Insights^

On June 25, 2026, the House Energy and Commerce Health Subcommittee held a markup to consider 15 bills to increase price transparency across the health care sector, including hospitals and insurers, to address concerns about prior authorization and other practices by Medicare Advantage plans, and to deal with the public health threat posed by illicit drugs. This memo covers the legislation related to price transparency and Medicare Advantage. All bills were advanced to the full committee on voice votes. Full Committee Ranking Member Frank Pallone (D-NJ-6) offered general support for the price transparency legislation but raised concerns about the Prices on the Wall Act, arguing that it could cause more confusion than it would help. Several amendments were offered during the markup but were ultimately withdrawn following a commitment from both Full Committee Chairman Bret Guthrie (R-KY-2) and Health Subcommittee Chair Morgan Griffith (R-VA-9) to work on the bill before it goes to full committee.

OPENING STATEMENTS

• Full Committee Chairman Bret Guthrie (R-KY-2)
• Full Committee Ranking Member Frank Pallone (D-NJ-6)
• Health Subcommittee Chairman Morgan Griffith (R-VA-9)
• Health Subcommittee Ranking Member Diana DeGette (D-CO-1)

PRICE TRANSPARENCY AND MEDICARE ADVANTAGE LEGISLATION MARKED UP

H.R. 9393, the Lower Costs, More Transparency Act of 2026 (Reps. Guthrie (R-KY-2) and Pallone (DNJ-6)), to require hospitals, surgical centers, labs, and imaging providers to post prices and require health plans to disclose negotiated rates, cost-sharing estimates, and pharmacy benefit manager (PBM) spread pricing.

• Full Committee Chair Guthrie and Ranking Member Pallone spoke in favor of this bill, highlighting the amount of bipartisan work that went into getting to this point.
• Rep. John James (R-MI-10) stated he would support this bill but believes it does not go far enough in terms of making the prices easy to understand. He shared that he would be putting up his bill, H.R. 5582, the Patients Deserve Price Tags, as an amendment to strengthen the underlying bill.
• Rep. Greg Landsman (R-OH-1) offered an amendment to tack on language to ensure that the data shared is transparent, accurate, and understandable. This amendment was withdrawn after Rep. Landsman acknowledged it did not have the support.
• Rep. Buddy Carter (R-GA-1) offered an amendment to include language from the DOC Access Act, which would promote transparency of the vision and dental benefit industry. He argued that vision benefit managers (VBMs) cause harm to patients as they do not have a choice in their eye doctor or treatment. This amendment was withdrawn.
• Health Subcommittee Ranking Member Diana DeGette (D-CO-1) offered an amendment to include language requiring certain entities to share their ownership structures. This amendment was withdrawn following assurances from Health Subcommittee Chairman Griffith that they could talk about implementing changes.
• This bill was forwarded to the full committee following a voice vote.

H.R. 9397, the Premium Transparency Act (Reps. August Pfluger (R-TX-11) and Nathanial Moran (R-TX-1)), to ensure health insurer accountability through publishing of overhead costs and claim payments.

• Health Subcommittee Ranking Member DeGette highlighted that this language was already put into law within the ACA, but would still support the legislation.
• This bill was forwarded to the full committee following a voice vote.

H.R. 9396, the Prior Authorization Accountability Act (Rep. Craig Goldman (R-TX-12)), to require insurers to display which services were subject to prior authorization, the percentage of requests approved or denied, and the average amount of time between the request submission and determination.

• Health Subcommittee Chair Griffith, Health Subcommittee Ranking Member DeGette, and Rep. Mariannette Miller-Meeks (R-IA-2) spoke in support of the bill.
• This bill was forwarded to the full committee following a voice vote.

H.R. 9390, the Prices on the Wall Act (Rep. Mariannette Miller-Meeks (R-IA-2)), to require hospitals, ambulatory surgical centers, and labs to post the discounted cash price in dollar amount on the wall for each service they provide.

• Rep. Miller-Meeks (R-IA-2) spoke in support of the bill, highlighting the importance of physically seeing the prices.
• Full Committee Ranking Member Pallone expressed his concern that it will cause more confusion for consumers and could deter them from care. While he acknowledged the good intent behind the bill, he explicitly raised issues with the fact that the posted prices will not be what patients actually pay and that billing codes can be unclear.
• This bill was forwarded to the full committee following a voice vote.

