CLIENT PORTAL

Biden Moves to Bar Medical Debt From Consumer Credit Reports

06/11/24 9:58 AM EDT

bgov.com

President Joe Biden’s administration will formally propose a rule to bar medical debt from individual credit reports Tuesday, a move that would prevent major health care bills from negatively impacting borrowing.

Supreme Court to review Medicare DSH case

June 10, 2024 3:28 pm

The U.S. Supreme Court on Monday said it will review a lower-court’s decision that limits Medicare payments for hospitals that treat a disproportionate number of low-income patients.

The U.S. Court of Appeals for the District of Columbia Circuit sided with the Health and Human Services Department in September. A group of 213 hospitals that filed the initial case in 2017 petitioned the Supreme Court in December to review that decision.

The American Hospital Association said in a statement it is pleased the Supreme Court agreed to consider the case.

“It is critical to hospitals and health systems that HHS interpret the DSH fraction consistently across the statute,” Chad Golder, AHA general counsel and secretary, said in the statement. “The agency’s longstanding failure to do so has cost hospitals more than a billion dollars each year, directly harming the hospitals that serve America’s most vulnerable patients. We look forward to the Supreme Court rectifying this legal error next term.”

An HHS spokesperson said the agency does not comment on ongoing litigation.

Hospitals argue HHS should increase the number of patients who are eligible for Supplemental Security Income benefits under the Medicare disproportionate share hospital payment program. Benefits not only include cash payments but also the Medicare Part D subsidy and vocational rehabilitation services, hospitals argue.

HHS claims those benefits are only for patients who receive cash Social Security payments during the month that they are in the hospital. Hospitals contend patients enrolled in Social Security should receive those benefits, regardless of whether they received payments during the month of their hospitalization.

In a decision issued in September, the appellate court disagreed with the hospitals, citing statute that “expressly defines the term ‘supplemental security income benefits under subchapter XVI’ as ‘a cash benefit.’”

At least $1.5 billion in annual Medicare DSH payments are at stake, the hospitals said in the petition for the Supreme Court to review the case. The plaintiff hospitals estimate that shortfall based on a 15% gap between Medicare DSH payments doled out from 2006 to 2020 and providers’ interpretation of the reimbursement calculation.

The case has wide-reaching implications for hospitals and patients, including payments tied to the 340B drug discount program, the AHA, Association of American Medical Colleges, America’s Essential Hospitals, Catholic Health Association, Federation of American Hospitals and National Rural Health Association wrote in a related brief filed in February.

News

06/10/24 3:28 PM EDT

Supreme Court to review Medicare DSH case

modernhealthcare.com

The U.S. Supreme Court on Monday said it will review a lower-court’s decision that limits Medicare payments for hospitals that treat a disproportionate number of low-income patients.

June 10, 2024 3:14 pm

Momentum is building on both sides of the Capitol to make comprehensive changes to the federal 340B drug discount program — though it’s unclear how much money the plans would save.

Why it matters: Surging sales over the past five years have put 340B on pace to become one of the largest federal drug programs, per Avalere. But it’s mired in litigation and competing state efforts to set rules of the road.

Driving the news: House Energy and Commerce members signaled interest in new transparency requirements and addressing provider consolidation during an oversight hearing on Tuesday, increasing the likelihood that policy changes could be rolled into a year-end health deal.

A 340B bill from Reps. Larry Bucshon, Buddy Carter and Diana Harshbarger that’s backed by the pharmaceutical industry would codify the definition of a 340B patient and reset eligibility requirements for hospitals.
Bucshon told Axios that he’s still trying to find Democratic co-sponsors in the face of sharp criticism from hospitals and health systems in the program.
“There’s some Democratic support, and I’m not going to mention names, but there is,” he said.
Bucshon sponsored a 340B transparency bill that was advanced out of Energy and Commerce last year largely on partisan lines. Aspects were incorporated into the broader 340B bill that’s now on the table.

Across the Capitol, senators are still working on a 340B draft discussion bill that could define covered patients. It is expected to respond to the growing number of drugmakers that have restricted when providers can use 340B discounts at contract pharmacies.

Sen. John Thune said he was hopeful a draft would materialize by August recess.
“There’s a lot of good work being done on it,” Thune told Axios. “Hopefully we’ll have something to report later this summer.”
Sen. Debbie Stabenow, one of the Democratic leads in the Senate working group, is intent on getting a 340B reform bill passed before she retires, which could give the effort an extra lift.

Friction point: Hospital lobbyists are pushing back against the House bill, calling it a drug industry wish list and saying it would make many facilities ineligible for the program and create onerous compliance requirements.

“This bill would dismantle the 340B program and undermine the very purpose of the program … in essence, this bill would enrich drug companies by permitting them to abandon their 340B obligations,” the American Hospital Association wrote in a letter to Energy and Commerce.
Ryan White Clinics for 340B Access has also came out against the legislation, citing that it “misconstrues the intent of the 340B program as a program to increase access to affordable drugs” and “deviates from the program’s well-accepted purpose of allowing safety net providers to stretch scarce resources.”
Meanwhile, community health centers and the drug lobby PhRMA say the bill would ensure patients benefit from the program by stronger eligibility requirements.

