番茄社区

In this exclusive video interview, Jeremy Faust, MD, editor-in-chief of 番茄社区, and Chiquita Brooks-LaSure, administrator for the Centers of Medicare and Medicaid Services (CMS) discuss recent changes in the agency that will impact both clinicians and patients.

The following is a transcript of their remarks:

Faust: Hello, it's Jeremy Faust, medical editor-in-chief of 番茄社区.

We are joined today by Administrator Chiquita Brooks-LaSure. The administrator oversees the Centers for Medicare and Medicaid Services. In addition, she supervises Medicare, Medicaid, the Children's Health Insurance program (CHIP), and the Affordable Care Act health insurance marketplaces. CMS is a federal agency with an annual budget of greater than $1.36 trillion.

Administrator, thank you so much for joining us here on 番茄社区.

Brooks-LaSure: It's my pleasure to be here, thank you.

Faust: What should Americans know about open enrollment this year, and what should physicians know about changes in reimbursement?

Brooks-LaSure: Well, we have several open enrollments going on right now. I like to say that in CMS the "M" stands for three Ms, Medicare, Medicaid and CHIP, and marketplace coverage. We're now covering almost one in two Americans through our three Ms.

And so for this open enrollment, first starting with Medicare open enrollment, it's an incredibly exciting time for us. There are even more benefits that are available for seniors and people who rely on the Medicare program that we're incredibly excited about, and those really include the changes as a result of the prescription drug law or the Inflation Reduction Act, where prescription drugs are going to be more affordable.

This year, we're really trying to get the word out about a couple of things.

One is that for modest-income seniors and people with disabilities -- so Medicare beneficiaries who maybe make about $30,000 a year or less for a couple -- they're eligible for more savings as a result of prescription drug coverage. This is one of the programs that we call Extra Help, or LIS (Low Income Subsidy).

And I really mention this because doctors are one of the most trusted messengers for their patients. So you are key in helping people who come to you know how they can get the care that they need. This is just one of the benefits that has really been expanded, thanks to the president, that we're really trying to make sure that people know [about] during this open enrollment.

We also have marketplace open enrollment, which is the Affordable Care Act, which starts on November 1. We encourage everybody -- whether they're eligible for marketplace coverage, whether they're re-enrolling or choosing a new plan in Medicare, or whether they're re-enrolling in Medicaid -- to take a look at either of our websites: medicare.gov or healthcare.gov.

Faust: That's all excellent.

I think one question that people have on their minds is: how do we make sure that people who have this level of coverage get that same level of care?

An area of concern is that we read that there will be a cut in physician fees. Does this go against the goal of increasing Medicare and Medicaid coverage? Because doctors may say, "Well, I don't want to do that. I can't accept a lower rate, and so I'm going to go into a concierge practice."

So how do we make sure that we are actually getting these benefits into a doctor/patient relationship, especially with an eye on equity, because Medicaid also needs to be reimbursed at a higher rate in order to really address these disparities, is that right?

Brooks-LaSure: It is really crucial that we have all of the physicians in America wanting to participate in the Medicare and Medicaid programs because, just as you said, it's crucial for people not to just have a card in their pocket that says they're eligible, but to actually be able to go see the doctor, see a nurse, be able to see and get their treatment.

Some of the ways that we're trying to work with Congress to really make sure we're supporting doctors are some of the things that are new in our rules this year. Thanks to the work of the president and Congress, there are now additional services that we're able to cover -- things like mental health, in the Medicare program particularly, have been expanded. So family and marriage therapists and mental health counselors are now going to be covered.

We're also adding reimbursement for things like social determinants of health, some of these caregiver services. And we're trying to focus on, among other things, primary care and really trying to make sure that we're valuing the work that people are doing, particularly that upfront effort to see your doctor, not just when you're dealing with an acute condition of some sort.

Faust: Yeah. I think that those things are very much appreciated, especially those innovations like including social determinants of health and other things in not just care, but in reimbursement and what's valued.

But how do we go against this idea that the reimbursement cut is going to make it harder? Shouldn't rates be going up?

Brooks-LaSure: Well, there are things that we can do administratively and there are things that really are going to require Congress to respond.

