The Biden administration's latest election-year initiative on women's health would require hospitals to spend billions on maternity care improvements to stay in Medicare.

Why it matters: Maternal health has proven to be a winning issue for Democrats as restrictive abortion laws and insufficient care draw attention to poor access and outcomes.

Driving the news: CMS on Wednesday proposed the first-ever federal maternal health and safety requirements for hospitals.

• Hospitals would have to keep basic resuscitation equipment available in labor and delivery rooms, document maternal health training for staff and have written policies for transferring patients to other hospitals.
• All hospitals offering emergency services — even if they lack an obstetrics unit — would be required to have proper protocols and supplies for emergency deliveries and other needs.
• Facilities that don't comply could eventually be booted from Medicare.

Follow the money: The industry would pay about $4.46 billion over 10 years to implement the policy — or an average of $70,671 per year for each hospital, CMS estimated.

Zoom out: The United States is in the throes of a maternal mortality crisis, with a death rate more than double that of most other high-income countries. Hospitals across the country are closing or reducing unprofitable obstetrics wards.

• Hospitals and their advocacy groups say the new conditions are an unnecessary and onerous policy that could discourage more facilities from providing obstetric services.
• OB-GYNs are concerned that adding new conditions of Medicare participation could wind up reducing patient access to obstetric services.

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The Federal Trade Commission plans to sue the three biggest prescription drug middlemen for allegedly using negotiating tactics to steer patients to use more expensive drugs, including insulins, according to a source familiar with the matter.

Why it matters: It would follow a two-year FTC investigation that found pharmacy benefit managers use their dominance over the drug supply chain to hike prices and boost profits.

The FTC's case would target the three biggest PBMs — CVS Caremark, Express Scripts and OptumRx.

• Those PBMs manage about 80% of prescriptions and are integrated with the health insurers Aetna, Cigna and United Healthcare, respectively.
• The agency is also investigating drug manufacturers, although it is unclear if they will be included in this suit, according to the source, who spoke on the condition of anonymity.

The big picture: PBMs have been in the regulatory crosshairs in recent years, and the FTC is cranking up pressure as Congress looks at changing the way Medicare reimburses the companies and imposing new transparency requirements.

• The companies negotiate with drugmakers on behalf of insurers and employers and argue that they are in the business of taking on manufacturers to lower prices.

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If you haven't heard of digital twin technology in health care yet, you probably will soon.

Why it matters: Virtual likenesses of a human or an object are increasingly being seen as a powerful tool for research, writes Axios' Megan Morrone.

Zoom out: Right now "digital twin" has become shorthand for an array of AI models and can mean anything from a statistical model of a complex organism, to a video avatar of a billionaire trained on his speeches and posts, she writes.

• In health care, digital twins can be an AI model of a person or a part of a person used to analyze large quantities of health data in order to provide more personalized treatment or speed up drug development.
• They're not entirely new. Studies involving digital twins first began popping up in PubMed in 2017.
• Digital twins offer "tremendous opportunities for personalized healthcare," but they also pose potential ethical, societal and legal challenges, according to a review article in npj Digital Medicine.

Tina's thought bubble: I've struggled to fully wrap my mind around this concept. Lisa Shah, chief medical officer of a startup called Twin Health, told me to think about it like the challenge of building autonomous cars.

• "There's lots of inputs and outputs, lots of things that can go wrong when you're driving a car, so you have to almost create a digital replica of that car and be able to predict what's going to happen," Shah said.
• "We do the same thing," she said, only it's with digital twins of patients using Bluetooth-connected sensors to measure data points like blood pressure and heart rate.

A spate of at least 121 ransomware attacks hit U.S. health care providers over the last six months, originating from 10 distinct groups such as LockBit and ALPHV, according to a new report provided first to Axios from intelligence company Cyble.

Why it matters: The report identifies the most active actors targeting health care between January and June 2024, and where they've struck, including payment vendor Change Healthcare.

What they found: Five ransomware groups most actively targeting U.S. health care include INC Ransom, LockBit, BianLian, Medusa and ALPHV.

• "This diversity of actors suggests a fragmented approach to targeting the healthcare sector, with no single entity dominating this aspect of the cybercrime landscape," the company wrote in the report.
• Health care services were the most targeted segment — including service providers, equipment vendors, e-commerce companies, and consultants, as well as manufacturers.

Doctors are staring at a nearly 3% cut to their Medicare payments next year as they pressure Congress to mitigate the last round of reimbursement cuts.

Why it matters: It's become an annual rite for CMS to announce a decrease in physician payments, and for lawmakers to swoop in with a year-end "doc fix" to ease the pain.

• That's because Medicare doesn't allow annual inflation adjustments to doctor payments like it does for other providers.

A voluminous physician payment rule released Wednesday proposed a slew of policy changes beyond the pay reduction.

• If finalized, Medicare could pay for audio-only telehealth services if a patient can't or won't use video technology.
• The rule would also expand the number of medically necessary dental procedures Medicare can cover and create a new payment system for advanced primary care services reflecting a patient's medical and social complexity.

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🧑‍⚖️ Purdue Pharma creditors and states are preparing legal actions against members of the Sackler family after the Supreme Court denied them immunity for their role as the company's owners in the opioid crisis. (NYT)

👀 Language that would restrict soldiers' kids from getting gender-affirming care was added to the Senate's version of the annual defense policy bill, in what would be the first such federal restriction. (Axios)

💉 Novo Nordisk's once-weekly insulin failed to win approval from the FDA after regulators asked for more information to complete their review. (Bloomberg)

🏛️ The House Oversight Committee subpoenaed three senior White House aides Wednesday, demanding they sit for depositions regarding President Biden's health. (Axios)