Families USA's Center for Affordable Whole Person Care Newsletter |
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News from Congress Health Care Efficiency Through Flexibility Act - 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 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 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 – 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 improve transparency for researchers, policymakers, and other stakeholders on health care 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, 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 – 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 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 - 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 growth in alternative payment models.
Health Subcommittee Hearing on "An Examination of How Reining in PBMs Will Drive Competition and Lower Costs for Patients" - 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. Families USA’s Executive Director, Anthony Wright, testified at the hearing on the impact that these policies could have for patients.
Hearing to Consider the Nomination of Robert F. Kennedy, Jr., of California, to be Secretary of the Health and Human Services – 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 has since been confirmed as the Secretary of the Department of Health and Human Services.
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The Latest from the Administration CMS Innovation Center will end four alternative payment model tests early and will cancel two models not yet implemented - CMS
CMMI announced that four current alternative payment models, Maryland Total Cost of Care, Primary Care First, End Stage Renal Disease Treatment Choices, and Making Care Primary will be phased out by December 31, 2025. Additionally, CMMI will no longer pursue two previously announced models that have not yet begun: the Medicare $2 Drug List and Accelerating Clinical Evidence models. CMS estimates that these changes will save $750 million. However, this will have significant impacts on providers who participate in this models and have transformed their practices to meet model standards. CMS will lack data from the final years of these four models, which could impact the research and development of future alternative payment models. Additionally, practices that participate in these models will need to make significant, unexpected changes to conform to the requirements set by other payment reform models.
CMMI to scrap data collection on race, gender - Politico Pro
CMMI will stop collecting data on race, ethnicity, sexual orientation, gender, and preferred language. This is in response to Trump Administration Executive Orders on Diversity, Equity, and Inclusion efforts and could threaten to halt progress on addressing health disparities. Without access to stratified data, it will be more difficult to identify inequities and evaluate the success of CMMI models. No Surprises Act Consumer Advocate Toolkit - 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 to help advocates quickly find the resources they need for a consumer’s situation.
- No Surprises Act at a Glance, which gives a high-level overview of the NSA’s consumer protections.
Update to Independent Dispute Resolution Fees - 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. 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 - 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 - CMS
CMS announced the 15 drugs covered under Medicare Part D that they have identified for the second round of negotiations in the Inflation Reduction Act Medicare Drug Price Negotiation Program. 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, and Otezla. These drugs treat Type 2 diabetes, asthma, cancers, and more. Between November 2023 and October 2024, around 5.3 million Part D beneficiaries used these drugs, and they cost around $41 billion 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 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 - 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 - HHS
The U.S. Department of Health and Human Services released a report responding to a March 2024 Request For Information 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 - 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 and improvements to the Medicare Advantage program through marketing guardrails and updates to Medical Loss Ratio (MLR) reporting. Additionally, CMS requested comments on making State Medicaid Agency Contracts (SMACs) public.
Families USA submitted comment on this proposed rule, which can be read here.
Advance Notice of Methodological Changes for Calendar Year (CY) 2026 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies - CMS
CMS released this year’s Advance Rate Notice. It included proposals to complete the three-year, phased-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 possibility of further recalibrating the MA risk model with use of MA encounter data. CMS proposed to apply only the minimum statutory coding adjustment factor (5.9%) across Medicare Advantage plans for the upcoming calendar year. 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. |
State Updates Assembly Bill A2140 – 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 in the New York State Senate by state senators Krueger, Jackson, and Liu. This bill would provide needed relief from high health care costs to 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 to a public hearing on this bill.
Bill H.5159: An Act Enhancing the Market Review Process - Massachusetts
Massachusetts Governor Maura Healey signed Bill H.5159 into law. The bill expands Massachusetts’ existing health care transaction notice process and implements new reporting and oversight requirements on the health care sector, specifically for private equity investments. 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 – Ohio
Ohio Governor Mike DeWine signed House Bill 173 into law (including House Bill 49 as an amendment). The bill requires that 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.
HB 1004 - 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 into 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 - 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, as well as 155% for out of network services. 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 action.
