A new year is generally a time for hope, evaluating the previous year’s achievements, and setting new goals. Last year changed that somewhat when we put many of our goals on hold to immediately respond to the pandemic and the needs of our patients, each other, and ourselves. This year, we hope that things will be better.

The Centers for Medicare and Medicaid Services (CMS) has been trying to find new avenues to implement a conservative approach to Medicaid spending at the state level. At the end of January 2020, the agency introduced a program that enables states to convert funding into block grants and determine how best to allocate health funding in their own jurisdictions.

After news of the vincristine shortage affecting the cancer community made headlines in several news outlets, the country’s prescription medication issues took center stage again. It’s a sign of larger problem: supply, demand, and drug pricing are all enveloped in the same issue that’s directly affecting patients and their families.

The Oncology Care Model (OCM) is a value-based payment system that the Centers for Medicare and Medicaid Services is piloting. OCM focuses on decreasing the cost of cancer care while continuing to provide high-quality care, including a high level of care coordination and navigation and adherence to national guidelines for care. Part of OCM requires implementing certain practice changes, including documenting a 13-point care plan for each patient.

A patient is rushed to the emergency room, diagnosed, and taken to surgery immediately. The patient recovers, but weeks later a bill arrives beyond any expectation, and too often ability, to be paid. This practice has become so routine that it has its own name: balance billing or, more commonly, surprise medical billing. It strikes many Americans with the burden of their ailment once again. 

With the 2020 election cycle kicking into high gear, upcoming presidential debates will continue to highlight health care as a major domestic issue. Downstream contests for House and Senate seats are also in play, and health care will serve a huge role in those campaigns, too. Candidates are offering a slew of different options like a new single-payer system, Medicare expansion, Medicare for All, Medicare for All with an additional buy-in program, and many other iterations.

The high cost of prescription medications—often lifesaving drugs—has become an unsustainable burden for many American patients. It’s a central topic in the healthcare conversation and a complex issue with countless moving parts. National opinion polling finds that a majority of people want to see changes in drug pricing.

It’s an extraordinary time for biomedical research. Advancements in science, investments in research studies, and an increased access to patients through clinical trials have continued to transform the medical community’s understanding of cancer care and the best ways to treat and cure tumors. Achieving successful outcomes requires specific and dedicated therapies, tailored to each individual.

Surprise medical bills—a long-time problem for patients and consumers—was not on the legislative radar until recently. In short order, the issue has quickly moved through the House Energy and Commerce Committee, one of the most powerful on Capitol Hill, to offer some hope for consumers. Part of the committee’s mark up added an amendment allowing for arbitration to address specific medical charges if hospitals disagreed with the agreed-upon rate. Some committee members felt that without it, providers would have limited recourse in special circumstances.

As challenges mount to find new and innovative ways to provide quality health care at affordable prices for patients, a battle is brewing over what patients can and cannot know about their healthcare costs. On June 24, President Trump released an executive order directing his administration to take steps to improve healthcare prices and transparency to address the pricing woes patients face.

According to the Centers for Disease Control and Prevention, 50 million Americans experience acute and chronic pain daily. Managing the pain is debilitating and costly, and the impact on the economy is felt through employment issues along with a heightened burden on the healthcare system.

In March and April 2019, the Centers for Medicare and Medicaid Services (CMS) issued several proposed and final rules that affect patient coverage for cancer-related benefits, payment models, and the paperwork nurses often complete to ensure those benefits are billed correctly.

Medicare Part D will continue to give patients access to certain cancer drugs, according Centers for Medicare and Medicaid Services’ (CMS’s) final ruling issued May 16, 2019. The final rule does not allow for utilization controls like step therapy and prior authorizations for patients who are already in an established treatment regimen; does not restrict drugs that have had certain price increases over a specified time period; and does not restrict new formulations of an existing protected class drug.

The state of Kentucky has seen some of the most success in reducing its uninsured rate thanks to the Affordable Care Act’s Medicaid expansion that took effect on January 1, 2014. The results of a new study, published in the Journal of the American College of Surgeons, showed that as the number of insured individuals rose, so too did important cancer screening rates.

As Washington attempts to address the soaring costs of prescription medications, some experts are attempting to shed light on the many complicated aspects of the drug pricing issue. The free-market system has countless moving parts, and perhaps so-called big government ownership isn’t the answer to inflating drug costs. As the author aptly states, “From a public-relations standpoint, drug companies are often their own worst enemies. Occasionally, a breathtakingly awful company taints the image of the whole industry.”

On April 8, 2018, nearly a dozen Democratic senators announced they would investigate the marketing practices of e-cigarette giant Juul along with a new deal to sell a minority stake of the company to Altria, maker of Marlboro cigarettes. Not long ago, the U.S. Food and Drug Administration (FDA) and Juul—along with others in the smoking cessation community—supported efforts to use electronic tobacco mechanisms to help 60 million Americans quit smoking. However, along the way, the U.S. surgeon general and FDA discovered that youth smoking and vaping have seen a dramatic increase from the advertising, marketing, and distribution of e-cigarettes.

