CMS encouraged to toss out proposals in the rule that 'would likely result in significant decrease in MSSP participation.'
Key stakeholders in the Medicare Shared Savings Program warn that the Centers for Medicare & Medicaid Services efforts to improve the program may actually dampen participation.
In a letter this week to CMS Administrator Seema Verma, AHA Executive Vice President Thomas P. Nickels said the hospital lobby "appreciates certain steps CMS is taking to improve the stability and flexibility of the MSSP" by embracing telehealth to expand access.
"However, we are concerned that, as a whole, the proposals in the rule would likely result in significant decrease in MSSP participation," Nickels said.
"While such an outcome may very well be CMS's expectation, it unfortunately disregards many of the lessons we have learned from the current program," he said.
The stakeholders' remarks were submitted ahead of yesterday's midnight deadline for comments on the proposed final rule.
Specifically, Nickels said CMS should not go forward with the proposed differentiation of participation options for high- and low-revenue ACOs. Instead, he said CMS should improve program methodology to reward improved quality and reduced costs.
He also urged CMS to allow new MSSP ACOs three years in upside-only risk, rather than two, with an option to move into downside risk sooner if they choose.
"Evidence demonstrates that per beneficiary savings correlate to experience, especially after ACOs' third year in the MSSP," Nickels said.
"Drastically shortening the length of time in which they can participate in an upside-only model, along with attempting to create arbitrary differentiations between physician- and hospital-led ACOs, does not empower ACOs to maximize their contribution to patient care and is not a pathway for improving the value of the MSSP for beneficiaries," he said.
American Medical Association Executive Vice President James L. Madara, MD, in a 10-page letter to Verma this week, provided a detailed list of recommendations on the proposed rule.
Among AMA's more than two dozen recommendations, CMS was urged to:
Extend ACO agreement periods to five years, as this will improve stability and predictability for ACO participants.
Retain the Track 1 model, potentially with modifications to encourage greater savings, instead of forcing all ACOs into two-sided risk models.
Raise proposed sharing rates for new ACOs because the proposed rates are too low.
Exclude ACO payment incentives under the Merit-based Incentive Payment System (MIPS) from ACO expenditures for purposes of comparing benchmark to actual spending and calculating each ACO’s savings and losses.
Incentives 'untenable' for new ACOs
The AHA and AMA recommendations were consistent with the findings of a recent poll by the National Association of ACOs, which found that 60% of ACOs would have been unlikely to have entered MSSP under the revised policies proposed by CMS.
Clif Gaus, president and CEO of NAACOS, said ACOs are ready to work with CMS to improve MSSP "without inadvertently forcing ACOs and providers to remove themselves from the bipartisan goal of lower-cost, higher-quality care."
"NAACOS believes that ACOs should take on risk," Gaus said in a media release. "But the speed of CMS's proposed path to risk and the agency's proposal to significantly cut financial incentives will make participation in this voluntary program untenable for new ACOs."
Specifically, NAACOS urged CMS to:
Reverse a proposal to reduce the shared savings rate from 50% to 25% for ACOs in shared savings only or low risk models. NAACOS said shared savings rates should be 50% for Basic Levels A and B, 55% for Basic Levels C and D, and 60% for Basic Level E.
Allow ACOs entering the program to remain in a shared savings-only model for four years with an additional fifth year available for those that demonstrate superior performance.
Make no distinction between high- and low-revenue ACOs. The proposed 25% threshold of ACO participant revenue as a percent of total ACO spending for the assigned population appears arbitrary and creates division where none should exist.
Finalize the proposal to enact extended, five-year agreement periods to provide more program stability and predictability.
Finalize proposals to more gradually introduce risk and to permanently include the current Track 1+ Model in the MSSP (renamed Basic Level E), creating a smoother glide path to risk.
Allow risk adjustment to change by +/-5% over an agreement period, rather than the proposed +/-3%, to reflect risk changes so ACOs are fairly judged on performance without being unfairly expected to manage a population's increasing disease burden.
Gaus said one survey respondents noted that the proposal put forward CMS make sense when looked at in isolation, but that the proposed revisions in their entirety create barriers to entry or continuation for most ACOs.
The $16 million settlement stems from a series of attacks in 2014 and 2015 that potentially exposed the electronic health information of nearly 80 million people.
