End-of-year federal healthcare update

FMA staff report

Telemedicine prescribing flexibilities extended through 2025

The U.S. Drug Enforcement Administration (DEA) and the Department of Health and Human Services (HHS) recently issued a rule that temporarily extends pandemic-era telemedicine prescribing flexibilities for controlled substances through Dec. 31, 2025. The rule marks the third temporary extension of these flexibilities, which authorize a practitioner to prescribe controlled substances via telemedicine, even when the practitioner has not conducted an in-person patient evaluation.  

There are various reasons for this action, including:

• Preventing a reduction in access to care for patients who do not yet have existing telemedicine relationships with their practitioners, pending promulgation of a final rule or rules addressing telemedicine more generally.
• Preventing backlogs with respect to in-person medical evaluations in the months shortly before and after the expiration of the telemedicine flexibilities and ensuring the availability of telemedicine for practitioners and patients who have come to rely on it.
• Addressing the urgent public health need for continued access to buprenorphine as medication for opioid use disorder amid the continuing opioid public health crisis.
• Allowing patients, practitioners, pharmacists, and other stakeholders sufficient time to prepare for the implementation of any future regulations that apply to prescribing controlled medications via telemedicine.
• Enabling the DEA – with HHS for rules that must be issued jointly – to conduct a thorough evaluation of regulatory alternatives in order to promulgate regulations that expand access to telemedicine in a manner consistent with the public health and safety, while also mitigating the risk of diversion.

Prior authorization reform comes for Medicare Advantage

A 2022 analysis of 46 million Medicare Advantage (MA) prior authorization requests underscores the need for reform: More than 80% of prior authorization appeals were overturned, and some payors – such as Humana – were inexplicably far more likely to require prior authorization than other plans. There is also massive, unexplained variance in the rate at which insurers deny prior authorization requests.

The Centers for Medicare & Medicaid Services (CMS) has taken a small step toward reform by proposing a rule to collect additional data from plans concerning their use of prior authorization and appellate decisions, add transparency to the prior authorization process, and provide more clarity around when prior authorization is permissible. While this does not solve the problems physicians face regarding MA plan prior authorization tactics, CMS appears to be listening to feedback and is slowly moving the needle in the right direction.

Medicare payment cut: What’s next?

While 41 U.S. senators and 233 U.S. House members on both sides of the aisle have signed letters urging leadership to prevent a 2.8% Medicare physician payment cut from taking effect on Jan. 1, action still needs to be taken on this issue during the congressional lame duck session. Please support this effort by contacting your U.S. House representative and urging them to co-sponsor HR 10073.