Congressional Republicans made Democrats an offer on a major package of year-end health provisions this week, sources say.
Why it matters: The large-scale offer shows that momentum remains behind finishing a major health package this year, though a deal is far from certain.
What’s inside: The offer includes additional health policies beyond what are regarded as “must do” extenders like community health center funding and telehealth flexibilities.
The big picture: Despite the offer, there is a long way to go. Some sources still expected that negotiators will run out of time and have to fall back on a three-month bare-bones extension of expiring programs.
The legislation would limit prices and ban hospital facility fees for dozens of health services deemed safe to get in a doctor’s office.
State lawmakers are moving to cap prices for dozens of routine health care services, saving New Yorkers an estimated $1 billion annually.
New legislation sponsored by state Sen. Liz Krueger and Assemblymember Chantel Jackson is designed to eliminate massive price discrepancies between hospital-owned facilities and doctor’s offices for the same services.
“The affordability of health care shouldn’t depend on what building it’s delivered in,” Krueger, whose Manhattan district includes many of the city’s biggest hospitals, said in a statement. “We cannot let big hospitals become the next Big Oil or Big Steel, with monopoly control over everything and people forced to pay more for the same basic procedure.”
If passed, the “Fair Pricing Act” would prevent most types of health care facilities from charging more than 150 percent of the Medicare rate for a specified set of services, such as vaccinations, MRIs, chemotherapy infusions and IV hydration. Public, safety-net and rural hospitals and federally qualified health centers would be exempt.
The prices of those services can vary immensely, according to 2022 claims data from the health fund for building service workers union 32BJ, which worked on the legislation. A flu shot in a doctors office averaged $23, compared with over $183 in a hospital’s outpatient center, according to the data. An initial, one-hour chemotherapy infusion averaged $410 in an office setting but $2,650 in hospital-owned outpatient facilities.
“The data’s pretty damning,” Claire Brockbank, director of policy and strategy for union’s benefit funds, said in an interview.
The bill’s impact could be far-reaching: Brockbank said it was written to apply to New Yorkers on most kinds of insurance, as well as patients paying out of pocket.
More context: Such price variations have caught the attention of policymakers across the U.S., as hospitals increasingly buy up local medical practices and hike their prices, in part by tacking on a so-called “facility fee” intended to help cover overhead.
New Yorkers would have saved more than $1 billion in 2022 if select services performed in hospital settings were paid the commercial insurance rate for doctor’s offices, according to research presented at a conference on hospital prices hosted by the union’s health fund earlier this year.
Sens. Bill Cassidy (R-La.) and Maggie Hassan (D-N.H.) released a bipartisan plan earlier this month to cut Medicare payments to hospitals’ outpatient departments to the level paid to independent practices.
New York lawmakers appear to be leading the way among state legislators with the introduction of their site-neutral legislation.
The bill is likely to provoke the state’s powerful hospital industry, which lobbied heavily against a prior legislative effort to ban facility fees. By the time that bill passed in 2021, it had been watered down to apply only to preventive services and otherwise required that hospitals simply give patients advance written notice of any facility fees not covered by their insurance.
The hospital industry insists the higher rates and facility fees are justified because they are subject to more stringent safety requirements and typically care for more complex patients.
What’s next: Krueger and Jackson’s bill will be taken up when the state Legislature reconvenes in 2025.
Acquisitions in the home care industry are poised to take off in 2025, fueled by lower interest rates and President-elect Donald Trump’s incoming administration.
Large home care providers including Addus HomeCare, Aveanna Healthcare and the Pennant Group said during third quarter earnings calls they would aggressively look for deals next year to gain scale and better compete for hospital referrals. The interest in deal-making is an about-face for an industry that has been burdened by labor shortages, rising costs and battles with Medicare Advantage organizations over better rates.
“[Consolidation] is definitely about scale and volume in exchange for rates,” said Tyler Giesting, director of healthcare and life sciences at advisory firm West Monroe. “As they grow, it also improves their top line so they can invest in capabilities they need to run the business in a way that the MA plans require, such as reporting on value-based care measures.”
The appetite for acquisitions spans home healthcare, personal home care services, private duty nursing and hospice companies.
Jeff Shaner, CEO of Aveanna Healthcare, told analysts during an earnings call the company was “revving up the M&A engine” to acquire home health, private duty nursing and hospice organizations in 2025. The Atlanta-based company operates in 22 states.
The Pennant Group CEO Brent Guerisoli said the Eagle, Idaho-based company wants to expand its footprint in home health. The company offers home health and hospice services across 13 mostly western states. In August, the Pennant Group acquired assets in Oregon, Washington and Idaho from Signature Healthcare at Home for $80 million.
“We are an opportunistic company and we are going to grow where we have strength and where there is great opportunity,” Guerisoli told analysts during an earnings call.
Addus HomeCare CEO Dirk Allison also told analysts during an earnings call the Frisco, Texas-based home care company would be looking to buy home health and personal care businesses after it completes the $350 million acquisition of Gentiva’s home care business, which is expected by the end of the year.
Addus HomeCare offers non-medical personal care, home health and hospice services across 22 states. Allison said the company’s deal pipeline for 2025 is more robust than in previous years.
“Over the past couple of years, the acquisition opportunities that meet our strategic objectives have been somewhat limited due to some unfavorable market conditions. However, we are starting to see a few more opportunities that could strengthen all three of our segments in markets where we currently operate,” Allison said.
