Telehealth, PBM reforms part of House year-end spending plan

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Telehealth provisions and pharmacy benefit manager (PBM) regulations are part of the year-end congressional spending bill.

The U.S. House of Representatives Appropriations Committee released the legislation known as H.R. 10445, the Further Continuing Appropriations and Disaster Relief Supplemental Appropriations Act, 2025. The bill is expected to be considered on the House floor this week, the committee’s announcement said.

The bill, known as a continuing resolution, has at least three emphases, said committee Chair Rep. Tom Cole (R-Oklahoma). It will allow President Donald Trump a voice in shaping the nation’s fiscal year 2025 spending plan, while avoiding a government shutdown and pumping $110 billion into disaster relief efforts in North Carolina, Georgia, Florida, Oklahoma, and the West.

Sorry, docs

The 1,547-page bill has a number of provisions regarding health care. Two things noticeably absent: a pullback of the looming 2.93% payment cut to physicians in the 2025 Medicare Physician Fee Schedule, and prior authorization reform, said Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association (MGMA). He called the legislation “a mixed bag for medical groups.”

MGMA is pleased with an extension of telehealth flexibilities through the end of 2026, increasing alternative payment model incentives to 3.53%, and extending the work floor used in Medicare geographic practice cost indices, he said.

“On the other hand, we are deeply disappointed that Congress failed to fully remedy the looming 2025 Medicare payment cut to physician practices,” Gilberg said in a statement. “Any cut, however fractional, is unacceptable.

“Finally, not including legislation to reform prior authorization, which has the support of a bipartisan majority of the House and Senate, nearly 500 endorsing stakeholder organizations, a CBO (Congressional Budget Office) score of zero, and little to no opposition, represents a huge congressional end-of-year failure and another win for big insurance to the detriment of America's patients,” he said.

Good for telehealth

The American Telemedicine Association (ATA) has described 2024 as the year of the Teleheath Super Bowl, and the super bowl is going right down to the wire, said Kyle Zebley, ATA senior vice president for public policy and executive director for ATA Action, the organization’s affiliated trade group.

“The extensions in this proposed legislation are very meaningful for countless Americans and would give our healthcare providers and hospital systems some certainty and the confidence needed to continue to invest in needed telehealth services,” Zebley said.

PBM reforms coming

CNN noted conservative Republicans were not happy about parts of the bill, and there could be repercussions in early 2025 when Trump takes office with Republican majorities in the Senate and House of Representatives.

At least two Democratic lawmakers praised parts of the bill. The legislation includes modest but important steps toward a health care system that favors families and seniors over profiteering corporations and middlemen, said Sen. Ron Wyden (D-Oregon), outgoing chair of the Senate Finance Committee.

The bill includes PBM reforms that the Senate Finance Committee has supported, Wyden said, crediting Committee Ranking Member Sen. Mike Crapo (R-Idaho).

“For too long, PBMs have operated with little scrutiny or accountability, and the result has been disastrous for seniors and families trying to afford their medicine,” he said. “These policies are an important start to bringing more common sense to the way Medicare and Medicaid pay for prescription drugs. I hope to build on PBM reforms in the days ahead, especially as it relates to independent community pharmacies that have suffered at the hands of these behemoth health care middlemen.”

However, the Pharmaceutical Care Management Association (PCMA), a PBM trade organization, ripped the budget resolution as a misguided $10 billion giveaway to Big Pharma.

The Hill reported the bill includes a ban on linking PBM compensation to a drug’s Medicare price. That practice could create an incentive for PBMs to steer patients to the highest cost drugs so PBMs can collect higher fees, or pocket money from discounted prices, the report said.

That so-called delinking policy for Medicare Part D will hike premiums for seniors by $13 billion, according to a statement by PCMA, which cited a study by University of Chicago Economics Professor Casey Mulligan.

“At the same time, employers will be dealt an unprecedented government intrusion into their commercial market contracting,” the PCMA statement said. “No longer will they have the final say on their contracts with pharmacy benefit managers (PBMs). Simply put, they will have fewer choices for providing patients access to needed medications.

“This bill does nothing to lower costs, nothing to improve pharmacy access, nothing to benefit patients,” the statement said.

Teaching clinicians

Rep. Frank Pallone (D-New Jersey), ranking member of the House Energy and Commerce Committee, highlighted five years of funding for the Teaching Health Centers program. That will “provide much-needed certainty that will allow programs to continue to invest in the educations of the next generation of health care providers. It includes significant funding increases each year, up to $300 million in fiscal year 2029, which is a 71 percent increase from current levels,” he said in a statement.

“It also increases funding for Community Health Centers, another key Democratic priority, so they can continue to provide lifesaving care to millions of Americans each year,” he added.