Anthem Inc. will pay the federal government $16 million to settle the largest health data breach in U.S. history, the Department of Health and Human Services announced.
The settlement stems from a series of cyberattacks on the Blue Cross Blue Shield carrier that occurred between December 2014 and January 2015 that exposed the electronic health information of 79 million people, HHS's Office for Civil Rights said.
The $16 million settlement is the largest ever under the Health Insurance Portability and Accountability Act.
"The largest health data breach in U.S. history fully merits the largest HIPAA settlement in history," OCR Director Roger Severino said in a media release.
"Unfortunately, Anthem failed to implement appropriate measures for detecting hackers who had gained access to their system to harvest passwords and steal people's private information," Severino said.
Anthem issued a statement saying that it cooperated with the OCR investigation, and "takes the security of its data and the personal information of consumers very seriously."
"Importantly, the agreement reached with OCR specifically states that this is not 'an admission, concession, evidence' that Anthem acted improperly," Anthem said.
Indianapolis-based Anthem discovered the breach in January, 2015 and notified HHS in March 2015. The health insurer discovered that hackers had accessed their IT system via an undetected continuous and targeted cyberattack designed to steal personal health data.
After filing their breach report, Anthem discovered the hackers had breached their system through spear phishing emails sent to an Anthem subsidiary that came after at least one employee responded to the malicious email and opened the door to further attacks.
OCR determined that between December 2, 2014 and January 27, 2015, the hackers stole electronic health information from about 79 million people, including names, social security numbers, medical identification numbers, addresses, dates of birth, email addresses, and employment information.
OCR said Anthem also failed to conduct an enterprise-wide risk analysis, had insufficient procedures to review information system activity, failed to identify and respond to suspected or known security incidents, and failed to implement adequate minimum access controls to prevent the cyberattacks that began as early as Feb. 18, 2014.
"We know that large healthcare entities are attractive targets for hackers, which is why they are expected to have strong password policies and to monitor and respond to security incidents in a timely fashion or risk enforcement by OCR," Severino said.
Anthem said that when it learned of the breach, its first priority was to ensure that its systems were secure, "which we did by engaging a world-class security organization and the FBI."
"Additionally, we provided initial notice within 4 business days, and credit protections within 11 business days. We are not aware of any fraud or identity theft that has occurred as a result of this incident, Anthem said.
Anthem already agreed to pay a record-setting $115 million to settle a class-action lawsuit filed over a 2015 breach.
In addition to the $16 million settlement, Anthem agreed to undertake corrective actions to comply with HIPAA Rules.
Before this week's settlement, the largest HIPAA-related settlement came in 2016, when Chicago-based Advocate Health Care Network paid $5.55 million after multiple potential violations that jeopardized the health records of more than 4 million patients.
Private payers, including Blue Cross Blue Shield of Tennessee, were bilked out of about $174 million in the compounding pharmacy scam, which inflated prices for invalidly prescribed pain creams and other drugs.
Four Florida men were charged in a multistate telemedicine scheme that billed at least $931 million in fraudulent claims to private insurance companies, the Department of Justice said Monday.
According to a 32-count indictment filed in U.S. District Court in Greeneville, Tennessee, the four defendants, owners of seven compounding pharmacies in Florida and Texas, set up an elaborate telemedicine scheme that solicited insurance and prescription drug information from consumers across the country.
Physicians unwittingly approved the prescriptions for pain creams and other drugs without knowing that the defendants were jacking up the prices of the invalidly prescribed drugs, which were billed to private payers.
Tens of thousands of patients and more than 100 physicians in East Tennessee bore the brunt of the scam, which ran from mid-2015 through April 2018. Private payers in the region, including Blue Cross Blue Shield of Tennessee, were bilked out of about $174 million, prosecutors said.
BCBS Tennessee issued a statement on Tuesday noting that it was "only one of hundreds of insurers impacted by this case."
"We remain committed to partnering with our customers, providers and law enforcement to fight fraud, waste, and abuse in the healthcare system," BCBST said.
All totaled, the indictment alleges that the defendants submitted not less than $931 million in fraudulent claims for payment. It's not clear how much was paid out.
The four Florida defendants were identified as Andrew Assad, 33, of Palm Harbor, Peter Bolos, 41, of Lutz, and Michael Palso, 44, of Odessa, and Larry Everett Smith, 48, of Pinellas Park.
