"I suspect that we are going to see exchange patients, fairly shortly, looking at their estimated costs on the ACA websites, and that could be a big," Holton stated. "I would anticipate seeing patients being concerned about that and patients calling in about that. So, at least developing some sort of response to what that might mean for patients."
A lot hinges on how lawmakers agree to fund the federal government. In addition to the potential expiration or continuation of enhanced premium tax credits, payers and providers are also wondering if telehealth flexibilities and the Hospital at Home program that expired on Oct. 1 will get another reprieve.
While many healthcare stakeholders are pushing for the extension of all these provisions, they also acknowledge that this is the problem. The appropriations bill will not provide a permanent answer for payers and providers.
"We bring up a lot to members of Congress and their staff that the long-term financial outlooks of our medical groups and integrated systems of care are not on a patchwork basis," Lattany said. "Also, this is the first government shutdown since 2019; is this going to be more common moving forward? Those types of interruptions are not great when you're thinking about long-term financial planning, as well as what your patient mix is going to look like every day."
Healthcare organizations like Holton's have already halted telehealth services without congressional action to ensure reimbursement. This means some patients can't access services the way that they want to and have for years now.
"This crisis -- and I think it can fairly be represented as a crisis -- demonstrates that healthcare reimbursement reform is needed across the board in a variety of different ways and that the piecemeal approach that has been taken, for example, with subsidies and Medicaid, are probably not going to address the fundamental problems that are resulting in increased healthcare costs, both for individuals and for the country writ large," Holton stated.
Claims reimbursement has been at a crossroads lately. CMS is trying to maximize savings in a nearly $5 trillion-dollar and growing industry, while healthcare providers are fighting for fairer rates. For example, CMS recently proposed a modest base rate hike of 2.5% in the 2026 Medicare Physician Fee Schedule after several years of rate cuts. The federal agency has yet to finalize rates for next year, but the American Medical Association has said the bump would not be enough to ensure physician practice sustainability after decades of underfunding.
AMGA is seeking a permanent fix to the telehealth flexibilities conundrum through legislation like the CONNECT Act, which would codify those telehealth waivers. However, Lattany doesn't see a permanent fix happening anytime soon.
"Cost is always the issue when you go to codify these things, and we currently exist in an environment where there are cuts to healthcare," she explained. "So, it's very unlikely."
Holton envisions this battle happening every two years if the extensions are approved as part of the government reporting.
"There needs to be comprehensive healthcare reimbursement reform that involves site-neutral payments, meaningful reform to MIPS and MACRA, insurance reform and PBM reform," she stated. "Until someone really takes a hard look at the global problems, we're just piecemealing along, going from crisis to crisis, unfortunately."