We are really looking at ways that we can use our administrative authority to encourage physicians to be able to get positive updates. We know how important it is, and it is our primary goal here at CMS and within the administration to make sure that we are supporting the workforce. We know what an important piece [it is]; everyone needs to get paid for the work that they're doing. We are looking for ways -- whether it's through our models -- really encouraging participation in ways where Congress has given us authority to pay additional dollars for quality and other types of arrangements.

Faust: So it will take Congress to act is, I think, the reality in terms of getting that reimbursement going with budget issues and budget neutrality.

OK, let's transition to a little bit more about what you can control, which is that we have the good news that CMS can negotiate the prices of drugs. We saw a list of that. Can you just give our viewers a sense of what impact that will have on healthcare costs?

Brooks-LaSure: It's so important that Medicare was given the authority to negotiate drug prices.

A lot of people don't realize that Medicare didn't have this authority. When Medicare was first created, drug coverage was really limited. Then when Congress passed Part D or the prescription drug part of Medicare, Medicare was forbidden from actually being able to get the best value for the dollar.

Now that Medicare is able to negotiate, it really puts us on a better playing field with organizations like the VA, commercial insurance; those of us who get our coverage through our employers – they negotiate. And the 10 drugs that are selected for this first negotiation, they cover conditions that are so common in the Medicare population -- things like diabetes, cardiovascular disease, blood cancers. Just some of these services that when people have these conditions, they have astronomically high -- or what feels to me very high -- drug costs. Some people are paying over $10,000 a year in their prescription drug costs.

So our ability to negotiate with the drug companies helps us to make sure that we're getting the best value for our dollar, the Medicare dollar. So it helps people in Medicare, but it also helps all of us as taxpayers who are supporting the Medicare system to make sure we're getting the best deal.

Faust: Right. And I think it's one of the few examples where people look at giving a government entity more power and being happy about it, so that's a win.

But I also think that CMS has the responsibility to look after its own solvency. In other words, the Medicare trust fund will someday run out unless actions are taken. One way you can do that is to decide what to cover and what not to cover using the reasonable and necessary standard. Now, you have done that in some cases where you've said, "Look, here's an FDA drug that's been approved, but we're not going to actually cover that." How do you make those calls and how does the agency make those calls?

Brooks-LaSure: For us, when we're making decisions about coverage, we really focus on the clinical benefit. We think about payment very separately from our decisions. It's our role to think about whether something is reasonable and necessary.

So the process that we go through is: FDA makes the decision and they have the responsibility about whether a drug or a therapy is safe and effective. Then what we do is our clinicians -- as well as talking to clinicians outside of the agency -- really make a determination: does this make sense for the Medicare population?

What we did in the case of Alzheimer's disease, we had been asked by a number of organizations to make a coverage decision -- we don't always do that, but we were asked to do that -- and we reviewed the evidence. We worked with FDA, and now that FDA has approved the drug under its traditional approval, we have broad approval when a clinician decides they want to prescribe the medication, and we have a registry. Any private entity can also open one up.

The reason why we did that was because we wanted to make sure we learned more about Alzheimer's disease, as we all know what a devastating disease that is, and we want to make sure that we continue to learn more about what's happening and ways to treat it.

Faust: Right. And I thought that was a fascinating use of the authority, for Leqembi [lecanemab] saying, "Look, we're going to do it," and Aduhelm [aducanumab] saying, "Look, we're not."

I think that there's a lot of controversy around that, but I do think that this is a regulatory authority that you have, and it's an important one given that literally the future of this program is in your hands and whoever else you work with and who supports you. Can we expect to see more of that? Those are hard decisions, but can we expect to see more of those kinds of choices?

Brooks-LaSure: There are hard decisions that CMS makes, and we really try to do that by engaging stakeholders very broadly. We've talked -- I've personally talked -- with so many people, both who have Alzheimer's disease [and] clinicians. And we really try to do that whatever the issue is -- whether it's nursing home staffing, whether it's open enrollment -- we really try to engage with stakeholders.

But there are critical issues that are facing our country in healthcare, and CMS tends to be at the center of many of those.

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