The renewed interest in deal-making could revive a buying frenzy in home care that began in 2021 and continued into 2023. Humana purchased Kindred at Home for $8.1 billion in 2021 and later rebranded it CenterWell. In February 2023, UnitedHealth Group acquired LHC Group for $5.4 billion and struck a deal to buy Amedisys for $3.3 billion four months later.
But higher interest rates, rising labor costs and the Justice Department’s scrutiny of the UnitedHealth-Amedisys deal put a damper on acquisitions in the second half of 2023 and the first half of this year, analysts said. In the first three quarters of 2024, home care acquisitions declined 25% compared to the same period last year, according to healthcare advisory firm Mertz Taggart.
In the past few months, lower interest rates have helped spark renewed interest in acquisitions, Mertz Taggart managing partner Cory Mertz said in a third quarter industry report.
The Trump administration and a Republican-controlled Congress could also help drive deals in the new year, Andrew Woods, chairman of consulting firm Liberty Partners Group told members of the National Alliance for Care at Home during a recent webinar. Woods said both might see home care as a less expensive alternative to facility-based care and encourage policies that drive more care to where people live.
“They understand, if they are old school Republicans, that deficits and debt matter. They’ll want to do everything they can to shore up the Medicare trust fund, not only with efficient services like home health, but other services in healthcare that can serve Baby Boomers,” Woods said.
The Justice Department’s lawsuit to block the bid from UnitedHealth Group’s Optum to buy Amedisys is a wild card that could disrupt deals in 2025, though some analysts don’t expect the suit will continue after President-elect Trump takes office.
Giesting also said the lawsuit could be dismissed by a new administration — and added most home care companies probably won’t make deals large enough to raise antitrust concerns in a highly fragmented industry.
Addus HomeCare, Aveanna and the Pennant Group did not respond to requests for comment on whether the lawsuit would affect their acquisition plans.
Large home care providers including Addus HomeCare, Aveanna Healthcare and the Pennant Group said during third quarter earnings calls they would aggressively look for deals next year to gain scale and better compete for hospital referrals.
Acute care hospitals received over $190 million in improper Medicare payments for outpatient hospice services, government watchdogs say.
An audit report released Monday by the US Department of Health and Human Services Office of Inspector General sampled over $283.7 million in Medicare Part B payments for outpatient services furnished by acute care hospitals to hospice patients from 2017 through 2021. The audit found that 70 out of the 100 services sampled by the agency did not comply with federal requirements.
The OIG noted in the audit that payments were made to acute-care hospitals for palliative care that were “already covered as part of the hospices’ per diem payments and should have been provided directly by the hospices or under arrangements between the hospices and acute-care hospitals.”
The OIG claims that this occurred due to factors including not having enough details in Medicare guidance, Medicare contractors not conducting prepayment and post-payment reviews, and not having a properly designed prepayment edit process.
Based on the sample, the OIG estimates that Medicare “could have saved $190.1 million” if “payments had not been made to acute-care hospitals that provided outpatient services to hospice enrollees for services related to the palliation and management of the enrollees’ terminal illnesses and related conditions.”
Additionally, the OIG estimated that enrollees “could have saved $43.6 million in deductibles and coinsurance that may have been incorrectly collected.”
The OIG made six recommendations to the Centers for Medicare & Medicaid Services, including improving system edit processes; educating hospitals to discern whether outpatient services palliated or managed conditions related to enrollees’ terminal illnesses; and clarifying Medicare guidance to specifically mention “related conditions.”
The CMS agreed with five of six recommendations but did not agree with the OIG’s first recommendation. The agency said it was concerned about the feasibility and effectiveness of the OIG’s proposed modifications to the system edits described in the report.
After reviewing the CMS’s comments, the OIG updated its first recommendation to the CMS’s system edit processes to help reduce improper payments in the future.
Sens. Bill Cassidy and Maggie Hassan are set to release a framework for Medicare site-neutral payment reforms as early as Friday.
Why it matters: Changes to the way hospitals are paid for outpatient procedures could be on the agenda in a lame duck session, and this framework fleshes out more options.
What’s inside: The framework is slated to be more expansive than some previous site-neutral policies and could look similar to what’s been proposed in the June 2023 MedPAC report.
While the hope is to get the framework out by Nov. 1, the timeline could slip. The goal is to release it before the election though, sources said.
The big picture: Hassan has previously been a leader on site-neutral payments with her SITE Act, but Cassidy’s involvement adds an influential Republican, who could potentially be HELP chair next year.
As Congress weighs the future of CMS’ Acute Hospital Care at Home Program (AHCAH), advocates are urging lawmakers to authorize a five-year extension, instead of another two-year plan, to bolster currently limited hospital and Medicaid participation. Advocates say CMS guidance, practitioner flexibilities and heightened commercial coverage of hospital-at-home programs would also further support AHCAH participation.
A key lobbyist previously told Inside Health Policy a five-year extension of AHCAH is more likely to appear in an end-of-year legislative package than a shorter extension, citing indications from Senate Finance Chair Ron Wyden (D-OR)’s staff that the senator supports a five-year extension.
Both the House Ways & Means and Energy & Commerce committees advanced legislation extending the hospital-at-home initiative by five years. Lawmakers are also poised to authorize a two-year extension of Medicare telehealth flexibilities that have helped hospitals operate AHCAH programs and meet the requirement of giving patients 24/7 access to either in-person or virtual nursing care.
As of Oct. 21, CMS has authorized 368 hospitals –about 6% of all U.S. hospitals identified by the American Hospital Association–to operate AHCAH programs.