H.R. 3514, Improving Seniors’ Timely Access to Care Act of 2025 (Reps. Mike Kelly (R-PA-16) and Suzan DelBene (D-WA-1)), to require plans to establish, and evaluate the implementation of, an electronic prior authorization.

• Reps. John Joyce (R-PA-13), Kim Schrier (D-WA-1), Miller-Meeks, Lizzie
• Fletcher (D-TX-7), and Troy Carter (D-LA-2) spoke in support.
• This bill was forwarded to the full committee following a voice vote.

H.R. 9392, the Medicare Advantage Cost Transparency Act (Reps. Diana DeGette (D-CO-1) and John Joyce (R-PA-13)), to require the inclusion of certain information in Medicare Advantage encounter data.

• Rep. Joyce spoke in support of the bill and emphasized the importance of including value- based contracting in this list of information to capture the full picture. He also shared the need for a uniform reporting standard so the data is comparable across plan types.
• This bill was forwarded to the full committee following a voice vote.

H.R. 5243, to require each Medicare Advantage plan to submit eligibility for supplemental benefits, types of benefit categories offered, and data on utilization of and payments for such benefits (Rep. Jennifer McClellan (D-VA-4)).

• This bill as amended was forwarded to the full committee following a voice vote.

H.R. 9395, the Transparency in Medicare Advantage Steering Act (Rep. Alexandria Ocasio-Cortez (D-NY14)), to require Medicare Advantage organizations to share the amount and form of compensation paid to an agent or broker, along with the total amount of compensation paid to agents and brokers.

• This bill was forwarded to the full committee following a voice vote.

On June 24, 2026, the Joint Economic Committee held a hearing to examine ways to prevent health care fraud and instances where health care programs are not being used as intended. Chairman David Schweikert (R-AZ-1) encouraged Committee members and witnesses to focus on tangible solutions to the issue. Members discussed ways to reduce health sector consolidation, prevent fraudulent actions from health plan brokers, and leverage technology to reduce fraud in federal health programs.

OPENING STATEMENTS

• Chairman David Schweikert (R-AZ-1)
• Ranking Member Maggie Hassan (D-NH)

WITNESS TESTIMONY

• Dr. Brian Blase, Founder and President, Paragon Health Institute – Testimony
• Dr. David Meyers, Associate Professor of Health Services, Policy, and Practice, Associate Director of the Center for Advancing Health Policy Through Research, Vice Department Chair, Brown University – Testimony
• Dr. Chris Pope, Senior Fellow, Manhattan Institute – Testimony
• Jessica Tillipman, J.D., Associate Dean for Governmental Procurement Law Studies, Government Contracts Advisory Council Distinguished Professorial Lecturer in Law, George Washington University Law School – Testimony

MEMBER DISCUSSION

Consolidation

Multiple members expressed concerns about the level of consolidation and vertical integration in the health system. Reps. Don Beyer (D-VA-8) and Victoria Spartz (R-IN-5) asked for solutions to prevent consolidation as well as to unwind some of the current consolidation. Dr. Meyers expressed that it would be extremely challenging to unwind current consolidation but gave recommendations to prevent further consolidation. These recommendations include structural separation, preventing health plans from acquiring more providers, and changing incentives, such as site neutral payment reforms, risk adjustment, and the medical loss ratio, to prevent encouraging more consolidation.

Brokers

Democrats on the Committee raised concerns about health insurance brokers. Ranking Member Maggie Hassan (D-NH) and Rep. Beyer wanted to understand how to prevent brokers from acting fraudulently. Dr. Meyers highlighted registering brokers, requiring stricter beneficiary understanding and consent for their plan of choice, and changing incentives for brokers to enroll a beneficiary in a specific plan by standardizing plan payments to brokers and making brokers a fiduciary of the beneficiary. Ms. Tillipman was supportive of reevaluating the specific incentives that create issues with brokers, but she cautioned the committee to not create broad disruptions.

Medicare and Medicaid

Chairman Schweikert suggested that a universal solution to fraud in Medicare Advantage would be to move to a capitated payment model, with a longer enrollment period. Dr. Meyers shared that a capitated model could be beneficial for improving plan incentives to support beneficiaries but cautioned that there would need to be a way for beneficiaries to leave the plan before their enrollment was over.

Rep. Spartz raised concerns about the high levels of automatic funding for federal health programs and questioned if Congress should provide more regular oversight. Dr. Blase agreed, sharing that the Medicare Part B trust fund will soon reach insolvency which will force Congress to address spending.

