News from Congress
Site-based Invoicing and Transparency Enhancement (SITE) Act– Senators Braun, Hassan, and Kennedy
Senators Braun (R-IN), Hassan (D-NH), and Kennedy (R-LA) introduced bipartisan legislation, which, if passed, would prevent off-campus emergency departments and outpatient hospital departments from charging higher rates as well as require these facilities to bill services to separate National Provider Identifiers (NPIs). The bill would save an estimated $40 billion for the Medicare program and advance site-neutral payment reforms. Savings generated through the implementation of these policies would be reinvested into a national nursing training program.
Committee Hearing: Consolidation and Corporate Ownership in Health Care: Trends and Impacts on Access, Quality, and Costs – Senate Committee on Finance
The Senate Committee on Finance heard testimonies from researchers, the CEO of a rural hospital, and the CEO of the American Academy of Family Physicians (AAFP) regarding industry practices in health care that increase the overall costs of care. Testimony helped provide the Committee information on health insurance consolidation, innovative payment models, pharmacy benefit managers, physician payments, and hospital outpatient departments. The hearing comes as the both the Senate and the House prepare legislative packages on health care costs, affordability, and competition.
Full Committee Markup on Bills to Improve Health Care Transparency - House Committee on Education & the Workforce
The House Committee on Education & the Workforce held a markup on four health care bills related to health care transparency and reporting. All four bills advanced to the House floor. Each of the bills is detailed here:
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H.R. 4509, Transparency in Billing Act, which passed 39-0, would forbid holding patients, health plans or insurers accountable for claims to items or services delivered at off-campus outpatient departments unless billed to a separate National Provider Identifier. It also grants enforcement authority to the Department of Labor to fine hospitals for failure to comply with this regulation.
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H.R. 4507, Transparency in Coverage Act, which passed 38-1, would require insurers to make public the data on cost sharing, enrollments, and individual in and out-of-network rate and payment information for all items and services. The bill also contains sections on PBM transparency and reporting.
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H.R. 4527, Health DATA Act, which passed 38-1, would ensure health plan fiduciaries are not contractually restricted from receiving cost or quality of care information about their plan. This would prevent contracts from including gag clauses.
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H.R. 4508, Hidden Fee Disclosure Act, which passed 38-1, would clarify the application of fee disclosure requirements in ERISA plans in relation to PBMs and third-party administrators.
The Latest from the Biden Administration
Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems Proposed Rule, CY 2024 - CMS
The Centers for Medicare and Medicaid Services (CMS) announced the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Proposed Rule for Calendar Year (CY) 2024. The proposed rate updates are OPPS 2.8%, ASC 2.8%, and continued Average Sales Price plus 6% for 340B. The proposed rule includes proposed updates to quality measures, continued support for Indian Health Services, tribal providers, and specific rural providers, updates to payments for intensive outpatient therapy and opioid treatment, and payment alignment for specific dental codes in OPPS with 2023 MPFS by assigning them to clinical Ambulatory Payment Classifications. To improve price transparency, CMS proposed instituting a CMS-standardized file for hospitals to submit data and additional elements needed in the data. Comments on the Proposed Rule are due by September 11th, 2023.
Medicare and Medicaid Programs: CY 2024 Payment Policies under the Physician Fee Schedule - CMS
The Centers for Medicare and Medicaid Services (CMS) announced the Medicare Physician Fee Schedule (MPFS) Proposed Rule for Calendar Year (CY) 2024. The proposed payment rates under PFS will be reduced by 1.25% in CY 2024, and the proposed CY 2024 PFS conversion factor is $32.75. CMS is proposing significant increases in payment for primary care and other types of direct patient care. The proposed rule includes new payments for caregiver training services, services addressing health-related social needs, and evaluation & management visits for patients with complex, chronic conditions. It will also expand the definition of telehealth services and continue the flexibilities of Public Health Emergency policies related to telehealth services. The proposed rule includes changes for Accountable Care Organizations (ACOs) and Medicare Shared Savings Program (MSSP) participants, by establishing a new Medicare Clinical Quality Measure collection type, making refinements to benchmarking methodology, and expanding beneficiary assignment. CMS estimates these changes will increase participation in MSSP by roughly 10-20%. Comments on the Proposed Rule are due by September 11th, 2023.
CMS Announces Multi-State Initiative to Strengthen Primary Care - CMS
The Centers for Medicare and Medicaid Services (CMS) announced a new primary care model – Making Care Primary - which will be tested in physician practices, Federally Qualified Health Centers (FQHCs), Indian Health Service facilities, and Tribal clinics across eight states (CO, MA, MN, NJ, NM, NY, NC, and WA). The model includes forced progression over ten years between three tracks, with progression depending on prior experience and intended support providers as they move into new payment models. Instituting the three tracks will help to build primary care capacity, shift providers into population-based payment models, and implement quality improvement frameworks to optimize care coordination and address health equity.