What we’re watching: The level of interest pursuing reforms could hinge on how CBO scores the bills, Avalere noted. That could factor such variables as whether 340B discounts are putting upward pressure on launch prices for drugs.

News

06/10/24 3:14 PM EDT

Momentum is building on both sides of the Capitol to make comprehensive changes to the federal 340B drug discount program — though it’s unclear how much money the plans would save.

June 5, 2024 3:16 pm

Momentum is building on both sides of the Capitol to make comprehensive changes to the federal 340B drug discount program — though it’s unclear how much money the plans would save.

A 340B bill from Reps. Larry Bucshon, Buddy Carter and Diana Harshbarger that’s backed by the pharmaceutical industry would codify the definition of a 340B patient and reset eligibility requirements for hospitals.
Bucshon told Axios that he’s still trying to find Democratic co-sponsors in the face of sharp criticism from hospitals and health systems in the program.
“There’s some Democratic support, and I’m not going to mention names, but there is,” he said.
Bucshon sponsored a 340B transparency bill that was advanced out of Energy and Commerce last year largely on partisan lines. Aspects were incorporated into the broader 340B bill that’s now on the table.

Sen. John Thune said he was hopeful a draft would materialize by August recess.
“There’s a lot of good work being done on it,” Thune told Axios. “Hopefully we’ll have something to report later this summer.”
Sen. Debbie Stabenow, one of the Democratic leads in the Senate working group, is intent on getting a 340B reform bill passed before she retires, which could give the effort an extra lift.

“This bill would dismantle the 340B program and undermine the very purpose of the program … in essence, this bill would enrich drug companies by permitting them to abandon their 340B obligations,” the American Hospital Association wrote in a letter to Energy and Commerce.
Ryan White Clinics for 340B Access has also came out against the legislation, citing that it “misconstrues the intent of the 340B program as a program to increase access to affordable drugs” and “deviates from the program’s well-accepted purpose of allowing safety net providers to stretch scarce resources.”
Meanwhile, community health centers and the drug lobby PhRMA say the bill would ensure patients benefit from the program by stronger eligibility requirements.

News

06/05/24 3:16 PM EDT

Three takeaways from the E&C 340B hearing

Momentum is building on both sides of the Capitol to make comprehensive changes to the federal 340B drug discount program — though it’s unclear how much money the plans would save.

June 5, 2024 3:06 pm

Lawmakers on the House Energy and Commerce Oversight and Investigations Subcommittee on Tuesday probed ways to reform the controversial 340B program amid fears of pending litigation.

The hearing comes as efforts to reform the program gain steam on the Hill. The program mandates drugmakers sell outpatient drugs at discounts to hospitals, community health centers and many provider-based rural health clinics.

Republicans on the committee last week proposed a bill authorizing HHS to audit hospitals on how they use their 340B savings, redefining “patient” and establishing criteria for contract pharmacy arrangements. The American Hospital Association has opposed the legislation, arguing that it would limit hospital participation and create unworkable compliance rules. A bipartisan Senate working group has also recently floated a discussion draft to bolster transparency and to consider how to define what a “patient” in the program is.

Full committee ranking member Frank Pallone (D-N.J.) criticized Republicans during the hearing for not inviting drugmakers and HHS officials to testify.

“The Republicans did not have a single drug manufacturer here to talk about their part of the program. We will also not hear from the Health Resources and Services Administration, HRSA, about what the agency needs to oversee the program,” he said.

Witnesses included health policy experts as well as executives from health care systems and hospitals, the latter of which affirmed the value of the program to patients, often referring to it as a “lifeline.”

Here are takeaways from the hearing:

1. Lawmakers fear inaction could give courts the upper hand

Some lawmakers worry that pending lawsuits challenging 340B requirements, including whether drugmakers can limit how many 340B pharmacies they ship to, could decide the future of the program before Congress does. A recent court decision on restricting pharmacies sided with drugmakers.

“I worry this entire program will continue to be legislated by the courts,” Rep. Scott Peters (D-Calif.) said. Other members also said recent court rulings have created uncertainty in the program and stripped HRSA of some of its oversight ability.

2. Everyone wants transparency but disagrees on how

Some Republicans on the committee want hospitals to report how they’re using the savings from the 340B program — aligning those reporting requirements with those used by community health centers.

Anthony DiGiorgio, a neurosurgeon and professor at the Institute for Health Policy Studies at the University of California, San Francisco, told lawmakers there are “bad actors” among hospitals that don’t use 340B savings as intended by the program.

But some providers pushed back on the proposed requirements in the GOP bill.

Sue Veer, president and CEO of Carolina Health Centers, a community health system, was skeptical about applying the same reporting requirements for community health centers to all 340B entities.

“Dealing with a single entity-section solution doesn’t work,” she told Rep. Buddy Carter (R-Ga.), who co-introduced the legislative reforms.

She suggested transparency metrics that “outline the population served,” including their insurance status and poverty levels.

“Just uninsured patients is not adequate. It’s important to look at the overall profile of the patients that are served,” she said. She called the bill a “starting place.”

Matthew Perry, president and CEO of Genesis HealthCare System, also told Carter he wasn’t opposed to transparency but is “opposed to transparency that cherry-picks the type of information that completely distorts what 340B is designed to do.”

