POLICY BRIEFINGS

HELP Releases Wide-Ranging Health Care Cost Legislation


Leadership of the Senate Health, Education, Labor, and Pensions (HELP) Committee released a draft bipartisan health care package last week that aims to contain health costs. The bill includes measures to address surprise insurance gaps, reduce the cost of prescription drugs, create more transparency in the health care system, improve public health, and increase health information exchange.

Under the legislation, patients would be required to pay only their in-network cost-sharing amount for out-of-network emergency care and treatments provided by ancillary out-of-network providers. The proposal outlines three options for resolving payment disputes between providers and insurers: an in-network guarantee under which providers can join a health plan’s network or bill through the facility where they practice; use of an independent dispute resolution process; or payment based on the median contracted rate for the services rendered. States would have the option of enacting or continuing with current state laws or regulations. If a patient is stabilized after entering a facility through the emergency department, the patient must be given advance notice of any out-of-network care, an estimate of the cost, and referrals for alternative options for in-network care. Health plans and providers would also be required to provide patients with estimates of their out-of-pocket costs for a service within 48 hours of a request, and to send any medical bills within 30 days of the service. Insurers would be mandated to keep their provider directories up to date.

In regard to rising drug costs, the bill would ban the practice of spread pricing by pharmacy benefit managers (PBMs) and require that PBMs provide quarterly reports on costs, fees, and rebates. PBMs would also be required to pass on 100 percent of the rebates negotiated to their client. The HELP proposal would prevent the Food and Drug Administration (FDA) from delaying applications for new insulin products. It also includes provisions to update drug patent registries, increase competition by preventing generic manufacturers from blocking competitors from coming to market, and give the FDA more flexibility in how the agency deals with petitions from brand manufacturers.

The package would prohibit gap clauses between providers and insurers that hide cost and quality information from consumers, as well as anti-tiering and anti-steering clauses in contracts between providers and health plans. It includes funding for programs related to vaccine education, maternal mortality, health care professional discrimination and bias training, and to improve the privacy and security of health information and electronic medical records.

Chairman Alexander has indicated that he is working with members of his panel to add a provision to tie patient costs to a drug’s negotiated price rather than its list price, and a measure to require more detailed disclosures from pharmaceutical manufacturers. The HELP Committee plans to hold a hearing on the discussion draft in June before marking it up prior to July 4. The current plan is for the bill to be combined with legislation being drafted by the Finance Committee before being brought to the Senate floor in July. The HELP Committee is seeking feedback on the discussion draft no later than 5 pm on June 5. Comments may be submitted to [email protected].


House Committees Seek Feedback on Part D Reforms


Bipartisan leadership of the House Energy and Commerce and Ways and Means committees are requesting feedback on draft legislation to reform how Medicare pays for Part D drugs. The bill would place a cap on out-of-pocket prescription drug costs for Medicare beneficiaries based on the current catastrophic threshold and reduce the share of catastrophic coverage costs that the federal government covers from 80 percent to 20 percent over four years. Such reforms generally have bipartisan support among lawmakers. The panels are also soliciting comments on other policies to modernize the Part D benefit structure. Comments may be submitted to [email protected] no later than June 6, 2019.


Doc Caucus Urges Administration to Reconsider Arbitration


The House GOP Doctors Caucus sent a letter to HHS Secretary Alex Azar, Director of the Domestic Policy Council Joe Grogan, and Labor Secretary Alexander Acosta last week regarding surprise insurance gaps. The letter praises the administration for acknowledging surprise medical billing as a significant problem facing American patients and urges the White House officials to look toward successful state models such as the ones enacted in New York and Maryland. The lawmakers argue that the arbitration model based on a third-party charge system is the most appropriate way to address surprise insurance gaps, and request that the administration “reconsider its comments that arbitration would be a disruptive and unnecessary distraction.” The letter also highlights the Caucus’s concerns with bundled billing and network matching approaches.

Hart Health Strategies Inc. has prepared an updated side-by-side comparison of current legislative proposals to address surprise insurance gaps and out-of-network care.



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