Additional CMS data suggest only a portion of those AHCAH-approved hospitals offer inpatient care in patients’ homes; just 105 out of 284 or about 37% of AHCAH-approved hospitals in 2022 reported at least one discharge through the program, according to a June 2024 report from Medicare Payment Advisory Commission.
Hospital staffers told MedPAC they struggled to start AHCAH programs because of uncertainty about the future of the CMS program, start-up costs, a lack of institutional support and workforce needs.
Meanwhile, Medicaid programs in 12 states – Oregon, Arizona, Texas, Oklahoma, South Dakota, Arkansas, Michigan, New York, Massachusetts, North Carolina, South Carolina and Florida – cover hospital-at-home services as of Sept. 30, Pippa Shulman, chief medical officer of Medically Home, told IHP. She said several state Medicaid programs are waiting for a congressional reauthorization of the AHCAH program before covering hospital-at-home services.
Shulman, along with the Bipartisan Policy Center, American Hospital Association and other groups, predict a five-year reauthorization would go further toward supporting hospital and Medicaid participation in the AHCAH program than a two-year extension.
A five-year AHCAH extension “can provide additional time for hospitals and health systems to make the necessary investments to stand up some of these programs and to also provide additional time to evaluate the results,” Jennifer Holloman, AHA’s senior associate director of policy, told IHP.
However, even with a lengthier AHCAH extension, hospital-at-home supporters say policymakers should support hospital uptake through guidance and practitioner flexibilities.
Additional CMS Support
In a July 2024 report, the Bipartisan Policy Center called on Congress to authorize funding for CMS to provide technical assistance to support hospitals and Medicaid agencies participating in the AHCAH program.
The technical assistance could include best practices for operating AHCAH programs and patient risk assessment screenings, BPC wrote. At the same time, BPC recommended CMS “strengthen regulatory guidance” with documents on escalation protocols for clinical deterioration, fall prevention, infectious prevention practices and the efficient use of telehealth and remote patient monitoring.
A CMS spokesperson said the agency has already “established a process to maintain the health and safety standards of care” for AHCAH, including guidance for hospitals “when there is evidence that there are clear gaps in communication and coordination of care that may lead to patient safety concerns.” They added the agency readily provides technical assistance to help facilities apply for AHCAH waivers at every stage of the application process.
The spokesperson did not comment on whether CMS sees a need for additional guidance and technical assistance to support hospital and Medicaid participation in the AHCAH program.
Holloman of AHA said CMS could continue to provide resources supporting upfront costs hospitals face when starting AHCAH programs. She added CMS could work with other agencies on policies supporting AHCAH programs such as expanding broadband internet access.
Congress has yet to reauthorize billions of dollars to an expired program expanding broadband internet access to low-income Americans through subsidies.
Practitioner Flexibilities
Aside from new CMS guidance, some hospital staffers say they would like additional types of practitioners to be allowed to care for patients in their homes.
Darcy Harris, physician executive director of Yale New Haven Health System clinical operations, said she would like Connecticut to allow community paramedics to care for patients in their homes. Community paramedics can care for AHCAH patients across the border in Massachusetts.
Allowing new types of practitioners to deliver acute care in patients’ homes “could help overcome barriers for more rural hospitals to participate in” the AHCAH program, wrote Allison Buffett, a senior policy analyst for BPC’s health program.
“However, it’s crucial to better understand why and how hospitals are adjusting their staffing to provide acute care at home and how these modifications impact the care quality, operational costs, and, most importantly, patient outcomes,” she wrote.
BPC has recommended CMS write a report to Congress on the cost and quality of AHCAH programs by September 2028 that includes staffing metrics and qualitative workforce data.
The CMS spokesperson noted that AHCAH-authorized hospitals cannot admit patients if they don’t also comply with state licensure requirements.
Commercial Coverage
Holloman of AHA and Collen Hole, innovation strategic advisor for AdvocateHealth, argue a five-year extension of the AHCAH program would also expand commercial coverage of hospital-at-home services. A permanent extension after the five years would go even further in unleashing commercial coverage, Holloman added.
Increased commercial coverage of hospital-at-home services could help hospitals pay for costly programs. Within one hospital, there could be Medicare beneficiaries who are eligible for hospital-at-home services but also patients with private insurance ineligible for such services, explained Mona Siddiqui, senior vice president of home & community services for Highmark Health.
“CMS may pay for hospital-at-home, but how are other payers paying for that as well?” Siddiqui asked.
Still, increased commercial coverage of hospital-at-home services alone wouldn’t solve every payment problem hospitals face.
Hole raised concerns that commercial payers are paying less for hospital-at-home services than services offered at hospitals because data, including some from CMS, suggest hospital-at-home programs reduce health care costs. But that line of thinking ignores the fact hospitals are currently struggling to pay for the high start-up costs for hospital-at-home programs, she said.
Siddiqui, meanwhile, noted while the AHCAH program covers hospital-at-home services, CMS does not cover skilled nursing facility services at home.
Some health systems are pausing, scrapping or delaying the launch of hospital-at-home programs despite a broader industry push to provide more healthcare in the home.
Health systems such as Tufts Medicine, Franciscan Health, Cone Health and UCSF Health pointed to high costs, a shortage of eligible patients and regulatory uncertainty as driving their decisions to curtail home-based hospital programs. But despite the hurdles, others are moving full-speed ahead with new programs or expansions.