Sen. Amy Klobuchar (D-MN) asked each witness to share the top bipartisan reform Congress should focus on. Dr. Blase highlighted the need for the federal government to recoup funds states have spent on improper Medicaid payments. Dr. Pope shared that there needs to be increased documentation of services received by enrollees in Medicaid managed care plans.

Technology

Chairman Schweikert was curious if there was a universal data solution to reduce fraud. Dr. Blase shared that while artificial intelligence may play a role, he would recommend Congress focus on reducing the distortions that occur due to government payment policies. Dr. Meyer suggested that developing a better plan finder tool could be beneficial, as well as overlaying technology on top of other larger reforms to increase their impact. Sen. Klobuchar was interested in technological improvements but highlighted that many government computer systems need system wide upgrades to bring them into the modern age. Ms. Tillipman agreed, sharing that public systems need widespread upgrades to allow them to share information broadly, which can reduce duplicate work and decrease fraud.

On June 10, 2026, the House Energy and Commerce Health Subcommittee held a hearing to examine proposals to improve price transparency in the health sector. These proposals included publishing pricing lists for health insurers and hospitals, requiring additional information in Medicare Advantage encounter data, and reporting related to ownership of health care facilities. There was strong bipartisan support for steps to increase price transparency and interest in understanding the impacts of such proposals on patients and employers. Concerns were also raised about the effects of consolidation and private equity involvement in the health care sector.

OPENING STATEMENTS

• Subcommittee Chairman Morgan Griffith (R-VA-9)
• Subcommittee Ranking Member Diana DeGette (D-CO-1)
• Full Committee Chairman Brett Guthrie (R-KY-2)
• Full Committee Ranking Member Frank Pallone (D-NJ-6)

WITNESS TESTIMONY

• Carol Skenes, Chief of Staff, Turquoise Health – Testimony
• Shawn Gremminger, President and Chief Executive Officer, National Alliance of Healthcare Purchaser Coalitions – Testimony
• Benedic Ippolito, PhD, Senior Fellow, American Enterprise Institute – Testimony
• Christopher Whaley, PhD, Associate Director of the Center for Advancing Health Policy through Research and Associate Professor of Health Services, Policy and Practice, Brown University School of Public Health – Testimony
• Sophia Tripoli, MPH, Senior Director of Health Policy, Families USA – Testimony

LEGISLATION BEING CONSIDERED

• H.R.___, to require hospitals, surgical centers, labs, and imaging providers to post prices and require health plans to disclose negotiated rates, cost-sharing estimates, and PBM spread pricing

• H.R. ___, to require hospitals post prices on the walls

• H.R. ___, to require health insurance issuers to publish overhead costs and claim payments

• H.R. ___, to require displaying of claim denial rates by insurers

• H.R. 5582, to provide for hospital and insurer price transparency

• H.R. 9117, to require health plan administrators to disclose pricing and payment data to plans, and to require itemized explanations of benefits and patient bills

• H.R. ___, to require the inclusion of certain information in Medicare Advantage encounter data

• H.R. ___, to require mandatory reporting with respect to certain health-related ownership information

• H.R. ___, to limit the compensation that may be paid to agents and brokers by Medicare Advantage organizations

MEMBER DISCUSSION

Consolidation and Ownership

Concerns were raised about how consolidation and private equity ownership can affect health pricing. Subcommittee Vice Chair Diana Harshbarger (R-TN-1) asked what was driving higher prices, to which Mr. Whaley responded that consolidation was the greatest factor. Full Committee Ranking Member Frank Pallone (D-NJ-6), and Reps. Kim Schrier (D-WA-8) and Marc Veasey (D-TX-33) were curious about why transparency in ownership was important. Mr. Whaley highlighted that when ownership is opaque, it can be extremely difficult for researchers to understand the impacts of consolidation, especially when single transactions are often small but greatly increase market power. Ms. Tripoli also commented that understanding ownership can help researchers and regulators better understand perverse incentives, such as upcoding.

