Families USA’s Center for Affordable Whole Person Care Bi-Monthly Newsletter

This newsletter will be sent out every other month to bring you the latest news from the front lines of the health care value movement and our work to rein in health care industry abuses and reorient economic incentives to ensure affordable, quality, equitable care and health for all.



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News from Congress

Health Subcommittee Legislative Hearing: “Lowering Unaffordable Costs: Legislative Solutions to Increase Transparency and Competition in Health care” – House Energy & Commerce Committee

The House Energy & Commerce Health Subcommittee held a hearing to discuss seventeen health care bills related to health care affordability, prescription drug prices, price transparency, and provider consolidation. Following both a subcommittee and full committee markup, six bills were advanced to address health care costs and price transparency. Most significantly, H.R. 3561, Promoting Access to Treatments and Increasing Extremely Needed Transparency (PATIENT) Act of 2023.The bill, voted out of committee 49-0, includes key provisions:

Codifying the Hospital Price Transparency rule by amending the statutory basis to explicitly require disclosure of negotiated rates in dollar amounts. It would also codify the Transparency in Coverage rule.

Requiring every hospital outpatient department to be assigned a unique health identifier number, therefore distinguishing them from the hospital location as it relates to billing.

Requiring providers to submit data to the Secretary on mergers and acquisitions, capital gains investments, and business structure of any parent companies.

Requiring certain outpatient drug administration services to be paid at the equivalent PFS rate when administered in any off-campus outpatient department regardless of whether that off-campus outpatient department is excepted under the BBA of 2015.

Another notable bill advanced out of committee (49-0) is H.R. 3284: The Providers and Payers COMPETE Act. This bill would require the Center for Medicare and Medicaid Innovation (CMMI) and the Department of Health and Human Services (HHS) to prepare reports evaluating the impact of regulatory changes and alternative payment models on provider and payer consolidation. Reports must also include information on particular regulations in Medicare Parts B, C, and D that impact provider and payer consolidation.

Additional Legislation to Watch

Spartz Re-Introduces Legislation to Combat Hospital Monopolies – Rep. Victoria Spartz

Representative Victoria Spartz (R-IN) re-introduced eight health care bills aimed at eliminating anti-trust loopholes for hospitals, evaluating anticompetitive contract clauses, and promoting transparency and site-neutral payments. These bills were originally introduced in the last Congressional session. Some highlights of the package include:

Preventing Hospital Overbilling of Medicare Act, would implement site-neutral payment policy addressing dishonest overbilling by off-campus hospital locations.

H.R.2890 - Stop Anticompetitive Healthcare Act of 2023, cosponsored by Rep. Pramila Jayapal (D-WA), would give the Federal Trade Commission (FTC) authority to investigate nonprofit hospitals for anticompetitive behavior.

Addressing Anti-Competitive Healthcare Contract Clauses Act, would commission a study by the Department of Justice and the FTC to assess anticompetitive contract clauses between health care insurers and providers, as well as related enforcement actions.

Holding Nonprofit Hospitals Accountable Act: would define a community benefit standard for tax-exempt hospital status, helping to ensure that nonprofit hospitals are meeting the expected requirements that earn them tax breaks.

Hern and Kuster release bipartisan transparent billing legislation – Reps. Hern and Kuster

Reps. Hern (R-OK) and Kuster (D-ME) introduced bipartisan legislation, the Facilitating Accountability in Reimbursements Act (FAIR Act), that, if passed, would work to address billing practices in off-campus hospital outpatient departments. The bill would require that all off-campus outpatient departments have a unique health identifier (NPI), as well as directs CMS to audit facilities recently converted to “off-campus” to make sure they meet the requirements of that designation. This bill would ensure transparency into billing practices for hospital off-campus sites-of-service.





The Latest from the Biden Administration



Partial Report on the Independent Dispute Resolution Process Oct. 1 – Dec. 2022 – CMS

CMS released an update on the Independent Dispute Resolution (IDR) process as it relates to implementation of the No Surprises Act. From October 1 to December 31, 2022 there were 110,034 disputes filed through the Federal portal, representing a 53% increase from the previous quarter. In a separate status update released by CMS in April, the Department reported a case load 14 times larger than they expected for the previous twelve months. Thus far, over 42,000 disputes have resulted in payment determinations, and 71% of these disputes were ruled in favor of the initiating party (the provider). In the face of legal challenges to the IDR process, the Department remains committed to full implementation of the No Suprises Act and the dispute process remains a critical element of implementation.

