The Medicare Payment Advisory Commission (MedPAC) held a public meeting on October 4-5, 2018. The commission discussed a variety of topics at the meeting including, opioid use in Medicare Part D, opioids and alternatives in hospital settings, and payment policies for advanced practice registered nurses (APRNs) and physician assistants (PAs). No draft recommendations were presented at the meeting.

Two sessions of the public meeting focused on opioids. The first of these was about prescription opioid use in Medicare Part D. MedPAC staff gave a presentation about opioid use in this part of Medicare, noting that while use has declined, it is still widespread. Many beneficiaries have multiple opioid prescriptions as well prescriptions for other drugs, including benzodiazepines. As the presentation was meant to be strictly informative, no draft recommendations were presented and much of the discussion focused on questions from commissioners that indicated areas for further exploration, such as the impact of formulary design, differences between enrollees in standalone plans versus joint Medicare Advantage-prescription drug plans, and the impact from individuals aging into Medicare. Commissioners did indicate that this was timely work and that they hope to continue working in this space.

This presentation was followed up with one on payments, incentives, and Medicare data related to opioids and alternatives in the hospital setting. This presentation stems from recent legislation, the SUPPORT for Patients and Communities Act that calls on MedPAC to report to Congress by March 2019 on 3 items:

1. How Medicare payments for opioids and non-opioid alternatives in inpatient and outpatient hospital settings
2. Incentives under these prospective payment systems for prescribing opioids and non-opioid alternatives
3. How Medicare tracks opioid use.

Staff briefly discussed these three items, indicating that further analysis is coming. In the discussion from commissioners, some expressed interested in gathering information and exploring opioid problems as a hospital-acquired condition. Other commissioners noted that the commission should look at the demand side of the problem, not just supply. As with the session on opioid use in Part D, commissioner expressed the importance of this work and were supportive of MedPAC exploring the issue of opioids in general.

Another session at the meeting focused on Medicare payment policies for APRNs and PAs. Staff presented two policy options to commissioners:

• Eliminate “incident to” billing for APRNs and PAs
• Requiring the practitioners to indicate field of practice (e.g. primary care) and update information regularly.

During the discussion portion of the session, many commissioners expressed support for eliminating “incident to” billing. A couple of commissioners noted that this recommendation would help to clear up the data surrounding billing and usage of services provided by APRNs and PAs. Additionally, some commissioners were curious as to how savings from this could be deployed elsewhere in the Medicare program, particularly in the primary care space. Many commissioners also expressed support for the second policy option of requiring these practitioners to indicate their filed of practice. Staff did note that specialties for APRNs and PAs would be self-identified and that they do not following the same credentialing process used by physicians. Draft recommendations related to this issue will likely be presented at an upcoming meeting.

Other topics discussed at this meeting including payment for services provided in inpatient psychiatric facilities, non-urgent and emergency care, and Medicare’s role in the supply of primary care physicians. The next public MedPAC will be held on November 1-2, 2018.