3. Who can use the program, and where can savings go? There’s uncertainty.

Democrats on the committee highlighted how 340B facilities in their districts use their savings to benefit patients and also asked providers who testified Tuesday how they’re using their savings. Veer replied to a question from subcommittee ranking member Kathy Castor (D-Fla.) by describing a home-visitation pediatric program her health centers operate.

“We’ve been able to really increase our access to all families [through the program] because of our contributions from 340B,” Veer said.

“And that’s due to the flexibility 340B provides,” Castor replied. “I appreciate your recommendations for some reforms, but you’re not recommending in any way we scale back the flexibility to determine the needs in the community.”

“No, I would not want to just scale back the flexibility, because every community is different,” Veer responded.

Republicans were more skeptical.

“There’s currently no requirement that 340B-covered entities pass savings onto patients,” Rep. John Joyce (R-Pa.) said, suggesting that participating hospitals are not offering drug discounts to patients, which Perry disagreed with.

Rep. Dan Crenshaw (R-Texas) asked whether specifying who is considered a patient in the program, or using a patient ID, can generate savings for patients who receive drugs through a 340B pharmacy. Some Republicans have argued that the current HRSA guidance on which patients can use the program is too overly broad.

Perry replied that his hospitals do track patients, but added that accidentally duplicating patients under a new tracking method might lead to losses for the hospital.

News

06/05/24 3:06 PM EDT

Three takeaways from the E&C 340B hearing

PoliticoPro

Lawmakers on the House Energy and Commerce Oversight and Investigations Subcommittee on Tuesday probed ways to reform the controversial 340B program amid fears of pending litigation.

UnitedHealth Hack Fuels Bids to Shield Americans’ Medical Data

June 4, 2024 3:49 pm

Cyberattacks compromising the health information of millions of Americans are prompting Congress and the Biden administration to take action to better protect highly sensitive personal data that’s profitable for hackers.

Up to a third of Americans had their private health information exposed in the cyberattack on Change Healthcare in recent months. The breach is believed to be the largest in health care in US history and has cost parent company UnitedHealth Group Inc. up to $1.6 billion in profits this year.

Lawmakers and regulators have been scrambling in their response. In May, Senate lawmakers grilled UnitedHealth Group CEO Andrew Witty over the attack, pressing the embattled executive on why the company left so much health information vulnerable and what should be done to avoid a repeat. Shortly after, the White House said it was weighing standards for hospitals to better protect patient information.

Now, senators on both sides of the aisle are keeping an open line with Witty and weighing legislation to better protect health information. They’ve also upped the pressure on the Biden administration’s labor and health departments to take on a greater role in both preventing and responding to cyberattacks.

The Department of Labor didn’t immediately respond to a request for comment. However, a Health and Human Services Department spokesperson said the agency is considering issuing new enforceable cybersecurity standards for the health-care sector, a move that could face a backlash from hospitals.

Trade group American Hospital Association has been vocal in its opposition to mandatory cybersecurity requirements for hospitals. In a May interview, the AHA’s national adviser for cybersecurity and risk, John Riggi, said that should the government take regulatory action, “hospitals alone should not be singled out.”

“The government needs to do more on offense against the fundamental source of cyber risk, foreign hackers and ransomware gangs attacking health care, ” Riggi said. “That’s not hospitals’ job. That’s the US government’s job.”

Lawmaker Response

The FBI said in a report that in 2023, the health-care and public health sector flagged the most ransomware attacks, with organizations having filed almost 250 complaints with the agency. That’s more than critical manufacturing, which flagged fewer than 220, and government facilities, the third-most hit sector in the report, which came in at 156.

The full extent of Change’s breach has yet to be determined. The company processes pharmacy requests and insurance claims for over 340,000 physicians and 60,000 pharmacies. The hack was discovered Feb. 21, and the company severed connections that distribute data and money across the health-care system, leading to a backlog of payments and claims.

Lawmakers are casting a wide net in their response. Some, like senators Ron Wyden (D-Ore.), who chairs the Senate Finance Committee before which Witty testified, and Bill Cassidy (R-La.), a member of that committee, are pushing for legislation to better protect critical health-care infrastructure.

Wyden said he’s working on proposing “minimum standards” for cybersecurity in health care. He said the details wouldn’t be revealed until later as part of legislation.

Wyden also called for the Federal Trade Commission and the Securities and Exchange Commission to investigate UnitedHealth to determine if laws were broken, Bloomberg News reported.

Cassidy said there’s two tracks for responding to Change: looking at what happened at the company, as well as examining the broader health industry.

Witty, Cassidy said, has remained available since the hearing to answer questions. Cassidy said one issue that’s been brought to his attention is that UnitedHealth was unable to do a full security analysis of Change before purchasing the company.

Cassidy said he is also concerned there are too many larger companies operating in the health-care space. “Should we have any organization that, if it goes down, everything else is affected?” he asked.

While he isn’t currently putting forth legislation, Cassidy said Congress should act. The lawmaker, who also is the top Republican on the Senate Health, Education, Labor and Pensions Committee, said if he becomes HELP chairman in the next Senate, cyber “will be a big priority.”

