The Center for Affordable Whole Person Care logo. A person icon with its arm raised in power with a 360 degree arrow symbolizing ''whole person care.'' [[link removed]]
Families USA's Center for Affordable Whole Person Care Newsletter
News [#news] Admin [#admin] State Updates [#state] Value in the News [#value] Resources & Events [#resources]
News from Congress
Health Care Efficiency Through Flexibility Act [[link removed]] - Representatives Buchanan (R-FL), Panetta (D-CA), and Crenshaw (R-TX)
Representatives Buchanan (R-FL), Panetta (D-CA), and Crenshaw (R-TX) introduced bipartisan legislation to delay the implementation of electronic clinical quality metrics (eQCMs) for accountable care organizations (ACOs). The CY 2025 Medicare Physician Fee Schedule Final Rule [[link removed]] directed ACOs to transition to reporting eQCMs by 2025 in order to better standardize and align ACO quality metric reporting with reporting requirements for non-ACO physicians. However, ACOs have indicated [[link removed]] that this transition would place a significant cost and administrative burden on them. In response to those concerns, this bill would test possible digital reporting methods and delay the transition to eQCMs until 2030. The bill has been referred to the Committee on Energy and Commerce and the Committee on Ways and Means.
Health Care PRICE Transparency Act [[link removed]] – Representative Davidson (R-OH)
Representative Warren Davidson (R-OH) introduced legislation that would further price transparency efforts and would allow consumers to shop around for the best prices on common medical procedures as well as transparency for researchers, policymakers, and other stakeholders on healthcare affordability. The bill would require each hospital to make public the standard charges, gross charges, de-identified minimum and maximum negotiated charges, discounted cash price, and billing codes associated with at least 300 shoppable services as specified by CMS. In addition, hospitals would be required to make public the in-network provider rates and out-of-network allowed amounts and billed charges for covered items and services, as well as negotiated rates and historical net prices for covered prescription drugs. This information would all be available to the public through an internet-based self-service tool. The bill has been referred to the committee on Energy and Commerce.
Capping Prescription Costs Act [[link removed]] – Senator Warnock (D-GA)
Senators Warnock (D-GA), Baldwin (D-WI), Booker (D-NJ), Blumenthal (D-CT), Fetterman (D-PA), Gillibrand (D-NY), Heinrich (D-NM), Kim (D-NJ), Klobuchar (D-MN), Murray (D-WA), and Welch (D-VT) re-introduced legislation that would cap annual out-of-pocket cost sharing for covered prescription drugs per year at $2,000 for individuals and $4,000 for families for people with commercial health insurance. This legislation would build on successes of the Inflation Reduction Act, which capped out-of-pocket costs for Medicare Part D users, and extend those savings to more than 173 million Americans in the commercial health care market. The bill has been referred to the Committee on Health, Education, Labor, and Pensions.
Preserving Patient Access to Accountable Care Act [[link removed]] - Representatives LaHood (R-IL), Dunn (R-FL), DelBene (D-WA), and Schrier (D-WA)
Representatives LaHood (R-IL), Dunn (R-FL), DelBene (D-WA), and Schrier (D-WA) introduced bipartisan legislation to extend incentive payments for qualifying participants (QPs) in advanced alternative payment models (AAPMs) through payment year 2027 and freeze the qualifying thresholds increase. Physicians engaged in advanced alternative payment models who deliver a certain percentage of care through such models qualify for QP status, resulting in bonus payments. These thresholds are set to increase each year, resulting in fewer physicians earning the bonus payments. The bill would extend this incentive program for an additional year, continuing to support the transition of more physicians into AAPMs and continued growth in alternative payment models.
Medicare Patient Access and Practice Stabilization Act [[link removed]] – Representative Murphy (R-NC)
Representatives Murphy (R-NC), Panetta (D-CA), Miller-Meeks (R-IA), Bera (D-CA), Bucshon (R-IN), Ruiz (D-CA), Joyce (R-PA), and Schrier (D-WA) reintroduced bipartisan legislation to adjust Medicare reimbursement for physicians. As proposed, it would override the CY 2025 Medicare Physician Fee Schedule Final Rule, [[link removed]] which included a decrease to the Medicare physician conversion factor. This bill would result in increased payments to Medicare providers and could increase costs for medical care for patients in Medicare. The bill has been referred to the Subcommittee on Health.