The companies were identified as: Germaine Pharmacy in Tampa; Synergy Pharmacy Services, in Palm Harbor; Precision Pharmacy Management, Tanith Enterprises, ULD Wholesale Group, and Alpha-Omega Pharmacy, all in Clearwater; and Zoetic Pharmacy in Houston, Texas.
The four defendants were each charged with conspiracy to commit healthcare fraud, mail fraud, and introducing misbranded drugs into interstate commerce.
If convicted, the four men face prison terms of up to 20 years for each mail fraud charge, up to 10 years for conspiracy, and up to three years in prison for introducing misbranded drugs into interstate commerce.
The indictment also seeks forfeiture of approximately $154 million.
The indictments come on the heels of the related Sept. 26 guilty plea by Scott Roix, 52, the CEO of HealthRight LLC, a telemedicine company in Pennsylvania and Florida, for his role in the scheme. Roix and HealthRight also pleaded guilty to wire fraud charges in a separate scheme that fraudulently telemarketed dietary supplements, skin creams, and testosterone.
The previously announced sales are part of CHS's ongoing divestiture strategy to consolidate operations and reduce debt.
Debt-laden Community Health Systems will sell its two-hospital Mary Black Health System to Spartanburg Regional Healthcare System in South Carolina in a deal that is expected to be finalized by year's end, the two companiesannounced.
Financial terms were not disclosed.
The 207-bed Mary Black Health System – Spartanburg, and 125-bed Mary Black Health System – Gaffney, were among the previously announced divestitures discussed by CHS earlier this year.
The sale includes all physician clinics and outpatient services attached to the two hospitals, which will become part ofSpartanburg Regional Healthcare System when the deal is finalized.
CHS has sold or announced the pending sale of 12 hospitals so far in 2018. The Franklin, Tennessee-based for-profit hospital chain has been struggling since its ill-advised $7.6 billion acquisition of Health Management Associates in 2013.
In 2017, CHS sold 30 hospitals that CHS executives said were low performing. However, a report this month by Axios challenges that assertion.
The four-hospital, nonprofit Spartanburg Regional, one of the largest health systems in South Carolina, includes three hospitals and serves an 11-county region.
When the sale is complete, CHS will run four hospitals in South Carolina.
On October 1, CHS completed the sale of 238-bed AllianceHealth Deaconess hospital in Oklahoma City to INTEGRIS Health. CHS Now runs seven hospitals in Oklahoma.
Aetna will pay New Jersey $365,000 to settle two separate patient confidentiality breaches, and Humana will pay Texas $700,000 for an inadequate network in Houston, Austin, and San Antonio.
Aetna and Humana this week will each paid hundreds of thousands of dollars to resolve disputes with state regulators in New Jersey and Texas.
Aetna agreed to pay New Jersey $365,211 to settle two separate cases where the health insurer improperly disclosed health information in 2017, potentially affecting about 850 New Jersey residents.
Meanwhile, in an unrelated case, the Texas Department of Insurance fined Humana $700,000 for inadequate network coverage in three counties.
New Jersey Settlement
The two settlements with New Jersey resolve two health information breaches that occurred in the summer of 2017.
The first instance was part of a multistate investigation of a health information breach that potentially affected about 12,000 Aetna customers, including 647 New Jersey residents.
Investigators said Aetna relied on a third-party mailing service that used oversized, transparent glassine address window that unintentionally disclosed the customers' HIV/AIDS status and other health issues.
In January, Aetna reached a $17 million settlement in a class-action suit brought by the affected customers.
Under the settlement with New Jersey, Aetna will improve safeguards to protect health information and ensure confidentiality. The company will also hire an independent consultant to monitor compliance.
"Companies entrusted with individuals' protected health information have a duty to avoid improper disclosures," New Jersey Attorney General Gurbir Grewal said in a media release.
"Aetna fell short here, potentially subjecting thousands of individuals to the stigma and discrimination that, unfortunately, still may accompany disclosure of their HIV/AIDS status," he said.
Aetna's second breach occurred in September 2017 and involved a mailing sent to 1,600 people concerning a study of patients with AFib. The envelopes for the mailing included the name and logo for the study – IMPACT AFib – which could have been interpreted as indicating that the addressee had AFib. Approximately 186 New Jersey residents were included in the AFib mailing.