CMS began letting health systems provide hospital-level care to patients where they live in March 2020 to free up beds during the COVID-19 pandemic. Under the Acute Hospital Care at Home waiver, Medicare reimburses hospitals at the same rate for home-based acute care as it does for care in a facility. The waiver expires at the end of December and Congress must decide to extend or end it.
The agency has approved 366 waivers across 138 health systems as of Oct. 10, according to a CMS spokesperson. While a CMS report released last month gave hospital-at-home a mostly positive review, health systems may not be actively enrolling patients or have suspended their programs for a variety of reasons.
Some health systems that received CMS waivers never even got their hospital-at-home programs off the ground.
University of California San Francisco Health scrapped plans to launch a program in May 2023 because the California Department of Health Care Services stopped licensing at-home acute care programs when the federal public health emergency expired, said Dr. Timothy Judson, the health system’s medical director of care delivery transformation.
Judson said in an email he still hopes to launch hospital-at-home because the health system doesn’t have enough beds.
“If the CMS waiver is extended, I certainly do hope that California will create a pathway for [hospital-at-home],” Judson said.
Greensboro, North Carolina-based Cone Health got a waiver from CMS in July 2022 to launch a program at Moses H. Cone Memorial Hospital in Greensboro, but is still in a planning phase, said a hospital spokesperson, who would not provide additional details on when or if Cone Health might launch a program.
Other health systems have backed away from plans to scale their hospital-at-home programs due to regulatory uncertainty.
For example, Franciscan Health in Crown Point, Indiana, launched its hospital-at-home program in 2021. An expansion is on hold until the system has more clarity on the federal waiver, as well as state licensing and accreditation requirements, according to a spokesperson.
Some health systems that launched programs when the COVID-19 pandemic created a huge influx of patients are finding it difficult to expand them as patient demand for care has returned to pre-pandemic levels.
That’s been a problem for St. Bernards Medical Center in rural Jonesboro, Arkansas. The health system launched its AcuteHealth at Home program in March 2021 with plans for it to grow, said a hospital spokesperson. While the program continues, St. Bernards paused an expansion because it can’t find enough eligible patients who live within 30 minutes of the hospital, as required under the federal waiver.
The costs of launching and scaling acute care-at-home programs can also be a challenge, given the financial resources required for the technology, staffing and ancillary services necessary to support home hospital programs.
Tufts Medicine paused its hospital-at-home pilot at Lowell General Hospital in Lowell, Massachusetts, last year due to financial constraints, a spokesperson said. The health system “remained confident in the benefits of the program,” but decided to focus its resources on a mobile integrated health program and a program directed at patients with complex health needs. The spokesperson said those programs are better at decreasing avoidable hospital admissions.
Executing hospital-at-home is difficult for some health systems, said Pippa Shulman, chief medical and strategy officer of Medically Home. The Boston-based company partners with health systems to provide the technology platform and some staffing for home-based hospital programs.
She said some health systems are able to provide 24/7 care at a small scale when they launch hospital-at-home programs, but struggle to provide services as they expand.
“You need to be able to [to provide care] for five patients, for 10 patients, and for 50 patients from when you start,” Shulman said. “That is the moral imperative. You have to make sure you deliver safe and effective care. You want people to tread carefully before they do this. It’s a big step.”
Even some health systems with successful hospital-at-home programs have encountered hurdles.
The University of Arkansas for Medical Sciences launched an acute care-at-home program last year at the UAMS Medical Center in Little Rock, Arkansas, in partnership with Contessa Health, a division of home health company Amedisys. The medical center has cared for approximately 200 patients at home during the first year of the program, but staffing has sometimes been a challenge, UAMS Medical Center CEO Dr. Michelle Krause said in an email.
“We have physicians available for video conferencing with patients, but Contessa has had difficulties securing nurses to visit patients and deliver supplies,” Krause said.
In an email, a Contessa spokesperson said nurses are vital to home-based care, but admitted staffing can be difficult. “No hospital-at-home program is immune from this constraint. Having a reliable partner in the nurse staffing arena doesn’t remove the hurdle, but significantly mitigates the headwind,” the spokesperson said.
Despite the challenges, some health systems still view hospital-at-home as a safe, viable and economical alternative to facility-based acute care.
AdventHealth Orlando is weeks away from launching its first hospital-at-home program, a year after receiving a CMS waiver, according to a spokesperson.
Advocate Health is also bullish on the concept. It offers hospital-at-home to patients at 10 Atrium Health hospitals in North Carolina. Atrium launched its first program in 2020 and expanded hospital-at-home prior to its merger with Advocate Aurora Health, said Colleen Hole, AdvocateHealth innovation strategic advisor. Hole said the health system has treated approximately 13,000 patients across North Carolina so far and is eager to expand the program to other states.
“To continue to build beds, which costs between $2 million and $5 million dollars per bed, is not cost-effective,” Hole said. “This model has proven that it will deliver excellent care without the time and expense of building [brick-and-mortar facilities].”
Patients who receive hospital care at home generally have lower mortality rates than their brick-and-mortar inpatient counterparts, according to a Centers for Medicare and Medicaid Services report on the Acute Hospital Care at Home initiative.
CMS said it’s difficult to conclude that the Acute Hospital Care at Home initiative resulted in lower Medicare spending overall as compared to brick-and-mortar inpatient care.
The COVID-19 initiative was extended past the end of the public health emergency, but is scheduled to expire at the end of this year. Congressional action is needed to extend the Acute Hospital Care at Home waivers.
The American Hospital Association supports the Hospital Inpatient Services Modernization Act, a bill that extends the waivers for five years through the end of 2029.
