CMS has announced the final rules for the 2025 physician fee schedule, the hospital outpatient prospective payment system (OPPS) and the Ambulatory Surgical Centers.  Within these rules, CMS is finalizing new coding and payment policies for advanced primary care management services, advancing maternal safety standards, removing barriers to expand access to care for those formerly incarcerated and others in underserved communities, and setting policies to reduce the use of opioids and to increase access to high-cost drugs in tribal communities.

Physicians will see finalized average payment rates reduced by 2.93% in CY 2025 compared to the average payment rates for most of CY 2024, while payment rates for hospital outpatient and ASC services will increase by 2.9% in CY2025.

You can find more at the links below.  Please contact me at (insert) with questions or if you’d like to learn more.

FINAL FULL PACKAGE: Calendar Year (CY) 2025 Physician Fee Schedule (PFS) Final Rule CMS-1807-F

Web links:

• Press Release: https://www.cms.gov/newsroom/press-releases/hhs-finalizes-physician-payment-rule-strengthening-person-centered-care-and-health-quality-measures
• PFS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2025-medicare-physician-fee-schedule-final-rule
• MSSP Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2025-medicare-physician-fee-schedule-final-rule-cms-1807-f-medicare-shared-savings
• QPP Fact Sheet and FAQs: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/3057/2025-QPP-Policies-Final-Rule-Fact-Sheet.pdf
• IRA Fact Sheet: https://www.cms.gov/inflation-reduction-act-and-medicare/inflation-rebates-medicare
• Federal Register: https://www.federalregister.gov/public-inspection/2024-25382/medicare-and-medicaid-programs-calendar-year-2025-payment-policies-under-the-physician-fee-schedule

To address disparities in health care, on March 19, 2024, co-chairs of the Pennsylvania Black Maternal Health Caucus Reps. Morgan Cephas, D-Phila.; Gina H. Curry, D-Delaware; and La’Tasha D. Mayes, D-Allegheny, and caucus members introduced the Momnibus legislative package, which outlines a group of bills to decrease maternal morbidity and mortality in Pennsylvania.

The bills would:

• Require health-related boards within the Department of State to complete implicit bias training as part of continuing education requirements.
• Extend Medicaid coverage to doula services, as well as establish the Doula Advisory Board to set standards and requirements for doulas.
• Require health insurance to cover doula services.
• Require health insurance to cover blood pressure monitors for pregnant and postpartum enrollees.
• Expand Medicaid coverage of blood pressure monitors for pregnant and postpartum enrollees.
• Designate maternal health deserts to target investments in maternal health care services.
• Enhance access to mental health services for pregnant or postpartum patients.
• Establish a program to distribute essential resources to new mothers.

“Our Momnibus package is the culmination of years of work to address the critical issues surrounding maternal health and well-being,” Cephas said. “These core areas of increasing access to care, eliminating maternal health deserts, and addressing social determinants of health, guide our focus in this comprehensive platform. This caucus has done an amazing job of developing a multi-pronged approach to achieve health and maternal care equity for birthing people across the state no matter where they live.”

Curry said, “When my co-chairs Reps. Cephas, Mayes, and I created the PA Black Maternal Health Caucus back in October 2023, we knew we had no time to wait before we sprinted into action. In my district and all across the commonwealth, women have become victims of health care system closures. These closures have created an alarmingly increasing problem of maternal health deserts. Nineteen counties in Pennsylvania have hospitals that don’t provide obstetric services and don’t have accredited freestanding birth centers. Thirty-one counties don’t have a Newborn Intensive Care Unit. This is a horrifying reality and one that we want to change now.

“The Momnibus legislation does many things, but most importantly, it will bring forth into motion the beginning stages of good legislation that will prevent Black mommas and birthing folks and all mommas throughout the commonwealth from dying and create a Pennsylvania where the birthing journey will bring joy and healthy live birthing experiences, leading to happier and healthier children, mothers, families and communities for generations to come. When we actively address the devastation that has created fear and destroyed hope around Black maternal health, we are addressing the restoration of hope in the birthing experiences that are yet to come.”

Mayes said: “Prior to the birth of my daughter Charlotte, up until my partner Heather and I were admitted to the hospital, I worried about my partner’s health, especially as Black patients are at the highest risk for maternal mortality and morbidity and we were grateful to welcome our child into the world. This underlying fear that I felt is rooted in dangerous medical assumptions about Black bodies and implicit biases that put patients at risk, especially pregnant Black women. We must address these race-based and gender-based disparities to ensure health care is equitable for all moms, birthing people and all Pennsylvanians. Thanks to my co-chairs and members of the PBMHC, the Pennsylvania Momnibus package represents the groundbreaking opportunity to pass legislation that boldly addresses the maternal health care crisis in our commonwealth, reduces maternal morbidity and mortality, and ensures pregnant and postpartum patients have access to critical resources.”

