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Families USA's Center for Affordable Whole Person Care Newsletter

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News from Congress

Examining the Bankruptcy of Steward Health Care: How Management Decisions Have Impacted Patient Care – Senate Committee on Health, Education, Labor & Pensions 

The Senate HELP Committee held a hearing on the impact of private equity firms such as Steward Health on patient care in hospitals. Steward executives are under scrutiny for shutting down hospitals across the country and selling critical equipment and real estate while patients were in serious risk of death or injury.  

 

While the HELP Committee issued a subpoena to compel Steward CEO Ralph de la Torre to appear as a witness, he failed to attend the hearing. By a 20-0 vote, the Committee voted to hold de la Torre in contempt of court and refer the matter to the U.S. Attorney for criminal prosecution. This will advance to a vote in the full Senate.  

 

Health Over Wealth Act – Senate Committee on Finance and House Judiciary Subcommittee on Health, Employment, Labor & Pensions 

Senator Ed Markey (D-MA) and Representative Pramila Jayapal (D-WA) introduced the Health Over Wealth Act. The bill would require that private-equity owned health care entities report to the department of Health and Human Services on debt (HHS), executive pay, and reductions in services to patients. Private equity-owned firms would be required to set up escrow accounts that cover five years of operation and capital expenses, to ensure that essential health care is provided even in the event of bankruptcy or sale. HHS would also have the ability to forcibly divest a firm from ownership of health care facilities if such firm reduces access to care, price gouges, or understaffs the facility.  

 

H.R. 9572 - Enhanced Enforcement of Health Coverage Act – House Ways and Means Committee 

Representative Gregory Murphy (R-NC) introduced H.R. 9572, which would increase penalties for group health plans and health insurance issuers for practices that violate balance billing requirements. Primarily, it would penalize insurers who fail to pay providers in a timely manner following Independent Dispute Resolution (IDR) decisions under No Surprises Act (NSA) arbitration. Notably, the bill would implement an interest rate on delinquent payments and create incremental penalties for repeat offenders. There is not widespread evidence that insurers are failing to pay providers and it is not yet clear what impact this legislation could have on future costs for consumers.   


The Latest from the Biden Administration

 

CY 2025 Inpatient Prospective Payment System Final Rule - CMS 

CMS published the CY 2025 IPPS Final Rule, including an increase in operating payment rates by 2.9%, support for underserved communities and changes to the Inpatient Quality Reporting program and Z-codes. The rule also finalized a 5-year mandatory CMMI model, Transforming Episode Accountability Model (TEAM), to test episode-based payments for five common, costly procedures performed at hospitals. Some specific changes included in the finalized rule include: 

Changing the severity designation of seven Z-codes related to housing instability and ensuring that hospitals who treat patients experiencing homelessness will receive higher payments to better address these patients’ needs. 

Adopting seven new quality measures, modifying two measures, and removing five measures to ensure that metrics better reward patient safety and experience and reflect evolving needs. 

 

Report on Prevention of Out-of-Network Ground Ambulance Emergency Service Balance Billing – Ground Ambulance and Patient Billing Advisory Committee 

The Ground Ambulance and Patient Billing Advisory Committee, established by the No Surprises Act (NSA), released a report making recommendations to Congress regarding how to proceed in protecting patients from surprise or balance bills for ground ambulance care. The Committee recommends that Congress require coverage of ground ambulance emergency medical services, through new legislation, rather than by updating the current NSA. Other key recommendations include that Congress prohibit balance billing and guarantee reasonable payment for ground ambulance emergency medical services and establish minimum guardrails for state and local regulated rates. 

 

Letter to CEOs on Biden-Harris Administration’s Time is Money Initiative – Secretary Xavier Becerra 

Secretary of the Department of Health and Human Services Xavier Becerra sent a letter to CEOs of health insurance companies, urging them to partner with the administration to ensure patients can easily use and stay informed about their coverage. Included within this letter is ensuring compliance with the NSA, keeping provider directories accurate, and continuing to keep consumers out of the middle of NSA disputes. 

 

Compliance and Enforcement - Center for Consumer Information and Insurance Oversight (CCIIO) 

The Center for Consumer Information and Insurance Oversight issued four new reports on enforcement of the NSA. Specifically, these reports issue corrective actions to four insurers who have failed to provide required Qualifying Payment Amount (QPA) disclosures to providers for purposes of NSA arbitration. Ensuring that providers have transparent access to QPA disclosures is important for a fair dispute resolution process. 

 

FACT SHEET: Biden-Harris Administration Announces New, Lower Prices for First Ten Drugs Selected for Medicare Price Negotiation to Lower Costs for Millions of Americans – The White House 

The Biden-Harris White House and the Department for Health and Human Services announced they reached agreements with all participating manufacturers on negotiated prices for the first 10 drugs selected for the Medicare price negotiation program. These new prices will cut the list price of these drugs between 38 and 79 percent, and will go into effect in 2026 for people with Medicare part D coverage. 

