A $19k Colonoscopy, CR PBM Provisions, & 2023 Hospital Spending

Hey all,

I was encouraged by the PBM provisions in the CR, not about the 40% increase in spending that has no business in a ‘continuing resolution’. It is amazing to me that Congress can’t do something good without layering on a bunch of unrelated spending to grease the wheels. Enjoy the rundown!

Best,

Jacob

The $19,000 Colonoscopy Bill in Chicago (KFF)

Tom Contos was charged $19,000 for a diagnostic colonoscopy at Northwestern Memorial Hospital, nearly triple the original estimate. Billing issues stemmed from coding for two procedures due to polyp removals, with high rates negotiated by his insurer, Aetna. Despite appealing, Contos was left with an out-of-pocket cost of over $4,000. These “non-profits” show their charitable spirit by not paying taxes—though patients might wish that charity extended to their medical bills. Full Article.

PBM Provisions in the Continuing Resolution (Cost Curve)

Brian Reid highlights significant PBM reforms in Congress’s year-end spending bill, including bans on Medicaid spread pricing, requirements for rebate transparency and pass-throughs, and stricter oversight of drug pricing practices. Section 227, delinking PBM remuneration from drug prices, faces strong industry opposition. The bill also tackles patent thickets and proposes new incentives for drug development. Reid underscores the sweeping implications for PBMs, noting their resistance to transparency measures that could reshape the healthcare landscape. Full Article.

Hospital Spending Surged in 2023 (Axios)

U.S. hospital spending grew 10.4% year-over-year in 2023, reaching $1.5 trillion—the fastest growth since 1990—driven by higher demand for medical procedures and increased outpatient care among Medicare patients, while prices remained stable. Hospitals accounted for 31% of the nation’s $4.9 trillion health expenditures, which rose 7.5% overall. Private health insurance spending surged 13%, contributing to increased revenues, as policy momentum builds to curb hospital costs amid rising scrutiny of private equity ownership in health systems. Full Article.