The co-chairs, as well as Reps. Lisa Borowski, D-Delaware, Elizabeth Fiedler, D-Phila., and Mandy Steele, D-Allegheny, modeled Pennsylvania’s Momnibus legislation after federal bills introduced by U.S. Rep. Lauren Underwood, D-Illinois, and U.S. Sen. Cory Booker, D-New Jersey.

The news conference can be viewed here or above.

A gallery of downloadable photos from the event is available here.

From Becker’s Clinical Leadership

Funding secured in multistate opioid settlements by then-Pennsylvania Attorney General Josh Shapiro, now Governor Shapiro, continues to help Pennsylvania prevent substance use disorder.

 The Pennsylvania Department of Drug and Alcohol Programs (DDAP) announced the availability of $2 million in funding to implement community-based prevention services throughout Pennsylvania to prevent opioid use disorder (OUD). Funding for these grants is provided from the Mallinckrodt Opioid Settlement, which was the result of a multistate investigation spearheaded by then-Attorney General Josh Shapiro that led to billions in settlement agreements with opioid manufacturers and distributors.

“Prevention really is our first line of defense in ensuring substance use disorder doesn’t develop,” said DDAP Secretary Dr. Latika Davis-Jones. “The Shapiro Administration is committed to providing critical prevention supports and resources throughout Pennsylvania’s cities, neighborhoods, towns, and communities as a whole. With this $2 million investment, DDAP will award approximately 10 grants of up to $200,000 each to eligible community-based organizations.”  

Applicants are required to propose activities that focus on the primary prevention of OUD. Primary prevention refers to programs or activities that prevent the initiation of substance use/misuse or prevent use beyond initial experimentation. In addition, all proposed activities must take place in community settings or post-secondary education settings including colleges or universities.

Examples of allowable prevention activities include:

• Community anti-drug coalitions that engage in drug use prevention efforts;
• Supporting community coalitions in implementing evidence-informed prevention, such as reduced social access and physical access, stigma reduction – including staffing, educational campaigns, support for individuals in treatment or recovery, or training of coalitions in evidence-informed implementation, including the Strategic Prevention Framework developed by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA);
• Engaging non-profits and faith-based communities as organizations to support prevention;
• Evidence-based or evidence-informed community education programs and campaigns for youth, families, and others;
• Youth-focused programs or strategies that have demonstrated effectiveness in preventing drug misuse and seem likely to be effective in preventing the uptake and use of opioids;
• Community-based education or intervention services for families, youth, and adolescents at risk for OUD and any co-occurring substance use disorder and mental health conditions; and
• Evidence-informed programs or curricula to address mental health needs of young people who may be at risk of misusing opioids or other drugs, including emotional modulation and resilience skills.

DDAP is placing a focus on health equity as a part of this grant opportunity. Based on a variety of criteria from the Pennsylvania Department of Health’s 2022 overdose death data, DDAP will select three grantees located in Philadelphia, three grantees located in Allegheny County and four grantees from the remaining 19 qualifying counties located within Pennsylvania with a crude death rate higher than the state average.

All applications must be submitted electronically by 12:00 PM on Friday, December 13, 2024. Applications will be competitively reviewed and scored based upon the applicant’s adherence to the funding announcement guidelines, and a timely submission to DDAP.

Questions regarding the grants and the application process should be forwarded to RA-DAGrantsMgmt@pa.gov.

The Centers for Medicare & Medicaid Services (CMS) has released a new toolkit to help partners share information with DACA recipients who will be able to enroll in health coverage through the Affordable Care Act (ACA) Health Insurance Marketplace ® for the first time starting November 1, 2024. DACA recipients who meet the eligibility criteria for coverage will qualify for a 60-day Special Enrollment Period (SEP) to select and enroll in a health plan through the Marketplace. Eligible DACA recipients who want 2024 coverage should select a plan by November 30, 2024, to have coverage that begins on December 1, 2024. DACA recipients who need 2025 coverage should enroll during Open Enrollment, which runs from November 1, 2024 – January 15, 2025 on HealthCare.gov.

This toolkit is designed to help you reach uninsured, qualified DACA recipients and inform them on how to enroll in Marketplace coverage. You can use these resources on social media, in listservs, and in other modes of communication.