As of June, 331 hospitals, across 136 systems and 37 states, had been approved to provide acute hospital services to patients at home.
WHY THIS MATTERS
The CMS study examined the quality of care for patients treated in the inpatient hospital setting, as compared to individuals with similar conditions and characteristics treated at home. AHCAH patients were found to be meaningfully different from inpatients receiving services furnished by the same hospital facility, CMS said.
In general, AHCAH patients were more likely to be white and live in an urban location and less likely to receive Medicaid or low-income subsidies.
These different characteristics of the AHCAH population may be partially attributable to the inclusion and exclusion criteria developed by participating hospitals for the purpose of identifying patients appropriate for Hospital at Home care, CMS said.
CMS specifically looked at 30-day mortality rates, 30-day readmission rates, and Hospital Acquired Conditions. The study found that beneficiaries who received care under the hospital at home initiative generally had a lower mortality rate than their brick-and-mortar inpatient comparison counterparts.
Results of the 30-day readmissions metric analysis demonstrated some differences, with readmission rates being significantly higher in the acute care at home group for two MS-DRGs, but significantly higher in the inpatient comparison group for three MS-DRGs.
Hospital acquired condition rates observed for beneficiaries served for patients at home were lower than HAC rates observed in the brick-and-mortar inpatient comparison group for all six types of HACs evaluated, though the differences in these rates were not statistically significant, CMS said.
Patients in AHCAH were primarily treated for a relatively small set of conditions. The study found that the most common Medicare Severity Diagnostic Related Groups (MS-DRGs) and Major Diagnostic Categories (MDCs) treated through the AHCAH initiative included respiratory conditions, circulatory conditions, renal conditions and infectious diseases.
COST
The study focused on select metrics, including length of stay per episode, the Medicare spending in the 30 days after hospital discharge and hospital service utilization, including services provided in-person and virtually through telehealth.
The analysis shows that acute care at home inpatient episodes had, on average, a slightly longer length of stay than comparable brick-and-mortar inpatient episodes.
Additionally, there was, on average, lower Medicare spending for services furnished in the 30-day post-discharge period for at-home episodes, as compared to brick-and-mortar inpatient episodes, across more than half of the top 25 MS-DRGs in the acute care at home group.
The differences attributable to hospital at home patient selection criteria and clinical complexity, as measured across the two groups, make it difficult to conclude that the AHCAH initiative resulted in lower Medicare spending overall as compared to brick-and-mortar inpatient care.
PATIENT EXPERIENCE
CMS hosted four virtual listening sessions with patients and caregivers and collected anecdotal information through site visits, direct correspondence with patients and hospital program operators.
Overall, patients and caregivers had positive experiences with the care provided in the home setting. This positive feedback was mirrored by clinicians’ experiences providing care to patients at home, CMS said.
THE LARGER TREND
CMS said its study offers new insights and lessons learned for quality improvement efforts for the health and safety of inpatients in the home setting. It also offers opportunities to further develop more targeted measures of cost, quality and utilization.
Acute Hospital Care at Home waivers went into effect during the COVID-19 public health emergency. The Consolidated Appropriations Act, 2023 extended the waivers and flexibilities until the end of this year.
The CAA required CMS to conduct a study and analysis on the initiative and post such a report on a CMS website by September 30.
State Medicaid programs across the country failed to promote access to health-care services that could have supported better maternal and infant health outcomes, a federal watchdog agency said.
A report released this week by the US Department of Health and Human Services Office of Inspector General surveyed managed care organizations across 41 state Medicaid programs.
The watchdog found many states didn’t fully leverage Medicaid managed care coverage and access requirements to promote access to maternal health care. The report said many states didn’t require their managed care organizations (MCOs) to cover important types of maternal health providers.
The report comes as the US grapples with some of the worst maternal health outcomes in the developed world. The Centers for Disease Control and Prevention estimates American mothers die at a rate of 22.3 deaths per 100,000 live births, with non-Hispanic Black women fairing considerably worse, averaging 49.5 deaths under the same metric.
In contrast, Denmark, which has a similar GDP per capita as the US, averaged 4.7 deaths per 100,000 births.
The report also highlighted that some states didn’t require their MCOs to cover certified nurse-midwives, freestanding birth centers, and maternal-fetal medicine specialists even though Medicaid requires that states cover these providers if they are licensed or otherwise recognized by the state.
Only one state out of the 41 queried reported it requires its MCOs to cover all four types of health professionals whose services are optional Medicaid benefits (lactation consultants, community health workers, doulas, and non-nurse midwives) the watchdogs asked about in the survey.
The OIG recommended the Centers for Medicare & Medicaid Services take steps to ensure that all states cover required maternal health services for people enrolled in MCOs.
The watchdog also asked the CMS to clarify states’ requirements to maintain network adequacy standards for OB/GYNs and that the agency support states in tailoring their network adequacy standards to better address maternal health-care needs. Those standards can also include appointment wait times and distance standards.
Under President Biden’s and Vice President Harris’s Inflation Reduction Act, some people with Medicare will pay less for some Part B drugs because the drug’s price increased faster than the rate of inflation.
The U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), today announced that some Medicare enrollees will pay less for 54 drugs available through Medicare Part B. The drugs will have a lowered Part B coinsurance rate from October 1, 2024 – December 31, 2024, since drug companies raised prices for each of these 54 drugs faster than the rate of inflation. Over 822,000 people with Medicare use these drugs annually to treat conditions such as cancer, osteoporosis, and pneumonia. Since April 1, 2023, people with Medicare have seen savings on over 100 drugs thanks to Inflation Reduction Act’s Medicare Prescription Drug Inflation Rebate Program.