“It’s better that Congress take information from all stakeholders—as opposed to what inevitably is a narrower view of a particular administration,” Cassidy said.

Agency Activity

The Biden administration is facing increasing pressure to take direct action on cyber safety.

Earlier this month, House Committee on Education and the Workforce Chairwoman Virginia Foxx (R-N.C.) wrote to the Department of Labor to ask what the Employee Benefits Security Administration is doing to investigate cyberattacks.

Foxx’s committee’s jurisdiction includes private employer health-care benefits. She wrote the committee is concerned about how the Employee Benefits Security Administration “is working to curb” risks for employer-sponsored benefit plans.

Her letter included a list of questions about the EBSA’s cybersecurity role, such as how many cybersecurity investigations the group has conducted since February 2021 and whether the agency has ever been “compromised by cybercriminals.” Foxx asked for responses by May 30.

“The Change Healthcare hack immediately affected workers’ and their families’ access to health care. Prescriptions could not be filled. Health care claims and payments were halted. Pharmacies, military hospitals, and clinics attempted workarounds to mitigate disruptions,” Foxx wrote.

In a March statement, the HHS said it was in regular contact with UnitedHealth leadership and others to ensure the effectiveness of the company’s response.

Days later, the HHS and DOL published a letter to health care leaders saying the agencies urge UnitedHealth, insurance companies, and other payers to take actions, though they stopped short of enforcement.

The HHS in May said that hospitals can require UnitedHealth notify patients if their data was compromised in the February attack.

The department is considering enforceable actions informed by voluntary performance goals for health sector groups released in January, according to an agency spokesperson.

Among those goals are things like reducing email security risks, adding multifactor authentication, and setting security requirements for outside vendors.

The HHS spokesperson declined to provide additional information on enforcement specifics, including who in the agency would be responsible.

Enforcement

Greg Garcia, executive director for cybersecurity of the Health Sector Coordinating Council, an advisory group that works with the government, said enforcement is “a difficult thing to do,” but would make a difference in improving health sector cybersecurity.

Garcia said a federal rule —which implements standards under the Health Insurance Portability and Accountability Act—currently requires health providers to have incident response plans, and that it’s enforced by the HHS Office for Civil Rights. In the event of cyber incidents, the HHS “depends on intel from industry, law enforcement,” and others, Garcia said, though “the interagency process and its information sharing protocols with industry are always a work in progress.”

An HHS spokesperson noted that the civil rights office investigates complaints filed with the group and conducts compliance reviews. Investigations may result in civil fines. The spokesperson also said the office submitted requests for Congress to increase the amount of fines it can impose in a calendar year, with the goal being to promote HIPAA compliance to protect sensitive patient data.

Still, Garcia noted the Change attack was due to problems with “basic cyber hygiene”—a lack of multifactor authentication—and that “no amount of cyber security controls will totally prevent cyberattacks.”

Cybersecurity is a “collective responsibility” that health providers can’t shoulder alone and the government does have a role to play, said Garcia, who has worked with the HHS on cybersecurity matters. Congress could help by giving the HHS and other agencies broad authority to fund or oversee better incentives for the private sector, he said.

He added that third party service providers are also responsible. “Change Healthcare is a third party service provider, and they screwed up and the fallout impacts their customers existentially,” Garcia said.

Under its 2025 fiscal year budget request, the HHS would create a $1.3 billion Medicare incentive program for encouraging hospitals to take up cybersecurity practices. The department noted there was a 95% increase in large breaches reported to the agency from 2018 to 2022.

The AHA’s Riggi said any minimum standard placed on hospitals alone wouldn’t solve health-care sector cybersecurity risks. Focusing solely on hospitals wouldn’t have prevented the Change attack, Riggi said.

“We need to secure the entire health-care system,” he said.

News

06/04/24 3:49 PM EDT

UnitedHealth Hack Fuels Bids to Shield Americans’ Medical Data

Bgov

Health care bills to watch

May 13, 2024 1:08 pm



Site-neutral payments	Passed	No action
PBM overhauls	Some proposals passed	Approved by Finance, HELP
Hospital price transparency	Passed	No action
$35 insulin	No action	No action
China biotech	No action	Approved by Homeland Security
Drug patent reforms	No action	Approved by Judiciary

Data: Axios Research

We’re trying out something new: a handy cheat sheet for some of the big-ticket policy items that could find a home in must-pass legislation.

Why it matters: The biggest deals will likely come after the election, but the coming weeks will reveal a lot about what will command lawmakers’ attention.

It’s important to watch the proposals that generate savings that could be used to help boost provider payments or extend expiring health programs.

Watch for updates throughout the year — and let us know if we’ve missed anything big or how we can make this feature more helpful to you.

Meanwhile, here’s a rundown of some the biggest targets on our radar.

Site-neutral payment policies

The issue: To have Medicare pay the same for physician-administered drugs regardless whether they’re administered in hospital outpatient departments or doctors’ offices.

Status: Passed House. No major action in Senate.

Backers/opponents: Consumer/patient groups support. Hospitals oppose.

Cost/savings: Saves $3.8 billion over a decade.

PBM overhauls

The issue: A range of proposals to overhaul PBM business practices to lower drug costs.

