News from Congress
Lower Costs, More Transparency Act - House Committees on Energy and Commerce, Ways and Means, and Education and the Workforce
Representatives Cathy McMorris Rodgers (R-WA), Frank Pallone (D-NJ), Jason Smith (R-MO), and Virginia Foxx (R-NC) introduced new bipartisan legislation that would increase health care price transparency and lower overall costs for patients and employers. This legislation builds upon prior efforts in each of three house committees: Energy and Commerce, Ways and Means, and Education and the Workforce. Key provisions of this bill include:
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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.
- Applying site-neutral payment policies to off-campus hospital outpatient departments for drug administration services.
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Requiring off-campus hospital outpatient departments to obtain a separate national provider identifier and to use that separate identifier when billing Medicare for items and services.
- Extending funding for the Community Health Center Fund and National Health Service Corps.
Bipartisan Primary Care and Health Workforce Act - Senate Committee on Health, Education, Labor, and Pensions
Senators Bernie Sanders (I-VT) and Roger Marshall (R-KS) introduced new bipartisan legislation that would address the primary care crisis in America and the major workforce challenges of nurses and primary care physicians. The bill would ban anticompetitive contract terms, requires hospital outpatient departments to bill under separate National Provider Identifiers, and bans hospitals from charging facility fees for telehealth and evaluation & management services. It would also provide more than $26 billion in funding, generated by combatting waste, fraud and abuse in the health care system. This funding would be allocated as follows:
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$5.8 billion per year for three years in funding for community health centers.
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An additional $3 billion in funding for community health centers to expand offerings in dental and mental health care.
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$640 million over the next three years to provide 2,100 scholarships and debt forgiveness to healthcare professionals working in impacted communities.
- $1.5 billion over the next five years for the Teaching Health Center Graduate Medical Education program to create more than 700 new primary care residency slots.
- $1.2 billion in grants to community colleges and state universities for two-year registered nursing programs.
The bill passed committee by a 14-7 vote and will advance to the Senate floor. Families USA submitted a Statement for the Record in support of this bill.
Hearing on Reduced Care for Patients: Fallout From Flawed Implementation of Surprise Medical Billing Protections – House Committee on Ways and Means
The House committee on Ways and Means held a hearing to learn about the challenges of implementing of the No Surprises Act (NSA) law from providers, Independent Dispute Resolution (IDR) entities, consumer health advocates, and insurers. The administration is currently considering new rulemaking under the IDR process in response to recent legal challenges. Representatives on this Committee were concerned about stagnation in the IDR process and recurrent challenges from providers, insurers, and consumers throughout the process. Families USA submitted a Statement for the Record to advocate for lawmakers to remain steadfast in their support for strong consumer protections under the No Surprises Act.
The Latest from the Biden Administration
States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model – Centers for Medicare and Medicaid Innovation (CMMI)
The Centers for Medicare and Medicaid Services (CMS) announced States Advancing All-Payer Health Equity Approaches and Development (AHEAD), a new voluntary total cost of care model, scheduled to operate for a total of eleven years through 2034. The model builds off of similar state models such as the Maryland Total Cost of Care Model, the Vermont All-Payer Accountable Care Organization Model, and the Pennsylvania Rural Health Model, includes hospital global budgets and an emphasis on primary care participation. The model will also include adjustments for social risk and stratified data collection to address health inequities. There are openings for eight states to participate and CMS will award up to $12 million per state for operating costs.
Federal Independent Dispute Resolution Process Suspended – Centers for Medicare and Medicaid Services (CMS)
Following a decision in Texas Medical Association et al. v. United States Department of Health and Human Services (also known as the TMA III lawsuit), CMS has suspended all Federal IDR process operations relating to the NSA. The ruling in the TMA III case vacated portions of the NSA regarding the validity of Qualifying Payment Amount calculations within the IDR process. Until further notice, disputing parties can continue to engage in open negotiation, but no decisions will be issued via federal dispute arbitration. The TMA III decision, alongside other ongoing litigation as well as pauses to the IDR process may expose consumers to higher cost-sharing until the administration establishes new rulemaking.
Guiding an Improved Dementia Experience (GUIDE) Model – Centers for Medicare and Medicaid Innovation (CMMI)
CMS announced a new alternative payment model for dementia care management, Guiding an Improved Dementia Experience (GUIDE). It will fund comprehensive, person-centered assessments and care plans, care coordination, and 24/7 access to a support line. Goals of the GUIDE model include improving care quality for people living with dementia, enabling them to remain in their homes and communities, and reducing strain on unpaid caregivers. To achieve this, participants will receive a lump-sum infrastructure payment, per-beneficiary-per-month payments for participants to provide care management and care coordination services, and allowances to bill for respite services. CMS also implemented health equity adjustments to the monthly payments and requires annual data reporting to identify ongoing disparities and track progress toward health equity objectives. The model will launch on July 1st, 2024 and operate for a total of eight years.
New CMS Rule Promotes High-Quality Care and Rewards Hospitals that Deliver High-Quality Care to Underserved Populations – Centers for Medicare and Medicaid Services (CMS)
CMS issued the final FY2024 Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System rule. This rule adopts hospital quality measures to foster safety, equity, and reduce preventable harm, recognizes homelessness as an indicator of increased resource utilization in the acute inpatient hospital setting, and finalizes a health equity adjustment in the scoring methodology for the Hospital Value-Based Purchasing Program. Additionally, acute care hospitals who participate in the Hospital Inpatient Quality Reporting Program will receive an increase in operating payment rates of 3.1% as an incentive to report more data on health equity.
Adjustments to ACO REACH – Centers for Medicare and Medicaid Services (CMS)
CMS announced changes to the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model for Performance Year 2024. Notable changes include revisions to payment risk adjustment methodology, which are expected to decrease benchmarks by 0.4%, and revisions to health equity benchmark adjustments to incorporate Low-Income Subsidy Status, and state-based Area Deprivation Index. The changes are intended to increase payments and provide resources for ACOs delivering care to patients in communities impacted by health inequities.
CMS Enforcement Actions on Hospital Price Transparency – Centers for Medicare and Medicaid Services (CMS)
CMS issued new civil monetary penalties to nine hospitals who have failed to meet price transparency requirements. The hospitals are in nine separate states and territories, and penalties range from $56,940 to $979,000 in cost. These enforcement actions serve as a deterrent for other hospitals with poor compliance on federal price transparency regulations.
Medicare Shared Savings Program Saves Medicare More than $1.8 Billion in 2022 – Centers for Medicare and Medicaid Services (CMS)
CMS announced that the Medicare Shared Savings Program (MSSP) saved $1.8 billion for Medicare in 2022, which is the sixth consecutive year with overall savings. Approximately 63% of participating Accountable Care Organizations (ACOs) earned payments for their performance in 2022. These ACOs included more than 550,000 participating clinicians supporting nearly 11 million Medicare beneficiaries. Continued success for MSSP demonstrates potential savings for both providers and consumers in alternative payment models which deliver a care relationship with accountability for quality and total cost of care, unlike care under traditional fee-for-service systems.
