Providers and payers were hit with a series of proposed legislation, policies and court action this week that affects drug prices, surprise bills and their contracts.
This includes Senate and House committee bills to lower drug costs and for single-payer healthcare, a Health and Human Services announcement ending LGBT discrimination protections in the Affordable Care Act and the setting of a July 9 date for the Fifth Circuit Court of Appeals to hear oral arguments in the appeal of a district court decision striking down the entire ACA.
SENATE HELP BILL
The Senate Committee on Health, Education, Labor and Pensions released a number of sweeping proposals in the Lower Health Care Costs Act of 2019. Chairman Lamar Alexander said he hoped to move the bill through the health committee in June, put it on the Senate floor in July and make it law.
The bill would end surprise medical bills by requiring patients to pay only the in-network amount, whether they receive out-of-network emergency care or non-emergency care at in-network facilities where they are treated by out-of-network providers. Insurance companies would pay providers the median contracted rate for the same services provided in that geographic area.
The bill would ensure that makers of brand drugs, including insulin products, are not “gaming the system” to prevent new, lower cost generics or biosimilars from coming to market. The bill would help generic-drug and biosimilar companies speed drug development and avoid patent infringement through transparent, modernized and searchable patent databases.
The bill would improve transparency by designating a nongovernmental, nonprofit entity to use de-identified patient healthcare data to better understand their healthcare costs. It would ban the practice of “spread pricing” by pharmacy benefit managers, in which a PBM charges employers, insurers and patients more for a drug than it paid to acquire the drug. It would also ban pharmacy gag clauses and anti-competitive terms in health insurance contracts. It would require healthcare facilities to provide a summary of services when a patient is discharged from a hospital to make it easier to track bills, and require hospitals to send all bills within 30 business days. It would require providers and insurers to give patients price quotes on expected out-of-pocket costs for care. It would require insurance companies to keep up-to-date provider directories.
Vaccines, technology-based models
The bill would increase vaccination rates and prevent disease outbreaks through a national, evidence-based campaign to combat the spread of vaccine-related misinformation. Grants would support immunizations, especially in communities with low vaccination rates. The bill would expand the use of technology-based healthcare models to help patients in rural and underserved areas access specialized care. It would give states, Tribes, and communities an evidence-based guide to developing programs to prevent obesity and support other community health initiatives such as reducing maternal mortality.
The bill would give patients full, electronic access to their own health claims information and ensure that the Department of Health and Human Services successfully implements interoperability provisions of the 21st Century Cures Act.
American Hospital Association Executive Vice President Tom Nickels said the AHA was supportive of the most of the HELP provisions but was concerned about the government getting involved in provider and payer contracts.
“Based on our initial review, however, we are concerned about several of the proposals that would allow the government to intrude into private commercial contracts between providers and insurers,” Nickels said. “Specifically, banning so-called ‘all or nothing’ clauses could lead to even more narrow networks with fewer provider choices for patients, while adversely affecting access to care at rural and community hospitals.”
The AHA’s preferred solution to stop surprise bills is to stop the practice of balance billing for ER services.
Nickels also said “We strongly oppose approaches that would impose arbitrary rates on providers, along with untested proposals such as bundling payments, which would be unworkable and would do nothing to solve the issue of surprise billing.”
Matt Eyles, president and CEO of America’s Health Insurance Plans said, “We agree with and support many of the principles outlined by the HELP Committee. Increasing competition and putting an end to Big Pharma’s gaming of the system will lower out-of-control drug prices for patients and consumers. We agree patients should be protected from surprise medical bills, and that policy solutions to this problem should ensure premiums and out-of-pocket costs do not go up for patients and consumers.”
AHIP also submitted a statement to the House Budget Committee strongly objecting to a proposal for single-payer healthcare that it said would force a government-run insurance system upon Americans.
“These proposals do nothing to address our top challenge: a growing health care affordability crisis. They would mean higher taxes on all Americans, higher total premiums and costs for the hundreds of millions of people enrolled in private coverage, longer wait times, and lower quality of care,” AHIP said.
The Department of Health and Human Services has proposed revising a section of the ACA on enforcing civil rights in healthcare that affects LGBT rule provisions.
“The proposed regulatory reform would maintain civil rights enforcement on the basis of race, color, national origin, disability, age, and sex, while revising certain provisions of the current Section 1557 rule that a federal court has said is likely unlawful,” HHS said. “The proposal also would relieve the American people of approximately $ 3.6 billion in unnecessary regulatory costs over five years.”
In 2016, HHS issued a new rule that redefined discrimination “on the basis of sex” to include termination of pregnancy and gender identity which it defined as one’s internal sense of being “male, female, neither, or a combination of male and female.”
In response to a subsequent lawsuit by several states and healthcare entities, on December 31, 2016, a federal court preliminarily enjoined the rule’s gender identity and termination of pregnancy provisions on a nationwide basis. A second federal court agreed. Because the preliminary injunction continues to be in effect, HHS said it cannot enforce the rule’s provisions the court said are likely unlawful.
Dr. Bruce Siegel, president and CEO of America’s Essential Hospitals, said the
administration’s proposal to roll back these protections will worsen existing barriers to access and increase disparities.
“Discrimination in any form has no place in healthcare,” Siegel said. “Our hospitals embrace this principle and care for all who walk through their doors. They have made progress closing gaps in care and reducing disparities among vulnerable populations, including the LGBTQ community and individuals with limited English proficiency. This is a step backward and undermines their work to build greater equity in care. We see no policy justification for this change, and we strongly urge the administration to reconsider its position.”
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