New Jersey and the other investigating states alleged that Aetna not only violated the federal Health Insurance Portability and Accountability Act (HIPAA), but also state laws pertaining to the protected health information of individuals in general, and of persons with AIDS or HIV infection in particular.
State investigators also alleged that the two data breaches contravened Aetna's representations to enrollees—made clear on the company website—that Aetna would safeguard their private health information through "extensive operational and technical protections" and its "commitment to information privacy and compliance with legislation such as HIPAA and state privacy laws."
Texas Fines Humana
The Texas Department of Insurance fined Humana $700,000 for an inadequate number of in-network anesthesiologists in the Houston, Austin, and San Antonio service areas.
Texas regulators said that customers of Humana, the fourth-largest insurer in the state, faced higher medical bills because they couldn't get in-network anesthesia services at more than 20 hospitals and surgical centers in three of the state's largest metro areas.
Texas insurance regulators contacted Humana in August after learning several of its network contracts for anesthesiology services had been canceled. Humana agreed to immediate corrective actions and to reprocess consumers' bills.
"Protecting consumers from balance bills was a priority in this case, and we've done that," Insurance Commissioner Kent Sullivan said. "Humana has agreed to process these as in-network claims. Not one Humana consumer will pay extra because of this network issue."
Sullivan said Humana submitted reports to TDI that included providers no longer in its networks and did not adequately or timely disclose the issue to the state or consumers.
"Texas has strict network adequacy standards, and we’re going to hold insurers accountable for meeting them," Sullivan said.
Encroachment into the provider space is happening because traditional providers are failing to meet consumer demands on price, access, choice, and convenience.
Theall-but-completed merger of CVS Health and Aetna is a response to the accelerating shift toward consumer-oriented healthcare delivery, says Gurpreet Singh, Health Services Leader at PwC.
Nontraditional companies from the retail and tech sectors will continue to enter the nearly $3 trillion healthcare sector to provide services that were once the exclusive domain of traditional care givers, Singh says. Traditional providers who don't adapt to this shift risk extinction, he warns.
"This is happening because there is an unmet need for the consumer," he says. "The consumer demands choice, access, convenience, and a cost-efficient price for services that, typically for a hospital, are higher-margin businesses," Singh tells HealthLeaders.
Retail newcomers using urgent care centers and in-store clinics are taking lucrative walk-in traffic from hospitals and leaving them with the highest-cost, most-complicated procedures.
"Are they going to be in the business of focusing just on the tertiary, quaternary care?" Singh says. "Or are they going to be in the business of providing experience and convenience and virtualized care to patients?"
Singh says hospitals can offset the squeeze from nontraditional competitors by choosing to focus on a particular strength, be it clinical expertise, integrated care, wellness, or customer service.
A product leader, for example, could be an academic medical center with a strong reputation for particular specialties, such as cardiovascular or oncology care. Singh says these product leaders can't simply rely upon their reputation for specific service lines.
"They're the ones that risk losing a lot of the front-door, higher-margin procedures," Singh says. "They're the ones that typically only have single-digit growth and potentially double-digit costs, where they're kind of upside-down."
These hospitals should also focus on virtual care for chronic conditions. "That allows you to treat more patients than just the patients that come to you as a destination medical center," he says.
The move to wellness
Retail newcomers are also well-positioned to embrace wellness, Singh says.
"We believe that, especially with a move towards value-based care, where outcomes are really rewarded, that wellness is going to be an important aspect for growth for many healthcare institutions," he says.
"Many of the retail clinics, because they have access to a large population, potentially have the opportunity and the benefit of focusing more on wellness and population health," he says. "They can provide the right behavior modification, the right advice that will make me healthier and as a result, reduce the cost of care longer term."
Winners & Losers
The hospitals that will fail in this competition with retail newcomers are those that can't distinguish themselves for their care, cost, customer service, or willingness to take on outcomes-based payment models, Singh says.
"Many community hospitals that don't have the scale suffer aren't profitable, and that's where, we're seeing hospital closings, mainly in smaller communities because they don't have the right economic profile," he says.
Community hospitals that don't have the resources or reputation to be products leaders could instead focus on being experience leaders, Singh says.
"They could operate more like a technology company, or a consumer products company where the experience that I get as a consumer is very convenient," he says.