Impacts of Price Transparency

Members showed bipartisan interest in understanding the potential impacts of price transparency legislation. Democratic members, such as Subcommittee Ranking Member Diana DeGette (D-CO-1) and Rep. Raul Ruiz (D-TX-25), commented that price transparency is important but does not directly affect affordability for patients, especially in emergency situations. Ranking Member DeGette and Rep. Ruiz were curious whether the witnesses believed price transparency legislation would reduce patient costs. Ms. Tripoli shared that price transparency would be much more useful for employers and health plan purchasers than individual patients and highlighted reinstating the Advance Premium Tax Credits as more impactful for addressing health care affordability. Subcommittee Chairman Morgan Griffith (R-VA-9) hospitals are sharing their pricing rates, but it is difficult for patients to understand due to the level of complexity.

Multiple Republican members, such as Full Committee Chairman Brett Guthrie (R-KY-2) and Rep. Mariannette Miller Meeks (R-IA-1) were curious about how employers have leveraged price transparency data to lower costs for employees. Mr. Gremminger shared that employers can use the data to engage in innovative plan designs, such as tiered pricing strategies to encourage employees to go to facilities with lower costs. Mr. Whaley shared that employers use claims data to exclude high-priced facilities. Rep. Gus Bilirakis (R-FL-12) asked about the current barriers to employers’ access to their claims data. Mr. Gremminger explained that plans will often only provide high-level data and charge large fees if an employer would like more granular data.

Gaps in Price Transparency Reporting

There was bipartisan interest in understanding how to improve gaps in price transparency requirements currently in place. Rep. Troy Balderson (R-OH-12) asked how to improve the usability of current price data. Ms. Skenes shared that making the data more understandable to patients would be very helpful, as well as addressing the gaps in drug reporting and various ways insurance companies cost-share with patients. Rep. Debbie Dingell (D-MI-6) was focused on understanding the gaps in ownership transparency. Ms. Tripoli stated that many smaller transactions do not meet the threshold for reporting, which makes them difficult to regulate and for intervention, if necessary. Rep. John Joyce (R-PA-13) asked the witnesses if enforcement for current price transparency measures was sufficient, to which both Mr. Whaley and Ms. Tripoli replied that it was not. Reps. Kat Cammack (R-FL-3) and Nick Langworthy (R-NY-23) wanted to understand what additional information could be beneficial to improving price transparency. Ms. Tripoli said that out-of-pocket spending and the quality of care could be beneficial, while Ms. Skene highlighted information on non-hospital entities and negotiated rates of care reimbursement.

On June 1, 2026, the Centers for Medicare and Medicaid Services (CMS) released an interim final rule on implementing the new Medicaid community engagement requirements enacted under H.R. 1, the One Big Beautiful Bill Act (OBBBA). The press release from CMS is available here. A fact sheet from CMS is available here. Comments on the interim final rule are due July 31, 2026.

BACKGROUND AND STATUTORY BASIS

Section 71119(a) of the WFTC legislation, signed into law on July 4, 2025, added section 1902(xx) to the Social Security Act (the Act), establishing a community engagement requirement for certain adults applying for or enrolled in Medicaid. Section 71119(d) directed CMS to publish this IFC to implement the requirement. CMS describes the policy as bringing Medicaid into alignment with work-focused requirements in other public benefit programs such as SNAP and TANF.

The requirement applies only to the 50 States and the District of Columbia that elect to cover the adult group under the State plan, or that operate certain section 1115 waiver demonstrations covering an equivalent population. It does not apply to the U.S. territories. Noncompliance results in denial of eligibility for, or disenrollment from, the adult group (or applicable section 1115 waiver demonstration), though an individual may reapply at any time and will be reassessed under the procedures for applicants.

APPLICABLE INDIVIDUALS

CMS implements the statutory definition of “applicable individuals” – the applicants and beneficiaries who must demonstrate community engagement. Applicable individuals are those eligible for or enrolled in the State plan adult group under section 1902(a)(10)(A)(i)(VIII) of the Act, as well as individuals eligible for or enrolled under certain section 1115(a)(2) expenditure authority that provides coverage equivalent to minimum essential coverage and who are age 19 through 64, not pregnant, not entitled to or enrolled in Medicare Part A or B, and not otherwise eligible under the State plan.

Individuals in other mandatory or optional eligibility groups, for example, parents and caretaker relatives under section 193, are not applicable individuals. CMS also clarifies that section 1915(b) and 1915(c) waivers are not “a waiver of such plan” for this purpose, and that it is reviewing approved section 1115 demonstrations to identify which demonstration populations could be subject to the requirement.