Status: Some proposals passed the House. Ways and Means approved changes to help pay for a telehealth extension. Senate Finance and HELP committees advanced proposals.
Backers/opponents: Bipartisan support among lawmakers. PBMs oppose.
Cost/savings: A range of estimates, some in the neighborhood of $1 billion over 10 years.

Hospital price transparency

The issue: Codifies regulations for hospitals to publicize prices for procedures.
Status: Passed House. No Senate action.
Backers/opponents: Bipartisan support.
Cost/savings: CBO found no budgetary impact.

$35 insulin beyond Medicare

The issue: To cap monthly insulin costs at $35 per month for commercially insured Americans and the uninsured.
Status: Two bills introduced in Senate.
Backers/opponents: Some bipartisan support in Senate. House GOP more opposed.
Cost/savings: Costs $629 million for the private market (latest known estimate).

China biotech crackdown

The issue: To cut off U.S. government funding for Chinese contract research firms that critics say are tied to Beijing and pose a security risk.
Status: Advanced from Senate Homeland Security and Governmental Affairs Committee. House Oversight marking up Wednesday.
Backers/opponents: Wide bipartisan support.
Cost/savings: Unclear.

Drug pricing patent reforms

The issue: Preventing tactics like “product hopping” and “patent thickets” that sponsors say drug companies use to delay competition from cheaper generic drugs.

Status: Advanced from Senate Judiciary Committee
Backers/opponents: Bipartisan Senate support. PhRMA opposes.
Cost/savings: Projected in 2022 to save about $1 billion.

News

05/13/24 1:08 PM EDT

Health care bills to watch

Telehealth’s future hangs in the balance

We’re trying out something new: a handy cheat sheet for some of the big-ticket policy items that could find a home in must-pass legislation.

April 11, 2024 10:48 am

A MATTER OF DOLLARS AND CENTS — Congress appears poised to keep eased Medicare telehealth rules in place with at least another temporary extension, but members are concerned about costs and unintended consequences.

Loosened virtual-care rules for Medicare and commercial markets expire at the end of 2024, and lawmakers are setting the stage for a possible temporary or permanent extension of the regulations to preserve expanded access. The House Ways and Means and Senate Finance committees have met recently to consider expanded telehealth rules.

In a House Energy and Commerce Health Subcommittee hearing Wednesday, Democrats and Republicans indicated support for maintaining expanded telehealth payment for older adults but raised a number of issues:

Cost: The cost to extend the eased rules is a major concern for lawmakers. A key question is whether virtual visits would be reimbursed at the same rate as in-person care.

“Making these authorities permanent is likely to cost much more than a short-term extension, and we want to make sure that whatever we move out of committee is paid for,” Health Subcommittee Chair Brett Guthrie (R-Ky.) said.

But, generally, lawmakers seemed willing to accept higher costs to expand access to virtual care. Full committee ranking member Cathy McMorris Rodgers (R-Wash.) acknowledged that extending the rules would be a “significant investment” but said that “we can’t afford to go backwards.”

Harvard researcher Ateev Mehrotra told lawmakers that expanded telehealth is associated with a “modest” increase in spending but also improved outcomes, particularly in mental health.

Trickle-down impact: Lawmakers want to ensure that changes to virtual care policy don’t hinder access to in-person care.

Rodgers said she wants to ensure patients decide whether they get in-person or virtual care. Witnesses and lawmakers noted that some patients may prefer in-person care.

Full committee ranking member Frank Pallone (D-N.J.) said he doesn’t want telehealth to be used to undermine consumer protections like network adequacy standards.

“We also need to ensure that we are not further fragmenting care and that telehealth is being used in a way that facilitates coordination,” Pallone said.

Industry ‘gaming’: Health Subcommittee ranking member Anna Eshoo (D-Calif.) raised concerns about the industry “gaming” virtual care to make it into a “cash cow.”

What’s next: The Medicare Payment Advisory Commission meets today on telehealth in Medicare.

News

04/11/24 10:48 AM EDT

Telehealth’s future hangs in the balance

Politico.com

The effort to keep ‘site neutral’ alive

March 27, 2024 2:38 pm

Insurers, employers, labor and consumer groups are pushing Congress to tweak Medicare payment policies.

The proposals, which fall under a policy known as site-neutral payments, would mean hospitals are paid the same amount for the same service, regardless of whether it’s provided in a hospital outpatient setting or at an independent physician’s office.

Insurers, unable to push through a top legislative priority in the latest spending bill, are already working on plan B — a lobbying blitz targeting lawmakers at home and in Washington.

It’s an uphill climb and requires overcoming opposition from the powerful hospital industry and hesitation by its allies in Congress, including Senate Majority Leader Chuck Schumer. But insurers, employers, unions and consumer groups are eyeing a possible year-end package as a vehicle for a policy that could save taxpayers billions.

Though there was bipartisan interest, a deal could not be reached in part because of the efforts from hospitals, which stand to lose billions of dollars over the next decade and warned members that the cuts would be devastating to care, particularly in rural communities.

Proponents of the policy plan to spend the next several months countering that argument by telling Congress that the status quo has consumers paying the price.

