The three biggest pharmacy benefit managers (PBMs) made more than $7.3 billion over five years marking up the prices of specialty generic drugs for cancer, HIV and other conditions, the Federal Trade Commission (FTC) charged in a report this week. It’s the second time the FTC has singled out CVS Caremark, Express Scripts, and OptumRx for driving up drug costs. The report could provide fodder if President-elect Trump opts to make good on vows to crack down on pharmacy middlemen. The report found that PBMs marked up prices for specialty generic drugs by hundreds and sometimes thousands of percent over their estimated acquisition costs from 2017 and 2022. Most of the highly marked-up drugs were dispensed at pharmacies affiliated with the PBMs. The three companies almost always reimbursed their affiliated pharmacies at a higher rate for the drugs than unaffiliated pharmacies. The report builds off earlier findings the FTC released in July that found that the three major PBMs garnered nearly $1.6 billion in extra revenue on just two cancer drugs in less than three years by steering business to affiliated pharmacies. Read more about the FTC report on PBMs.

On December 26, CMS approved Pennsylvania’s new 1115 demonstration titled, “Keystones of Health.” The state received authority to provide limited coverage for eligible incarcerated individuals for up to 90 days prior to the individual’s anticipated date of release from state prison or county jail. This approval also provides expenditure authority for certain housing and nutrition-related services to eligible Medicaid beneficiaries based on clinical and social risk criteria. The demonstration is effective through December 31, 2029.

The purpose of MA Bulletin 99-25-01 is to advise providers that the Pennsylvania Department of Human Services (Department) has updated the top 15 non-English languages used by Medical Assistance (MA) beneficiaries and to issue a revised top 15 non-English language tagline document. Additionally, this bulletin reminds providers of their responsibility to provide interpretation and translation services free of charge to all individuals who have Limited English Proficiency (LEP), vision limitations, and/or auditory limitations, and the federal guidelines that must be followed to accomplish this.

House Republicans are floating $2.2 trillion in Medicaid cuts over 10 years, including Medicaid work requirements, per-capita caps, elimination of enhanced federal funding for the Medicaid expansion population, and reversal of the Biden administrations eligibility rule. This news is based on a House Budget Committee chairman’s mark for the years 2025-2034 and a separate menu of offsets obtained by Politico that is based on the GOP’s “Reverse The Curse” proposal. That’s why it is incredibly important to talk with your Member of Congress about the importance of supporting Community Health Centers.

The US House announced its own Make America Healty Again (MAHA) Caucus, a companion to the Senate MAHA Caucus formed after Senators met with Health and Human Services Secretary nominee Robert F. Kennedy, Jr. The House MAHA Caucus is led by Rep. John Joyce, MD, (R-PA) and Rep. Lloyd Smucker (R-PA). As a reminder, the Senate MAHA Caucus explicitly includes “expanding community health centers” under its vision and goals. The House MAHA Caucus has yet to release a document outlining its goals.

House Democrats have reintroduced their medical debt relief bill and the Health Committee has already scheduled a meeting to begin moving the bill. The House Health Committee is set to take up House Bill 79 at a meeting on January 29. Advocates for the proposal say about 1 million Pennsylvanians are struggling with medical debt. Proponents note that those with medical debt, and those afraid of accumulating medical debt, may avoid necessary medical appointments and treatment, which can lead to the need for more expensive care. During his 2024-25 budget address, Gov. Josh Shapiro called for investments to support Pennsylvanians who are being crushed by medical debt, especially those in rural communities. Medical debt impacts Pennsylvanians’ access to quality health care and affects their credit. With only $4 million, the commonwealth can erase nearly $400 million in medical debt for low-income Pennsylvanians by partnering with nonprofits that buy that debt from health care providers for pennies on the dollar. The Department of Health estimates that there is about $1.8 billion in medical debt burden being carried by residents across the state. The House passed a medical debt relief bill in 2023, but it never moved in the Senate.

Rep. Arvin Venkat and Rep. Kristin Marcell have introduced a legislative package, HB 75 and HB 76. These legislative packages would amend the physician licensure acts in Pennsylvania to allow physician assistants to work with either classification of physician, a Doctor of Medicine or Doctor of Osteopathic Medicine, without having to align with the physician’s license type. The current law requires that physician assistants and supervising physicians must be licensed by the same state board.