DEMONSTRATING COMMUNITY ENGAGEMENT

An applicable individual demonstrates community engagement for a month by meeting any one or more of the statutory options. States must make all of the options available and may not offer only a subset.

The options are:

• Working not less than 80 hours;
• Completing not less than 80 hours of community service;
• Participating in a work program for not less than 80 hours;
• Being enrolled in an educational program at least half-time;
• Engaging in any combination of the above for a total of not less than 80 hours;
• Having monthly income not less than the Federal minimum wage multiplied by 80 hours (currently $580, based on $7.25 × 80); or
• Being a seasonal worker whose average monthly income over the preceding six months meets that income threshold.

CMS defines the qualifying activities broadly and aligns them, where possible, with SNAP and TANF definitions. “Work” includes self-employment, in-kind work, and certain unpaid work such as internships and trial work periods. “Community service,” “work program,” and “educational program” are likewise defined by reference to existing program standards.

MANDATORY EXCEPTIONS

States must deem an applicable individual compliant for any month in which, for part or all of the month, the individual was under age 19; entitled to or enrolled in Medicare Part A or B; described in a mandatory eligibility group under section 1902(a)(10)(A)(i)(I) through (VII); or a specified excluded individual. A separate exception applies to recently incarcerated individuals: a person is deemed compliant for a month if, at any point during the three-month period ending on the first day of that month, the individual was an inmate of a public institution. These exceptions are assessed against the applicable months in the State’s review period.

Specified Excluded Individuals

The statute lists nine categories of “specified excluded individuals” who are removed from the definition of applicable individual altogether and therefore need not demonstrate community engagement. States must determine excluded status before assessing compliance. The nine categories are:

• Former foster care children
• American Indians and Alaska Natives
• Parents, guardians, caretaker relatives, or family caregivers of a dependent child age 13 or under, or
• of a disabled individual;
• Veterans with a disability rated as total;
• Individuals who are medically frail or otherwise have special medical needs;
• Individuals complying with TANF work requirements and individuals not exempt from (and meeting)
• SNAP work requirements;
• Participants in a drug or alcohol rehabilitation or treatment program;
• Inmates of a public institution; and
• Individuals who are pregnant or entitled to postpartum coverage.

MEDICALLY FRAIL OR SPECIAL MEDICAL NEEDS EXCLUSION

CMS defines a medically frail individual as one whose physical, mental, or other behavioral health condition significantly impairs the ability to comply with the community engagement requirement and who falls within at least one of five categories: blind or disabled; has a substance use disorder (SUD); has a disabling mental disorder; has a physical, intellectual, or developmental disability that significantly impairs one or more activities of daily living; or has a serious or complex medical condition. An individual needs to meet only one category. CMS applies a functional standard rather than a purely diagnostic one: a qualifying condition alone is not enough, and a person who can perform 80 hours per month of qualifying activities despite the condition would not qualify. CMS declined to adopt the existing alternative benefit plan definition of medically frail, to add categories beyond the five in the statute, or to let States add their own.

For the SUD category, the exclusion applies regardless of whether the individual is in active treatment and includes those in early or sustained recovery, but excludes individuals in “stable recovery” (five or more years). States must verify medically frail status on an ex parte basis using reliable information, including adjudicated claims or encounter data from the preceding 12 months, and may not deny the exclusion based on the absence of claims data; where status cannot be verified from available data, the State must allow the individual to submit documentation. States must reverify at least every 12 months.

SHORT-TERM HARDSHIP EXCEPTIONS

States may elect to offer a short-term hardship exception, but if they do, they must recognize all of the statutory hardship circumstances rather than selecting only some. The qualifying circumstances, applicable for all or part of a month, are: receipt of inpatient, nursing facility, ICF/IID, inpatient psychiatric, or similar-acuity services; residence in a county subject to a Presidentially declared emergency or disaster, or in which the unemployment rate is at or above the lesser of 8 percent or 1.5 times the national rate (which requires a State request to the Secretary); and the need to travel outside one’s community for an extended period to obtain medical treatment for a serious or complex condition. The institutional- services and medical-travel circumstances are triggered by an individual’s request.

ASSESSING COMPLIANCE AND REVIEW PERIODS

At application, States must require an applicable individual to demonstrate community engagement for at least one, but not more than three, consecutive months immediately preceding the month of application, as specified in the State plan. For enrolled beneficiaries, States must require demonstration for one or more months (not necessarily consecutive) during the eligibility period, assessed at renewal and, at State option, through more frequent verifications between renewals. CMS uses the term “review period” to describe the months under consideration in each context.

