Oz’s CMS looks very different
Two major healthcare conferences recently occurred – the HIMSS conference in Las Vegas followed by the Centers for Medicare and Medicaid Services (CMS) Quality Conference the next week. CMS Administrator Dr. Mehmet Oz spoke at both conferences and Oz and other top sister agency officials discussed the Trump administration’s vision for healthcare.
Suffice it to say that the Trump CMS is vastly different in tone and philosophy than Biden’s CMS. Furthermore, while themes and approaches were similar between Trump 45 and 47, you can say that Trump 47 is on steroids when it comes to grand visions and efforts to implement change. It is both the personality and drive of Oz as well as President Trump now understanding government and what it takes to implement change. If Trump 45 was incremental and conservative in approach, Trump 47 is far more aggressive and swift.
At the HIMSS conference, Oz went all in on the use of AI, agentic AI, and digital health. Opening the CMS conference, Oz raised some of the same themes, saying CMS is devoted to a tech-first transformation, interoperability, and patients engaging digitally. He said technology was a solution to controlling disease exacerbation, rural health access, and driving annual wellness visits.
Let’s reflect a bit on some of the key themes from Oz and other top officials.
Oz also noted the following:
- Oz is clearly obsessed with quality. He emphasized that bad quality care is our biggest problem. This is so true. Poor quality means overutilization and often people accessing healthcare at the most expensive settings.
- Oz, too, is obsessed with primary care and prevention. He wisely called out the great misnomer – that people who do not engage in primary care and prevention are healthy and we don’t need to worry about it. He noted studies say the opposite. He is right here, too. Numerous studies on direct primary care (DPC) show the major savings (10% to 15%) of intensive focus on primary care. A Wakely study of wellness visits among Medicare enrollees found that those with better attachment to wellness visits save the system $885 per year.
- Oz’s dedication to technology transformation is evident as well. CMS has announced a number of new models. The flagship initiative is ACCESS, which teams digital healthcare companies with Medicare fee-for-service (FFS) physicians to deploy remote monitoring and other tech-enabled chronic condition management. ELEVATE and TEMPO also focus on technology enablement in Medicare.
- Oz also calls out the sorry state of rural health. Rural health has had challenges for years and the Medicaid reductions in the One Big Beautiful Bill Act (OBBBA) will certainly add to the woes. A $50 billion five-year program was set up to innovate rural healthcare, including the use of digital technology to address specialty, mental health, ER and urgent care coverage shortages. Technology certainly can play a role here too.
- Perhaps most important, Oz featured the administration’s efforts on drug price reform. I have given Trump 47 a great deal of credit for truly moving the needle on drug prices. It will be a long path, but no president has initiated such significant change. While the Biden administration did pass Medicare drug price negotiations, the provision attacks a limited number of drugs per year in terms of lowering costs. Trump has used a SWAT-team approach to driving meaningful change:
- An executive order on transparency throughout the drug channel.
- An executive order seeking to move forward on most-favored-nation (MHN) pricing.
- Aggressive drug negotiations with 16 of the 17 top brand makers. This has led to MFN-pricing in Medicaid, commitments to MFN pricing on new drugs, deep discounts for self-pay Americans, and lower prices in Medicare, especially for GLP-1s.
- Trump 47’s CMS just unveiled 5-year MFN payment models for Part B Medicare, Part D Medicare, and Medicaid. In Medicare, a subset of drugs will be tested for MFN.
- And Trump is taking the Medicare drug price negotiations very seriously. When Trump took over, price concessions doubled. Out of fairness, Biden had but one year to seek concessions.
No, the commercial world is not touched; it will take a while to get to full MFN in Medicaid and Medicare, but I go back to the sweeping nature of what Trump is trying to do. It simply was not accomplished by any other president.
- Relatedly, expanding GLP-1s in Medicare and Medicaid is a key focus. Trump announced a proposal, beginning in mid-2026, to expand GLP-1 coverage in Medicare and Medicaid to obesity alone (meaning no other disease state benefiting from GLP-1s is evident). The expansion can occur due to the deep discounts Trump negotiated with drug makers.
- Fraud, waste, and abuse will remain center stage and deservedly so. Oz has introduced a FFS prior authorization program to rein in excess for certain services, CMS negotiated all -line-of-business prior authorization reforms with health plans. He unveiled aggressive Risk Adjustment Data Validation (RADV) audits in Medicare Advantage, although these may be hobbled in the short term due to a federal court’s striking of the underlying rule governing the audits.
- CMS has been seeking to transform payment in Medicare and Medicaid for years and Trump 47 continues this. Value-based care (VBC) payment transformation is being emphasized through various new models and successors to long-standing ones in Medicare. Overall, the record on VBC transformation is more mixed, with few models showing large savings if any. But Medicare FFS remains a large and expensive system, which needs reform. I have argued pilots need to be fewer in numbers and leverage common measurement. Trump 47 seems to be going in a different direction, proliferating models with the view that everything needs to be tested.
- Most controversially, Trump 47 and Oz have aggressively moved to remake benefits under the Affordable Care Act (ACA). The Biden years saw a pure dedication to comprehensive insurance models and rich subsidies to support them. While Democrats blame soaring premiums on the expiration of the enhanced Exchange subsidies, the truth is premiums have been soaring for years. A lot goes into it, but at least part of it is driven by costly benefits. Now, more and more cannot afford the premium freight; if they can, they have coverage in name only. They cannot afford to use it. Trump 47 and a GOP Congress have moved to introduce efforts to emphasize lower costs plans and alternatives:
- DPC expansion
- Health Savings Account (HSA) expansion
- Bronze and catastrophic plan changes, including value-based prevention models in multi-year catastrophic coverage
- Opening coverage in catastrophic plans to more people
- Seeking to allow non-network plans to be qualified health plans under the ACA
Again, the benefits remake is controversial and likely will have fallout in terms of the risk and adversity in more traditional comprehensive coverage models. But it is also true that the American healthcare system is on a crash course. The CMS Actuary projects healthcare spending will increase 7% per year through the early 2030s. That is unsustainable. Different approaches need to be explored.
#healthcare #coverage #cms #oz
— Marc S. Ryan