Better Solutions for Healthcare, a coalition of insurers and employers, is mobilizing employers — “folks who own dry cleaners and grocery stories and work in service industry gigs” — to meet with lawmakers in their districts and share “stories about how, as employers, their employees are negatively impacted by higher hospital costs,” said Adam Buckalew, a Republican lobbyist working on behalf of the organization.

One insurance lobbyist granted anonymity to talk about the strategy said that part of the plan is to approach lawmakers from rural areas, including House Ways and Means Chair Jason Smith (R-Mo.) and Senate Finance ranking member Mike Crapo (R-Idaho), to argue that the changes won’t be as damaging to constituents as opponents claim.

“That’s a key component of any kind of educational effort — put the facts out there on the scope and scale of the impact that these changes would have,” the lobbyist said.

Although advocates hope they can eventually push broad site-neutral payment reforms, they’re focused on narrower policies that were tucked into a larger bill that passed the House last year in a 320-71 vote.

One policy would apply to physician-administered drugs in Medicare that are provided at hospital-owned outpatient departments located away from the facility, while a second would require those outpatient departments to use a “unique identifier” that’s different from the hospital’s for claims and services.

The two items would save the federal government roughly $4 billion over 10 years, according to the nonpartisan Congressional Budget Office. It’s a sum hospitals claim would be devastating, even if some of it were used to offset future payment cuts for facilities that treat a large number of low-income patients.

Congress had tried to include the two site-neutral provisions among other health policy riders in both government funding packages that passed this month. But the riders all dropped out of the funding legislation amid disagreements about the scope of some of the other health provisions and the size of the spending bills overall.

“The outcome of recent government funding negotiations has made it clear that members of Congress have serious concerns about policies that would undermine patient access to hospital care, especially at a time when providers are facing unprecedented pressures,” said Charlene MacDonald, the executive vice president of public affairs at the Federation of American Hospitals.

LOWER COSTS?

Those who criticize hospitals — including Arnold Ventures, a research and advocacy organization funded by billionaire John Arnold, the left-of-center nonprofit Families USA and its Consumers First coalition — argue that the two provisions would lower costs for patients.

“The hospital industry has been out there with misinformation about how this would hurt them … We want to be the counterbalance to the industry who want to keep the status quo,” said Jane Sheehan, the deputy senior director of federal relations at Families USA. “Under the status quo, patients and consumers are suffering.”

A study funded by Arnold Ventures found that off-campus hospital outpatient departments in rural areas make up 7 percent of Medicare spending, and argued the site-neutral reforms would have a relatively small impact on them. Many rural hospitals would be exempted from the policies, the report said.

“These are targeted solutions, I don’t think the intent is to come in with a sledgehammer and smash these facilities,” said Sheehan.

The American Hospital Association called the study “misleading at best,” and claimed that rural hospitals would lose $272 million in revenue over the course of a decade from the proposals.

Proponents are also up against Schumer, a New York Democrat, who is closely aligned with hospitals in his state. House Energy and Commerce Chair Cathy McMorris Rodgers (R-Wash.) told POLITICO that Schumer objected to the “unique identifier” provision in the most recent spending package.

But lobbyists hope he could be swayed by extracting deals on other policies he wants — such as cracking down on how drugmakers use the patent system to maintain exclusivity on treatments. They point to his 2015 vote supporting the last site neutral effort that passed in Congress as reason to believe he is open to reforms.

“I could see a scenario where Schumer eventually signs off on the limited site neutrality policy, if there’s a lot of Democratic priorities included. But it has to be a very big package,” said a Democratic health care lobbyist granted anonymity to talk about client issues.

Schumer’s office didn’t respond to a request for comment.

END-OF-YEAR STRATEGY

The most likely timing for any larger package with those kinds of tradeoffs would be an end-of-the-year deal during the lame duck session.

Lawmakers have kicked many high-priority health care extenders to Dec. 31, including pandemic-era telehealth waivers and community health center funding. Buckalew said the to-do list creates more momentum behind the site-neutral policies and “forces a broader negotiation in the health care space.”

While many lobbyists and congressional staffers say the package of health policy riders fell out of funding bills for reasons other than the hospital-targeted provisions — giving them hope that they could find their way into a year-end package — they’re not taking any chances, working to get some members who are close with hospitals or concerned about impacts to rural facilities on board.

Meanwhile, those working to keep the issue alive are also encouraging its congressional supporters — including Rodgers in the House and Sens. Maggie Hassan (D-N.H.) and Mike Braun (R-ind.) — to continue pushing the policies.

When people see policies that are “impacting their wallets, impacting their ability to get the care they need when they need it, they get activated — they get energized by these issues. Spread the word to the public. Congress has the power to push back on this and that does resonate,” Sheehan said.

The effort to keep ‘site neutral’ alive

03/27/24 2:38 PM EDT

PolicoPro

Insurers, employers, labor and consumer groups are pushing Congress to tweak Medicare payment policies.

Funding bill is mixed bag for pandemic efforts

03/25/24 3:57 AM EDT

Pandemic preparedness advocates found things to like in the latest minibus, but also some worrying cuts.

While most of the country (and much of Congress) has moved on from pandemics, advocates are trying to maintain readiness while a reauthorization of the Pandemic and All-Hazards Preparedness Act remains stalled.