“The President’s lower cost prescription drug law continues to put money back in the pockets of seniors and people with disabilities,” said HHS Secretary Xavier Becerra. “President Biden and Vice President Harris promised to lower prescription drug costs – and they have delivered.”
“No one should have to choose between paying for their health care or putting food on the table,” HHS Deputy Secretary Andrea Palm said at an event announcing the updated list in Pennsylvania today. “The Inflation Reduction Act is all about bringing down the price of health care and making sure the American people benefit.”
Because of the Biden-Harris lower cost prescription drug law, the Inflation Reduction Act, which established the Medicare Prescription Drug Inflation Rebate Program, some people with Medicare who use these drugs in the last quarter of 2024 may save between $1 and $3,854 per day. For example, someone taking a drug called Kymriah, which treats cancer, could save as much as $3,000.
“The Biden-Harris Administration is dedicated to ensuring people with Medicare have access to their prescription drugs, and the Inflation Reduction Act continues to deliver on our goal to improve affordability,” said CMS Administrator Chiquita Brooks-LaSure. “Discouraging price increases above the rate of inflation by drug companies and negotiating lower prices on some of the most expensive and most frequently used drugs in the Medicare program delivers on our promise to bring savings to Medicare enrollees.”
The Medicare Prescription Drug Inflation Rebate Program is just one of the Inflation Reduction Act’s prescription drug provisions aimed at lowering drug costs. In August, the Biden-Harris Administration announced it had reached agreements for new, lower prices for all 10 drugs selected under the first round of the Medicare Drug Price Negotiation program. If these new prices had been in effect last year, Medicare would have saved an estimated $6 billion. Once these prices take effect in 2026, people with Medicare Part D are expected to save an estimated $1.5 billion in total out-of-pocket costs.
In addition to the negotiated prices, another major cost-savings benefit begins in 2025, when all people with Medicare Part D will benefit from a $2,000 cap on annual out-of-pocket prescription drug costs. In 2024, some enrollees who have high drug costs are already seeing their annual out-of-pocket costs capped at about $3,500.
The Inflation Reduction Act requires drug companies to pay rebates to Medicare when prices increase faster than the rate of inflation for certain drugs. CMS intends to begin invoicing prescription drug companies for rebates owed to Medicare no later than fall 2025. The rebate amounts paid by drug companies will be deposited in the Federal Supplementary Medical Insurance Trust Fund, which will help ensure the long-term sustainability of the Medicare program for future generations.
The U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), today announced that some Medicare enrollees will pay less for 54 drugs available through Medicare Part B.
New Jerseyans and their employers spent more than $7,900 per person on health care in 2021, a study released Thursday by the Murphy administration found, 15% higher than the national average and a sharp jump from the years before COVID-19.
The increase in spending was driven by higher prices, the authors said, noting that consumers didn’t visit hospitals or doctors’ offices much more frequently.
“It supports pretty much what we’ve all been feeling and hearing,” said Laura Waddell, health care program director for New Jersey Citizen Action, a consumer group. “Health care affordability has been (an issue) for a long time now and it’s been affecting all of us in so many ways.”
The study was one of four reports released by the Murphy administration as part of its Health Care Affordability, Responsibility and Transparency Program, or HART, for short. The program, launched in 2021, is expected to provide data that can help guide policymakers.
It’s one of a series of laws and initiatives that have been rolled out both statewide and nationwide since the Affordable Care Act began in 2010 in a bid to increase access to health care and slow down the fast-rising costs.
Still, many consumers say they remain squeezed. A 2022 survey by the nonprofit health researcher Altarum found nearly three in five New Jerseyans reported being burdened by health care costs within the last year, without signs that health outcomes are improving, the authors said.
The Murphy administration has set out to slow down the rate of health care spending hikes to 3% by next year and 2.8% by 2026.
Is it attainable? One study of New Jersey residents who are between the ages of 18 and 64 and are covered by commercial insurers found:
CHARLESTON, W.Va. (AP) — For decades, Jeff Card’s family company was known for manufacturing the once ubiquitous tin boxes where people could buy newspapers on the street.
Today, reach into one of his containers and you may find something entirely different and free of charge: Naloxone, the opioid overdose reversal drug.
Naloxone distribution containers have been proliferating across the country in the more than a year since the U.S. Food and Drug Administration approved its sale without a prescription. Naloxone, a nasal spray most commonly known as Narcan, is used as an emergency treatment to reverse drug overdoses.
Such boxes — appearing in neighborhoods, in front of hospitals, health departments and convenience stores — are one way those supporting people with substance use disorder have sought to make Narcan, which can cost around $50 over the counter, accessible to those who need it most. Not unlike little free libraries that distribute books to anyone who wants one, the metal boxes used formerly as newspaper receptacles aren’t locked and don’t require payment. People can take as much as they think they need.
Advocates say the containers help normalize the medication — and are evidence of steadily reducing stigma around its use.
Sixty Narcan receptacles were distributed across 35 states in honor of Thursday’s “Save a Life Day” — a naloxone distribution and education event started by a West Virginia nonprofit in 2020. Containers were purchased from Card’s Texas-based Mechanism Exchange & Repair, which still serves newspaper customers but has expanded to manufacturing other products amid the newspaper industry’s decline.