 

Answers to Questions for the Record Following a Hearing on Hospital and Physician Consolidation and Its Impact on the Federal Budget – Congressional Budget Office 

Following a May 2024 testimony on hospital consolidation and its impact on the federal budget, the CBO received several questions about vertical integration, pharmacy benefit managers, anticompetitive behavior, and site-neutral payment reform. In response to these questions, the CBO reiterates that an expansion of Medicare’s use of site-neutral payments would not increase the prices paid by commercial insurers. CBO expects that the trend of increasing consolidation in health care markets will continue and is implicitly reflected in the projected cost growth.    

 

Oak Street Health Agrees to Pay $60M to Resolve Alleged False Claims Act Liability for Paying Kickbacks to Insurance Agents in Medicare Advantage Patient Recruitment Scheme - United States Department of Justice 

Oak Street Health agreed to pay $60 million to resolve allegations that it violated the False Claims Act, which prohibits payment to induce referrals of patients. Oak Street Health was found to have paid $200 per referral to third-party insurance agents, who contacted seniors eligible for or enrolled in Medicare Advantage and delivered marketing messages designed to generate interest in Oak Street Health. 

 

Kidney Care Choices (KCC) Model – First Annual Evaluation Report, Performance Year 2022 - CMS 

CMS released a report evaluating the Kidney Care Choices Model during its first year of implementation. The report shows relatively modest results so far, with no statistically significant changes in patient hospitalizations, emergency department visits, readmissions, or Medicare payments or costs. Compared to patients not participating in the model, KCC participant usage of in-home dialysis treatments increased by 26% and kidney transplant waitlisting increased by 11%.  Early results of this model have afforded patients greater access to kidney care treatments at no additional cost. 

 

State Updates 

2871. An Act enhancing the health care market review process – Massachusetts Senate

The Massachusetts Senate Ways and Means Committee passed S. 2871 by a vote of 38-2. The bill would expand oversight of private equity firms, pharmaceutical manufacturing companies, and pharmacy benefit managers and require for-profit companies to submit additional information on finances and corporate structure. It would also expand the role of the Massachusetts Health Policy Commission in reviewing and approving proposed transactions in the health care space. The bill also establishes a health insurance bureau in the Department of Insurance to conduct rate reviews of premium rates for health benefit plans. The bill now awaits a vote in the Massachusetts Senate. 

 

CMS Announces Qualified Health Plan (QHP) Directory Pilot – State of Oklahoma 

CMS is partnering with the state of Oklahoma to create a directory pilot program to help inform the design and feasibility of a future National Directory of Healthcare. The pilot will develop an automated, centralized directory for Qualified Health Plans and providers to improve data accuracy, lessen burden on providers and payers, and improve the patient and provider experience.  

 


Health Care Value in the News 

 

Hospital Consolidation

UnitedHealth Group Abandons Two Acquisitions Following Antitrust Division Scrutiny – Justice Department 

Vertical integration is shaping the future of U.S. health care – Brown School of Public Health 

The Rise Of Health Care Consolidation And What To Do About It – Health Affairs 

One or Two Health Systems Controlled the Entire Market for Inpatient Hospital Care in Nearly Half of Metropolitan Areas in 2022 - KFF 

 

Hospital Pricing    

Steward Health CEO Shuns Hearing in Rare Rebuff of Congress - Bloomberg 

California’s cap on health care costs is the nation’s strongest. But will patients notice? - ABC 

Rural NC County Is Set To Reopen Its Shuttered Hospital With Help From a New Federal Program - KFF 

 

Health Equity   

Implementing Revised Federal Race/Ethnicity Data Standards Won’t Sufficiently Address Health Inequities – Health Affairs 

Disparities in Health and Health Care: 5 Key Questions and Answers - KFF 

  

No Surprises Act

2023 Data From The Independent Dispute Resolution Process: Select Providers Win Big – Health Affairs 

A Win For Providers: Appellate Ruling Maintains Status Quo For No Surprises Act Arbitration Process -  Health Affairs 

 

Payment Reform

The Failing Experiment Of Primary Care As A For-Profit Enterprise – Health Affairs 

Out Of Balance: Fixing Our Health System’s Neglect Of Primary Care – Health Affairs 

Are Changes To The Medicare Physician Fee Schedule Driving Value In US Health Care? - Health Affairs  

 

Prescription Drugs

Impact of federal negotiation of prescription drug prices - Brookings 

Interpreting The First Round Of Maximum Fair Prices Negotiated By Medicare For Drugs – Health Affairs 

CMS Should Do More To Fulfill The IRA's Promise To Lower Drug Costs For Patients – Health Affairs  

 

Price Transparency

Price Transparency: Feds Raise Stakes As Help For Hospitals Dries Up - Forbes 

 

Site Neutral Payments   

Hospital Mergers are giving rise to opaque ‘facility fees’ that add costs to medical bills – Spotlight PA 

CBO pushes back on criticism of site-neutral - Axios 


Families USA Resources

 

Publications and Reports

Families USA released Families Need Relief from Runaway Prescription Drug Costs: Congress Should Expand the IRA to Protect More People, a fact sheet that advocates for expanding the Inflation Reduction Act by extending inflationary rebates to the commercial market, increasing e the number of drugs eligible for negotiation in Medicare, and allowing commercial insurers to voluntarily adopt the Medicare negotiated prices. 