"I can check on the availability of the physician, and I can book my appointment online. I can go into the clinic or the hospital and do my copay right away. I can get sort of referrals and care management right away," he says.
"When you think about consumers, I call it the at-home-health CEO, the person that is between the ages of 35 and 55, who's probably caring for themselves, for a child and a parent. They're making choices for three different generations, so convenience becomes important."
"Those hospitals that can move aggressively towards that convenience and provide services for that at-home-health CEO will be the winners," Singh says. "The ones that can't will be the losers."
Plaintiffs say clinicians at the Evanston, Illinois health system failed to recognize signs of fetal distress that led to oxygen deficiency and devastating brain injuries for a newborn.
A Chicago jury on Tuesday awarded $50 million to the family of a child whose delayed diagnosis of severe oxygen deficiency before birth at NorthShore University HealthSystem led to severe and permanent brain injuries.
When Julien Florez was born on March 22, 2009 at NorthShore, in Evanston, Illinois, he was blue, had an uneven heart rate, and was unable to breathe on his own, according to a complaintfiled with Cook County Circuit Court.
The attending physicians and nurses performed chest compressions on the newborn and worked to get oxygen to his brain and organs for an hour, but the newborn suffered a hypoxic ischemic encephalopathy due to the lack of oxygen to his vital organs, the Florez family's physician said, according to the complaint.
Because of the HIE, Julien developed cerebral palsy. He's now nine years old and struggles with basic tasks. His English and Spanish vocabularies are limited to about 30 words and he communicates primarily through gesturing with his hands. Additionally, Julien has decreased motor skills, bilateral hearing loss and difficulty walking, the complaint read.
The complaint charged that the attending clinicians failed to recognize signs of fetal distress shown on a fetal monitor strip prior to his birth, and made matters worse by prescribing Pitocin for his mother Aimee Florez to speed up and strengthen contractions, which put more stress on the baby in the womb.
In addition, the complaint charged that the medical staff waited too long to call for a C-section, which kept the child in an unsafe environment for several hours and led to the brain injury.
"Had Aimee never been given Pitocin and been administered a more-timely C-section, Julien's injury could have been prevented altogether," plaintiff's attorney Patrick A. Salvi II said in a media release.
"Medical records show Aimee was given Pitocin despite the warning signs that Julien may not be tolerating the stresses of labor," Salvi said. "Instead of letting her body figure it out, her doctors started a medicine that runs the risk of resulting in increased stress to the baby."
Salvi said the plaintiff's declined a $10 million settlement offer during the trial.
NorthShore issued a statement saying it was "disappointed with this decision and intend to appeal the matter."
"We support the clinical care provided by our labor and delivery team who continually places the utmost priority on patient care and safety," NorthShore said.
The five-year program involves 832 acute care hospitals and 715 group practices representing 1,547 Medicare providers and suppliers in 49 states.
Nearly 1,300 providers have signed on to participate in Medicare's newest at-risk bundled payment initiative, the Centers for Medicare & Medicaid Services announced Tuesday.
The BPCI Advanced Model was unveiled in January and runs from October 1, 2018 through December 31, 2023, building on the Bundled Payments for Care Improvement Initiative (BPCI) that ended September 30.
The participantsin the five-year program include 832 acute care hospitals and 715 physician group practices representing 1,547 Medicare providers and suppliers in 49 states and the District of Columbia, CMS said.
Under the new payment model, providers are at risk for financial losses if they can't contain patient care costs within a spending range set by Medicare. They keep a share of what they save on costs, as long as quality metrics are met.
BPCI Advanced will include 32 bundled clinical episodes—29 inpatient and three outpatient. The top three clinical episodes are major lower joint replacement, congestive heart failure, and sepsis.
"To accelerate the value-based transformation of America's healthcare system, we must offer a range of new payment models so providers can choose the approach that works best for them," CMS Administrator Seema Verma said in a media release.
"The Bundled Payments for Care Improvement – Advanced model was the Trump Administration's first Advanced Alternative Payment Model, and today we are proud to announce robust participation," Verma said.
"We look forward to launching additional models that will provide an off-ramp to the inefficient fee-for-service system and improve quality and reduce costs for our beneficiaries," she said.
The BPCI program qualifies as an Advanced Alternative Payment Model under the Medicare Access and CHIP Reauthorization ACT, which means that providers in the model will be exempted from reporting requirements under the Merit-based Incentive Payment System.
