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PBMs, telehealth, transparency lead Congress' 2024 to-do list


Presidential election years tend to be poor times to attempt major healthcare legislation, but Congress' failure to cope with its 2023 responsibilities has raised the prospects that significant bills could pass in 2024.


Lawmakers left town before Christmas having failed to complete much-delayed fiscal 2024 appropriations legislation—the prior fiscal year ended Sept. 30—and leaving in place temporary spending bills that last until Jan. 19 and Feb. 3, depending on the part of government.


The wrangling ended up stalling not just the major healthcare spending that goes into annual appropriations, but a number of key programs that needed to be reauthorized and significant bipartisan bills that advanced though varying stages of the legislative process. Bottled up by the budget battle were bills dealing with pharmacy benefit mangers, telehealth, hospital payments, physician payments and various price transparency measures.

Members of Congress and aides said they were hopeful many of the held-up items would move in the new year.


At the very least when it comes to healthcare, Congress must pass bills to keep the Health and Human Services Department and the Food and Drug Administration funded (FDA funding is attached to agriculture appropriations even though the agency is part of HHS). Likely added to those would be reauthorizations of healthcare initiatives such as community health centers and medical education programs.


How even that may happen, however, remains unclear and promises to be messy. The House departed Washington Dec. 14 with budget talks stuck, and even Republicans in the Senate were sounding alarms about House suggestions of funding the rest of fiscal 2024 with a stopgap bill known as a continuing resolution, or CR, that holds spending flat.


"A full-year CR would be extremely damaging," Senate Appropriations Committee Vice Chair Susan Collins (R-Maine) said a day before the upper chamber left for the year. Collins is the ranking Republican on the panel and leads spending negotiations for the Senate GOP.


That uncertainty about even the basics, in addition to the worries that election politics will interfere with legislating, clouds the picture for other priorities. But some lawmakers still see chances to advance other bills.


Perhaps at the top of the list is legislation targeting pharmacy benefit managers. The House, in one of its last major actions of 2023, passed the Lower Costs More Transparency Act of 2023, which would require hospitals, laboratories, PBMs and others to release information on prices and crack down on how PBMs negotiate prescription drug prices for employers and health insurance companies.


The Senate has not moved a similar bill to the floor, but the Finance Committee and the Health, Education, Labor and Pensions Committee have passed bipartisan legislation that includes many of the same items. Indeed, it goes further on PBMs because the measures would ban so-called spread pricing and prohibit PBMs from linking their compensation to high drug list prices.


Finance Committee ranking member Mike Crapo (R-Idaho) said he is optimistic the House and Senate could combine their legislation, either in a broader healthcare bill or as part of a fiscal 2024 spending package.


HELP Committee Chair Bernie Sanders (I-Vt.) said he would like to do more to curb pharmaceutical prices, but vowed to at least keeping pushing the PBM legislation. "We're gonna stay on the high cost of prescription drugs," he said.


Several other items stand a chance of advancing in 2024.


One is Medicare pay for doctors. The new year brought a 1.25% cut in physician reimbursements, sparking an outcry from medical societies and concern on Capitol Hill. In addition, accountable care organizations are seeing their 5% bonuses for saving money trimmed.


A bipartisan, bicameral group of lawmakers has signaled a desire to undo some of those cuts, and the Senate Finance Committee approved a bill that would at least partially restore Medicare physician payments to calendar 2023 levels.


Senate Budget Committee Chair Sheldon Whitehouse (D-R.I), who sits on the Finance Committee, has high hopes for a bipartisan bill to continue the ACO bonuses as a way to spur further savings.


"We can draw good lessons from what made them succeed, and try to extrapolate those good lessons more broadly through the healthcare system," Whitehouse said. "That's a very important goal because we're headed for just enormous healthcare spending."


Several lawmakers and staffers pointed to telehealth as an area in which Congress could act in 2024. At a minimum, many members of Congress want to renew flexibilities for telehealth services granted during the COVID-19 public health emergency. The House passed just such a bill.


Although lawmakers didn't mention it specifically in interviews, another significant piece of legislation that could stay in the mix is an effort to ban hospitals from charging hospital rates for care delivered in outpatient settings.


Such site-neutrality measures are included in the House-passed Lower Costs bill and would have a strong chance of remaining in whatever final legislation moves. That's because, as House Energy and Commerce Committee Chair Cathy McMorris Rodgers (R-Wash.) said when the bill cleared the House, it saves the government hundreds of millions of dollars.

There is one major dark horse candidate to pass in 2024: legislation that targets Medicare Advantage payments to health insurance companies. In years past, Republicans have opposed reining in Medicare Advantage, while Democrats sought to reduce federal support for the privatized Medicare program.


But recent news about excessive use of prior authorization denials by Medicare Advantage insurers and overpayments by Medicare has triggered GOP complaints.


Rep. Dr. Larry Bucshon (R-Ind.) said in a late-year hearing that Congress should investigate insurers that have been accused of improper denials of care. Senate HELP Committee ranking member Dr. Bill Cassidy (R-La.) has offered a bill to crack down on overpayments.


There is no shortage of other healthcare legislation that could move. Sen. Ben Ray Luján (D-N.M.) pointed to telehealth measures and to legislation to help people sickened by nuclear weapons tests in his state. "There's still much more that needs to be done, and much that was left on the table," he said. "I'm always optimistic that something can get done, but there is concern with how the House of Representatives under the Republican majority is willing to take up policy."


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