News & Updates

HealthAffairs Source Article | Comments Courtesy of Matt Zavadsky

The conversation still references surprise bills, when it should focus on surprise coverage…

-------------------------------

Most Patients Undergoing Ground And Air Ambulance Transportation Receive Sizable Out-Of-Network Bills

Karan R. Chhabra, Keegan McGuire, Kyle H. Sheetz, John W. Scott, Ushapoorna Nuliyalu, and Andrew M. Ryan

PUBLISHED: APRIL 15, 2020

 

https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2019.01484

 

ABSTRACT

“Surprise” out-of-network bills have come under close scrutiny, and while ambulance transportation is known to be a large component of the problem, its impact is poorly understood. We measured the prevalence and financial impact of out-of-network billing in ground and air ambulance transportation. For members of a large national insurance plan in 2013–17, 71 percent of all ambulance rides involved potential surprise bills. For both ground and air ambulances, out-of-network charges were substantially greater than in-network prices, resulting in median potential surprise bills of $450 for ground transportation and $21,698 for air transportation. Though out-of-network air ambulance bills were larger, out-of-network ground ambulance bills were more common, with an aggregate impact of $129 million per year. Out-of-network air ambulance bills averaged $91 million per year, rising from $41 million in 2013 to $143 million in 2017. Federal proposals to limit surprise out-of-network billing should incorporate protections for patients undergoing ground or air ambulance transportation.

 

CONCLUSION

Among commercially insured patients, the vast majority of emergency medical transportation occurs out of network, with charges exceeding plan payments by hundreds to thousands of dollars. Despite the financial burden of ground and air ambulance transportation, both have largely evaded state and federal legislation. Federal proposals to limit surprise out-of-network billing should incorporate protections for patients who receive ground or air ambulance transportation.

ABC News Source Article | Comments Courtesy of Matt Zavadsky

ABC News tonight profiled EMS On the Front Lines - a stark reality of what EMS teams in NYC are battling! This battle is being fought in communities all across America, and EMS professionals are on the front line!

Communications, Fleet, Logistics, Billing, Admin, EVERYONE is effected by this scourge... This story is one of many being retold in cities and towns across our country - even in ours!

Please keep all EMS providers in your thoughts and prayers, and even more importantly, HELP them - talk to your elected officials, push for the proper PPE to help them remain safe,

AND, when you see a firefighter, police officer, EMS worker, THANK THEM for putting themselves on the line (but keep at least a 6 foot buffer )

Do everything you can to keep them safe, as they work to save others.  The life they save, might be yours, or one of your loved ones!

---------------------------

 

EMS on the front lines dealing with 'madness,' sleeping in their cars to avoid infecting their families

The FDNY said that about 20% of members were out sick with symptoms of COVID-19.

By Eva Pilgrim, Katie O'Brien, Josh Margolin, Enjoli Francis

March 31, 2020

 

 

Emergency medical service workers in Queens, New York, described living and working in what amounts to a "war zone" as they seek to help residents during the COVID-19 pandemic.

 

"We have thousands of people that are sick. Thousands that are dying," Oren Barzilay, president of FDNY-EMS Local 2507, told ABC News on Tuesday. "It's all over our city. It's not just an isolated case. It's all around us."

 

Barzilay said that the city had even broken a record for 911 calls Monday -- 7,200 calls -- passing Friday's record of 7,100.

 

John Rugen, a 16-year veteran with the fire department, described the situation for EMS workers as "madness."

 

He said that while his workers were "still holding the line" and doing what was necessary to save lives, they were short on personal protective equipment and needed a lot of supplies.

 

"We want people to be mindful when they call 911. ... We're dealing with severely ill people at the moment that need our attention," he said. "The hospitals are overwhelmed as we are overwhelmed."

 

 

ABC News followed EMS at a safe distance in Queens on four calls on Tuesday, including two reports of fever and cough, a COVID-19 patient and a person who had died. As they arrived for each call, EMS workers wore thin, blue gowns, gloves and masks.

 

During one call that ABC News witnessed, Tracy Sims stood outside as EMS workers entered the home of her aunt who'd been diagnosed with COVID-19 the previous week.

 

Sims told ABC News that her aunt's doctor had sent her home so she could self-quarantine but that the aunt, who's in her 60s, also had a touch of pneumonia and was feeling winded and short of energy.