The toolkit includes the following resources:

• Drop-In Article
• Fact Sheet
• Fillable Flyer
• Frequently Asked Questions (FAQs)
• Postcard
• Social Media Messages
• Social Media Graphics

Help CMS spread the word about this new opportunity for DACA recipients to apply for and select an affordable health plan on HealthCare.gov.

Visit healthcare.gov/immigrants/coverage/ for more information on health coverage for immigrants, and visit the Partners Tools & Toolkits page for additional Marketplace Open Enrollment resources, including a Spanish version of the new toolkit that will post soon.

Open Enrollment for Pennie.com plans starts today!

That means it’s time to enroll in health insurance for 2025, now through January 15th. For plans starting January 1st, make sure you enroll by December 15.

Nine out of 10 Pennsylvanians qualify for financial assistance! These tax credits save the average person more than $500 a month on a health insurance plan.

Now is the time to shop around! Plans and prices change from year to year, so don’t wait until the last minute to look at your options for 2025.

If you need help or want to know if you qualify for financial assistance, call or text our FREE, statewide helpline:

FOR FREE HELP, CALL OR TEXT:  877-570-3642

September was Sickle Cell Awareness Month. CMS hopes partners and providers will continue their work in raising awareness, sharing resources, and learning how they can better help patients with sickle cell disease and their families.

CMS has released a new resource: CMS Sickle Cell Disease (SCD) Health Care Provider Toolkit: Resources for Health Care Professionals to Support Individuals with SCD

This new toolkit builds on the CMS Sickle Cell Disease Action Plan (released in September 2023) to strengthen the infrastructure for primary care and other care settings to care for people with sickle cell disease, improve care management, and assist providers with supporting the needs of people with sickle cell disease and other chronic conditions. The SCD Toolkit consist of 6 sections that equip healthcare providers in delivering quality care to individuals with sickle cell disease. This toolkit is designed to assist the care team in supporting people by introducing sickle cell disease, including the common barriers to care, and summarizing CMS program coverage for services around social determinants and drivers of health as well as and new sickle cell disease treatments.

CMS will continue the work throughout the year to look for ways to address disparities that affect the communities we serve and providing resources to help advance health equity. Share the following resources with your community this month and beyond to raise awareness about sickle cell disease.

Resources

• NEW! CMS Sickle Cell Disease (SCD) Health Care Provider Toolkit: Resources for Health Care Professionals to Support Individuals with SCD
• NEW! CMS Data Snapshot: Sickle Cell Disease Disparities in  Medicare Fee-For-Service Enrollees
• Read our CMS Sickle Cell Disease Action Plan, which outlines CMS’ actions to improve health outcomes and equity for people with SCD.
• Watch our Sickle Cell Disease video to learn more about SCD disparities, symptoms, and treatment options.
• Download The Invisible Crisis: Understanding Pain Management in Medicare Beneficiaries with Sickle Cell Disease, which highlights options for pain management in SCD patients.
• Read our Prevalence of Sickle Cell Disease among Medicare Fee-for-Service Beneficiaries Age 18-75 Years, in 2016 data highlight to learn about common chronic conditions among SCD patients and more.
• Explore our Coverage to Care initiative, which helps patients understand their health coverage and connect to health care services, including chronic care management resources for providers and patients.
• Review the Medicaid and CHIP Sickle Cell Disease Report, T-MSIS Analytic Files (TAF) 2017 for data about Medicaid and CHIP enrollees with SCD.
• View the Centers for Disease Control & Prevention’s Fact Sheets on Sickle Cell Disease to learn more about the disease and 5 Facts You Should Know About Sickle Cell Disease for more information about how to manage SCD and how it can be cured for certain patients.

Visit the National Heart, Lung, and Blood Institute’s What Is Sickle Cell Disease? webpage to learn about symptoms, diagnosis, treatment options, and more.

People wanting to support the well-being of youth and families in their communities can now take free online courses through Penn State’s Prevention Learning Portal (PLP). The portal offers instruction and resources on how to choose, implement and sustain programs and practices that promote healthy communities.

Our Evidence-based Prevention and Intervention Support (EPIS) initiative is leading this groundbreaking effort, with support of the Pennsylvania Commission on Crime and Delinquency, the Pennsylvania Department of Drug and Alcohol, the Pennsylvania Department of Education, the Substance Use and Mental Health Services Administration and the Penn State College of Health and Human Development. EPIS is also partnering with Colorado State University to produce content for the PLP.