| | | | |  | | By Chelsea Cirruzzo and Ben Leonard | | | | | | | 
Hospitals are pressuring CMS to give low ratings to Medicare Advantage plans that routinely deny patient care. | Pablo Martinez Monsivais/AP | HOSPITALS PRESS CMS FOR MA HELP — Hospitals that have repeatedly chafed at Medicare Advantage care denials are pressing the Biden administration to hit plans where it hurts: their bottom lines, POLITICO’s Robert King reports. A hospital industry group is asking CMS to give a poor mark to Medicare Advantage plans in their star ratings — which help people select an option — if they regularly deny medical care overturned on appeal. CMS’ decision could impact billions of dollars in revenue for plans and hospitals. The request from the Federation of American Hospitals comes as contract disputes between hospitals and Medicare Advantage plans are on the rise. More than a dozen health systems have already dropped Medicare Advantage, a private insurance alternative favored by more than 30 million Americans. Hospitals say they need help from CMS to deal with the financial toll from care denials. But insurers counter they’re working to root out unnecessary and wasteful care and give patients more value. “Left to their own devices, a lot of health systems and health professionals actually over-order and overuse unnecessary tests,” said Sachin Jain, president and CEO of the nonprofit Medicare Advantage plan SCAN Health. But under Medicare Advantage, “they no longer have a blank check from their Medicare patients to do whatever they please.” The FAH hopes that CMS adds a quality measure to the star ratings, which will ding a plan if a certain amount of care denials are overturned on appeal. A common complaint from hospitals is that most denials get overturned eventually. “If that is ultimately adopted … then consumers would have more transparency into the practices of [Medicare Advantage] plans they are enrolling in,” said Charlene MacDonald, executive vice president of public affairs for the FAH. CMS said it is seeking feedback on the proposal. WELCOME TO FRIDAY PULSE. My last book of 2023 is going to be “Killers of the Flower Moon: The Osage Murders and the Birth of the FBI.” What should I read next year? Drop your book recs to ccirruzzo@politico.com and bleonard@politico.com and follow along @ChelseaCirruzzo and @_BenLeonard_. TODAY ON OUR PULSE CHECK PODCAST, your host Chelsea talks with POLITICO health care reporter Robert King, who breaks down the Biden administration's efforts to curb high prescription drug prices by requiring drugmakers receiving research funding from HHS to commit to a fair price, or no higher than they charge in other countries.
| | | | | | | A message from PhRMA: PBMs decide if medicines get covered and what you pay, regardless of what your doctor prescribes. PBMs say they want patients to pay less, yet they often deny or limit coverage of lower-cost generics and biosimilars. Instead PBMs cover medicines with higher prices so they make more money. Learn more. | | | | | | | 
The FDA has recalled three applesauce products — WanaBana apple cinnamon fruit puree pouches, Schnucks-brand cinnamon-flavored applesauce pouches and variety pack, and Weis-brand cinnamon applesauce pouches — that are linked to dozens of cases of acute lead poisoning in U.S. children. | FDA via AP | INTENTIONAL APPLESAUCE POISONING — The FDA believes tainted cinnamon applesauce that sickened scores of children was purposely contaminated, POLITICO’s Meredith Lee Hill and Marcia Brown report. “We’re still in the midst of our investigation. But, so far, all of the signals we’re getting lead to an intentional act on the part of someone in the supply chain, and we’re trying to sort of figure that out,” Jim Jones, the FDA deputy commissioner for Human Foods, told POLITICO. What happened: State and local officials first noticed elevated levels of lead in children during standard blood screenings — tests the CDC recommends to help reduce lead exposure typically from sources like paint or water in kids under age 6. Federal officials are working with state and local health departments to identify lead-poisoning cases linked to the contaminated applesauce products. The contaminated pouches were sold under three brands — Weis, WanaBana and Schnucks — linked to a manufacturer in Ecuador. The FDA says it’s inspecting that facility. The theories: The FDA continues to investigate how the pouches became contaminated and hasn’t drawn any conclusions, but it believes it’s “economically motivated.” Generally, that refers to altering ingredients to make products appear higher in value, such as by replacing a vital ingredient with a cheaper substitute, often so companies can produce a cheaper item and sell it at a higher price.
