April 10-11, 2025

04/10/2025 . 10:30 am - 11:00 am

Reforming physician fee schedule updates and improving the accuracy of relative payment rates

Staff Contacts:

ISSUE: For many years, the Commission has found that payments under fee-for-service Medicare’s physician fee schedule (PFS) have been adequate to ensure that beneficiaries’ access to clinician care is as good as, or better than, that of privately insured individuals. However, commissioners have voiced concerns about whether current-law updates to Medicare’s PFS will continue to be adequate, given inflation trends.

KEY POINTS: Commissioners have noted that any increase to PFS payment rates will increase the financial burden on taxpayers and on beneficiaries—through higher cost–sharing and premiums—and could magnify the effects of mispriced services. In March, commissioners discussed the Chair’s draft recommendations to replace the current–law updates to the physician fee schedule with an annual update based on a portion of the growth in the Medicare Economic Index and improve the accuracy of the PFS’s relative payment rates.

ACTION: Commissioners will vote on the draft recommendations.

04/10/2025 . 11:05 am - 12:30 pm

Structural differences between the PDP and MA–PD markets

Staff Contacts:

ISSUE: There are two distinct markets within the Part D program: the stand-alone prescription drug plan (PDP) market for FFS beneficiaries and the Medicare Advantage–Prescription Drug plan (MA–PD) market for beneficiaries who are enrolled in Medicare Advantage (MA). Consistent with the shift from FFS to MA in the broader Medicare program, Part D’s enrollment has also shifted from PDPs to MA–PDs. While there are still many PDPs participating in the markets nationwide, some recent trends may raise concerns about the long-term viability of the PDP market.

KEY POINTS: Enrolling in a stand-alone PDP is the only way FFS beneficiaries can obtain Part D drug coverage. Premium-free PDPs, or benchmark plans, serve an important role in ensuring FFS beneficiaries who receive the LIS have drug coverage at no cost.

ACTION: Commissioners will review and discuss the analytic findings and provide feedback on future directions for this work.

04/10/2025 . 1:30 pm - 2:55 pm

Assessing the utilization and delivery of Medicare Advantage supplemental benefits

Staff Contacts:

ISSUE: In addition to covering Part A and Part B services, Medicare Advantage (MA) plans may provide supplemental benefits to their enrollees, such as reduced cost sharing for Part A and Part B services, reduced Part B and Part D premiums, and other services not covered under FFS Medicare such as dental, vision, or hearing services. The majority of the supplemental benefits provided by MA plans are financed by the rebates that plans receive from Medicare. New flexibilities for plans, combined with the growth in rebate dollars in recent year, have allowed MA plans to significantly expand the number of supplemental benefits they offer, but relatively little is known about enrollees’ use of the benefits and spending associated with them.

KEY POINTS: Available data may be insufficient for examining enrollees’ use of supplemental benefits.

ACTION: Commissioners will review and discuss the analytic findings.

04/10/2025 . 3:00 pm - 4:15 pm

Exploring the effect of Medicare Advantage on rural hospitals

Staff Contacts:

ISSUE: MA enrollment has been growing rapidly in rural areas.

KEY POINTS: MA patients represent an increasing share of rural hospitals’ revenue.

ACTION: Commissioners will review and discuss analytic findings on the impact of MA on rural hospitals’ volume and profitability.

04/10/2025 . 4:20 pm - 5:20 pm

Paying for software technologies in Medicare

Staff Contacts:

ISSUE: Software is becoming increasingly important and pervasive in healthcare. In our June 2024 report, the Commission discussed Medicare’s coverage of and payments for certain types of software that are used to diagnose or treat an illness or injury without being part of a hardware medical device: algorithm-driven software (called software-as-a service or SaaS by CMS) that helps practitioners make clinical assessments, such as software that detects diabetic retinopathy; and prescription digital therapeutics, which are prescribed by clinicians and typically administered by patients on a mobile phone, tablet, or smartwatch to diagnose or treat an illness or injury, such as software that provides cognitive behavioral therapy. Since 2018, FFS Medicare has covered and paid for SaaS that receive approval or clearance by the Food and Drug Administration.

KEY POINTS: There are many challenges to covering and paying appropriately for SaaS.

ACTION: Commissioners will review and discuss findings from interviews with developers of medical software and a commercial insurer.

04/11/2025 . 9:00 am - 10:30 am

Access to hospice and certain services under the hospice benefit for beneficiaries with end-stage renal disease and beneficiaries with cancer

Staff Contacts:

ISSUE: The Medicare hospice benefit covers palliative and support services for beneficiaries who are terminally ill with a life expectancy of six months or less if the illness runs its normal course. When a beneficiary chooses to enroll in the hospice benefit, the hospice provider assumes all financial risk for costs and services that are reasonable and necessary for palliation of the patient’s terminal illness and related conditions.

KEY POINTS: In the hospice proposed rules for fiscal years 2024 and 2025, CMS raised questions about access to care under the hospice benefit for certain high-cost services that may be palliative for some hospice beneficiaries—specifically, dialysis for beneficiaries with end-stage renal disease and radiation, blood transfusions, and chemotherapy for beneficiaries with cancer.

ACTION: Commissioners will review and discuss findings from staff analyses and interviews concerning access to hospice and certain services under the hospice benefit.

04/11/2025 . 10:35 am - 12:00 pm

Regulations, star ratings, and FFS Medicare policies aimed at improving nursing home quality

Staff Contacts:

ISSUE: About 1.2 million beneficiaries live in nursing homes (NHs) due to functional and/or cognitive impairments that prevent them from living in the community. As a group, the long-stay NH population has significant care needs and high medical costs, and there have been long-standing concerns about the quality of care they receive in NHs.

KEY POINTS: CMS has several regulatory and FFS Medicare payment policies aimed at improving the quality of care in nursing homes.

ACTION: Commissioners will review and discuss the analytic findings.