 

Families USA released a fact sheet on A National Patient Safety Board: What America Needs to Ensure Patient Safety to advocate for the establishment of a National Patient Safety Board (NPSB). An NPSB would identify and anticipate harm in the health care system, study precursors, and develop and deploy solutions to address the 250,000 deaths caused by medical errors each year. 

 

 

Families USA and 16 co-signed organizations submitted comments to CMS on the Calendar Year 2025 Medicare Physician Fee Schedule Proposed Rule. The comments focused on the proposed creation of bundled payment codes to advance health equity and the delivery of high-value primary care, proposed financial support for Medicare Shared Savings Program providers who deliver care to under-resourced communities, and the opportunity to connect more patients to providers who are held accountable for the cost and quality of their care. 

 

Families USA submitted two comment letters, co-signed by 28 total organizations, on the Calendar Year 2025 Medicare Hospital Outpatient Prospective Payment System Proposed Rule. The first letter, submitted on behalf of Consumers First, advocates for strengthening and enforcing hospital price transparency, establishing comprehensive site-neutral policies, improving hospital quality measurements, and addressing our nation’s maternal health crisis through setting federal quality standards for the delivery of obstetric services. The second letter encompasses coverage issues, including various measures to improve health care quality, equity, and access, such as continuous coverage for children in Medicaid and CHIP, expanding Medicaid reimbursement, and Medicare enrollment for formerly incarcerated individuals. 

 

Families USA submitted a Statement for the Record for the Finance Committee Inflation Reduction Act Hearing to reaffirm the impact of the IRA on achieving affordable and accessible health care. Specifically, the statement highlights how the IRA makes prescription drugs more affordable for people on Medicare and is extending critical health insurance subsidies. For more information, check out our blog post, Tackling High Health Care Costs for Millions: The IRA’s Promising Path Forward. 

 

Resources from our Partners

Georgetown Center on Health Insurance Reforms (CHIR) 

Outpatient Facility Fee Reform – State Action Briefs 

 

Primary Care Collaborative 

The State of Primary Care – How Well Your State is Delivering Primary Care 

 

U.S. of Care

Patient-First Care (a.k.a. Value-Based Care)

 

U.S. Public Interest Research Group (PIRG) 

Why medical debt should be removed from credit reports 

 

Upcoming Events

From the Frontlines: Forging the Path Forward Together: Health Action Conference 2025

Register now to join us for Families USA’s annual Health Action Conference 2025! This two-day hybrid event, held on January 23-24, 2025, at the Capital Hilton in Washington, DC, marks a pivotal moment for health advocacy as we enter a new administration.

This year, we celebrate 30 years of collaboration while looking forward to shaping the future. Together, we'll ensure everyone in America has access to high-quality, affordable health care. Join us to learn from national experts, network with fellow advocates, and equip yourself with the tools to drive impactful policy change.

 

Overpayment, Marketing Abuses, Care Delays and More: Top Priorities for Medicare Advantage Reform

Join Families USA at 1 PM EST, on Tuesday October 8, as we host an expert panel discussion about MA policy challenges, including some of the biggest abuses driving MA overpayment, key policy solutions, and opportunities to organize and advance a pro-consumer MA policy agenda in 2025.

 

The Medicare Advantage (MA) program has grown rapidly over the past few decades and, as of 2023, provides coverage to more than half of eligible Medicare beneficiaries. While enrollment continues to rise, MA plans are engaging in widespread corporate abuses that are a major driver of wasteful Medicare spending, threatening the sustainability of the Medicare program, and directly harming the financial well-being of those who rely on Medicare for their coverage.

 

The Time is Now: Coming Together to Win Against Big Hospital Corporate Greed

Join Families USA and leading health advocates at 3PM EST on Thursday, October 24 for a National Organizing Rally to energize national and state partners for the Congressional lame duck fight to rein in the greed of big health care corporations. We will discuss the state of play on key pro-consumer policy reforms including price and billing transparency legislation and same service, same price legislation, and opportunities to unify around key collective actions to ensure Congress feels a groundswell of support from all of us on the need to take action right now.

 

Want to Tweet about these issues? Use our partner toolkit!   

If you would like to reach out, please contact Mike Persley, Strategic Partnerships Campaign Manager, at [email protected]

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