| | | | POLITICO AT CES® 2024: We are going ALL On at CES 2024 with a special edition of the POLITICO Digital Future Daily newsletter. The CES-focused newsletter will take you inside the most powerful tech event in the world, featuring revolutionary products that cut across verticals, and insights from industry leaders that are shaping the future of innovation. The newsletter runs from Jan. 9-12 and will focus on the public policy-related aspects of the gathering. Sign up today to receive exclusive coverage of the show. | | | | | | | | | CDC: GET THE SHOT PLEASE — With hospitalizations for respiratory illnesses rising, the CDC is warning providers that not enough people have been vaccinated against Covid-19, flu and respiratory syncytial virus. But not all shots are easy to come by. According to an agency alert Thursday, over the past four weeks, hospitalizations have jumped 200 percent for the flu, 51 percent for Covid and 60 percent for RSV. While emergency room visits for kids with pneumonia have also increased since September, the agency said that’s consistent with previous respiratory illness seasons, which typically last over the winter months. Flu — Flu vaccinations across all age groups are lower than last year. As of Nov. 18, adults received 7.4 million fewer flu shots than in the 2022-2023 season. For most age groups, including children and pregnant people, the vaccination rate hovers between 33 and 36 percent, while the rate for people 65 and older is almost 59 percent. Covid — Slightly more than 17 percent of adults have gotten the updated Covid shot, similar to last year, and nearly 8 percent of children under age 18 received theirs. RSV — As of Dec. 2, about 17 percent of adults 60 and older received an RSV shot. While the CDC doesn’t track the number of infants who receive the new RSV vaccine, providers and parents said they’ve struggled to find the shot amid a shortage. The White House announced yesterday that 230,000 more doses would be on the way by January after near-daily pressure on manufacturers to release more doses.
| | | | A message from PhRMA:   | | | | | FEW MEDICARE ENROLLEES GET OPIOID HELP — About 52,000 people on Medicare overdosed on opioids last year, but few beneficiaries receive medication for substance use disorder, a new report by the HHS Office of Inspector General said Thursday. Why it matters: An estimated 83,827 opioid-related deaths occurred in 2022, mostly driven by synthetic opioids like fentanyl. Among Medicare beneficiaries, an estimated 1.1 million have an opioid use disorder. Still, 18 percent in 2022 received medication for their condition, the report found, with significant disparities across states. Florida, for example, has the highest number of Medicare enrollees with opioid use disorder, and 6 percent received treatment. Overall, less than 10 percent of enrollees in Florida, Kansas, Nevada and Texas received medication for substance use. According to the report, enrollees who are female, receive government subsidies or ages 65 and older have the greatest challenges in getting treatment. However, in 2022, a record high number of enrollees — 600,000 — received Narcan, an overdose-reversing drug, leading to affordability concerns about over-the-counter costs.
| | | | SUBSCRIBE TO CALIFORNIA CLIMATE: Climate change isn’t just about the weather. It's also about how we do business and create new policies, especially in California. So we have something cool for you: A brand-new California Climate newsletter. It's not just climate or science chat, it's your daily cheat sheet to understanding how the legislative landscape around climate change is shaking up industries across the Golden State. Subscribe now to California Climate to keep up with the changes. | | | | | | | | BERNIE FLOATS NEW DRUG PRICING BILL — Senate HELP Chair Bernie Sanders (I-Vt.) floated new legislation on Thursday that he said would cut the price of weight-loss drug Ozempic from $12,000 a year to $1,200, Ben reports. During a Health, Education, Labor and Pensions Committee hearing on diabetes, Sanders said he’ll “soon” introduce a bill prohibiting the pharmaceutical industry from charging U.S. patients more than in other nations like Canada, Germany and France. Sanders claimed it would cut the price of prescription drugs by more than half. It’s unclear what the legislation might look like. A spokesperson for Sanders declined to offer further details. HELP committee ranking member Bill Cassidy (R-La.) said he shared Sanders’ goals of pursuing affordability generally but didn’t address Sanders’ potential legislation. Cassidy has a bill in the Senate Finance Committee’s jurisdiction that would lift the prohibition on Medicare covering weight-loss drugs.
| | The Peterson Health Technology Institute has appointed seven members to its inaugural advisory board: Melinda Buntin, professor of health policy and economics at Johns Hopkins University; Dr. Thomas Insel, co-founder and executive chair at Vanna Health; Margaret McKenna, advisory partner at Andreessen Horowitz; Dr. Anaeze Offodile II, executive vice president and chief strategy officer at Memorial Sloan Kettering Cancer Center; Dr. William Shrank, venture partner at Andreessen Horowitz; Ariel Stern, incoming digital health chair and professor of digital engineering at the University of Potsdam; and Dr. Charlotte Yeh, chief medical officer at AARP Services, Inc.
| | | | A message from PhRMA: PBMs decide if medicines get covered and what you pay, regardless of what your doctor prescribes. PBMs say they want patients to pay less, yet they often deny or limit coverage of lower-cost generics and biosimilars. Instead PBMs cover medicines with higher prices so they make more money. Learn more. | | | | | Roll Call reports that Rep. Diana DeGette (D-Colo.) is in line to replace outgoing Rep. Anna Eshoo (D-Calif.) as the ranking member on the House Energy and Commerce Health Subcommittee. KFF Health News reports on rifts over when to use N-95 masks among providers. | | | | Follow us on Twitter | | | | Follow us | | | | |
