Families USA's Center for Affordable Whole Person Care Inaugural Newsletter

News from Congress

Series of Bills Introduced to Improve Hospital Competition and Health Care Value -Office of Representative Victoria Spartz (R-IN-5) 

In June, Rep. Spartz introduced a series of bills aimed at improving hospital competition and enhancing health care value. Highlights include: 

• H.R.8129- Oversight of Anti-Competitive Behavior of Non-Profit Hospitals Act, which would give the Federal Trade Commission (FTC) the authority to enforce antitrust law on tax-exempt hospitals;  
• H.R.8133- Transparency of Hospital Billing Act, which would expand efforts to prevent hospitals from increasing costs for patients by extending site-neutral payments in Medicare to more physician practices that are not on a hospital’s campus and codifying CMS’s authority to mandate and enforce further site-neutral payments in Medicare; 
• H.R.8130- Competition in State Healthcare Markets Act, which would direct the Assistant Secretary for Planning and Evaluation (ASPE) of the Department of Health and Human Services (HHS) to conduct annual studies on health care consolidation and competition at the state level and publish a report every ten years; and  
• H.R.8135- Addressing Anti-Competitive Contracting Clauses Act, which would direct the Comptroller General, FTC, and Department of Justice, to study the impact of anti-competitive contracting clauses on consolidation, prices, and access of health care. 

House Republican Healthy Futures Task Force releases policy agenda -Healthy Futures Task Force House Affordability Subcommittee  

In July, House Republicans released their policy proposals to promote a “modernized and personalized approach to health” and lower the cost of health coverage and health care. Notable proposals include: promoting transparency of health care prices; building on current site-neutrality provisions to ensure fair payment rates through Medicare; and conducting Congressional oversight of the Federal Trade Commission (FTC) to ensure it is properly investigating harmful health care consolidation.   

The Latest from the Biden Administration

CMS Innovation Center Strategy Refresh -Center for Medicare and Medicaid Innovation (CMMI)

On November 7, the Center for Medicare and Medicaid Innovation (CMMI) published its strategy refresh to drive the health delivery system towards transformation, including focusing on equity in all initiatives; paying for health care based on value; and delivering person-centered care. The five strategic objectives include: 1) drive accountable care, 2) advance health equity, 3) support care innovations, 4) improve access by addressing affordability, and 5) partner to achieve system transformation. The goal of the strategic refresh is to ensure that the health system achieves equitable outcomes through high quality, affordable, person-centered care.

Policy Approaches to Reduce What Commercial Insurers Pay for Hospitals’ and Physicians’ Services -Congressional Budget Office (CBO)

The Congressional Budget Office released a report in September 2022, analyzing policies for lowering health care services costs in commercial insurance plans, and projecting savings for each policy option including: hospital price transparency; increased competition in health care markets; and caps on commercial health care prices-with the largest savings attributed to capping commercial health care prices.  

Biden-Harris Administration Makes More Medicare Nursing Home Ownership Data Publicly Available, Improving Identification of Multiple Facilities Under Common Ownership -Centers for Medicare and Medicaid Services (CMS) 

CMS published information about ownership of all Medicare-certified nursing homes as part of their continued effort to improve quality of care and facilitate transparency across facilities. The release of this data advances the President’s Executive Order to promote competition in the health care market, and comes only months after CMS, in April, publicly released data on mergers, acquisitions, consolidations, and changes of ownership of hospitals and nursing homes enrolled in Medicare from years 2016-2022. The release of this data also marks a continued effort to improve the quality of care in nursing homes, facilitating transparency and quality trends across facilities.  

Inpatient Prospective Payment System (IPPS) final rule -CMS

On August 1, 2022, CMS issued the final rule for the Medicare Hospital Inpatient Prospective Payment System (IPPS) for CY23. The IPPS rule updates Medicare fee-for-service payment rates and policies for inpatient hospitals and long-term care hospitals. In the final CY23 rule, CMS adopted ten new measures for the Hospital Inpatient Quality Reporting (IQR) Program, including three health equity-focused measures; finalized a payment increase for hospitals by 4.3% (higher than the proposed rate of 3.2%); and finalized a "birthing-friendly" hospital designation to promote the quality and safety of maternity care. The rule also enacted a harmful pause in the calculation and publication of CMS Patient Safety and Adverse Events Composite (CMS PSI 90) data for FY23. This data is critical to patient and safety transparency, as it reports preventable complications from surgery attributed to hospitals. 

Medicare Physician Fee Schedule (MPFS) final rule -CMS 

On November 1, 2022, CMS issued the final rule for the Medicare Physician Fee Schedule (MPFS) for CY2023.  The MPFS rule updates reimbursement rates for physician services. This year's rule finalizes proposals to the Medicare Shared Savings Program (MSSP) including advanced incentive payments, health equity assessments, and benchmark updates. The advanced incentive payments will encourage and support new, low revenue Accountable Care Organizations (ACOs) to participate in the program. The updated benchmarks should aid in long-term ACO participation, while the health equity assessments will adjust the ACO Merit-based Incentive Payment System (MIPS) quality reporting category score to acknowledge those ACOs that are high performing while serving a high proportion of underserved beneficiaries. The rule goes into effect January 1, 2023.  