VERIFICATION

States must first conduct ex parte verification, maximizing reliance on reliable electronic data sources already available to the State, before requiring an individual to submit information. CMS directs States to use specified data sources and may permit additional sources and addresses how to proceed when no data source is available or when available data are not reasonably compatible with information the individual provides. Only then may a State request documentation from the individual.

NONCOMPLIANCE PROCEDURES

When a State cannot verify that an applicable individual has met (or is deemed to have met) the requirement, it must send a notice of noncompliance and allow 30 calendar days from receipt for the individual to make a “satisfactory showing” of compliance or of an exception or exclusion. Coverage continues during that 30-day period. If no satisfactory showing is made, the State must, after first checking whether the individual qualifies on another basis, deny the application or disenroll the beneficiary no later than the end of the month following the month in which the 30-day period ends, with applicable notice and fair-hearing rights. CMS confirms that States may not impose a waiting or “lock-out” period; individuals may reapply at any time.

IMPLEMENTATION TIMING AND GOOD FAITH EFFORT EXEMPTION

States must implement the requirement no later than January 1, 2027, and may implement earlier through a State plan amendment or section 1115 demonstration. Applications pending at implementation are adjudicated under the rules in effect on the date of submission; compliance for those individuals is first assessed at their next renewal. The IFC also implements the statutory good faith effort exemption, under which the Secretary may grant a temporary, time-limited exemption from timely implementation. States must address statutory criteria (actions taken toward compliance, significant barriers, and a detailed plan and timeline). CMS expects to approve initial requests for no longer than six months, with extensions available only until no later than December 31, 2028, contingent on quarterly milestone reporting. Exempt States that meet their reporting obligations will not be treated as noncompliant or subjected to corrective action under section 1904 during the exemption.

OUTREACH, MANAGED CARE, AND MONITORING

States must conduct outreach and provide notice of the requirement to affected individuals before the implementation date, with prescribed notice content. States may use managed care plans to assist with outreach, education, data sharing, and referrals to work programs (subject to limits on what may be reflected in capitation rates), and the IFC addresses conflict-of-interest considerations for plans and contractors. For monitoring, CMS will rely on existing eligibility and enrollment data collections – the Performance Indicator (PI), Eligibility Processing (EP), and T-MSIS data sets – and § 435.562 requires States to submit timely, complete, and accurate data on implementation and the impact of the requirement.

RESTORATION OF SUSPENDED ELIGIBILITY AND ENROLLMENT REGULATIONS

Section 71102 of the WFTC legislation suspends, until after September 30, 2034, the amendments made by the 2024 Eligibility and Enrollment final rule (89 FR 22780) to various Medicaid and CHIP eligibility and enrollment provisions, including those governing applications, renewals, changes in circumstances, and timeliness standards. Because those provisions are necessary to implement and enforce the community engagement requirement, the IFC restores, until October 1, 2034, the pre-2024-rule versions of the affected regulations, including §§ 431.213(d), 431.231(d), 435.907, 435.911(c), 435.912, 435.916, 435.919, 457.340(d)(1), 457.344, and 457.960, along with conforming changes.

On May 20, 2026, the House Energy and Commerce Health Subcommittee held a hearing to examine Medicare payment reforms, focusing on the Medicare Access and CHIP Reauthorization Act (MACRA) and the Physician Fee Schedule (PFS). Members discussed ways to reform the PFS to provide more stability in payment updates, how primary care reimbursement is different from other specialties, how the PFS is driving provider consolidation, and more.

OPENING STATEMENTS

• Subcommittee Chairman Morgan Griffith (R-VA-9)
• Subcommittee Ranking Member Diana DeGette (D-CO-1)
• Full Committee Chairman Brett Guthrie (R-KY-2)
• Full Committee Ranking Member Frank Pallone (D-NJ-6)

WITNESS TESTIMONY

• William Fox, MD, MACP, Cahir Emeritus, American College of Physicians Board of Regents, Fox & Brantley Internal Medicine – Testimony
• Steven Furr, MD, FAAFP, Family Medicine Physician – Testimony
• Dana Smetherman, MD, MPH, MBA, FACR, Chief Executive Officer, American College of Radiology – Testimony
• Rick Snyder, MD, President, HeartPlace – Testimony
• Farzad Mostashari, MD, Chief Executive Officer and Co-Founder, Aledade – Testimony

MEMBER DISCUSSION

Physician Fee Schedule

There were broad, bipartisan concerns about the need to reform the Physician Fee Schedule (PFS). Health Subcommittee Chairman Morgan Griffith (R-VA-9) asked how current budget neutrality rules create competition between specialties. Dr. Smetherman shared that currently, if one specialty receives an increase, another specialty must receive a cut to compensate. Reps. Raul Ruiz (D-CA-25), Lizzie Fletcher (D-TX-7), Mariannette Miller-Meeks (R-IA-1), and Troy Balderson (R-OH-12) highlighted the need for a stable update schedule and suggested tying it to inflation. Mr. Fox agreed, stating that stable payments allow for long-term planning and practice expenses, such as rent, salaries, and equipment, which increase every year. Rep. Nick Langworthy (R-NY-23) was curious about the importance of payment policies keeping up with technological advancements. Dr. Snyder shared that it was extremely important, as technological advancements can often reduce costly procedures and improve the delivery of care.

Primary Care

Multiple Democrats focused on the importance of primary care, and some of the struggles that primary care providers are facing. Health Subcommittee Ranking Member Diana DeGette (D-CO-1) and Full Committee Ranking Member Frank Pallone (D-NJ-6) were curious about the importance of primary care providers and their role in chronic disease management. Dr. Furr highlighted the time providers spend coordinating care across specialties and providing chronic care management, and he argued that this reduces long-term spending. Rep. Robin Kelly (D-IL-2) asked why primary care should be reimbursed differently than other types of care. Dr. Fox shared that Medicare is not designed to pay for these services and instead relies on a fee-for-service model that is difficult to apply to primary care. Dr. Furr added that primary care is focused on preventive care. Reps. Marc Veasey (D-TX-33) and Troy Carter (D-LA-2) asked about how reimbursement policies influence what specialties medical students are choosing to practice. Dr. Fox shared that the number one driver of specialty choice was earning potential, and therefore, primary care is often not chosen. Dr. Furr highlighted the need to rethink how Medicare reimburses graduate medical education (GME) to encourage providers to train in rural areas.

Consolidation

There were concerns about the effects of Medicare reimbursement on health sector consolidation. Health Subcommittee Vice Chair Diana Harshbarger (R-TN-1) questioned if Medicare reimbursement was driving consolidation, to which Dr. Fox shared that the lower payment rates can cause independent providers to close or sell to hospitals if they do not have positive margins.

Reps. John Joyce (R-PA-7) and Kim Schrier (D-WA-8) asked about the effects of consolidation on patients. Dr. Fox shared that independent physician practices help to reduce costs for patients. Dr. Snyder highlighted that independent practices have more autonomous clinical decision-making, which can allow the physician and patient to agree on a treatment plan that is the most suitable for the patient.

Merit-based Incentive Payment System (MIPS)

There was bipartisan interest in MIPS and its effect on physician practices. Full Committee Chairman Brett Guthrie (R-KY-2), and Reps. Kat Cammack (R-FL-3) and Schrier wanted to understand the administrative burden of MIPS reporting and how to best reduce it. Dr. Furr shared that MIPS reporting is time-intensive, especially for smaller or rural practices. Dr. Furr suggested that one standardized measure would be very impactful. Dr. Smetherman highlighted that MIPS does not align with radiologists’ practice, making it very difficult to report metrics. He suggested that specialty-specific measures that measure the quality of care provided are important. Rep. Gus Bilirakis (R-FL-12) questioned how the PFS should be updated to better reflect practice expenses in reimbursement, especially for physicians in independent practices. Dr. Smetherman shared that for specialties that are very technology-intensive, addressing budget neutrality or updating the PFS will ensure that patients continue to receive the best treatment. Rep. John Joyce (R-PA-13) asked if tethering practice expense increases for independent practices to a percentage of hospital outpatient cost data for similar services could be beneficial. Dr. Snyder stated that it would significantly level the playing field.

Other Topics

• Rep. Troy Balderson (R-OH-12) was curious about leveraging health information technology to improve care. Dr. Mostashari shared that technology can be extremely helpful if the payment incentives align to encourage proper use.
• Rep. Lori Trahan (D-MA-3) highlighted the reimbursement rate discrepancies for care provided to males versus females for the same types of procedures.