 

"If you're having trouble breathing and, you know, you're an older person, you're by yourself, who's going to go inside to help her?" Sims said to ABC News. "Nobody can go inside to help her."

 

Barzilay said that Local 2507 had roughly 4,500 EMTs/paramedics with the New York Fire Department, including officers. Of those, he said more than 500 were showing signs and symptoms of COVID-19 and more than 50 members had tested positive for the virus.

 

The FDNY confirmed to ABC News that more than 20% of the EMS workforce was out sick. The Federal Emergency Management Agency was sending a contingent of paramedics and ambulances to help backfill.

 

Rugen said that when EMS workers arrived at a call, they went in suspecting that everyone in the home or at the scene had COVID-19 in order to protect themselves.

 

He said that while his station had gloves and N95 masks, it was running short. He told ABC News that he'd even called some stations last week and learned that they didn't have any masks left.

 

For Rugen, going out every shift puts him at risk. He said he had stage 4 lung cancer from Sept. 11 and that even cigarette smoke could close his lungs.

 

"This could attack me and kill me because I have shortage [of] lung capacity," he said of COVID-19.

 

Yet, he said, he worked because he liked taking care of people and had been working with the department since he was 16 years old.

 

Tracy Sims told ABC News that her aunt's doctor had sent her home so she could self-quarantine but that the aunt, who's in her 60s, also had a touch of pneumonia and was feeling winded and short of energy.

 

Rugen said he'd even decided to stop seeing his son, who has an underlying medical condition, to prevent him from possibly catching the virus. Rugen said he still Skyped with his young son whom he had not seen for a week.

 

"It's hard," he said. "Very hard."

 

Barzilay said that Rugen's decision was a common one among city EMTs. Barzilay said that other members of the service were afraid to go home and chance putting their family members at risk.

 

"They're sleeping in their cars. We have dozens and dozens and dozens of members who are sleeping in their cars.

They rather stay here, sleep in the car, wash up and go do it again," he said about working their shifts, which ranged from 16 hours to 20 hours long.

 

Sims, whose aunt had been diagnosed with COVID-19 and got assistance from EMS Tuesday, told ABC News that she was terrified.

 

"I'm scared for her. ... I'm scared for me. For everybody. ... It's emotionally taxing," Sims said. "I want this thing to be over."

COVID-19 EMS Patient Management: Myth vs. Reality
Free Webinar Recorded March 13, 2020
Watch On-Demand Now► | Download Slides

Medic Ambulance Service and Solano County Public Health in Solano County, CA are on the front-line of managing COVID-19 confirmed and persons under investigation (PUI) patients at Travis AFB in Northern California. More than 40 patients have been transported to area hospitals for further treatment. 

Hear first-hand from Jimmy Pierson, President/COO Medic Ambulance;  Dr. Bela Matyas, Solano County Public Health Director; and Ted Selby, Solano County EMS Administrator, how they planned for and executed the management of these patients and the impacts from a public health and EMS perspective. This valuable webinar will give attendees the ‘ground level truth’ about things like:

• Myth vs. Reality of PPE
• Crew preparation and communication
• Ambulance decon
• Crew member quarantine
• Public Health Information 

The presenters will plan 30 minutes of content so that there will be significant time to answer participant questions.

Presenters

• Bela T. Matyas, MD, MPH, Health Officer / Deputy Director, Solano County Public Health
• James Pierson, President / COO, Medic Ambulance Service, Vice President, California Ambulance Association
• Ted Selby, Agency Administrator, Solano County Emergency Medical Services

Hosting Organizations

• Academy of International Mobile Healthcare Integration
• National Association of Emergency Medical Technicians (NAEMT)
• International Academies of Emergency Dispatch (IAED)
• FirstWatch Solutions
• California Ambulance Association
• Paramedic Chiefs of Canada

Roll Call Source Article | Comments Courtesy of Matt Zavadsky

There is $10 million in the bill for training for First Responders….

------------

House OKs $8.3 billion coronavirus aid package with little debate

Trump has said he would accept a higher spending level than the original $2.5 billion White House request

By Jennifer Shutt

March 4, 2020

 The House approved an $8.3 billion emergency spending package to help contain the rapidly spreading COVID-19 illness on Wednesday after about 15 minutes of debate, as the death toll continued to mount in the United States and worldwide.