CMS Extends Medicare Advantage Value-Based Insurance Design Model - CMMI

CMMI announced an extension of the Value-Based Insurance Design (VBID) Model for an additional five years, through 2030. The model began in 2017 and, by the end of 2023, will serve over 6 million Medicare Advantage beneficiaries in 49 states and DC. The model, to date, includes initiatives on provider choice and care planning as well as a Hospice Benefit Component for end-of-life care. During the next period, the model will introduce Area Deprivation Index-based benefits to address health disparities and inequities in underserved communities. Changes to the model are intended to build on the model’s successes and encourage greater focus on care coordination and delivery, alongside addressing social needs like food insecurity and transportation access.



Hospital Price Transparency Enforcement Updates - CMS

CMS published updates to their enforcement process for the Hospital Price Transparency rule, including requiring corrective action plan (CAP) completion deadlines, earlier and automatic civil monetary penalties (CMPs) (ie. CMS will no longer be issuing warnings before issuing fines), and streamlining the compliance process. The Hospital Price Transparency rule has been in effect since January 1, 2021 and has issued four fines. CMS considers around 70% hospitals to be in compliance with the rule, but third-party organizations have released data suggesting that compliance is much lower around 20%. (verify with PRA study). These updates to the enforcement process are intended to encourage compliance and will ideally result in more complete hospital pricing publications.



Rate Announcement: Medicare Advantage and Medicare Part D Payment Updates - CMS

CMS finalized 2024 payment rates for Medicare Advantage and Part D with an anticipated payment increase of 3.32% for MA plans. This is expected to result in a $13.8 billion increase in Medicare Advantage payments in the upcoming year. This year, CMS will start recovering improper payments made to insurance companies in Medicare Advantage and transitioning the Medicare Advantage risk adjustment model codes to ICD-10 codes in an attempt to align the model with other federal programs and keep the model up to date. Technical revisions to the model and adjustments to per capita cost calculations in this rate announcement will be phased in over three years.



March 2023 Report to the Congress: Medicare Payment Policy - MedPAC

MedPAC released their March report to Congress on Medicare payment policy, Medicare Advantage, and the Medicare Part D Prescription Drug program. The March report includes recommendations for adjustments to payment rates for inpatient and outpatient settings- including renewed support of site neutral payment policy-, a status report on ambulatory surgical center services, recommendations for redistribution of disproportionate share hospital and uncompensated care payments, and a status report on Medicare Advantage and the Part D program. MedPAC reports to Congress multiple times a year and will submit their next official recommendations in June.



HHS Making Ownership Data for Hospice and Home Health Agencies Publicly Available - HHS

For the first time, HHS published ownership data for all Medicare-Certified Hospice and Home Health Agencies. The detailed information on the ownership of more than 6,000 hospices and 11,000 home health agencies is part of an increased push for transparency in market consolidation by the Biden-Harris administration. This newly publicly available data will help to support policymakers and researchers in identifying trends in performance, market consolidation, and health care costs and quality post-merger or acquisition. CMS is expected to publish the data quarterly, in a searchable format.



FY 2024 Hospital Inpatient Prospective Payment System (IPPS) Proposed Rule - CMS

CMS released the Inpatient Prospective Payment System (IPPS) proposed rule for fiscal year 2024. The rule proposes updates to the payment rate for inpatient services, and this year CMS put forward a 2.8% increase. The proposed rule also includes an adjusted payment rate for long-term care hospitals, continuation of the low-wage hospital policy for another year, updates for rural emergency hospitals, additions to social determinant of health codes and quality reporting, and an RFI on the specific challenges faced by Safety-Net hospitals. Comments are due June 9th and the final rule is expected this summer.



HHS Releases New Guidance on Medicaid Reentry Section 1115 Demonstration to Increase Health Care for People Leaving Carceral Facilities – HHS

Following California’s approved Medi-Cal (CalAIM) 1115 waiver earlier this year, HHS released additional guidance for states wishing to apply for a Reentry Section 1115 Demonstration Opportunity to provide coverage for incarcerated, soon to be released, individuals. The coverage would help those individuals receive coordinated care beginning prior to their release, particularly pertaining to substance use disorder and mental health services. CMS provided this guidance as a way to encourage additional states to apply for the demonstration. Comprehensive reentry coverage can improve not only the health and wellbeing of individuals in carceral facilities but also that of the broader community and state Medicaid programs.



Economic Well-Being of U.S. Households in 2022 - The Federal Reserve

The Federal Reserve released results from the 2022 Survey of Household Economics and Decision-making that reports on the financial well-being from the year before. Key findings from their report are: in 2022, 28% of U.S. adults went without some form of medical care because of cost, 63% would be able to cover a $400 emergency expense, 16% had medical debt from them or a family member, 42% of uninsured people went without medical treatment because they could not afford it in comparison to 26% of insured people. These findings demonstrate the financial health and well-being of families and individuals in relation to the affordability and accessibility of their health care.





