Weekly Spotlight

Well, that was… fun.

SHP doesn’t have a lot of wisdom to impart. Today’s digest features a smattering of offerings from a variety of sources, prognosticating on the future of various health policies. We have highlighted a few such articles on topics of interest to this readership but other publications abound.

We’re not offering any unique insights as yet but will continue to monitor the horizon for thoughtful ruminations from those more informed. Instead, I’ll offer a wisdom famously shared by former US Secretary of Defense, Donald Rumsfeld:

There are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns—the ones we don’t know we don’t know. And if one looks throughout the history of our country and other free countries, it is the latter category that tends to be the difficult ones.

In my opinion, just about everything that has been written making predictions about the second Trump administration falls into the category of known unknowns. We know these are things we have to keep an eye on, but I’d argue that none but a few in the inner circle may have a reasonable idea of what may happen next. If past is precedent, even those in the know may not know.

Other Regulatory News

Centers for Medicare and Medicaid Services (CMS)

PFS and OPPS Final Rules are Out

CMS has published final rules for the CY 2025 Physician Fee Schedule and Hospital Outpatient Prospective Payment System. Hospitals will get a pay bump. Provider pay cuts remain. CMS has finalized a new payment policy that more than doubles the Medicare reimbursements hospitals receive for performing coronary computed tomography angiography (CCTA) exams. CMS moved CCTA into a higher ambulatory payment classification (APC). CCTA revenue codes 75572, 75573 and 75574 all now fall under APC 5572. This update raised the CCTA payment rate from $175 all the way to $357.13.

#Provider, #Hospital

CMS Resources on Medicare Prescription Payment Plan

CMS has released a public-facing webpage, available at, that includes information about the Medicare Prescription Payment Plan and an interactive wizard to help Part D enrollees determine if the payment option might help them. In addition to the public-facing webpage, CMS has developed multiple resources to support education and outreach.

#Drug, #Patient

OIG report finds holes in hospital price transparency compliance

HHS OIG Finds Many Hospitals are not Publishing Their Prices in accordance with the Price Transparency Law.

#Hospital

DSH payments are back at the Supreme Court: 3 things to know

A hospital industry challenge to how the CMS computes Medicare disproportionate share hospital payments is up for consideration at the Supreme Court. While a decision in the multibillion dollar case is months away, the outcome will have ramifications for other pending cases involving DSH, a program to compensate hospitals that treat disproportionate shares of low-income patients.

#Hospital

Medicare Advantage

2 Midnights Rule, a Boon to Providers – Starting this year, private Medicare plans have to cover their members’ hospitalizations at the higher inpatient rate if their doctors predict they’ll have to stay beyond two midnights.

Prior Auth Reform the Docs Can Endorse – These are the simple changes in the prior authorization process that physicians support:

• Uniform procedures among payers — 51%
• Greater automation on providers’ end — 19%
• A central database of procedures — 12%
• Other — 9%
• More e-filing/e-delivery options on payers’ end — 8%

MA plans Sue Over Star Ratings – UnitedHealth Group, Blue Cross Blue Shield of Louisiana, Humana, Centene, and Elevance have each filed lawsuits challenging the way Medicare graded the quality of their Medicare Advantage plans.

MA Insurers Soar on Trump Election Win – U.S. health insurers focused on the Medicare market jumped on the expectation that the second Trump administration will pay higher rates to companies that provide private versions of the U.S. health program for seniors.

#Hospital, #Patient, #Payer, #Provider

Food and Drug Administration (FDA)

How will Trump’s election change the FDA? History yields some clues

Much will depend on Congress — and agency staffers

#Device, #Drug

No Evidence “Right to Try” Saved ‘Thousands’ of Lives

Former President Donald Trump has boasted that his “Right To Try” law, boosting terminally ill patients’ access to potentially lifesaving medications not yet approved by the Food and Drug Administration, has saved lives.

#Drug, #Patient

Health and Human Services (HHS)

Trump States He’ll Let RFK Jr. ‘Go Wild’ On Health, Food And Medicines

His statement signals his intentions to tap Kennedy Jr. to determine what happens with health and science policy, operations and research in the U.S. government.

#All

Hill Happenings

MEDPAC November Meeting

Sessions and links to presentations:

Reforming physician fee schedule updates and improving the accuracy of payments

Considering the participation bonus for clinicians in advanced alternative payment models

Structural differences between the PDP and MA–PD markets

Workplan: Assessing Medicare Advantage provider networks

Medicare’s coverage limits on stays in freestanding inpatient psychiatric facilities

#All

18 clinicians taking legislative seats

Fifteen physicians and three nurses have been elected to congressional seats, with three additional races still too close to call, Medscape reported Nov. 7.

#All

Hospitals Push Back on Cassidy / Hassan Site Neutral Bill

The American Hospital Association argues that this framework would limit critical hospital-based care, leading to increased wait times and decreased access to care for patients.

#Hospital

Notable Notes

TTVR with Evoque device linked to substantial benefits after 1 year

Treating severe tricuspid regurgitation (TR) with the Evoque transcatheter tricuspid valve replacement (TTVR) system from Edwards Lifesciences is associated with significant improvements in symptoms and quality of life (QOL) after one year.

#Device

Cardiologist behind EARLY TAVR explains how proactive treatment improves patient outcomes

To take a deeper dive into the results and what they mean, Cardiovascular Business spoke with Philippe Genereux, MD, medical director of the structural heart program at Morristown Medical Center, and principal investigator of EARLY TAVR. He explained why intervening early on patients with asymptomatic severe aortic stenosis (AS) leads to better outcomes.

#Device, #Patient, #Provider

Robotic aortic valve replacement may offer certain benefits over TAVR

Using advanced robotics to guide surgical aortic valve replacement (SAVR) procedures may be a safe and effective alternative to transcatheter aortic valve replacement (TAVR) in low- and intermediate-risk patients with severe aortic stenosis (AS), according to a new analysis published in The Annals of Thoracic Surgery.

#Device, #Patient, #Provider

How four partnerships are advancing cutting-edge cancer care

Partnerships between research institutes, academic medical centers, universities and technology companies are tackling cancer care.

#Hospital, #Patient, #Provider

Why health equity’s goal shouldn’t be outcomes

Health systems across the nation are working to improve health equity for patients, but many systems approach the issue with an outcomes-focused lens, which may actually make equity harder to achieve.

#Patient

SCAI shares STEMI recommendations for cardiologists and cath labs

The Society for Cardiovascular Angiography and Interventions (SCAI) has published a new consensus statement on how to best manage patients with ST-elevated myocardial infarction (STEMI).

#Provider, #Patient

10 states with the most cardiologists per capita

Nearly 50% of all U.S. counties do not have a single practicing cardiologist.

#Provider, #Patient