Outpatient Prospective Payment System (OPPS) final rule -CMS 

On November 1, 2022 CMS issued the final rule for the Outpatient Prospective Payment System (OPPS) for CY23. The OPPS rule updates payment rates that Medicare pays to hospitals for outpatient services. The rule finalizes public health emergency (PHE) flexibility to administer behavioral health services via telehealth and allow reimbursement for remote behavioral health services provided to beneficiaries in their homes, subject to certain requirements. The rule goes into effect on January 1, 2023 

Price Increases for Prescription Drugs 2016-2022 -Office for the Assistant Secretary for Planning and Evaluation (ASPE), Department of Health and Human Services (HHS)  

ASPE issued a report in September 2022 that analyzed drug price changes from 2016-2022. The report adds additional evidence that drug prices are increasing faster than the rate of inflation. Between July 2021 and July 2022, there were 1,216 drugs whose price increases exceeded the inflation rate of 8.5%. The average price increase for these drugs was 31.6% with some drug prices increasing by more than 500%. In an attempt to reduce these rising drug prices, the recently passed Inflation Reduction Act will now require manufacturers to pay rebates to Medicare for Part D drugs whose price increases exceed inflation, with measurement starting October 1, 2022 in an attempt to reduce rising drug prices.  

CMMI Extends BPCI Advanced Model -CMMI  

The Bundled Payment for Care Improvement Advanced (BPCI Advanced) Model has been extended for another two years. The Model aims to support health care providers who invest in practice innovation and care redesign to better coordinate care and reduce expenditures, while improving the quality of care for Medicare beneficiaries.  

Enhancing Oncology Model, Applications are Open -CMMI 

The Enhancing Oncology Model (EOM) is a voluntary, 5 year, episodic-based payment initiative that builds on lessons from the Oncology Care Model (OCM) before it. Under this model, participating oncology practices agree to take on financial and performance accountability and improve care coordination.  

State Updates 

State to launch health care price transparency tool -NM Department of Health 

In late 2023, New Mexico will join eighteen other states developing or operating All-Payer Claims Databases (APCD) making health care, quality, and other data available to the public. APCDs can aid in the standardization of data across state and sub-state agencies and offer the ability to compare across states on cost, service utilization, and quality.  

Newsom Signs Bill Establishing Office of Health Care Affordability After Negotiations -State of Reform 

Through passage of SB-184, California has established an Office of Health Care Affordability that will analyze state health care spending and set cost growth targets for the state. California joins Delaware, Rhode Island, and Connecticut, which received funding for their existing cost growth target programs, and five other states — Massachusetts, New Jersey, Nevada, Oregon, and Washington — that are implementing health care cost growth targets.  

More on this issue: California’s New Law Targets High Health Care Costs- Arnold Ventures 

OHA Releases CCO 2021 Financial Reports -Oregon Health Authority 

The Oregon Health Authority analyzed financial statements from the state’s 16 contracted coordinated care organizations (CCOs) and found that their average operating margin was 2.1%, up from 1.5% in 2020 year, indicating their financial stability in 2021. CCOs deliver coordinated health benefits and other services to more than one million members enrolled in the Oregon Health Plan (OHP), majority of whom are enrolled in Oregon’s Medicaid program.  

Baker-Polito Administration, Centers for Medicare and Medicaid Services Announce Five Year, $67.2 Billion Agreement for MassHealth Reforms -Office of Governor Charlie Baker  

Massachusetts has received approval from CMS to extend their MassHealth 1115 waiver demonstration through December 2027. The MassHealth system has been successful in offering near-universal coverage to Massachusetts residents and continues to reform health care delivery in the state through Accountable Care Organizations (ACOs) and Community Partner Organizations.  

Oregon Health Authority, Centers for Medicare and Medicaid Services Approve Oregon’s Five Year Medicaid Waiver -Oregon Health Authority 

Oregon has received approval from CMS to extend their Medicaid 1115 demonstration waiver through 2027.  The 2022-20227 waiver is focused on addressing and eliminating health inequities through a whole-person care approach. They will continue to advance these priorities through expanding coverage to children under six and for health-related social needs such as food and housing supports. The state has received $1.1 billion in federal support from Designated State Health Programs funds. 

Arizona Health Care Cost Containment System, Centers for Medicare and Medicaid Services Approve Arizona’s Five Year Medicaid Waiver -CMS 

Arizona received approval for an extension of their 1115 waiver demonstration through September 2027. The waiver has been successful in expanding eligibility and coverage, increasing access to home- and community-based services, and supporting integrated health plans. Under this waiver they will continue this work with additional focus on health equity and addressing comprehensive care needs. There is a requested amendment to improve mental health services that is pending approval by CMS.