Continuing the Shapiro Administration’s commitment to get stuff done for Pennsylvanians, the Pennsylvania Insurance Department (PID) today announced that 259 Pennsylvanians successfully appealed denied health service claims through PID’s new Independent External Review process. In total, the external review process overturned 50.1 percent of appealed denials, helping to ensure more Pennsylvanians receive the health services they deserve and marking a strong start for the process’s first year. Click here to learn more about the overturned denials.

CMS is adding four new documents to the No Surprises Act (NSA) toolkit to help assisters and advocates who work with consumers faced with surprise medical bills. The new resources include:

• A Quick Start Guide to help advocates quickly find the resources they need for a consumer’s situation;
• The No Surprises Act at a Glance, which gives a high level overview of the NSA’s consumer protections;
• A resource outlining the Key Responsibilities for Health Care Providers and Facilities Under the No Surprises Act; and
• A resource outlining the Key Responsibilities for Group Health Plans and Health Insurance Issuers Under the No Surprises Act.

Altogether, the toolkit contains more than 20 individual resources and a PDF compilation of all the resources. It is posted at https://www.cms.gov/nosurprises/consumer-advocate-toolkit.

Issuing Next Generation IT Solicitation and Launching OPTN Board Special Election Process with a New Nominating Committee Represent Major Advances in Historic Reform of Organ Transplant System

The Health Resources and Services Administration (HRSA), a division of the U.S. Department of Health and Human Services, announced two key advances in the historic effort to improve the Nation’s organ transplant system and better serve the patients, families, donors and health care providers who make transplantation possible. HRSA is:

• Releasing a new solicitation to support the next generation of Organ Procurement and Transplantation Network (OPTN) technology infrastructure that is agile, resilient, interoperable, and user-friendly; and
• Launching the special election process for a new OPTN Board of Directors with the formation of a Transitional Nominating Committee, a critical step in HRSA’s commitment to strengthen OPTN governance, mitigate conflicts of interest, and establish independence.

“Modernizing the organ transplant system to better serve the more than 100,000 people on the organ transplant waiting list has been one of HRSA’s top priorities in the Biden-Harris Administration,” said HRSA Administrator Carole Johnson. “With bipartisan leaders in Congress, we have worked to reform this lifesaving system to ensure that it meets the highest standards for performance, transparency, and accountability. Americans on the organ waitlist deserve no less. We look forward to the progress to come in the months and years ahead as HRSA continues to implement the bipartisan Securing the U.S. OPTN Act.”

The new solicitation released today will enable HRSA to modernize OPTN IT systems and build on the OPTN modernization awards announced in September 2024. As a Multiple Award Blanket Purchase Agreement, it will allow HRSA to engage with experienced vendors to develop key pieces of the modern OPTN IT system in a timely and efficient manner. The solicitation is posted on the General Services Administration e-Buy platform and announced on SAM.gov.

A transitional nominating committee will support the Special Election for a new OPTN Board of Directors, which in partnership with HRSA oversees organ allocation policy and membership standards. In forming the Transitional Nominating Committee, HRSA solicited public input, engaged with community members, and sought input from board governance and organizational leadership experts. The nominating committee will publicly solicit candidates for the board, develop a slate of board candidates for a vote by OPTN members, and select a date in spring 2025 for the special election. Members of the Transitional Nominating Committee will not be eligible to serve on the new OPTN Board of Directors. The committee is temporary and will be dissolved once the Special Election is completed.

The nominating committee includes individuals with extensive clinical transplant expertise, patients with transplant experience, leaders with extensive board governance expertise and ethics experts. For the full list of the Transitional Nominating Committee, see HRSA’s OPTN Modernization Initiative webpage.

Together, these actions build on HRSA’s ongoing efforts to improve the transplant system for those on the waitlist by bolstering OPTN performance, transparency, and accountability including:

• Securing passage of the bipartisan Securing the U.S. OPTN Act to modernize the system for the first time in four decades.
• Working with Congress to receive a significant increase in congressional appropriations to support this critical modernization work.
• Transitioning from a single OPTN vendor to multiple vendors with distinct expertise to better support OPTN operations to reflect the comprehensive skills needed to manage this critical network.
• Separating the OPTN Board of Directors from the OPTN contractor to remedy potential conflicts and for the first time in 40 years, ensure that the OPTN Board of Directors is independent rather than one-and-the-same as the corporate boards of the vendor.
• Addressing “pre-waitlist” inequities in the transplant waitlist process and reducing variation in organ procurement practices.

Learn more about the OPTN Modernization Initiative.