July 2025

     In this issue we feature: 

• Driving Change in Washington: June 2025 Fly-In Recap
• Congress Passes Budget Reconciliation; How H.R. 1 Will Affect LUGPA Members
• LUGPA Supports Bipartisan Bill to Protect Access to Cancer and Complex Therapies Act
• LUGPA Comments on CMS Drug Pricing Guidance
• Major Insurers Commit to Prior Authorization Reforms; LUGPA Supports Effort to Reduce Administrative Burden
• LUGPA Endorses the Medicare Beneficiary Co-pay Fairness Act
• LUGPA Supports Reintroduction of the Improving Seniors’ Timely Access to Care Act

Driving Change in Washington: June 2025 Fly-In Recap

In June, LUGPA physicians and administrators held over 20 meetings on Capitol Hill, engaging with key members and staff from the House Ways and Means, Energy and Commerce, and Senate Finance Committees. These strategic discussions highlighted the urgent challenges facing independent urology and elevated LUGPA’s top federal priorities during a critical window for congressional action.

Advancing Medicare Physician Payment Reform: LUGPA called for immediate support of H.R. 879, the Medicare Patient Access and Practice Stability Act, to prevent further cuts to Medicare physician reimbursement. This bipartisan legislation would not only reverse the 2.83% cut that took effect on January 1, 2025, but also provide a 2% positive adjustment to reflect rising practice costs and lay the foundation for permanent, inflation-based updates.

Restoring In-Office Dispensing (IOD) Rights: H.R. 2484, the Seniors’ Access to Critical Medications Act, was a major focus. LUGPA urged lawmakers to restore the flexibility that allowed practices to mail Part D medications—a critical service for patients facing transportation or mobility barriers. Lawmakers expressed strong interest in the bill’s GAO study provision, safety standards, and emphasis on caregiver access.

Protecting Access to Complex Therapies: LUGPA advocated for a fix to the Inflation Reduction Act’s unintended impact on physician-administered drugs. The Protecting Patient Access to Cancer and Complex Therapies Act would maintain ASP+6% reimbursement for Medicare Part B drugs and shift cost savings to manufacturers, not providers. This solution would protect patient access to vital therapies without increasing taxpayer or patient costs.

Promoting Site-Neutral Payment Reform: LUGPA continued its push for site-neutral payment policies that level the playing field between hospitals and physician offices. Lawmakers agreed that aligning payments for identical services can reduce unnecessary consolidation, support patient choice, and strengthen Medicare’s fiscal sustainability.

Looking Ahead: Post-Reconciliation Strategy: While many offices were preoccupied with a sweeping reconciliation package, lawmakers and staff emphasized that once negotiations conclude, healthcare bills—including those addressing reimbursement and site-neutrality—will begin moving again. LUGPA is actively laying the groundwork for reengagement and positioning its priorities for inclusion in post-reconciliation legislation.

Key Takeaway: Independent urology practices face increasing headwinds—from reimbursement instability to workforce shortages and challenges to accessing drugs. LUGPA’s June Fly-In ensured these issues remain a visible and urgent part of the national policy conversation. Continued engagement will be critical as legislative momentum resumes in the months ahead.

Congress Passes Budget Reconciliation; How H.R. 1 Will Affect LUGPA Members

On July 3, 2025, the House passed H.R. 1, the “One Big Beautiful Bill Act,” by a 218–214 vote via budget reconciliation, following Senate approval. Awaiting the President’s signature, the bill impacts Medicare, Medicaid, the Affordable Care Act (ACA), health savings accounts (HSAs), and rural health support. This summary focuses on provisions affecting LUGPA members, highlighting LUGPA’s key role in securing the Medicare reimbursement fix.

LUGPA’s Critical Advocacy

LUGPA’s relentless advocacy ensured the 2.5% PFS increase was readded to H.R. 1. Through strategic engagement during the June 2025 fly-in, LUGPA successfully influenced lawmakers to prioritize this critical relief for independent urology practices, reinforcing its leadership in reimbursement policy.

Key Provisions:

Medicare

• PFS Payment Increase (Sec. 71202): A 2.5% Physician Fee Schedule conversion factor increase for 2026 provides short-term financial relief for urology practices. LUGPA’s advocacy during the negotiations and at our June 2025 Capitol Hill fly-in was pivotal in reintroducing and securing this provision after concerns from the Senate Byrd Bath, although long-term reform is still needed.
• Orphan Drug Exemption (Sec. 71203): Exempts orphan drugs from Medicare price negotiations, thereby supporting access to urologic treatments.