The vote was 415-2, easily eclipsing the two-thirds threshold necessary for passage under suspension of the rules. The two 'no' votes were Republicans Andy Biggs of Arizona and Ken Buck of Colorado. In a statement after the vote, Biggs called it a "larded-up bill" that wouldn't solve the problem and wastes taxpayer dollars.

The Senate is expected to quickly send the legislation to President Donald Trump, who said last week he would accept a higher spending level than the $2.5 billion the White House originally requested. Only half of that amount was new funding, with the rest pulled from existing programs that lawmakers said would shortchange other priorities.

"We worked together to craft an aggressive and comprehensive response that provides the resources the experts say they need to combat this crisis," Senate Appropriations Chairman Richard C. Shelby, R-Ala., said in a statement. "I thank my colleagues for their cooperation and appreciate President Trump’s eagerness to sign this legislation and get the funding out the door without delay.”

Trump's legislative director, Eric Ueland, confirmed after the House vote that the president "looks forward to signing" the bill.

Only hours earlier, Shelby said negotiators were "at a standstill" over Democratic demands to maintain drug and vaccine affordability provisions that GOP lawmakers said would stifle innovation. Asked what triggered quick turnaround in sentiment, House Appropriations Chairwoman Nita M. Lowey, D-N.Y., said: "Just a willingness on the part of both sides to have a deal."

The measure includes $300 million for the federal government to buy drug treatments, tests and eventually vaccines for the coronavirus-caused illness when those are developed.

The package would maintain standard procurement requirements for federal contracts requiring a "fair and reasonable" price for those supplies. It would also provide the Department of Health and Human Services with authority to ensure that they are "affordable in the commercial market" as long as product development isn't delayed as a result.

Keep reading>

AJC Source Article | Comments Courtesy of Matt Zavadsky

Interesting article that depicts additional activity toward evaluating EMS performance for the privilege of serving a community!

------------------------

State demands more accountability on EMS selection

AJC EXCLUSIVE: EMERGENCY MEDICAL SERVICES

By Yamil Berard, The Atlanta Journal-Constitution

Feb 21, 2020

 

 

State officials are about to assert unprecedented control over how emergency medical service providers are selected, with reforms they say will wring out politics and conflicts of interest while saving lives.

 

Under new rules expected to take effect this spring, regional EMS councils will have to give the state detailed performance data on ambulance service before even considering a change of providers. Those performance measures will drill into how quickly and how well ambulances help infants and children in respiratory distress, victims of gunshots, stroke sufferers and people in cardiac arrest.

 

If the councils fail to provide data or to adhere to specific rules that will govern their selection processes, the state will likely reject any changes, said David Newton, director of EMS and Trauma in the Georgia Department of Public Health.

 

“If you didn’t follow the procedure, guess what, you’ve got to start over,’’ Newton on Thursday told a room of a few dozen EMS leaders who serve on the state’s Emergency Medical Services Advisory Council. “And that’s obviously not what anyone wants.”

 

The moves are the latest in a series of reforms Newton has been firing off in his first year as the state’s top EMS leader.

 

His goal has been to bring more accountability to EMS providers in Georgia, following criticisms of gaps in state oversight.

 

Among the critics, the Atlanta-based Georgia Ambulance Transparency Project raised questions about potential conflicts-of-interests by ambulance executives and EMS operators on the regional councils. Fire chiefs in the Atlanta metro area also have raised concerns that regional council decisions don’t reflect community needs.

 

What’s more, an Atlanta Journal-Constitution investigation last June found that state has failed in its duty to ensure the quality and reliability of Georgia’ emergency medical services system. State standards are vague and oversight weak, leaving the system vulnerable to breakdowns and political pressures, the AJC reported.

 

At Thursday’s address to EMSAC leaders, Newton made it clear that the state would no longer tolerate arbitrary decision-making by the councils.

 

“So, if someone says, in a written form, I would like the X-Y-Z emergency response zone examined because they were mean to my grandmother, that’s probably not a good thing to do,” Newton said.

 

Major overhaul

In moves late last year to reform the selection process, Newton announced that the state planned to implement a rule limiting the number of representatives from any one organization on the regional councils.

 

Yet another reform will require each council member to complete a conflict-of-interest statement that discloses personal affiliations and financial interests. Leaders of the Ambulance Transparency Project had urged the state to require the disclosures, concerned that ambulance executives were able to sway decisions that may not be in the public’s best interest.