Scoop: Health riders left out of minibus

03/18/24 8:14 AM EDT

Cyberattack Paralyzes the Largest U.S. Health Care Payment System

Health care riders addressing PBM reforms and hospital transparency are due to be left out of the next government funding bill after congressional leadership quashed a committee-led effort to add them to the package, sources said.

March 5, 2024 5:27 pm

The hacking shut down the nation’s biggest health care payment system, causing financial chaos that affected a broad spectrum ranging from large hospitals to single-doctor practices.

“This is worse than when Covid hit because even though we didn’t get paid for a while then either, at least we knew there was going to be a fix,” said Molly Fulton, who runs five urgent care centers around Columbus, Ohio.

An urgent care chain in Ohio may be forced to stop paying rent and other bills to cover salaries. In Florida, a cancer center is racing to find money for chemotherapy drugs to avoid delaying critical treatments for its patients. And in Pennsylvania, a primary care doctor is slashing expenses and pooling all of her cash — including her personal bank stash — in the hopes of staying afloat for the next two months.

These are just a few examples of the severe cash squeeze facing medical care providers — from large hospital networks to the smallest of clinics — in the aftermath of a cyberattack two weeks ago that paralyzed the largest U.S. billing and payment system in the country. The attack forced the shutdown of parts of the electronic system operated by Change Healthcare, a sizable unit of UnitedHealth Group, leaving hundreds, if not thousands, of providers without the ability to obtain insurance approval for services ranging from a drug prescription to a mastectomy — or to be paid for those services.

In recent days, the chaotic nature of this sprawling breakdown in daily, often invisible transactions led top lawmakers, powerful hospital industry executives and patient groups to pressure the U.S. government for relief. On Tuesday, the Health and Human Services Department announced that it would take steps to try to alleviate the financial pressures on some of those affected: Hospitals and doctors who receive Medicare reimbursements would mainly benefit from the new measures.

U.S. health officials said they would allow providers to apply to Medicare for accelerated payments, similar to the advanced funding made available during the pandemic, to tide them over. They also urged health insurers to waive or relax the much-criticized rules imposing prior authorization that have become impediments to receiving care. And they recommended that insurers offering private Medicare plans also supply advanced funding.

H.H.S. said it was trying to coordinate efforts to avoid disruptions, but it remained unclear whether these initial government efforts would bridge the gaps left by the still-offline mega-operations of Change Healthcare, which acts as a digital clearinghouse linking doctors, hospitals and pharmacies to insurers. It handles as many as one of every three patient records in the country.

The hospital industry was critical of the response, describing the measures as inadequate.

Beyond the news of the damage caused by another health care cyberattack, the shutdown of parts of Change Healthcare cast renewed attention on the consolidation of medical companies, doctors’ groups and other entities under UnitedHealth Group. The acquisition of Change by United in a $13 billion deal in 2022 was initially challenged by federal prosecutors but went through after the government lost its case.

So far, United has not provided any timetable for reconnecting this critical network. “Patient care is our top priority, and we have multiple workarounds to ensure people have access to the medications and the care they need,” United said in an update on its website.

But on March 1, a bitcoin address connected to the alleged hackers, a group known as AlphV or BlackCat, received a $22 million transaction that some security firms say was probably a ransom payment made by United to the group, according to a news article in Wired. United declined to comment, as did the security firm that initially spotted the payment.

Still, the prolonged effects of the attack have once again exposed the vast interconnected webs of electronic health information and the vulnerability of patient data. Change handles some 15 billion transactions a year.

The shutdown of some of Change’s operations has severed its digital role connecting providers with insurers in submitting bills and receiving payments. That has delayed tens of millions of dollars in insurance payments to providers. Pharmacies were initially unable to fill many patients’ medications because they could not verify their insurance, and providers have amassed large sums of unpaid claims in the two weeks since the cyberattack occurred.

“It absolutely highlights the fragility of our health care system,” said Ryan S. Higgins, a lawyer for McDermott Will & Emery who advises health care organizations on cybersecurity. The same entity that was said to be responsible for the cyberattack on Colonial Pipeline, a pipeline from Texas to New York that carried 45 percent of the East Coast’s fuel supplies, in 2021 is thought to be behind the Change assault. “They have historically targeted critical infrastructure,” he said.

In the initial days after the attack on Feb. 21, pharmacies were the first to struggle with filling prescriptions when they could not verify a person’s insurance coverage. In some cases, patients could not get medicine or vaccinations unless they paid in cash. But they have apparently resolved these snags by turning to other companies or developing workarounds.

“Almost two weeks in now, the operational crisis is done and is pretty much over,” said Patrick Berryman, a senior vice president for the National Community Pharmacists Association.

But with the shutdown growing longer, doctors, hospitals and other providers are wrestling with paying expenses because the steady revenue streams from private insurers, Medicare and Medicaid are simply not flowing in.

Arlington Urgent Care, a chain of five urgent care centers around Columbus, Ohio, has about $650,000 in unpaid insurance reimbursements. Worried about cash, the chain’s owners are weighing how to pay bills — including rent and other expenses. They’ve taken lines of credit from banks and used their personal savings to set aside enough money to pay employees for about two months, said Molly Fulton, the chief operating officer.