“It’s fortunate and unfortunate,” said Card, who started making the Narcan containers over two years ago. “Fortunate for us that we’ve got something to build, but unfortunate that this is what we have to build, given how bad the drug problem is in America.”
Opioid deaths were already at record levels before the coronavirus pandemic, but they skyrocketed when it hit in early 2020. The U.S. Centers for Disease Control and Prevention estimated there were about 85,000 opioid-related deaths in the 12 months that ended in April 2023. But since then, they fell. The CDC estimate for the 12 months that ended in April 2024 was 75,000 — still higher than any point before the pandemic.
The reasons for the decline are not fully understood. But it does coincide with Narcan, a medication that’s been hard to get in some communities, becoming available over the counter, as well as with the ramping up of spending of funds from legal settlements between governments and drugmakers, wholesalers and pharmacies.
The U.S. Food and Drug Administration approved use of Narcan to treat overdoses back in 1971, but its use was confined to paramedics and hospitals for decades. Narcan nasal spray was first approved by the FDA in 2015 as a prescription drug, and in March, it was approved for over-the-counter sales and started being available last September at major pharmacies.
“That took the barriers away. And that’s when we realized, ‘OK, now we need to increase access. How can we get naloxone into the communities?’” said Caroline Wilson, a West Virginia social worker and person in recovery who coordinated this year’s Save a Life Day.
Last year, all 13 states in Appalachia participated in the day spearheaded by West Virginia nonprofit Solutions Oriented Addiction Response. Community organizations in hundreds of counties table in parking lots, outside churches and clinics handing out Narcan and fentanyl test strips and training people on how to use it. They also work to educate the public on myths surrounding the medication, including that it’s unsafe to have in easily accessible places. Narcan has no effect on people who use it without opioids in their system.
This year, with the effort expanding to 35 states and a theme of “naloxone everywhere”, the group sent out 2,000 emergency kits containing one Narcan dose to be placed in locations like convenience store bathrooms or parks. The 60 tin newspaper boxes — which sell for around $350 apiece — were purchased with grants.
Aonya Kendrick Barnett’s harm reduction coalition Safe Streets Wichita installed one of the Kansas’ first Narcan receptacles — which she refers to as “nalox-boxes” — in February. The boxes, now sold by a few different companies, can look different, too. Some look like newspaper boxes, while others look like vending machines.
Since installing a vending machine Narcan container — which just requires a zip code be entered on the keypad to access the medication — it’s distributed around 2,600 packages a month.
“To say, ‘Hey, we have a 24-hour vending machine, come over here and come get what you need — no judgment,’ is so bold in this Bible belt state and it’s helping me break down the the stigma,” she said.
Kendrick Barnett said there’s no place for judgment when it comes to what she calls live-saving health care: “People are going to use drugs. It’s not our job to condemn or condone it. It’s our job to make sure that they have the necessary health care that they need to survive.”
The Save a Life Day box her organization received is going to go in front of their new clinic, scheduled to open in October.
In Erie, Pennsylvania, 74-year-old stained glass artist Larry Tuite said he grew concerned seeing overdoses increasing in his city. He began leaving Narcan packages on the windowsills of 24-hour markets in town that sell products like pipes and rolling papers. He was shocked at how quickly they disappeared.
“As many as I give out, I run through them really quickly,” said Tuite, who keeps cases of the drugs stacked along the walls of his studio apartment.
The Save a Life Day container, which he got permission to put outside one such store, has helped him to disperse even more Narcan. At least a dozen people have been saved by the medication he’s distributed, he said.
Tasha Withrow, a person in recovery who runs a harm reduction coalition based out of Putnam County, West Virginia, said Narcan wasn’t something she ever had access to when she was using opioids.
“People can just reach in and grab what they need — we didn’t have that back then,” she said, while stocking a container in a residential neighborhood earlier this week. “To actually see that there is some access now — I’m glad that we’ve at least moved forward a little bit in that direction.”
The Health Resources and Services (HRSA) is awarding nearly $75 million in funding for health care services in rural areas, including for opioid treatment and recovery programs, maternal health initiatives and rural hospitals, HHS announced Tuesday (Sept. 24).
A statement on the awards says they support key factors driving rural health disparities. A full list can be found on HRSA’s website.
For substance use disorder in rural communities, HRSA is awarding nearly $54 million to 18 organizations for uses including creating access points for treatment, supporting the behavioral health workforce and collaborating with social services.
About $9 million is being awarded to five organizations in southern states to expand access to health care services before, during and after pregnancy.
HRSA is also providing about $12 million In funding for technical assistance to rural hospitals to help them add services and improve financial sustainability of facilities that often struggle to remain solvent.
“The Biden-Harris Administration believes health care should be available to everyone regardless of where they live. That’s why we are investing heavily in rural communities, which have historically lacked resources and access to health services” HHS Secretary Xavier Becerra said.
Rep. Carol Miller (R-WV) and several other sponsors recently introduced legislation to permanently authorize the Rural Communities Opioid Response Program, a HRSA program that provides grants for substance abuse disorder treatment facilities in rural areas and is currently not codified in law.
“The Rural Communities Opioid Response Program provides funding to rural communities that are in need of recovery facilities, and the program should be authorized to provide certainty for communities and providers,” Miller said in a statement. “I thank my colleagues for partnering with me on this bipartisan issue to establish addiction prevention services in the most rural areas of the United States.”
The Supreme Court’s overturn of Chevron deference in June is expected to boost hospitals’ latest effort to get the federal D.C. district court to overturn CMS’ cuts to disproportionate share hospital payments, after the same court rejected similar arguments in a previous case when the Chevron doctrine was still in place.