To improve transparency, the state also made it clear that regional councils must comply with the state’s open meetings law. A pending goal will require council members to undergo training on open meeting requirements.

 

But the most profound change is a requirement that regional councils conduct uniform assessments of the existing level of service in each geographical zone, even before anyone vies for a contract.

 

To conduct the assessments, agencies would have to submit data from patient trip reports to Newton’s office, which they are already required to do but sometimes don’t.

 

Newton also would like agencies to report performance data established under the National Highway Traffic Safety Administration’s EMS Compass initiative. The initiative depends on standardized measures of performance to improve the quality of care to patients.

 

For example, the state wants providers to show the councils that they are transporting patients to the hospitals that are equipped to meet their needs, Newton said.

 

If a patient has experienced severe burns in a car fire after an accident, the state would want to know if the EMS agency transported the victim to a Level One Trauma Center, which can provide the highest level of care.

Continue reading►

Source Article | Comments courtesy of Matt Zavadsky

Bente Bouthier did a nice job reporting on a complex topic…

------------------

Senate Bill Would Set Universal Rate For EMS Transport, Providers Say It's A Bad Idea

By BENTE BOUTHIER

February 18, 2020

 

https://indianapublicmedia.org/news/senate-considering-bill-to-set-universal-rate-for-ems-transport,-providers-say-its-a-bad-idea.php

 

Indiana lawmakers are considering legislation that would peg all of the state’s ambulance and transportation costs to in-network rates.

The Senate’s Insurance and Financial Institutions Committee will decide by the end of February whether to pass the bill with its current language.

House Bill 1372 attempts to eliminate instances of patients getting surprise bills after receiving emergency medical services that weren’t covered by insurance.   

Many EMS providers lobbied against the bill, saying setting costs at in-network rates will dramatically cut the industry’s already low revenue.

Matt Zavadsky is the president of the National Association of Emergency Medical Technicians. He says EMS providers don’t reap the same benefits of in-network rates as regular healthcare providers. Primary care physicians who go with in network rates usually get more patients, which usually compensates for reduced fees.

“People aren’t going to call 9-1-1 more just because we’re now in-network with any of their insurance payers,” he says.  "The concept of accepting an additional rate without having an additional volume to help cover the lost revenue per call doesn't work in the emergency medical services industry setting."

In-network rates would lock in the universal rate for transportation costs.

Zavadsky says this means Indiana EMS services could receive less compensation than what it costs to operate.

He also says tax payers will either have to make up for the revenue loss or accept a decrease in services in their community if the bill’s language remains unchanged.

Before any laws are passed changing reimbursement rates for EMS providers, Zavadsky says lawmakers should examine how much healthcare costs more carefully. 

He suggests using the FAIR database which looks at costs of all healthcare by region, rather than setting a statewide average.

"Instead of going right to, setting a statewide, in-network rate for ambulance services, maybe the first step is finding out what it really costs to provide ambulance services in the communities across the state of Indiana."

He says under HB 1372's current language, insurance companies would be the primary beneficiary. 

"If the insurance companies have to pay less, they benefit financially," Zavadsky says. "The patient is going to get a higher bill from the ambulance provider. The ambulance providers are going to have a reduced reimbursement, which means they're going to suffer."

The Senate committee is considering two amendments to the bill, one of which would remove the in-network rates for providers that are owned by or have a contract with a municipality.

The other would allow ambulance providers and insurance companies negotiate prices of transportation costs.

Tribune-Star Source | Comments Courtesy of Matt Zavadsky

Lots of YELLOW in this one – shrouded by all the discussions about “surprise billing” (which is actually more appropriately termed “surprise coverage”), insurers are increasingly sending reimbursement for ambulance services to the patient instead of the provider – despite executed assignment of benefits authorizations from the patient. 

This has a significant impact on revenue for ambulance providers and is leading to additional financial hardships for agencies and taxpayers.

----------------------

Ambulance providers warn of pending Indiana House bill

It has unintended consequences for patients, maybe even on taxes, they say

By Howard Greninger Tribune-Star

2/16/20

 

https://www.tribstar.com/news/local_news/ambulance-providers-warn-of-pending-indiana-house-bill/article_93a86117-482c-5c73-8170-80087ffb70f9.html

A group that represents ambulance service providers says a bill pending in the Indiana General Assembly could cut their insurance reimbursements and result in layoffs, longer response time and possibly even higher local taxes.