“This is worse than when Covid hit because even though we didn’t get paid for a while then either, at least we knew there was going to be a fix,” Ms. Fulton said. “Here, there is just no end in sight. I have no idea when Change is going to come back up.”

Diana Holmes, a therapist in Attleboro, Mass., has been unable to submit roughly $4,000 in claims for her work since Feb. 21. “It’s not like we have reserves,” she said.

The hospital industry has labeled the infiltration of Change “the most significant cyberattack on the U.S. health care system in American history,” and urged the federal government and United to provide emergency funding. The American Hospital Association, a trade group, has been sharply critical of United’s efforts so far and the latest initiative that offered a loan program.

“It falls far short of plugging the gaping holes in funding,” Richard J. Pollack, the trade group’s president, said on Monday in a letter to Dirk McMahon, the president of United.

“We need real solutions — not programs that sound good when they are announced but are fundamentally inadequate when you read the fine print,” Mr. Pollack said.

The loan program has not been well received out in the country.

Diana Holmes, a therapist in Attleboro, Mass., received an offer from Optum to lend her $20 a week when she says she has been unable to submit roughly $4,000 in claims for her work since Feb. 21. “It’s not like we have reserves,” she said.

She says there has been virtually no communication from Change or the main insurer for her patients, Blue Cross of Massachusetts. “It’s just been maddening,” she said. She has been forced to find a new payment clearinghouse with an upfront fee and a year’s contract. “You’ve had to pivot quickly with no information,” she said.

Blue Cross said it was working with providers to find different workarounds.

Florida Cancer Specialists and Research Institute in Gainesville resorted to new contracts with two competing clearinghouses because it spends $300 million a month on chemotherapy and other drugs for patients whose treatments cannot be delayed.

“We don’t have that sort of money sitting around in a bank,” said Dr. Lucio Gordan, the institute’s president. “We’re not sure how we’re going to retrieve or collect the double expenses we’re going to have by having multiple clearinghouses.”

Dr. Christine Meyer, who owns and operates a primary care practice with 20 clinicians in Exton, Pa., west of Philadelphia, has piled “hundreds and hundreds” of pages of Medicare claims in a FedEx box and sent them to the agency. Dr. Meyer said she was weighing how to conserve cash by cutting expenses, such as possibly reducing the supply of vaccines the clinic has on hand. She said if she pulled together all of her cash and her line of credit, her practice could survive for about two and a half months.

Through Optum’s temporary funding assistance program, Dr. Meyer said she received a loan of $4,000, compared with the roughly half-million dollars she typically submits through Change. “That is less than 1 percent of my monthly claims and, adding insult to injury, the notice came with this big red font that said, you have to pay all of this back when this is resolved,” Dr. Meyer said. “It is all a joke.”

The hospital industry has been pushing Medicare officials and lawmakers to address the situation by freeing up cash to hospitals. Senator Chuck Schumer, Democrat of New York and the chamber’s majority leader, wrote a letter on Friday, urging federal health officials to make accelerated payments available. “The longer this disruption persists, the more difficult it will be for hospitals to continue to provide comprehensive health care services to patients,” he said.

In a statement, Senator Schumer said he was pleased by the H.H.S. announcement because it “will get cash flowing to providers as our health care system continues to reel from this cyberattack.” He added, “The work cannot stop until all affected providers have sufficient financial stability to weather this storm and continue serving their patients.”

Cyberattack Paralyzes the Largest U.S. Health Care Payment System

03/05/24 5:27 PM EDT

New York Times

The hacking shut down the nation’s biggest health care payment system, causing financial chaos that affected a broad spectrum ranging from large hospitals to single-doctor practices.

CMS offers help for doctors and hospitals affected by Change outage

March 5, 2024 2:26 pm

The Centers for Medicare and Medicaid Services on Tuesday said it will consider granting accelerated Medicare payments to affected doctors and hospitals on an individual basis, similar to a program that doled out $100 billion during the Covid-19 pandemic.

It’s one of several ways the agency will try to help doctors and hospitals devastated by the Change Healthcare cyber attack and comes a day after Senate Majority Leader Chuck Schumer called for accelerated payment approval.

Hospitals and physicians have complained of trouble receiving payments and, in some cases, of having little cash on hand because of the attack on UnitedHealthcare subsidiary Change Healthcare on Feb. 21, which runs the payment and processing systems for scores of health systems.

HHS did not return a request for comment on how much money is available for accelerated payments. The agency gave generous terms for repayments of accelerated payments for those affected by Covid-19, but it remains unclear if those same terms would apply for this round of funding.

CMS has also instructed independent Medicare contractors that process claims to expedite any provider’s request to change to a new processing platform.

The agency is also calling for Medicare Advantage and Medicaid-managed care plans to relax requirements for prior authorization, which requires doctors to get insurer approval before performing certain services or prescribing drugs. The outage has affected the ability of doctors and hospitals to submit such requests.

In addition, CMS is calling for independent Medicare contractors to make sure they can receive paper claims.

“While we recognize that electronic billing is preferable for everyone, the [contractors] must accept paper submissions if a provider needs to file claims in that method,” the agency said.