After several years of back-to-back, complex health care legislation, stakeholders still believe there is work to be done while allowing in-progress initiatives to mature.
The upcoming session will be a non-budget year in which leaders have urged their members to prioritize emergency legislation and expedite a move that would give the 125-member General Assembly up for election more time to campaign.
Sen. Ed Charbonneau, R-Valparaiso, doesn’t expect the same big legislation of 2023. As Chairman of the Senate Health and Provider Services Committee, he has authored, co-authored and sponsored several hefty bills, including public health financing, pharmacy benefit managers (PBMs) monitoring and price monitoring in five prominent not-for-profit hospital systems.
I think a lot of times, we go back and make changes before the original thing we did has a chance to show whether we made the right decision the first time, Charbonneau said. It will probably be a good session to see how we do (and) how they play.
But others see the need for constructive changes sooner rather than later, including the very hospitals affected in the 2023 session.
Brian Tabor, the president of the Indiana Hospital Association, said the organization is working on a proposal to address the interrelated issues related to the state’s Hospital Fee Assessment and Medicaid rates. Hospitals claim very low they must shift costs to private insurers, thus raising prices.
We have a lot of hospitals across the state that are struggling a lot right now and we can’t wait until the budget session to move this forward, Tabor said.
Tabor said such measures would not require reopening the budget but would still require legislation to change existing law. However, after a $1 billion Medicaid accounting snafu earlier this week, meeting Medicaid rates will be a tough sell in 2024. But Tabor said the entities’ proposal includes a state assessment of plans to managed care, which can be used to leverage federal funding and offset Medicaid costs along with hospital costs.
Whatever happened to the consumer database?
The Indiana Department of Insurance (IDOI), a relatively small agency, has some major responsibilities when it comes to legislative priorities for containing growing health care costs. An agency spokeswoman declined an interview request and did not respond to an emailed list of questions issued on Friday, Dec. 15.
Following the 2020 law, the department must develop and maintain a All Payers Claims Database (APCD), which will collect claims data from various health payer sources including insurers, health maintenance organizations, PBMs and others into one consumer-facing dashboard.
… we think it’s helpful to see a big-picture view of all health care and health care claims, IDOI Commissioner Amy Beard told the interim Health Care Administration Task Force in August.
But implementing the much-anticipated dashboard is a lengthy process and it’s uncertain how much of an impact it will have on healthcare costs.
IDOI commissioned Onpoint Health Data to a four-year, $8.2 million contract to design and maintain the APCD, which appears to be nearing the launch date, based on a review of three meetings’ worth of materials that include demo websites and contract data.
At the last APCD advisory board meeting in September, IDOI’s presentation included previews of what the website might look like and Jonathan Handsborough, APCDs executive director, reported that most submitter registrations had been completed.
Also in August, during a State Budget Committee meeting, Beard detailed fines for health payers who do not submit claims data to the APCD.
The civil penalty ensures appropriate accountability for reporting to the APCD and is essential to ensuring that the APCD collects as much data as possible to achieve its statutory goals, such as identifying health care needs and informing policy, Beard told the committee. … The department is currently working closely with health payers to ensure their knowledge of submission requirements and procedures as part of the implementation of this new program and expects that compliance with these requirements will be high.
The proposed civil penalty would start at $100 per day, per violation for the first 30 days before increasing to $1,000 per day, per violation.
He also told committee members that IDOI has allocated $5.5 million in their budget for APCD.
But while one Hoosier might compare the cost of hip replacements at hospitals, not everyone is convinced it will make a difference in lowering prices. Charbonneau noted that employers, through company insurance policies, have paid most of the costs and that Hoosiers choosing between options are likely to consider other factors.
If I had insurance, I wouldn’t pay so much attention to the cost, he said. If I have a hospital that I have right in the area, that is convenient for me to go there.
Consumers are more likely to travel further for a cheaper hip replacement if only their employers or insurers see the cost savings, he said.
Tabor, a member of the APCD advisory board, said the project has potential as long as it is truly comprehensive. He noted that Onpoint also developed the Maines APCD and includes reams of information, including prescription drugs.
What we don’t need, I think, is another database that’s just about price, Tabor said. When we started this discussion in 2020, someone thought, We just need hospital prices there. We have now; that can be used (elsewhere) I also see (the APCD) as a tool to not only compare price but to really help a consumer navigate cost, quality and what can be a complex system of care health
However, he flagged the potential for a legal challenge, noting that federal law prohibits states from regulating some large insurance plans and they may not be legally compelled to submit to the APCD.
Other ongoing projects
In addition to the APCD, the IDOI has at least two other legislative obligations: regulating PBMs and developing a tracking system for prices in five nonprofit hospital systems, comparing those to Medicare’s 285% rate.
For the latter, IDOI reported in August that it issued a request for services to find a third-party vendor and that hospitals are required to submit data by March 2024. By November, the calculations should be completed with Medicare’s comparison for a final report to the Health Care Cost Task Force in December.
Also at the August meeting, Beard told the committee about ongoing efforts to license PBMs and audit pharmacy claims with a semiannual report. Lawmakers spent a significant amount of time in the 2023 legislative session trying to understand the costs and benefits of PBMs, which ultimately come down to a reporting system to calculate claims and dictate that rebate savings be passed on to consumers.
Healthcare in 2025 and beyond
Tabor said he hopes continued data collection efforts will help leaders take a more nuanced and thoughtful approach to health care, even if those efforts won’t happen in 2024.
When we get to 2025, and if we need legislation, we can focus on legislation that empowers market-based solutions. I think we have a lot of transparency in the hospital but where we don’t have (transparency) is how the premiums are actually calculated, Tabor said. While I don’t like all of the policies that have been put in place in the past, I think it’s wise to take a deeper look at making policy decisions that are data-driven and not cycled from session to session.
Additionally, smaller pieces of legislation for 2024 may address nursing workforce shortages but generally not the burdensome pieces of legislation from 2023.
I think if we take a breath and we look at some of that data, we look at what’s being collected, I think we can get to smarter decisions in 2025 and beyond, Tabor said.
Charbonneau did not rule out the possibility of some health care legislation, saying he is considering a bill to monitor the 340B Drug Pricing Program, which allows some cash-strapped hospitals to buy expensive pharmaceuticals at a discount . However, Charbonneau wanted to know which hospitals used the program and whether some of the states serving wealthier populations were benefiting from poorer systems.
I talked to Dr. (and Indiana US Rep. Larry) Buschon about it recently. He’s been trying to deal with it at the federal level and they haven’t been able to do much, Charbonneau said. It appears to be a well-intentioned program that has a kind of life of its own and has gone far in mission goals.
He emphasized that he did not want to imply impropriety or any illegal activity, just a larger review of the current program to increase transparency.
As a former hospital CEO with a business background, Charbonneau said he felt frustrated by the slow adoption of cost-saving measures at the state level when it came to increasing quality and affordability in health care.
Over the years, this has become very frustrating. We just don’t seem to be making progress in the health care area, Charbonneau said.
He noted that the Indiana Chamber of Commerce often ranked low state in terms of health care costs, which he said hurts the Indiana Economic Development Corporation’s ability to recruit companies to the Hoosier State.
We have work to do and we need to get there, Charbonneau said. But it’s painstakingly slow, it seems. But it will work the more attention we pay to it, the more publicity we get. The more of our 6.8 million Hoosiers we can educate on all of this, the better.
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