House Bill 1372, heard last week Wednesday before the Senate’s Insurance and Financial Institutions Committee, initially would set all ambulance transportation costs to in-network insurance rates.

That would have the effect of setting rates without the knowledge or agreement of ambulance service providers, the Indiana Emergency Medical Services Association, which represents emergency medical services companies.

“This bill’s original wording was not intended to do what it would end up doing if it [goes through unchanged] … which is to put [the] EMS industry out of business,” said Russell Ferrell, chief executive officer and president of Trans-Care Ambulance, a company that employs 350 people statewide. It is based in Terre Haute and has 40 employees here.

The bill as it stands also could result in cities or counties increasing taxes, Ferrell argued.

“Testimony to the [Senate] committee from Fort Wayne stated it would cost $2.8 million more to that city,” Ferrell said. “That is public-private ambulance service there.”

Nate Metz, president of the Indiana Emergency Medical Services Association, said the issue arose in 2017, when private insurance companies decided to cover only about 30 percent of charged costs with direct payments to ambulance services and then made direct payments to patients for the rest of the benefit.

“Then the patient is responsible and has to wait on a second bill from an ambulance provider…” Metz said. “That tactic significantly delays cash flow to an ambulance provider and turns the patient into a self-pay patient. That creates the perception that patients are getting 100 percent of the bills from ambulance [providers]. We want an assignment of benefit to force [insurance firms] to pay an EMS provider off of our bill and not [pay] the patient.”

Metz said it costs $400,000 to $500,000 a year to operate an ambulance, with ambulance runs costing $285 to $500 per trip. And profit margins are slim, with many ambulance firms operating on a break-even status, he said.

“Our state has lost 12.8 percent of its service providers from 2018 to 2019,” Metz said.

The Senate committee is considering two amendments, one that removes the in-network reimbursement for ambulance services owned by a municipality or an ambulance service that has a contract with a municipality or government agency.

Another amendment would allow a negotiation between ambulance firms and insurance providers, with disputes going to binding arbitration.

Metz said that could be difficult for volunteer organizations because they would have to pay court costs to go to arbitration. Instead, Metz said the issue needs more discussion. Metz said he hopes the ambulance billing language can be removed from the House bill and a revised reimbursement system can be addressed in the 2021 session.

Multiple attempts last week to reach bill author Rep. Martin Carbaugh, R-Fort Wayne, for comment were not successful.

The Senate committee is slated to meet again on the issue Feb. 19, but may not make a decision until the last week of February.

Legislative committees have until Feb. 27 to pass bills to their full chambers. The General Assembly is slated to adjourn March 14.

Axios Source Article | Comments Courtesy of Matt Zavadsky

Interesting findings, for us both as healthcare providers, employers, and consumers!

Health care prices still rising faster than use of services

2/14/20

Bob Herman

 

Employers, workers and families continued to spend a lot more on health care in 2018, but that wasn't because people used more services, according to the latest annual spending report from the Health Care Cost Institute, which analyzes commercial health insurance claims.

 

The bottom line: Higher prices remain the main culprit for exploding spending among those with private health insurance.

 

By the numbers: Annual per-person spending among the commercially insured, after accounting for inflation and drug rebates that help reduce premiums, grew by an average of 3.8% between 2014 and 2018, according to HCCI.

• Three-quarters of that rise was attributed to hospitals, doctors, drug companies and others raising prices.

 

The intrigue: Two small pieces of data stick out within the report.

• The average out-of-pocket price for emergency room visits jumped 37%, from $368 in 2014 to $503 in 2018 — a reflection of surprise billing tactics.

 

• The average price of drugs administered in doctors' clinics soared 73% from 2014 to 2018. These infusion medicines overseen by doctors are driving up drug spending by a lot, and they don't usually come with rebates.

 

Go deeper: HCCI is getting a new health insurance partner to submit data

Commentary: Interesting news, especially in light of the revolutionary new ET3 model CMMI is rolling out for ambulance services…

-----------------

House lawmakers introduce bill to tighten CMMI's reins

MICHAEL BRADY 

February 04, 2020

https://www.modernhealthcare.com/politics-policy/house-lawmakers-introduce-bill-tighten-cmmis-reins

A bipartisan group of House lawmakers on Monday introduced a bill to ramp up transparency and accountability efforts for the CMS' Center for Medicare and Medicaid Innovation.