FTC and DOJ Propose Changes to HSR Form for More Effective, Efficient Merger Review - FTC, DOJ
The Federal Trade Commission (FTC) and Department of Justice (DOJ) are proposing changes to the premerger notification form and premerger notification rules for entities engaging in large mergers or acquisitions. This proposed rule, if finalized, would apply to large hospital and health plan mergers. Key proposed changes include the disclosure of information that screens for labor market issues and provision of details about transaction rationale, previous acquisitions, projected revenue streams, market conditions, and the structure of entities such as private equity investments. These changes will enable the two agencies to more effectively screen transactions for potential competition issues. Comments are due by August 28th, 2023.
President Biden Announces New Actions to Lower Health Care Costs and Protect Consumers from Scam Insurance Plans and Junk Fees as Part of “Bidenomics” Push - The White House
President Biden held an event at the White House in early July to announce new “Bidenomics” plans, including a series of actions aimed at health care costs and value. Key elements of the announcement are:
The administration will impose limits on junk insurance plans, which have misled consumers into purchasing insurance plans which provide little to no essential coverage
The Consumer Financial Protection Bureau, HHS, and Treasury will collaborate in examining ways in which medical credit cards and loans have skirted consumer protections to saddle patients with higher costs and significant medical debt
The administration will issue new guidance on surprise medical billing, including clarifications about the classification of facility fees (see below)
FAQs about Affordable Care Act and Consolidated Appropriations Act, 2021 Implementation Part 60 - CMS
The Center for Medicare and Medicaid Services (CMS) issued updated guidance on the No Surprises Act (NSA). The department is monitoring the impact of facility fees on consumers for services rendered outside of hospital settings, and encourages states, providers, and plans to minimize the burden on patients. CMS also clarified that facility fees are defined as items and services for purposes of the Transparency in Coverage rules and Good Faith Estimates of the NSA; therefore, plans and providers are required to make price comparison information for facility fees publicly available.
Evaluation of the Impact of the No Surprises Act on Health Care Market Outcomes: Baseline Trends and Framework for Analysis - HHS
The Assistant Secretary for Planning and Evaluation (ASPE) at HHS released the first of five annual reports on health care market consolidation and the impact of the No Surprises Act (NSA) on market outcomes. This report focuses on the state of physician group and hospital consolidation, and prevalence of out-of-network billing prior to adoption of the NSA in 2022. It also established a framework for four subsequent annual reports, which will quantify the impact of the NSA on market outcomes.
Update: Enhancing Oncology Model Factsheet - CMS
The Center for Medicare and Medicaid Innovation (CMMI) announced 67 oncology physician group participants in the new Enhancing Oncology Model (EOM), which will run for the next five years. The EOM is intended to align payment incentives with care quality as practices take on downside risk and earn performance-based-payments based on quality and savings. The model emphasizes improvements to health equity through screening for health-related social needs and additional payments for dual-eligible enrollees. The goal of the model is to make cancer care more accessible and affordable for consumers and parallels the mission of the President’s Cancer Moonshot
June 2023 Report to the Congress: Medicare and the Health Care Delivery System - MedPAC
MedPAC submitted their June 2023 report to Congress on Medicare payment policy, Medicare Advantage, and the Medicare Part D Prescription Drug Program. The report re-affirmed their prior commitment to site-neutral payments, recommending that payment rates be aligned across sites of service for specific ambulatory surgical classifications. Additionally, they advocated for reforms to Medicare’s wage index systems to achieve more equitable payments across providers, presented a stratified analysis on outcome measures for Medicare beneficiaries, and discussed methods to account for social risk factors and reduce health disparities.
Innovation Center Releases RFI on New Episode-Based Payment Model - CMMI
The Centers for Medicare and Medicaid Innovation (CMMI) has issued a request for information (RFI) regarding the design of a future episode-based payment model. CMMI will build on lessons learned from the Bundled Payments for Care Improvement (BPCI), Bundled Payments for Care Improvement Advanced (BPCI Advanced), and the Comprehensive Care for Joint Replacement (CJR) models to design and implement a new episode-based payment model focused on accountability for quality and cost, health equity, and specialty integration. Comments are due by August 17th, 2023.
New Website Helps Consumers Learn about Surprise Medical Bills - CMS
The Center for Medicare and Medicaid Services (CMS) has launched a new website to help educate consumers on their rights and protections against surprise billing under the No Surprises Act. The website is intended to be a comprehensive resource guide to help consumers dispute surprise bills or payments, submit complaints, and establish an action plan. It is also available in Spanish.
Advisory Committee on Ground Ambulance and Patient Billing (GAPB) Will Hold Virtual Public Meeting on August 16 – CMS
The No Surprises Act requires the administration to establish and convene an advisory committee for the purpose of reviewing options to improve the disclosure of charges and fees for ground ambulance services, better inform consumers of insurance options for such services, and protect consumers from balance billing. The next public meeting will be held virtually on August 16, 2023. You can register for the meeting here.
