Healthcare reform is coming. CFOs are already trying to gauge the impact of 4 major policies.

President-elect Donald Trump's agenda for his second term could bring significant changes to the healthcare industry, focusing on deregulation, market competition and accessibility.

The incoming administration is likely to take an incremental approach to cost cutting, and could significantly influence the outcomes of several pending health-related lawsuits, potentially reshaping key aspects of healthcare policy. Many Biden-era regulations may be targeted for reversal using a combination of the CRA, new rules, legislative efforts and executive orders.

Here are some of the top impact drivers we're tracking:?

1. Removal of ACA enhanced subsidies: ACA subsidies are set to expire at the end of 2025, which could increase premiums for enrollees by more than 75% and leave millions uninsured. The loss of commercially insured patients and increase in uninsured or Medicaid patients could lead to significant revenue loss and increased bad debt for many providers. Congress is actively working to remedy this before the current legislative session ends with a one-year extension.?
2. Changes to Medicare Inpatient Only list: The previous Trump administration took steps to eliminate the Inpatient Only (IPO) list of procedures, which Medicare pays for only when performed in a hospital inpatient setting. While these initial efforts were ultimately rolled back, phasing out the IPO — or weakening it by removing large numbers of its covered procedures — is another area the new Trump administration may focus on. If fewer procedures require an inpatient setting, hospital providers will have to work even harder to justify care plans and defend their inpatient treatment decisions in order to receive fair payment.?
3. Personnel changes driving volume to Medicare Advantage: With Dr. Mehmet Oz set to serve as the new CMS administrator, providers and advocacy groups have raised concerns about the potential expansion and prioritization of Medicare Advantage plans, for which Dr. Oz has previously expressed support. These plans are notorious for significantly increasing providers’ administrative burden and denying claims twice as much as commercial plans.?
4. Expanded use of site-neutral payments: Site-neutral payments, which would require Medicare to pay the same rate for services delivered regardless of the care site, have already been enacted for certain off-campus provider-based hospital outpatient departments (HOPDs). However, site-neutral payments do not account for differences across sites of care, including hospitals’ 24/7 care and higher costs due to comprehensive licensing, accreditation and regulatory requirements. A mid-sized health system could lose $5 million or more annually if site-neutral payments are implemented, one of the reasons Ensemble and advocacy groups like the AHA continue to reject calls for the implementation of additional site-neutral payment policies for HOPDs.??

A partner through the uncertainty?

With so many unknowns surrounding the new administration’s impact on healthcare, one thing remains constant — we’re proactively looking ahead to calculate how these shifts will impact the finances of our provider partners and we’ll continue tracking changes as they arise, working to mitigate harm at every step of the way.?

Regulatory Updates?

• Medicare has issued a new Medicare Change of Status Notice which must be delivered to the patient no later than 4 hours before discharge and as soon as possible after a status change to observation when the patient is in the hospital for more than 3 days but was inpatient for less than 3 days and meets other eligibility requirements. Learn more here and here.?

• CMS has announced that as of April 1, 2025, home health agencies will not have claims rejected related to telehealth G codes (G032, G0321, and G0322) which overlap with an inpatient, skilled nursing, or swing bed stay. These services are non-payable reporting items, so they do not create any duplicate payment. Learn more.?

• Ambulatory Surgical Center Payment Updates for October 2024 include new CPT and HCPCS codes as well as updates for drugs, biologicals and skin substitutes. Learn more.?

• A Massachusetts behavioral health organization has agreed to pay up to $6.5 million to resolve allegations that the health system violated the federal and Massachusetts False Claims Act and Anti-Kickback Statutes. Learn more.?

• A former hospital CEO in Texas has agreed to pay $5.3 million to resolve allegations under the False Claims Act involving illegal payments to physicians for laboratory referrals in violation of the Anti-Kickback Statute and for causing the submission of false claims for laboratory testing to Medicare, Medicaid and TRICARE. Learn more.?