The Strengthening Innovation in Medicare and Medicaid Act—HR 5741—would require the HHS secretary to keep track of how a demonstration model affects beneficiaries' access to care. HHS would also have to monitor the effects of delivery and payment changes on healthcare disparities and alleviate related issues that could negatively affect health outcomes.

The bill aims to boost transparency by creating an expedited process for Congress to reject models and makes it easier for the public to comment on proposed models and changes.

The Innovation Center, also known as CMMI, would also have to consult with experts on the healthcare needs of minorities, rural and underserved populations, and the financial demands of safety-net and rural providers.

Providers and suppliers could seek hardship exemptions from the Innovation Center if they would be subject to undue economic hardship or if the agency's requirements caused vulnerable populations to lose access to specific providers.

Reps. Terri Sewell (D-Ala.), Adrian Smith (R-Neb.), Tony Cárdenas (D-Calif.) and John Shimkus (R-Ill.) introduced the legislation.

"It is essential that Congress ensures that CMMI functions as intended, to improve the quality and efficiency of care delivered, and incorporates greater opportunity for public input," Sewell said. "The legislation we introduced today would safeguard the center from implementing politically driven or other policy changes made unilaterally by any administration that could be harmful to patients and providers."

Lawmakers, especially those who represent rural or underserved populations, have expressed concern that the Innovation Center has too much discretion to design, test and implement new payment models without adequately considering their effects on healthcare delivery outcomes.

"This bill would reduce uncertainty throughout the healthcare marketplace by providing for appropriate oversight of CMMI," Smith said.

House leader aims for surprise billing deal by Presidents Day

RACHEL COHRS  

January 28, 2020

Source Article: https://www.modernhealthcare.com/politics-policy/house-leader-aims-surprise-billing-deal-presidents-day

House Majority Leader Steny Hoyer (D-Md.) wants the House to move on legislation banning balance billing as soon as mid-February, he told reporters Tuesday.

So far, the House Energy & Commerce and Ways & Means committees have been at odds over the best approach to address payment for bills a patient receives from an out-of-network provider at an in-network facility.

"We are trying to bring those together and create a consensus so that we can move a bill, and move a bill sooner rather than later. Sooner meaning within this work period if we can get to agreement," Hoyer said, referring to the House work period that ends the week of Feb. 10.

However, some are skeptical House leaders can work out their differences that quickly after a bipartisan, bicameral compromise brokered by leaders of the House Energy & Commerce and Senate health committees fizzled last year amidst intense insurance and provider industry lobbying.

The Ways & Means Committee leaders have not yet elaborated on their proposal beyond a one-page outline released in December. Ways & Means health subcommittee Chair Lloyd Doggett (D-Texas) said Tuesday he has not seen policy details beyond the one-pager.

"When we really get going it's a short month," Doggett said.

Ways & Means Committee Chair Richard Neal (D-Mass.) said Monday that he wants to shape the legislation in concert with the Energy & Commerce Committee and expects to hold a markup in the next three weeks.

Several stakeholders including hospital groups, a new conservative coalition, and physician staffing firms that oppose the Energy & Commerce proposal because of its inclusion of benchmark payment rates have not yet thrown their weight behind the Ways & Means idea and are awaiting more information.

Ways & Means ranking Republican Kevin Brady of Texas has said that he and Neal are pursuing a revenue-neutral approach to ban balance billing, though lawmakers by May 22 have to find a way to fund extensions of several Medicare and Medicaid programs including funding for community health centers and delaying cuts to Medicaid disproportionate-share hospital payments.

Neal said Monday that there may be alternative funding sources other than surprise billing legislation.

"I've got some ideas," he told reporters.

House Energy & Commerce Committee leaders estimated their bill would provide nearly $20 billion to fund community health centers for five years.

House committee chairs have missed leadership goals for surprise billing legislation before.

House Speaker Nancy Pelosi (D-Calif.) in December gave the chairs of the House Energy & Commerce, Ways & Means and Education & Labor committees a deadline to come to a consensus ahead of an appropriations package, but they failed to do so.