccines. So Kimberly would love to turn this question to you now. What does Johnson and Johnson do to help overcome vaccine hesitancy? And where do you think public officials do the best to serve their constituents in this area?

Kimberly Davis: Sure. Thank you. I think since. I get what it is. Are we almost a year? I don’t even remember. I remember when, I live in Virginia and I remember when the city of Alexandria sent me my email that said, Hey, you’re next up, click here and choose your appointment. I did not hesitate. I clicked it. And I was there on Sunday in this huge line to get my shot. But up until that time, we talked very much both internally and in the external environment about the history of vaccine hesitancy in communities of color, because of a lack of trust. And when we were speaking earlier, I talked about the black doctors’ COVID consortium in Philadelphia. And I see Julie nodding and I know others know. There are groups like that all over the country. Folks on the phone will recall that the first shot we saw administered, which was a Pfizer shot, was to an African-American nurse in New York. Those things are not unintentional. They are telegraphed to show people that if I will do it, you will do it.

And I think we, as a company said, from the beginning, you don’t need to wait for our shot, take the first one available and throughout our company and really across the country both manufacturers and healthcare professionals have just tried to demonstrate by showing up with solid science and solid research that the vaccines are safe. And that in order to minimize the pandemic that people needed to take the shot. So I feel it is something that we have continued to work towards. I know many associations, provider associations, and Suzanne, I don’t know if you have anything to add there, but many are lining up to just say I did it please do it.

And I think the next wave is what we, Pfizer’s in front of the FDA right now for five to 11-year-olds. So it felt to me like as over 18, because wasn’t it 15 to 18. So as an adult, I use air quotes sometimes I was able to do it, but when my 12-year-old, 13-year-old was eligible, I took her. So it’s just a conversation that we continue to have to de-stigmatize and to suggest for the good of the order that we need to do that. Health equity is something that is very important. I think years ago, people talked about white coat syndrome and cultural competency with medical professionals.
And I think now we have those same conversations, but it seems very real and very poignant for people who are comfortable and don’t need exceptions or accommodations to do that. I see a lot of nodding, so I’m sure some of my other panelists want to jump in, so I’ll stop.

Suzanne Michelle Joy: I’ll jump in since, I don’t know if you read my bio, maybe that’s what you’re getting at. But I did come from physician land at the American College of Physicians before this full disclosure. And yeah, I think right now we’ve gotten, most of the people or pretty much all the people who wanted shots. So the low-hanging fruit. I think the challenge now is really dispelling some of those myths, like Kimberly was saying, I’ve heard about so many amazing interventions as far as nurses getting on the phone, being a really powerful one, answering questions, cold calling people, and being willing to answer questions or concerns that they have. Knocking door to get people to sign up. And mobile units. I think working with more flexible hours for people that have childcare or eldercare issues, I think we’re really in that phase of trying to combat some of the, maybe misinformation that’s out there and also just trying to make it accessible which I think is hand-in-hand with an excellent point can really be making about it being also a racial issue. I’ll also say on a slight element of good news, which I don’t get to do very often. The new CDC numbers are actually pretty promising. I think the number of vaccine doses went up 30% from the week before to this week, which I think is amazing. And the number of I think its hospitalizations went down 8%. I think there are a few different reasons for that. Certainly the booster shots, now being an option for some people. I think like Kimberly was saying we’re right on the cusp of hopefully getting our kids vaccinated. If you agree, that’s the right decision for your kids. I think that is huge. Almost a million kids in four weeks were hospitalized with COVID and obviously they pass it onto their family members. So I think that’s a big part of it. And then again, just dispelling some of those myths and getting to the more underserved communities I think is another really important prong of that. So just wanted to give a shout up, hopefully tide’s changing, but I think at this point it’s really targeted efforts as opposed to just the broad brush efforts that we’re in now.

Jennifer Rosen: I think we’d be remiss to, if we didn’t make mention of the impact of vaccine mandates happening to. There are more and more companies large and small are requiring vaccines as a condition of employment. It’s made a huge difference.

Suzanne Michelle Joy: A hundred percent agree. Thank you for raising that. Also the federal mandates. Federal workers, which my husband just got an email today. So I know that’s a controversial issue, but definitely agree with Jennifer that it’s moving people to get vaccinated one way or another.

Anne Dolan: Absolutely. Returning to our discussion about healthcare careers what incentives should be used to entice people and interest people in to starting a career in the healthcare industry.

Lisa Hawke: I’ll jump into this. I think one of the biggest impediments is the cost of the education. You have a number of folks who are coming out of college heavily in debt. My daughter was thinking about going to medical school. She’s gonna go down a different path, but she was staring down $80,000 a year for four years if she wanted to go into medical school. Even some of the state school medical schools are $60,000. It’s just astronomical and beyond the means of the vast majority of Americans. And and that’s just at the top, and then you work your way down. I remember at one point people were talking about well let’s just get more mid-level providers. The mid-level providers are retiring at the same rate that the Baby Boomer doctors are.
So it’s not like you can just easily, go down, the care triangle in terms of, we have to address the cost of educating our entire workforce and unless, or until we do that, we aren’t going to have the workforce that we need. And that’s going to require huge investments across the board. So I think that’s the single most important thing that we need to do. I guess the other thing that I would say, as a hospital lawyer and lobbyist for, my entire career we’ve got to make sure that providers are getting paid a reasonable amount for the care that they’re providing. There are a number of folks who don’t want to go into pediatric because it’s such a poor payer, which is sad, right? It’s horrible. But Medicaid is a very poor payer for picking your specialty within pediatrics. And that’s a huge impediment in terms of access to care for low-income individuals and black and brown populations as well, and rural populations in terms of access to care. So unless, and until we start to get to a point where we’re paying our providers appropriately for the care that they’re providing, whether it’s a hospital, a physician, a community clinic, whatever it’s going to be a disincentive to go into certain parts of health care, as opposed to the more profitable lines of healthcare like orthopedic surgery or whatever.

My dad is a retired cardiac surgeon. And I asked him at one point, dad, would you do this all over again? He said I love taking care of patients, but I would’ve done something different cause I just ended up in a business instead of being able to just solely focus on providing care to patients so that I think that’s another big impediment that needs to be addressed.

Jennifer Rosen: Yeah, I’d a hundred percent agree with that, even with the direct care workforce, which doesn’t require as much education and training and the cost of education isn’t as cumbersome. There’s still the thought that, if you’re doing this really hard job, physical labor of taking care of someone in a nursing home, when you can make the same exact money working at a fast-food restaurant there’s something wrong here, right?

It’s an easy kind of decision for a lot of folks. But also it’s really about seeing a career path. And a lot of those who don’t know a lot about the direct care industry when they think about these jobs and they see them advertised, don’t really understand what the possibility is for a career path and career growth. So if you’re somebody who is a natural care provider by your personality, for instance, doesn’t know that you can start as a CNA right out of high school and then work your way up within the industry and become an administrator one day. And so we need to do a lot more education and awareness. The same way we roll out public awareness campaigns in the public health space, right? Statewide campaigns and national campaigns. We need to start doing more of that in the education space, and it’s gotta be focused on these career paths.

Julie Cantor-Weinberg: I never knew so many pharmacists till I started my current job, Prime employs like a zillion pharmacists and pharmacists tax, which has been the kind of work you do working for a managed care entity is very different at a drug store of both are equally important. So I think the awareness of educating people on the different kinds of career paths that are out there given a given credential is really important. And we have to make sure that we don’t burn out people that are maybe directly patient-facing as well, facing the pandemic and everything going on with vaccine.

Suzanne Michelle Joy: Julie took the words out of my mouth, but I just, I did want to mention the burnout issue. Cause I know working for physician organizations, that was a huge issue. Not only amongst the older generations that have just had it after a few decades, but also even the younger generations. And I think we’re moving into this environment of value-based care, which is great. And team-based care, which is also amazing. But I think we just, as we do that, we need to think very consciously that we’re not overburdening them with paperwork. So that as Lisa was saying, they can do what they want to do and treat patients. And that we’re really thinking smartly about how the interplay between the different team members work so that everyone can practice to the top of their full licensure, which I think is amazing. And also cost-effective for the patient as well.

Kimberly Davis: I think Jennifer said something earlier, which would change would like to end with, which is, we also need to normalize that, you can start having these conversations in middle school or high school because not everybody is going to want to go to college a four-year college. Not everybody wants to be an RN or an MD. So if we start having these conversations with younger folks and build this up as a career opportunity, which can lead to someplace else, I think all the things my fellow panelists have said come to fruition. We need to recognize that many of us are well-educated if not over-educated, but there, there are different ways to look at success and we need to be aware of that and normalize.

Anne Dolan: Absolutely. Thank you so much for that, Kimberly, and for everyone, the robust discussion on this topic. We’ve moved from federal reconciliation to vaccination and workforce development and covered a ton in a short amount of time. So thank you all so much for joining for this great conversation.

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Wonk Week’s Healthcare Issue Area Deep Dive

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Wonk Week’s Healthcare Issue Area Deep Dive

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