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Families USA Resources
Publications and Reports
Families USA Applauds Bipartisan Talks to Advance Commonsense Health Care Solutions, Leads Call Urging Lawmakers to Focus on Improving Affordability and Lowering Health Care Costs
Families USA and nearly 70 undersigned organizations submitted a letter to House and Senate leadership on key steps to address America's health care affordability crisis through commonsense reforms. Rather than continuing forward with cuts to health care coverage, the letter calls for advancing proven solutions to save money and improve care, including: -
Promoting meaningful transparency and accountability
- Reducing waste and inefficiencies driven by corporate health systems
- Rooting out conflicts of interest that increase health care costs
If enacted, these policies would set a critical foundation for reining in rising health care industry consolidation and unjustifiably high prices.
Consumers First Legislative Agenda 2025: Policy Solutions for the 119th Congress to Drive Value into the U.S. Health Care System
Consumers First, a national alliance representing families, working people, employers, and primary care clinicians, released a policy agenda of bipartisan policy solutions that seek to lower health care costs and improve health outcomes in this country. Five key policy reforms included in this agenda include: addressing consolidated health care markets and removing distortions created by ineffective payment systems, lowering prescription drug costs, increasing price and quality transparency, establishing national data-sharing and interoperability standards, and developing a national workforce strategy to address persistent shortages and improve care delivery.
Making Health Care Affordable: Reining In Health Industry Abuses To Lower People’s Costs and Generate Budget Savings
This policy agenda makes commonsense policy recommendations aimed at resolving the health care affordability crisis targeted at four specific areas: promoting meaningful transparency and accountability, reducing waste and inefficiencies driven by corporate health systems, rooting out conflicts of interest that increase health care costs, and providing direct relief to working families and patients. Several of the policies included in the agenda, including price and billing transparency and site-neutral payments for drug administration services, passed the House of Representatives in 2023 with overwhelming bipartisan support as part of the Lower Costs, More Transparency Act but were ultimately left out of the final government funding package in late 2024.
The Nuts and Bolts of Medicare Physician Payment – and Why it Needs Reform
Families USA released a factsheet explaining that the methods through which health care providers and physicians are paid directly impacts how our health care system delivers care, including the quality of care that patients receive and the extent to which health care services are integrated and coordinated across multiple providers and care settings to effectively meet patients’ needs. U.S. health care payment and delivery systems must be meaningfully designed to provide the affordable, high-quality health care and health that all of our nation’s families deserve.
Congress Must Act: Stop Big Health Care Corporations from Keeping Workers and Small Businesses Under Water
This factsheet outlines the ways in which medical monopolies harm health care affordability for workers across the United States. There is no better way for Congress to deliver for the American people and small businesses than by passing pro-consumer reforms that lower health care costs by making the health care system more transparent, competitive and affordable. Policymakers should increase hospital and plan transparency, enact comprehensive same service, same price payment reforms and honest billing reforms, and restrict the use of anti-competitive practices and clauses in health care contracting agreements.
Lay of the Land: Primary Care, Provider Payments and What’s Next
Families USA published a fact sheet that outlines the problems facing the primary care system and details promising efforts taking place to promote access to high-quality, comprehensive primary care for all people in the U.S. It calls policymakers to take steps to strengthen our nation’s primary care workforce and infrastructure through critical improvements to how primary care practitioners are paid. It is essential that advocates work with policymakers to rebalance health care payment rates to more accurately value primary care providers and shift U.S. health care payment away from the inefficiencies of fee-for-service economics and toward a system that enables and incentivizes health care providers to deliver high-quality, high-value care, including comprehensive and advanced primary care.
Resources from our Partners Milbank Memorial Fund
The Health of US Primary Care: 2025 Scorecard Report — The Cost of Neglect Public Interest Research Group (PIRG)
New protections from medical billing errors, other medical debt problems FTC decided not to block an acquisition that could impact supply and prices of important medicines. Third Way A Policymaker’s Guide to America’s Hospital Financing System Want to Tweet about these issues? Use our partner toolkit! |
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