Health Subcommittee Hearing on "An Examination of How Reining in PBMs Will Drive Competition and Lower Costs for Patients" [[link removed]] - House Energy & Commerce Committee
The House Ways and Means Subcommittee on Health held a hearing titled “An Examination of How Reining in PBMs Will Drive Competition and Lower Costs for Patients.” The hearing sought to explore bipartisan solutions to regulate pharmacy benefit managers (PBMs)’s role in the high price of prescription drugs. Lawmakers also used the hearing as an opportunity to examine possible cuts to Medicaid and the Affordable Care Act that would have massive implications on patients’ access to health care. Families USA’s Executive Director, Anthony Wright, testified at the hearing on the impact that these policies could have for patients. His written testimony can be accessed here and a video of his testimony can be found here.
Health Subcommittee Hearing on Modernizing American Health Care: Creating Healthy Options and Better Incentives [[link removed]] – House Ways and Means Committee
The House Ways and Means Subcommittee on Health held a hearing titled “Modernizing American Health Care: Creating Healthy Options and Better Incentives.” The hearing focused on the price of treating chronic disease and specifically the value of preventative care in addressing those challenges. The hearing explored avenues for employers and families across the country to seek healthy options and incentivize lifestyle choices, as well as the issues of administrative burden for providers.
Hearing to Consider the Nomination of Robert F. Kennedy, Jr., of California, to be Secretary of the Health and Human Services [[link removed]] – Senate Finance Committee
The United States Senate Finance Committee held a hearing to question Robert F. Kennedy Jr. on various matters related to health as part of his confirmation to be Secretary of Health and Human Services. Lines of questioning including physician payment, payment reform, No Surprises Act, vaccines, hospital closures, and affordability. Kennedy indicated his personal beliefs and plans for the short- and long-term direction of the Department of Health and Human Services under his leadership. Kennedy has since been confirmed as the Secretary of the Departments of Health and Human Services.
Orphan Cures Act [[link removed]] – House Committee on Energy and Commerce, House Committee on Ways and Means
Legislation was re-introduced to expand exemptions for orphan drugs in the Inflation Reduction Act (IRA) Medicare Drug Negotiation Program to include orphan drugs with more than one orphan designation. The bill would also amend the eligibility timeframe so that the 7 years of exemption before a drug becomes eligible for the Negotiation Program would only begin once an orphan drug received a non-orphan designation. Orphan drugs are a classification of drugs [[link removed]] that treat small populations of people with rare diseases or conditions, they are also some of the most expensive drugs on the market [[link removed]] . Currently the IRA exempts all orphan drugs with one orphan designation from negotiation.
The Latest from the Trump Administration
“ Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government [[link removed]] " – The White House
President Donald Trump signed an executive order that directs the Department of Health and Human Services and other agencies to recognize only two genders and immediately cease the collection of data related to sexual orientation and gender identity. Separately, CMMI has been advised [[link removed]] to stop collecting data on race, ethnicity, sexual orientation, gender, and preferred language. Together, these policies could threaten to halt progress on addressing health disparities. Without access to stratified data, it will be more difficult to identify inequities and evaluate progress of health equity initiatives.
No Surprises Act Consumer Advocate Toolkit [[link removed]] - CMS
CMS released new tools to help consumers understand their surprise billing rights. This toolkit is designed for consumer advocates and others who help individuals resolve medical billing problems. The newest items in the toolkit include:
A Quick Start Guide [[link removed]] to help advocates quickly find the resources they need for a consumer’s situation
The No Surprises Act at a Glance [[link removed]] , which gives a high-level overview of the NSA’s consumer protections
Update to Independent Dispute Resolution Fees [[link removed]] - CMS
The Department of Health and Human Services, the Department of Labor, and the Department of the Treasury have certified Independent Dispute Resolution (IDR) entity fees in accordance with the IDR Fees Final Rule [[link removed]] . The independent dispute resolution process is used when providers and insurers cannot agree on payment for out-of-network services. The IDR fees remain unchanged from 2024 for disputes initiated on or after January 1, 2025. For these disputes, the administrative fee amount is $115 per party per dispute, and the certified IDR entity fee ranges are $200-$840 for single determinations and $268-$1,173 for batched determinations.
2024 Report to Congress [[link removed]] - CMMI
The Centers for Medicare and Medicaid Innovation (CMMI) released their annual report to Congress on progress in the implementation of alternative payment models (APMs). As of 2024, CMMI models are serving more than 57 million beneficiaries through 192,000 providers and will continue to serve patients in the future through models such as ACO Reach, AHEAD, ACO Primary Care Flex, TEAM, and Making Care Primary.