Medicaid

• HCBS Expansion (Sec. 71123): Expands home and community-based services, potentially increasing urology referrals.
• Eligibility Redeterminations (Sec. 71107): 6-month eligibility checks for non-disabled adults start January 1, 2027, potentially reducing patient volumes.
• Community Engagement Requirements (Sec. 71119): Mandates 80 hours per month of work or volunteering, which may limit enrollment.

Affordable Care Act (ACA)

• Stricter eligibility verification, exclusion of certain legally present immigrants (e.g., DACA recipients), and a shortened open enrollment period (to December 15) are expected to reduce ACA enrollment by up to 3.1 million in 2026, impacting patient coverage.

Tax-Related Health Provisions

• HSA Expansions (Sec. 71306–71308): Starting in 2025, HSAs will cover telehealth, bronze/catastrophic plans, and direct primary care, potentially boosting demand for urologic procedures.
• Premium Tax Credits (Sec. 71305): Removes low-income exemption for repaying excess credits, which may reduce ACA enrollment.

Rural Support

• Rural Health Transformation Program (Sec. 71401): Allocates $50 billion (2026–2030) to support rural urologists enrolled in CHIP, Medicare, or Medicaid.

Implications

• Reimbursement: The 2.5% PFS increase offers temporary relief, but LUGPA’s continued advocacy is essential for long-term reform.
• Patient Access: HCBS and rural support may enhance access to urologic care, but Medicaid and ACA changes could reduce patient volumes.
• Affordability: HSA expansions improve payment options; premium tax credit changes may limit coverage.
• Rural Practices: Rural funding supports urologists but depends on state allocation.

H.R. 1 presents both opportunities (reimbursement relief and rural support) and challenges (reduced ACA and Medicaid enrollment) for LUGPA members. LUGPA’s advocacy helped to secure the critical PFS increase, but ongoing efforts are vital to ensure sustainable urology practice and patient access.

LUGPA Supports Bipartisan Bill to Protect Access to Cancer and Complex Therapies Act 

LUGPA strongly supports the Protecting Patient Access to Cancer and Complex Therapies Act, which was reintroduced on July 9 by Representatives Greg Murphy, M.D. (R-NC), Adam Gray (D-CA), and Neal Dunn, M.D. (R-FL). This important bipartisan legislation seeks to protect Medicare beneficiaries’ access to physician-administered drugs for cancer and other complex conditions by stabilizing the Medicare Part B reimbursement model. 

The bill addresses a growing concern stemming from the Inflation Reduction Act, which authorized Medicare to negotiate drug prices. These negotiations could lead to reimbursement cuts of up to 50%, jeopardizing the current ASP+6% model (already reduced to 4.3% under sequestration). Without reform, these reductions could compromise the ability of independent practices to deliver complex therapies in-office, leading patients to higher-cost hospital settings and reducing access to timely care.

To mitigate these risks, the bill proposes replacing reduced provider add-on payments with equivalent rebates from drug manufacturers directly to Medicare. This approach preserves Medicare’s cost savings goals while maintaining the financial stability that community-based physicians need to continue offering advanced therapies in their offices.

LUGPA played a key role in advancing this legislation by providing detailed policy and clinical insights to congressional offices and helping secure co-sponsors. During our most recent fly-in, LUGPA representatives met with Representative Gray’s staff and shared information highlighting the bill’s importance to independent practices and the patients they serve. We will continue to work with lawmakers to promote this commonsense solution, which safeguards access to care while supporting fiscal responsibility in Medicare.

LUGPA Comments on CMS Drug Pricing Guidance

In late June, LUGPA submitted formal comments to the Centers for Medicare & Medicaid Services (CMS) in response to the Draft Guidance for the Medicare Drug Price Negotiation Program’s 2028 Initial Price Applicability Year. This marks the first year that physician-administered Part B drugs will be subject to price negotiation under the Inflation Reduction Act (IRA). Under the proposed guidance, reimbursement would shift from the current ASP + 6% model to MFP + 6%, potentially reducing provider payment by up to 50% for negotiated drugs.

