Quick notes:

  • Lower costs for prescription drugs is something that the public and Congress want to achieve.
  • The Senate is looking to pass a bill that would attempt to eliminate “surprise” medical bills.
  • Improved transparency between health care companies and patients is also a goal.

 

 

Congress was back in session in September, and health care legislation replaced Russia and Team Trump as a major focus for political partisans in both parties.

What is Congress targeting with health care this session? Think surprise medical bills, prescription drug pricing, and, hopefully, health care company transparency, with more on the congressional plate.

Certainly, all of the above is what the general public wants to see Congress targeting this autumn.

According to the KFF Tracking Poll for September 2019, a rolling survey of U.S. consumer direction on key health care issues, Americans have some goals in mind now that Congress is back in session:

  • 70% of Americans surveyed by KFF want Congress’ help in lowering prescription drug costs.
  • Protecting the mandatory care and coverage for preexisting medical conditions, as laid out in the Affordable Care Act, is a priority for 69% of Americans.
  • Lowering the overall cost of health care is a big deal to 64% of U.S. health consumers.
  • Protection from so-called “surprise” medical bills is a priority for 56% of Americans.

 

Congressional focus on these health care issues

Here’s a snapshot of where Congress is headed on all health care fronts this fall, and what might be accomplished, according to health care experts.

High prescription drug costs. Drug costs have long been on the political agenda and the push to force pharma companies to lower drug prices remains strong, both among the public and in Congress and the White House.

“Right off the bat, Trump’s plan to allow the import of drugs from Canada will be high on the agenda,” says Gail Trauco, a registered nurse and CEO and patient advocate at The PharmaKon LLC, in Atlanta, Georgia. As U.S. Health and Human Services Secretary Alex Azar said recently, “President Trump has been clear: for too long American patients have been paying exorbitantly high prices for prescription drugs that are made available to other countries at lower prices.”

Trauco says the White House plan has an international flavor, with the goal of allowing safe importation of certain prescription drugs to lower prices and reduce out-of-pocket costs for U.S. health consumers.

Unfortunately for consumers, there are plenty of obstacles to a clear path for lower prescription drugs imported from overseas.

“The $112 billion Chinese tariffs has not included cancer drugs imported,” she says. “Additionally, the U.S. pharmaceutical industry and regulators have argued importing drugs could threaten consumer safety.”

Congress will hear from U.S. state regulators, wholesalers, and pharmacists, acting as intermediaries for consumers, before drafting any proposals for the safe importation of prescription drugs already available in the U.S., Trauco says.

One consumer demographic that would likely benefit from a major push for prescription drug legislation would be U.S. seniors who depend on Medicare.

“Drug prices continue to skyrocket across the board and will probably be the focus of the most controversial bill to be debated,” says Terrence M. Ryan, CEO and founding partner at HealthChampion, in Chicago, Illinois. “If a new bill passes it would include capping what people on Medicare would pay for prescription drugs at $3,100 a year beginning in 2022. It would also cap increasing drug costs by forcing drug manufacturers to reimburse Medicare if the manufacturers increase their prices above inflation.”

Surprise medical bills. Medical experts view surprise medical bills as a contentious issue, with the public generally OK with the idea of hospitals and doctors receiving less money for services, as long as those bills come with a decided lack of “surprise.”

“Big insurance companies want a solution that allows them to decide how much physicians are paid for your care,” Trauco says. “Yet the physician groups are opposing this policy.”

So far, surprise medical bills have been limited to bills for out-of-network emergency care, Trauco says. “What we’re hearing is the definition of surprise medical bills should be expanded to include all medical bills that are greater than what a patient expected to pay,” she says.

A bill that would defuse the financial crisis triggered by surprise medical bills can’t come too soon, Ryan says.

“Surprise medical bills are a focus on Capitol Hill … as the Senate looks to pass the Lower Health Care Costs Act,” he says. “This new bill would attempt to eliminate the problem of surprise medical bills which today affects one in six patients who go to the hospital.”

According to Ryan, the bill aims to regulate what hospitals can charge for services and make those prices transparent to the patient prior to receiving any medical care.

“This happens today because hospitals charge for services based on what is called their ‘Charge Master,’” Ryan explains. “The chargemaster is a complex system of codes and fees that calculates what patients are charged and subsequently what discounts are given to them by using insurance,” he says.

The problem is that these chargemasters are kept under lock and key and very rarely made public. “So when a discount is provided through insurance it’s never clear what the discount amount is actually applied to. Hence, surprise medical bills always show up,” Ryan explains.

Health care transparency. Another major health care focus revolves around health care transparency, i.e., how health care companies can better share information with patients and families.

“When consumers aren’t in control of their own healthcare data it’s hard for them to make the most informed decisions when it comes to care, medication, treatments and lifestyle,” Ryan says. “To date, many of the large electronic medical record vendors have made it impossible to share a person’s medical history with them.”

“This system puts the EMR vendors, payers and providers in control, leaving the consumer in the dark,” he says.

One big issue that is linked to health care transparency that needs congressional action is increased pricing, across the board, says Ryan.

“From prescription drugs to procedure costs, it’s becoming increasingly difficult for people to acquire the best medical care possible,” he says. “When care becomes cost-prohibitive, the majority of our population is put at risk.”

A deeper dive — Related reading on the 101:

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