Doctors and hospitals helping the government to experiment with better ways of paying for health care are pleading with the Trump administration to ditch stricter rules that could expose them to losing Medicare payments sooner.

The new proposed rules — which the White House’s Office of Management and Budget is currently reviewing — crack down on so-called Accountable Care Organizations (ACOs), which are health providers that band together to try to provide better and less costly care for seniors on Medicare. These ACOs need to have more skin in the game, according to administration officials, who say the providers have cost the government money instead of saving it.

The ACOs strongly disagree — and they’re trying to make their case before the rules are finalized, probably early next month. They even have their own association to do the advocacy.

“I think their motivations are in the right direction,” said Clif Gaus, CEO of the National Association of ACOs. Gaus was referring to the Centers for Medicare and Medicaid Services, which issued the proposed rule. “I just think they don’t appreciate the complexity and the time that’s needed.”

The conflict exists even around a health-care goal pretty much everyone agrees on — the need to reward providers for the quality of the care they provide instead of just blindly paying for services that may or may not be what patients need most. It’s a daunting objective, requiring an entirely new system of incentives for primary-care doctors, specialists, hospitals and clinics to coordinate care and work together.

The Trump administration — just as the Obama administration before it — has tried to tackle the problem through different experiments in the massive Medicare program. One of them involves ACOs, in which groups of providers are rewarded with bonuses if they hit savings targets laid out by the government. Under current rules, the ACOs that miss their savings targets don't have to pay back Medicare for six years. Under the proposed new rules, they'd have to start paying back Medicare in just two years.

Commercial insurers have also moved in that direction, working to set up their own ACOs. About 17 million people currently get their care from a Medicare ACO, and another 8 to 14 million people get care from a privately run ACO, according to an analysis by Oliver Wyman.

But at least in the Medicare program, ACOs have largely failed to reach their savings targets. Officials have pointed to findings by consulting firm Avalere that ACOs cost the agency $384 million in their first four years.

“The time has come to put real ‘accountability’ in Accountable Care Organizations,” CMS Administrator Seema Verma wrote in a piece published by Health Affairs in August.

But according to Gaus, providers already have plenty at stake without making the system even harder on them. It’s costly for doctors and hospitals to even set up an ACO, he argues. If the administration requires them to take on financial risk in just two years instead of six years — as it’s proposing in the new rules — it could discourage more providers from participating and cause many current participants to drop out.

Gaus met yesterday with staff for Joe Grogan, who handles health-care policy at OMB (The Health 202 profiled Grogan a year ago.) Shortly before Thanksgiving, Gaus said, he met with Verma. Also present at that meeting were representatives from the American Medical Association and the American Hospital Association, which also oppose the stricter rules.

“We’re on pins and needles as to whether we’re going to have a compromise,” Gaus told me.

Gaus’s group also plans to release a report Wednesday morning to counter estimates that its members have cost Medicare dollars. Instead of considering how ACOs fell short of their savings targets, the report looks at their spending on patients compared with spending on a control group of patients not in ACO programs.

There are a few things in the potential new rules the ACOs do like. The administration is proposing to extend contracts with the organizations from three years to five years and has suggested implementing a small risk-adjustment program, which can help protect ACOs from large losses.

But there’s much more they don’t like. Under the proposal, the organizations would share only in savings for the first two years and after that would have to start paying Medicare back if they don’t meet the targets. And providers could retain just one-quarter of the savings, instead of half the savings.

“Two years is too short, and 25 percent of savings is a nonstarter,” Gaus said.


AHH: The Supreme Court announced it would not review lower-court decisions blocking efforts by Kansas and Louisiana to end public funding for Planned Parenthood, a move that “showed a split among the panel’s conservatives and might indicate a reluctance by the majority to take on controversial cases at a time when the Supreme Court is in the political spotlight,” our Post colleague Robert Barnes reports.

Three justices who wanted to take up the case cited the issue of abortion as the reason their colleagues opposed getting involved. “What explains the court’s refusal to do its job here? I suspect it has something to do with the fact that some respondents in these cases are named ‘Planned Parenthood,’ ” Justice Clarence Thomas wrote, who "rebuked his colleagues for what he said was a dodge," Robert writes. 

Two justices nominated by Republican presidents, Chief Justice John Roberts and Justice Brett Kavanaugh, joined the four liberal justices in declining to review the two cases. "The cases, which the court has been pondering since September, have to do with whether individual Medicaid recipients who receive services from providers such as Planned Parenthood have a right to challenge a state’s decision to cut off funding to the providers," Robert writes. "Five regional courts of appeal have said they do, while one has said they do not. That is the kind of split that normally prompts the Supreme Court to act."

OOF: There have been a record number of cases of the rare polio-like illness acute flaccid myelitis this year, according to the Centers for Disease Control and Prevention. There are now 158 confirmed cases of AFM, up from 149 cases in 2016 and 120 cases in 2014. The number of cases in 2017 and 2015 were much lower.

“It’s still not clear what’s causing the kids to lose the ability to move their face, neck, back, arms or legs,” the Associated Press’s Mike Stobbe reports. “The symptoms tend to occur about a week after the children had a fever and respiratory illness.”

“This year’s confirmed cases are spread among 36 states. The states with the most are Texas, with 21, and Colorado, 15,” he adds. “But it’s not clear if the state tallies truly represent where illnesses have been happening. For example, the numbers in Colorado may be high at least partly because it was in the scene of an attention-grabbing 2014 outbreak, and so doctors there may be doing a better job doing things that can lead to a diagnosis.”