LUGPA’s comments warned that this change could severely disrupt access to infused and injected therapies, especially in office-based settings that offer both lower-cost care and improved patient convenience. We urged CMS to preserve the ASP-based payment model, exclude Maximum Fair Prices (MFPs) from ASP calculations, and continue publishing ASP data to avoid harmful spillover effects into Medicare Advantage and commercial insurance. This advocacy supports LUGPA’s ongoing mission to protect patient access and ensure the financial sustainability of independent urology practices nationwide.

Major Insurers Commit to Prior Authorization Reforms; LUGPA Supports Effort to Reduce Administrative Burden

In a major development for providers and patients alike, federal health officials announced that leading health insurers have voluntarily committed to a series of reforms aimed at reducing the burdens of prior authorization. During a roundtable hosted by HHS Secretary Robert F. Kennedy Jr. and CMS Administrator Mehmet Oz, insurers representing coverage for over 75% of Americans—including Cigna, Aetna, and UnitedHealthcare—pledged to adopt six key reforms to streamline the prior authorization process for Medicare Advantage, Medicaid Managed Care, and ACA Marketplace plans.

The commitments include:

• Standardizing and automating the electronic prior authorization process
• Reducing the overall volume of services subject to prior authorization
• Ensuring continuity of care when patients change insurance plans
• Enhancing transparency and communication regarding determinations
• Increasing the use of real-time decision tools
• Requiring medical review for all denied requests

These voluntary reforms follow growing frustration among providers about the delays and care disruptions caused by the current prior authorization system. According to a 2024 AMA survey, 91% of physicians stated that prior authorization can lead to adverse clinical outcomes, while 82% reported that patients abandon treatment due to delays in obtaining approval.

LUGPA strongly supports this initiative to reduce administrative barriers that hinder timely, effective patient care. We echo the calls from policymakers, including Rep. Greg Murphy (R-NC) and Sen. Roger Marshall (R-KS), both physicians, for strong oversight and accountability to ensure these reforms are implemented as promised. As CMS continues to encourage modernization and improved efficiency in healthcare delivery, LUGPA will remain a vocal advocate for policies that enable independent practices to focus on what matters most: patient care.

LUGPA Endorses the Medicare Beneficiary Co-pay Fairness Act

In an effort to help address the rising cost of care for patients, LUGPA has joined a coalition advocating for the Medicare Beneficiary Co-pay Fairness Act. This bipartisan bill would cap out-of-pocket costs for seniors enrolled in Medicare Advantage and Medicare Part D plans. This legislation is a crucial step toward ensuring affordable access to care, particularly for patients facing serious health conditions that require high-cost specialty medications.

Independent urology practices regularly care for patients with cancer, chronic urologic disorders, and other complex conditions, many of whom struggle with the financial burden of high cost-sharing under their current insurance plans. For these patients, out-of-pocket expenses can be a barrier to starting or continuing medically necessary treatments.

By establishing cost caps and predictable expense limits, the bill protects Medicare beneficiaries from unexpected financial shocks and empowers providers to focus on delivering timely, uninterrupted care. LUGPA is actively working alongside a broad coalition of patient advocates, specialty societies, and healthcare stakeholders to champion this legislation.

LUGPA Supports Reintroduction of the Improving Seniors’ Timely Access to Care Act 

On May 21, a bipartisan group of lawmakers reintroduced the Improving Seniors’ Timely Access to Care Act. This key LUGPA-supported bill aims to streamline the prior authorization process for Medicare Advantage (MA) plans. Led by Representatives Ami Bera, M.D. (D-CA), Mike Kelly (R-PA), Suzan DelBene (D-WA), John Joyce, M.D. (R-PA), and Senators Roger Marshall, M.D. (R-KS) and Mark Warner (D-VA), this legislation addresses one of the most pressing administrative burdens facing physicians.

With nearly 33 million Americans enrolled in Medicare Advantage, outdated prior authorization practices are causing significant delays and denials of medically necessary care. According to federal audits, 75% of denied MA claims are later approved, revealing deep flaws in the current system.

The bill would:

• Require Medicare Advantage plans to implement electronic prior authorization (e-PA) using standardized systems
• Improve transparency around authorization requirements and usage
• Grant HHS authority to enforce timely determinations, including real-time decisions for routine services
• Mandate federal oversight and public reporting on prior authorization practices

LUGPA strongly supports this bipartisan effort to reduce administrative red tape and ensure patients can access timely, appropriate care. As a longtime advocate for prior authorization reform, LUGPA applauds the reintroduction of this legislation and encourages Congress to act swiftly on behalf of physicians and the patients they serve.