Daniel Hettich, a health care partner at King & Spalding specializing in Medicare reimbursement litigation, told Inside Health Policy that “the answer is pretty clearly yes” when it comes to the hospitals having a greater chance of succeeding in this litigation.
However, how much of an increased chance the hospitals have is still unclear, according to Hettich, who says he’s unsure if the SCOTUS decision is a complete “gamechanger,” or instead simply moves the needle a bit in the hospitals’ direction.
Shannon Medical Center, along with 79 other hospitals across the country, filed a complaint against HHS in the D.C. district court earlier this month. The hospitals claim retroactive rulemaking under the Part C Days Final Rule, which allowed the government to reduce DSH payments retroactively through a change to the Medicare fraction, is unlawful.
“The Part C Days Final Rule is arbitrary and capricious, an abuse of discretion, and otherwise contrary to the Medicare Act and Supreme Court law,” the complaint says.
The plaintiffs also argue against multiple rulings by the Provider Reimbursement Review Board (PRRB), and they are asking the court to reverse PRRB’s dismissal of their appeals. PRRB argues the plaintiffs filed their appeals with the Board prematurely, resulting in dismissal. The court must decide whether the plaintiffs were in the right to appeal to PRRB before it decides whether CMS was acting within its authority.
According to Hettich, current Medicare statute allows for retroactive rulemaking only under certain limited circumstances. When the Chevron doctrine of courts deferring to agencies’ interpretations of vague statute was still in place, CMS would just have to prove that its actions fit under its own interpretation of the statute. Now it’s up to the court to decide whether CMS’ actions were reasonable.
Hettich believes SCOTUS could potentially be interested in this case, as it explores questions about the “hygiene” of the administrative state. However, if HHS loses this suit and appeals, the case might not get SCOTUS review as this doesn’t typically happen unless there is a circuit split, Hettich told IHP.
Another health care attorney told IHP that this case, Shannon Medical Center v. Becerra, does not exist in a vacuum, as other recent cases have dealt with the same hotbed issues, such as Lake Region Healthcare Corporation v. Becerra and the latest Allina Health System v. Becerra litigation.
House Budget Committee Republicans advanced a bill along party lines Wednesday (Sept. 25) that would codify the responsibilities of the Congressional Budget Office’s Panel of Health Advisers, reduce the number of members on the panel, and give the House and Senate Budget Committee chairmen and ranking members the same authority as the CBO director to appoint the advisers — a move committee Democrats blasted as an attempt to politicize the panel.
The HEALTH Panel Act (H.R. 9686), introduced last week by Reps. Buddy Carter (R-GA) and Michael Burgess (R-TX), would formally establish the Panel of Health Advisors to provide technical expertise in health-related areas and enhance the CBO’s analyses, cost estimates and studies on health care issues and policies.
During the markup, both bill sponsors emphasized that CBO’s cost estimates are crucial in determining whether a health care bill can move forward, which underscores the importance of keeping the Panel of Health Advisers nonpartisan.
“Myself, along with other members of this committee, are concerned that the vesting [of] sole appointment authority in one individual [means] the panel is not inclusive of different ideological positions and fails to accurately represent a range of stakeholders with expertise across the health care sector,” Carter said.
Democrats on the committee unanimously opposed and voted against the legislation during Wednesday’s markup. While both parties have plenty of complaints about CBO, Republicans’ political intention is to “cook the books” in how the CBO handles health care issues, according to Rep. Lloyd Doggett (D-TX).
“Stacking the panel with a number of additional industry representatives will not produce more accurate estimates, and it will certainly politicize one of the few institutions that we can turn to for objective analysis and accountability on our work,” Doggett said during the markup.
This comes two weeks after the Panel of Health Advisers met behind closed doors to discuss multi-cancer screening tests, cell and gene therapies, the long-term budgetary impacts of preventive services and vertical integration in health care markets.
Currently, the Panel of Health Advisers has 22 members, all appointed by the CBO director. However, under the new bill, the panel would be reduced to 15 members, with appointments made by the chairs and ranking members of the House and Senate Budget Committees along with the CBO director. The legislation specifies that these members must have expertise in fields like health finance, economics, actuarial science or other health-related areas.
Under the legislation, members would serve three-year terms with a limit of two terms, and initial appointments would have staggered terms to ensure continuity. The CBO could also require panel members to disclose potential conflicts of interest and sign confidentiality agreements to protect sensitive government information.
The bill, which now heads for a full House vote, would require the panel to meet at least once a year and produce an annual report on its activities. This report would include recommendations approved by at least nine members, which the CBO director must take into account when conducting cost estimates or studies. The report would also be shared with the Budget committees of both the House and Senate.
CBO Director Phillip Swagel cautioned against legislation giving Congress a larger role in CBO appointments during a House Budget Committee hearing two weeks ago focused on improving CBO. He warned that this type of legislation could introduce political dynamics and undermine the panel’s non-partisan, expert-driven mission.
“Its experts (are) non-political, and I would worry about moving it, even inadvertently, toward the political side,” Swagel said.
Carter pushed back against similar critique during Wednesday’s hearing, arguing that the panel is “already defined by politicization and crippled with political bias” since the CBO director is currently the only one who selects its members.
Carter said during the markup that Federal Election Commission filings reveal over 80% of current panelists who made political contributions in the past five years donated exclusively to liberal candidates or left-leaning organizations, with not a single member contributing to conservative candidates or right-leaning groups.
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