State Updates

Colorado HB23-1215: Limits on Hospital Facility Fees – Colorado State Legislature

Colorado’s bill limiting the use of facility fees passed through both state legislature chambers, and is awaiting Governor Polis’s signature. Once enacted, this bill would prevent providers from billing facility fees, not covered in full by insurance, for some preventative services. It will require newly affiliated health facilities to provide written notice to its patients of the adoption of a facility fee.



Colorado SB23-252: Medical Price Transparency – Colorado State Legislature

Colorado's state price transparency bill passed through both state legislature chambers in Colorado, and is awaiting Governor Polis’s signature. Once enacted, this bill would require hospitals to publicly share their Medicare reimbursement rates (not negotiated charges), require the State Department to monitor and assess whether CO hospitals are compliant under the federal Price Transparency rule, and move enforcement authority to the CO State Department. Once enacted, the law would distinguish violations of the bill as deceptive trade practices. This bill is an important step in codifying price transparency regulations at the state level.



Maine S.P. 720: Prohibiting Certain Medical Facility Fees -Maine State Senate

Maine’s Senate President Troy Jackson introduced a bill that would ban facility fees for all services other than those delivered on a hospital campus, in a facility with a hospital emergency department, or emergency services in freestanding emergency facilities. The bill would specifically ban facility fees for outpatient evaluation and management services and additional outpatient, diagnostic, and imaging services. If passed, the bill would also require an annual report on all facility fees billed within a calendar year at any location. The bill would ideally make routine care more affordable for patients in Maine by limiting the use of facility fees for a large amount of non-emergency care. The bill was referred to the Committee on Health Coverage, Insurance and Financial Services, who have held one public hearing and one working session on the legislative text.



CVS Health and Catholic Health Collaborate for Long Island Medicare Patients -CVS Health

CVS Health and Catholic Health have come together as a joint participant in the Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH) program, serving almost 40,000 Medicare beneficiaries in Long Island, New York. The two organizations are focused on improving care coordination, home-based care, providing transportation services, and addressing social determinants of health. Catholic Health has previously been a participant in the Medicare Shared Savings Program (MSSP) with their Physician Partner ACO. The two organizations together are an integrated organization of clinical networks, primary care providers, and health clinics.







Health Care Value in the News



Hospital Pricing

Hospital Survival in Rural Markets: Closures, Mergers, And Profitability – Health Affairs



The Harms of Hospital Mergers and How to Stop Them -The American Economic Liberties Project



What’s Behind Losses At Large Nonprofit Health Systems? - Health Affairs





Payment Reform

Benchmarking Changes and Selective Participation in the Medicare Shared Savings Program – Health Affairs



Surprise Billing

Providers Challenge Payments in ‘No Surprises’ Act Dispute Resolution Process – Health Affairs



What’s next on the No Surprises Act – Axios



Price Transparency

Checking In on Hospital Price Transparency – Kaiser Health News



The Relationships Among Cash Prices, Negotiated Rates, And Chargemaster Prices For Shoppable Hospital Services – Health Affairs









Families USA Resources

Publications and Reports:

The Power of Price Transparency: Unveiling Health Care Prices to Promote Accountability and Lower Costs: This paper outlines additional steps needed to strengthen the Hospital Price Transparency rule and achieve full price transparency for policymakers, researchers, and consumers to help lower health care costs and drive towards higher value health care.



Now Senior Director of Health Policy, Sophia Tripoli, testified before the House Energy and Commerce Health Subcommittee in late March on the issues of health care affordability, industry consolidation, and transparency. Read her complete written testimony here.

Consumers First issued a joint statement for a congressional hearing on “Lowering Unaffordable Costs: Examining Transparency and Competition in Health Care.” The letter discussed solutions to anti-competitive behaviors, rising industry consolidation, and unfair and unjustifiable prices.



Consumers First issued a joint statement for the record for the House Energy and Commerce Health Subcommittee hearing on “Lowering Unaffordable Costs: Legislative Solutions to Increase Transparency and Competition in Health Care.” The statement tracks recommendations made late in March for a similar hearing.



Families USA’s Health Equity Task Force on Payment and Delivery Reform published federal policy priorities to transform the U.S. healthcare system toward achieving health equity, and includes the Task Force’s legislative and administrative policy recommendations for 2023.



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Resources from our Partners

American Academy of Family Physicians

Quality Payment Program: MIPS Value Pathways (MVPs)

American Benefits Council

Council Amicus Brief before the U.S. District Court for the Eastern District of Texas (Tyler Division) in TMA v Tri-Agencies III (Surprise Billing)

Public Interest Research Group

Testimony of U.S. PIRG at a House Ways and Means Committee, Subcommittee Health hearing on Why Health Care Is Unaffordable



For more information, please contact Mike Persley, Strategic Partnerships Campaign Manager, at [email protected]



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