The 116th congressional session is well underway. Committee meetings are being held and policy discussions are taking shape all over Capitol Hill. In January 2019, the U.S. House and Senate held separate public hearings on the biggest healthcare issue from the 2018 midterm election: drug pricing.

In a move that echoed the Department of Justice’s (DOJ’s) previous stance on the Affordable Care Act (ACA), the Trump administration’s DOJ announced it was siding with a lower court’s ruling that stated ACA was invalid and unconstitutional. Siding with conservative state attorneys general who sued and won a lower federal court judgment on the constitutionality of law, DOJ issued a terse, two-sentence letter supporting the judge’s decision to strike the law down.

Health care remains a top domestic policy issue for Americans. Across the board—regardless of political ideology—Americans are concerned about the quality of health care, access to providers, and rising costs associated with medications and treatment. In February 2019, the Centers for Medicare and Medicaid Services’ (CMS) Office of the Actuary released a report outlining the projected growth in national health spending from 2018–2027.

For the past year, President Trump has championed efforts to lower drug prices for Americans to more accessible and affordable medications. Lowering soaring prescription costs is an issue with wide bipartisan support in Congress. To date, several Congressional committees have held hearings in early 2019 with pharmaceutical executives.

To improve access to new cancer therapies and provide national consistency in coverage, on February 15, 2019, the Centers for Medicare and Medicaid Services (CMS) announced a proposed plan of coverage with evidence development for CAR T-cell therapy. The public is invited to share comments for the next 30 days.

U.S. drug pricing systems are difficult for patients to understand, cumbersome to maneuver, and limited in access and affordability. In Medicare’s current structure, certain medications are designated as a protected class of drug, and Medicare Part D plans are obligated to cover them.

On October 25, 2018, U.S. Department of Health and Human Services (HHS) Secretary Alex Azar announced an advanced notice of proposed rulemaking (ANPRM) calling for a demonstration project to more closely align Medicare payment for certain Medicare Part B drugs and biologics with international prices, which an HHS analysis showed to be 1.8 times lower on average than in the United States. The proposal is a follow-up to the president’s prescription drug blueprint and HHS request for information to reduce patient out-of-pocket costs for prescription drugs. HHS estimates a savings of $17.2 billion over five years.

One of the biggest challenges in medical practice is finding a way to spend enough time with each patient amid all the regulatory paperwork. To streamline workflows and encourage better provider-patient relationships, the Centers for Medicare and Medicaid Services (CMS) proposed new reforms to roll back certain regulatory efforts that were saddling clinicians with cumbersome paperwork. As part of those efforts, CMS reevaluated some of its reimbursement methods to improve efficiency with its required paperwork.

With more states legalizing medical aid in dying options for patients, the process is often vague and misunderstood. One patient, Aaron McQ, shared his story as he prepared to self-administer his life-ending medication. His story explains the nurse's key role in education and shared decision making to address the concerns of the patient.

Healthcare reform has been a hot political topic since before the introduction of the Affordable Care Act. Potential changes in the American healthcare system will be at the hands of which party controls the House of Representatives and the Senate. The upcoming midterm elections in November 2018 could determine a shift in power and potentially add further Medicaid expansion to the list of incoming health care changes.

On July 16, 2018, Kevin Brady (R-TX), House Ways and Means Committee chair, announced that he’s working with the Trump administration to restore funding to key Affordable Care Act (ACA) payments. Previously, the White House suspended more than $10.4 billion in payments to insurers, which brought criticism from Democrats and stern warnings of rising healthcare premiums.

ONS shared the perspective of nurses caring for patients who may struggle to afford cancer drugs in comments submitted to the Department of Health and Human Services (HHS) on its Prescription Drug Reform Request for Information.

An initial proposal from the Trump administration might cut funds for outreach related to the Affordable Care Act (ACA). As of yet no decisions are finalized and funding may still remain consistent, but limiting funding for outreach of the ACA, known to most as Obamacare, isn't a new move for the current administration. In 2017, it cut funding for navigators who educated and enrolled Americans in the ACA marketplace, leading to confusion among potential applicants and lower enrollment numbers. If funding is cut again this year, new or returning enrollees are unlikely to find success when looking for coverage.

Recent care delivery models have focused on providing value-based care to patients. The changes provide opportunity for APNs to take a leadership role in implementing models and systems to effectively deliver that care. Here’s what APNs need to know about the new models.

The Centers for Medicare and Medicaid Services (CMS) finalized a rule on November 1, 2017 that would reduce the current Medicare Part B drug payment to 340B hospitals from average sales price (ASP) plus 6% to ASP minus 22.5%.  However, rural sole community hospitals (SCHs), children’s hospitals, and PPS-exempt cancer hospitals are excluded from this payment adjustment in 2018.

On August 25, 2017, ONS submitted comments to the House Ways and Means Health Subcommittee in response to its Medicare Red Tape Relief Project. The initiative, sponsored by subcommittee chairman Pat Tiberi (R-OH), asked providers for input on ways to improve health care for seniors and reduce Medicare regulations and mandates.