OUCH: The CDC is back this holiday season with a devastating warning for cookie-dough lovers: Just say no.

It's a year-round warning that the health agency pushes in particular around this time every year, our Post colleague Lindsey Bever reports.

The CDC is warning people not to eat unbaked cookie dough because the raw flour may be contaminated with E. coli and raw eggs are a known carrier of salmonella bacteria, Lindsey reports.

“Both bacteria are killed in the cooking process, but contaminated food that is not cooked or is undercooked has been known to make people ill,” she adds. “In recent years, public health experts have become vocal about raw flour, too. The CDC reported that in 2016, more than 60 people across the United States were sickened with E. coli from raw flour.”

That means people should avoid taste-testing batter or dough for cookies, cakes, pies, breads and pizza crusts, per the CDC. But, Lindsey writes, “not all public health experts agree that raw cookie dough is dangerous.”


— In a video posted to his Twitter feed, former President Barack Obama urged people to sign up for health coverage through his landmark health-care law. There are just five days left, including today, before open enrollment for 2019 Obamacare plans closes through

"Well it’s that time of year again. The time my team tries to get me to reference some viral trend or otherwise make a fool out of myself in the name of encouraging more young people to sign up for health insurance — but not this year,” Obama says in the video message.

“You know why? Because this year is different. Young people have stepped up like never before … So this year I’m giving it to you straight. Sign up for health insurance on before the deadline on December 15.”

The former president’s push comes amid lagging enrollment after the first five weeks of sign-ups. The group Get America Covered, co-founded by Joshua Peck, who served as's chief marketing officer under the Obama administration, estimates sign-ups will drop by 800,000 people at the end of the enrollment compared with last year.


— Rep. Kevin Brady (R-Tex.), chairman of the House Ways and Means Committee, released a revised version of the House’s tax relief package, which includes a delay of several health-care related taxes.

The plan would delay the tax on medical devices for five years, postpones the health-insurance tax for two years and delays the so-called "Cadillac tax" on high-cost health plans for another year. The plan also permanently repeals the tanning tax.

“This package delivers bipartisan relief from some of Obamacare’s most egregious taxes including ones that stifle innovation, reduce jobs, and increase the cost of families’ health insurance,” Brady said in part of his statement on the revamped package.

“But Monday’s move may not get Mr. Brady and House Republicans closer to turning their ideas into law,” the Wall Street Journal’s Richard Rubin reports. “The measure will need support from at least nine Senate Democrats, who have been opposed to his proposals… If lawmakers can’t agree on a year-end tax bill, all of these items would fall to the next Congress, which begins in January with Democrats holding more leverage because they will control the House.”


— The Trump administration will consider Oklahoma’s request to implement work requirements for its Medicaid beneficiaries, The Hill’s Nathaniel Weixel reports.

The state’s plan would require “able-bodied” individuals in the Medicaid program to work for 80 hours a month starting in February. If they fail to meet these requirements for three months, they will be dropped from coverage until they meet them.

The Trump administration also already approved waivers to impose requirements in Arkansas, Indiana, Kentucky, New Hampshire and Wisconsin.

Oklahoma estimates about 6,000 people would be affected if the requirements were imposed. “If approved, Oklahoma would join Wisconsin as the only other state that did not expand Medicaid under ObamaCare but still chose to impose work requirements on Medicaid recipients,” Nathaniel writes. “Oklahoma’s eligibility requirements are also some of the strictest in the nation.”

— Here are a few more good reads: 

The funding pledge comes following news reports that in September the Trump administration ordered NIH scientists to stop buying new human fetal tissue.
U.S. lawmakers have reached an agreement on the Farm Bill that drops a proposal to tighten food stamps restrictions backed by President Donald Trump, and are looking to vote on it this week, according to congressional staffers.
Migrant children are not supposed to be detained for more than 20 days in unlicensed facilities. Texas may be able to license two family detention centers, in Dilley and Karnes County, after an appeals court ruling last week.
Texas Tribune
Public Safety
The alarms terrified employees at the Bethesda installation and led to a massive police response.
Dan Morse
Study says method saw an annual average compound growth rate of 261 percent from 2015 to 2017.
Lisa Rapaport
Women seeking abortions in Nashville will now have to travel hours outside the city after the only clinic offering abortions in the region has temporarily halted its services.
Associated Press


  • The House Energy and Commerce Subcommittee on Health is scheduled to hold a hearing on implementing the 21st Century Cures Act.
  • The Patient-Centered Outcomes Research Institute board meets to consider new research proposals, including treatment for anxiety and depression in expectant and new mothers.

Coming Up

  • The House Energy and Commerce Committee Subcommittee on Oversight and Investigations is scheduled to hold a hearing on "Examining the Availability of SAFE Kits at Hospitals in the United States" on Wednesday.
  • The Heritage Foundation holds an event on "Defending the Rights and Wellbeing of Children Today" on Wednesday.
  • The House Oversight and Government Reform Subcommittee on Healthcare, Benefits and Administrative Rules holds a hearing on “Exploring Alternatives to Fetal Tissue Research” on Thursday.
  • Medicaid and CHIP Payment and Access Commission holds a public meeting on Thursday and Friday.

— Justice Brett Kavanaugh avoids controversy in first cases on the Supreme Court:

— Who Trump wants in his inner circle: