WAYS AND MEANS COMMITTEE APPROVES LEGISLATION TO EXPAND ACCESS TO CARE FOR RURAL PATIENTS AND SENIORS, IMPROVE HEALTH CARE PRICE TRANSPARENCY, AND HOLD HEALTH CARE EMPIRES ACCOUNTABLE

The following information was released by the Committee on Ways and Means:

Large hospital systems and insurance companies will be required to be more transparent about their prices and financing practices while seniors and patients living in rural and underserved communities will have more access to better health care under legislation approved by the Ways and Means Committee. Among the policies advanced by the Committee are reforms that will force health insurers and providers to be more open and honest about the cost of care before a patient undergoes treatment. Insurance companies that provide Medicare Advantage plans will also be required to disclose more information about their companies' finances including revenues and administrative spending provide clearer guidelines for how they utilize the prior authorization process, and update and streamline that process to ensure seniors get timely access to care.

In addition to ensuring patients have the information they need to make more informed health care decisions, the Committee also approved legislation to expand and protect access to care in rural and underserved communities including remote patient monitoring services and anesthesia services as well as legislation to provide long-term care sooner for the sickest patients who need it. For seniors in nursing homes, legislation approved by the Committee will ensure essential caregivers, like a family member, can enter and provide care even during a designated emergency when other visitation rights might be suspended.

The Committee's reform efforts deliver on President Trump's Great Healthcare Plan to lower health care costs, empower patients with more transparency, and demand more accountability from health care empires.

Ways and Means Committee Chairman Jason Smith (MO-08) issued the following statement:

"While the bills approved by the Committee each respond to unique health challenges, they all share a common goal: putting patients in charge of their health care. Where there are gaps in access to certain health care services like anesthesia, remote monitoring, or the critical care and comfort provided by family members to seniors in nursing homes we have advanced solutions that address those shortages. When it comes to ensuring access to timely care for seniors, the Committee has cut through red tape and ended a Medicare box-checking exercise that delayed Medicare beneficiaries from receiving acute care in long-term care hospitals including rural patients at critical access hospitals and improved the prior authorization process that many insurers appear to be abusing through opaque processes and delay tactics to deny care. In the interests of price transparency and insurer accountability, we have also strengthened reporting requirements for Medicare Advantage insurance plans to better disclose their business finances while demanding a wide spectrum of health care providers and insurers provide patients with health care pricing information upfront so that Americans are not stuck with massive, unexpected health care bills after treatment. Sadly, on that final effort, every Democrat on the Committee voted against holding the nation's health care empires accountable for transparent pricing. The legislative work the Ways and Means Committee continues to do to expand access to quality, affordable health care for seniors, for rural and underserved communities, and for working families has been informed by hearings and in the case of several reforms inspired by the efforts of President Trump through his Great Healthcare Plan."

Essential Caregivers Act (H.R. 9641)

1.2 million Americans live in the more than 15,000 nursing homes across the U.S. and 38 million Americans are caregivers to adult family members, including nursing home residents.

60 percent of nursing home residents experience loneliness.

Isolation and loneliness are associated with a 50 percent higher risk of dementia, a 32 percent higher risk of stroke, and a nearly 4x risk of death among heart failure patients.

During the COVID-19 pandemic, some state governments like New York, New Jersey, Pennsylvania, Michigan, and California imposed excessively restrictive visitation limitations on nursing homes and other facilities, even for caregivers and family members.

This bill requires nursing homes and other similar care facilities to allow residents to designate an essential caregiver who can enter the facility and care for the resident even in times of an emergency when regular visitation is suspended, and imposes fines on nursing homes and other facilities that fail to allow essential caregiver visitation.

The bill passed the Committee 38-0.

Rural Patient Monitoring Access Act (H.R. 3108)

Remote patient monitoring (RPM) empowers patients to take charge of their health by using innovative technology to stay connected with their health care provider, and advances care coordination to better treat patients with complex chronic diseases.

RPM use has reduced heart attack and stroke rates by as much as 50 percent for individuals with uncontrolled hypertension and resulted in a 27 percent reduction in hospital admissions.

RPM is a critical tool incorporated in value-based care to lower costs and improve quality.

An RPM program lowered spending by 52 percent for Medicare patients with heart failure.

RPM bridges care gaps for rural patients who face disproportionately higher rates of chronic disease and related mortality.

Current Medicare payment rules arbitrarily decrease RPM reimbursement for services provided in certain rural areas.

This bill establishes a national floor for RPM reimbursement, eliminates negative payment adjustments to remote monitoring services in rural areas, strengthens quality of remote monitoring by clarifying technology and response requirements, and bolsters clinical evidence of RPM by requiring a report on hospital admissions and inpatient days for patients furnished RPM.

The bill passed the Committee 39-0.

Medicare Access to Rural Anesthesiology Act (H.R. 9642)

81 percent of rural counties lack a physician anesthesiologist, and more than half have no anesthesia provider at all.

In 2022, 78 percent of rural facilities reported anesthesia staffing gaps, more than double the 35 percent that reported such gaps in 2020.

When a hospital loses anesthesia providers, surgeries move to distant urban hospitals, forcing patients to travel longer distances which can be especially difficult for seniors.

In 1986, Congress created a bonus payment for certain nurse anesthetists delivering care in rural areas, but rural anesthesiologists are not eligible for this bonus payment.

This bill provides a cost-based bonus payment to anesthesiologists for anesthesia services provided in certain rural hospitals with low surgical volume.

The bill passed the Committee 41-0.

Saving Today's Acute-Care Resources (STAR) Act (H.R. 9468)

Long-Term Care Hospitals (LTCHs) treat the sickest Medicare patients who need hospital-level care for extended periods.

In 2015, Congress revised Medicare payments to LTCHs to ensure LTCHs received their higher reimbursement only when caring for the truly sickest patients.

Under the new rules, LTCHs receive the higher LTCH payment only for admitting patients who previously stayed at least 3 days in an intensive care unit (ICU) or were treated for 96+ hours on a ventilator; otherwise, the LTCH receives reimbursement equivalent to a standard hospital stay, which is lower than the LTCH rate.

While the revised payment system restored integrity and curbed excessive Medicare spending on LTCHs, its unintended effects included lower LTCH admissions, facility closures, and reduced patient access to care.

For example, in 2012, there were 421 LTCHs nationwide, falling to 338 in 2023.

Current law does not allow LTCH reimbursement for patients discharged from a Critical Access Hospital (CAH) even if they meet the ICU or ventilator requirements patients must go first to a standard hospital and meet the criteria again, leading to unnecessary hospital transfers.

This bill creates a new expedited admission pathway that allows seniors with the sickest conditions to access LTCHs without first being forced to spend three days in an ICU or 96 hours on a ventilator, and it allows rural seniors being cared for in CAHs to be directly admitted to an LTCH.

The bill passed the Committee 40-0.

Improving Seniors' Timely Access to Care (H.R. 3514)

54 percent of Medicare beneficiaries 32.8 million are enrolled in Medicare Advantage (MA).

In 2024, MA insurers received 53 million prior authorization requests, up from 49.8 million in 2023, an average of 1.7 requests per enrollee.

Insurers fully or partially denied 7.7 percent of requests (4.1 million), up from 6.4 percent in 2023.

11.5 percent of denials were appealed, and nearly 81 percent of denials were overturned suggesting insurers may be abusing the prior authorization process.

This bill delivers on President Trump's Great Healthcare Plan to strengthen health care price transparency and insurer accountability:

Requires standard prior authorization requests to be completed in 7 days and urgent requests to be completed within 72 hours.

Streamlines and simplifies burdensome pre-approvals by transitioning to an electronic prior authorization process.

Requires plans to publicly disclose prior authorization information including the number of requests, denials, and approvals, as well as the total time to resolution.

Requires enrollee involvement in prior authorization program development and an annual review of prior authorization processes.

Requires CMS to assess real-time prior authorization processes.

Requires reports to Congress evaluating implementation of the bill's prior authorization improvements.

The bill passed the Committee 42-0.

Medicare Advantage MLR Transparency Act (H.R. 9644)

Under Medical Loss Ratio (MLR) requirements, large insurers including Medicare Advantage (MA) plans are required to spend 85 percent of revenue on direct medical care or quality initiatives with the remaining 15 percent available for administrative overhead, compliance, policy implementation, and corporate profit.

MA is the most profitable sector of the private health insurance market.

In 2021, MA insurers reported profits averaging $1,730 per enrollee at least double the margins reported by insurers in the individual and employer markets.

The MLR is questionably effective at regulating profits with insurance companies gaming the system through vertical integration.

This bill delivers on President Trump's Great Healthcare Plan to strengthen health care price transparency and insurer accountability by:

Requiring MA plans to submit to CMS and publicly post on their website more detailed revenue and spending information.

Requiring CMS to align the standards of benefit information across all insurance types in the Medicare and commercial markets.

The bill passed the Committee 42-0.

Health Care Price Certainty for All Americans Act (H.R. 9645)

Health care prices are negotiated and then kept secret, making it difficult for patients to navigate the health care system and employers to control costs.

The Trump Administration took historic action to require hospitals and health insurers to publicly disclose important price information, but the Biden-Harris Administration let hospitals and health insurers ignore transparency rules.

Less than 25 percent of hospitals are compliant with current price transparency rules.

Health care price transparency has the potential to dramatically lower overall health care costs.

This bill delivers on President Trump's Great Healthcare Plan to strengthen health care price transparency and insurer accountability by:

Requiring hospitals, laboratories, imaging providers, and ambulatory surgical centers to provide transparent pricing for patients and employers, with increased penalties for noncompliant providers.

Requiring insurers to publish the real prices they negotiate, the in-network rates, out-of-network amounts, and drug prices.

Requiring insurers to give patients a real-time cost estimate before they get care and the actual out-of-pocket price for a specific service.

Requiring a C-suite executive to personally certify that published prices are true, putting CEOs on the hook for accurate and complete pricing information.