After hearing complaints from providers, CMS said it will issue preliminary target prices before each model year of BPCI Advanced to allow for planning.
At a conference in Washington, D.C., this week, American Hospital Association CMO Jay Bhatt, DO, said hospitals' success in bundled payment models requires access to timely data for evidence-based decisions on changes to care delivery, and cooperation across care settings.
"We especially need payers to routinely provide timely—if not real-time—data in a readily usable format to hospitals and others participating in bundled payment models so that these participants can make evidence-based decisions on changes to care delivery," Bhatt said.
Bhatt said stakeholders should also communicate about what works, and what doesn't, reduce regulatory burdens, balance risk and reward, and integrate accountability for quality and financial incentives across care venues and payer models.
Clarification: The wording of this story has been updated to clarify that participants share a portion of the money they save, if they meet quality goals.
Analysts are looking askance at the C-suite turnover at the Ft. Lauderdale-based health system, which has had four CEOs in the past three years.
The ongoing leadership turnover at Broward Health has not gone unnoticed by financial markets.
Standard & Poor's Global Ratings said this week that the sudden departure of Broward Health CEO Beverly Capasso "does not immediately affect" the bond rating agency's BBB+ long-term rating, but "reinforces our negative outlook."
"The negative outlook reflects Broward Health's continued void in permanent senior leadership with many positions filled on an interim basis during a period of significant challenges and heightened external scrutiny," S&P said in a ratings brief.
Capasso, a former board member at Fort Lauderdale-based Broward Health, was named CEO in January and resigned abruptly last Wednesday. A system spokesperson told HealthLeadersthat Capasso had cited personal reasons.
"Having signed a three-year contract, we believed that Ms. Capasso would be in the role for a longer period to bring stability to the organization," S&P said.
Capasso and four other Broward Health leaders—General Counsel Lynn Barrett, board Chairman Rocky Rodriguez, and board members Christopher Ure and Linda Robison—face misdemeanor charges for allegedly mishandling the dismissal of former interim CEO Pauline Grant in 2016 in violation of Florida's Sunshine Law, which requires public entities to conduct their business publicly.
Capasso was on the board when Grant was fired over kickback allegations in late 2016, as the Sun Sentinel reported. All have pleaded not guilty.
S&P said that permanent leadership appointments and management stability are key factors when assessing health systems' credit ratings.
"In our opinion, the turnover in the CEO position—four CEOs in the past three years—highlights further instability in senior leadership and a heightened credit risk from ineffective management and governance practices," S&P said.
"We will continue to monitor developments as they evolve and expect to have an in-depth discussion with management during our next annual surveillance update."
The order follows a federal judge's ruling last month that CMS was still responsible for cost-sharing payments to Montana Health Co-op, even though Congress provided no funding.
A federal claims court has ordered the Centers for Medicare & Medicaid Services to pay Montana Health Co-op more than $1.2 million in cost-sharing payments that the Trump Administration and Congress reneged on last fall.
Judge Elaine D. Kaplan had ruled that the federal government was statutorily obligated to make good on the CSR payments for the fourth quarter of 2017, which Kaplan said "was not vitiated by Congress’s failure to appropriate funds for that purpose."
The $1.2 million payout was the amount that CMS said it would have paid Montana Health for the quarter had the funding not been cut off.
The CSR payments lowered premiums, copays and deductibles for eligible enrollees in the Affordable Care Act Marketplaces.
CMS had been making the payments from 2014 through October 2017, but stopped after Congress refused to appropriate the money. Montana Health and other stakeholders filed suit seeking the payments for the fourth quarter.
Even without the CSR funding, health insurers still had to provide the coverage at a reduced rate for the eligible enrollees, which prompted silver plan premium hikes for non-eligible enrollees to offset the lost CSR payments.
Julius W. Hobson, Jr., a senior policy advisor with Washington, DC-based Polsinelli, says the claims court ruling is not the end of the fight.
"Until, and unless, the U.S. Supreme Court finally rules on this matter, we will continue to see suits filed and considered by lower federal courts," he says.
"The question is whether the Administration will seek to expedite appellate review on this matter. Otherwise, we will continue to see state-by-state judicial decisions. I have no expectations that Congress will address the matter now or in the near future."