Medicare Drug Price Negotiation Program: Selected Drugs for Initial Price Applicability Year 2027 [[link removed]] - CMS
As part of the Inflation Reduction Act of 2022, Medicare will negotiate directly with pharmaceutical manufacturers over the price of specific drugs; CMS has announced the 15 drugs covered under Medicare Part D for the next cycle of negotiations. The fifteen drugs selected include Ozempic/Rybelsus/Wegovy, Trelegy Ellipta, Xtandi, Pomalyst, Ibrance, Ofev, Linzess, Calquence, Austedo/Austedo XR, Breo Ellipta, Tradjenta, Xifaxan, Vraylar, Janumet/Janumet XR, Otezla. These drugs treat Type 2 diabetes, asthma, cancers, and more. Between November 2023 and October 2024, around 5.3 million Part D beneficiaries [[link removed]] used these drugs and the drugs cost around $41 billion [[link removed]] dollars in total gross covered prescription drug costs to Medicare Part D. Once negotiation is complete, the new prices will go into effect for these 15 drugs in 2027. in total gross covered prescription drug costs to Medicare Part D. Once negotiation is complete, the new prices will go into effect for these 15 drugs in 2027. in total gross covered prescription drug costs to Medicare Part D. Once negotiation is complete, the new prices will go into effect for these 15 drugs in 2027.
Projecting the Impact of the $2,000 Part D Out-Of-Pocket Cap for Medicare Part D Enrollees with High Prescription Drug Spending [[link removed]] - Assistant Secretary for Planning and Evaluation, Office of Health Policy
As part of the Inflation Reduction Act of 2022, Medicare Part D enrollees now have their out-of-pocket drug costs capped at $2,000 per year. ASPE estimates that about 11 million Part D enrollees are expected to reach the $2,000 out-of-pocket cap and these enrollees are projected to have average out-of-pocket savings of about $600 per enrollee in 2025. This cap is particularly impactful for enrollees living with cystic fibrosis, multiple myeloma, metabolic and immune disorders, and for those who received major organ transplant procedures.
Consolidation in Health Care Markets: RFI Response [[link removed]] - HHS
The U.S. Department of Health and Human Services released a report responding to a March 2024 Request For Information [[link removed]] seeking comments on consolidation in health care. The report notes the following:
provider consolidation leads to higher prices and less access for patients;
mergers and acquisitions in health care services, especially by private equity, result in quality reductions;
physicians that worked with private equity firms offered mixed reviews;
there is a widespread desire for transparency into private equity-led transactions;
consumers are dissatisfied with private health insurers, especially vertically integrated insurers.
Medicare and Medicaid Programs; Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly [[link removed]] - CMS
CMS released a proposed regulation on technical changes to Medicare Part C and Part D. The proposed rule included codification of several provisions of the Inflation Reduction Act, proposed coverage of weight loss drugs for the purpose of weight loss under Medicare Part D and Medicaid, and improvements to the Medicare Advantage program through marketing guardrails and updates to Medical Loss Ratio (MLR) reporting. Additionally, CMS requested comment on making State Medicaid Agency Contracts (SMACs) public.
Families USA submitted comment on this proposed rule, which can be read here [[link removed]] .
[[link removed]] [[link removed]] Advance Notice of Methodological Changes for Calendar Year (CY) 2026 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies- [[link removed]] CMS
This year’s Advance Rate Notice included proposals to complete the three-year phase-in implementation of the 2024 CMS-HCC Risk Adjustment Model, which would result in 100% of Medicare Advantage risk scores and risk adjusted payments being calculated by the updated model. CMS also mentioned the positivity to further recalibrate the MA risk model with the use of MA encounter data. CMS did not propose to apply a coding adjustment for Medicare Advantage plans above and beyond the statutory minimum adjustment of 5.9%. The final rate notice should be published on or before April 7, 2025.
Families USA submitted comment on this Advance Rate Notice, which can be read here [[link removed]] .
State Updates
Assembly Bill A2140 [[link removed]] – New York
New York State Assembly Members Lasher, Epstein, Gonzalez-Rojas, and Simon introduced legislation that would require outpatient or ambulatory services in the state be paid on a site-neutral basis. The bill was also introduced [[link removed]] in the New York State Senate by State Senators Krueger, Jackson, and Liu. If passed, New York would become the first state to implement site-neutral pricing for hospital services. This landmark bill would provide needed relief from high health care costs to millions of families and individuals across New York and would save $1.5 billion annually in state health care spending.
Sophia Tripoli, Senior Director of Health Policy at Families USA, submitted written testimony [[link removed]] to a public hearing on this bill.
Bill H.5159: An Act Enhancing the Market Review Process [[link removed]] - Massachusetts
Massachusetts Governor Maura Healey signed Bill H.5159 into law. The bill expands Massachusetts’ existing health are transaction notice process and implements new reporting and oversight requirements on the health care sector, specifically for private equity investment. It also allows for enforcement of stricter penalties for noncompliance with reporting requirements and imposes new obligations on private equity investment in health care providers in Massachusetts as a response to the Steward Health bankruptcy.
House Bill 49 [[link removed]] – Ohio
Ohio Governor Mike DeWine signed House Bill 173 [[link removed]] into law (including House Bill 49 as an amendment). The bill requires hospitals maintain and make public a list of all standard charges for all hospital items or services, and develop an internet-based price estimator tool. The Ohio Director of Health will monitor hospitals’ compliance with this bill and impose penalties for failure to comply. This bill makes Ohio the first state to require that hospitals publish upfront prices in dollars.
HB 1004 [[link removed]] - Indiana
Indiana state representatives Carbaugh, McGuire, Smaltz, and Gore introduced bipartisan legislation to establish a scaled hospital facility fee excise tax for hospitals that charge more than 265% of the Medicare OPPS rate for a facility fee. Revenue from the excise tax would be reinvested to Medicaid and rural health care development. The bill also creates a price ceiling for non-profit hospitals (excluding community hospitals) of 300% the Medicare rate. Violation of the price ceiling would remove the nonprofit status of the hospital. The bill has passed its first committee with bipartisan support and awaits a vote on the state house floor.
HB 1174: Support Colorado’s Health Care Safety Net Act of 2025 [[link removed]] - Colorado
Colorado state representatives Brown and Sirota and state senators Bridges and Jodeh introduced legislation that would cap prices for in-network inpatient and outpatient services provided to members of small group plans and the state employee health plans to 165% of the Medicare rate and 155% for out of network. The bill would also set a primary care reimbursement minimum of 135% of the Medicare rate. The bill has been introduced to the Colorado General Assembly and awaits further movement.
Health Care Value in the News
Hospital Consolidation
Growth of Private Equity and Hospital Consolidation in Primary Care and Price Implications [[link removed]] - JAMA
Systematic Review of Integration Strategies Across the US Healthcare System: Assessment of Price, Cost, and Quality of Care [[link removed]] - JACS
Hospital Pricing
He Went in for a Colonoscopy. The Hospital Charged $19,000 for Two. [[link removed]] - KFF
Hospital Payment Caps Could Save State Employee Health Plans Millions While Keeping Hospital Operating Margins Healthy [[link removed]] – Health Affairs
Health Equity
The Organ Transplantation System Is Inequitable. Modernized Data Can Help Fix That [[link removed]] – Health Affairs
Enhancing Design And Implementation Of ACO REACH’s Equity-Focused And Beneficiary Engagement Design Elements [[link removed]] – Health Affairs
No Surprises Act
EBSA May Face Financial Cliff in March [[link removed]] - ASPPA
Payment Reform
Medicare Accountable Care Organizations In 2023: Large Savings With Increasing Value-Based Programmatic Competition [[link removed]] – Health Affairs
A Value-Based Primary Care Model That Doubles Primary Care Investment [[link removed]] – Health Affairs
Prescription Drugs
Prescription Drug Policy, 2024 And 2025: The Year In Review And The Year Ahead [[link removed]] – Health Affairs
It’s about to get harder to find your prescription drugs [[link removed]] - Vox
Price Transparency
Price transparency divides hospitals, CMS [[link removed]] - Politico
Site Neutral Payments
Florida hospital CEO says Medicare site-neutral payment reform ‘makes some sense’ [[link removed]] - STAT
Should Hospitals Be Paid the Same as Doctors' Offices for the Same Service? [[link removed]] - MedPage
Families USA Resources
Publications and Reports

The Health of US Primary Care: 2025 Scorecard Report — The Cost of Neglect [[link removed]]
Public Interest Research Group (PIRG)
New protections from medical billing errors, other medical debt problems [[link removed]]
FTC decided not to block an acquisition that could impact supply and prices of important medicines. [[link removed]]
Third Way
A Policymaker’s Guide to America’s Hospital Financing System [[link removed]]
Want to Tweet about these issues? Use our partner toolkit [[link removed]] !
If you would like to reach out, please contact Mike Persley, Strategic Partnerships Campaign Manager, at [email protected]
Copyright © 2024 Families USA, All rights reserved.
Our mailing address is:
Families USA
1225 New York Ave NW
Suite 800
Washington, DC xxxxxx
United States
If you believe you received this message in error or wish to no longer receive email from us, please unsubscribe: [link removed] .