Trump Admin Proposes Major Medicare FFS Reform Rule
The Trump administration continues its efforts to reform Medicare and make its mark on healthcare reform. A new Medicare fee-for-service (FFS) reform proposal will significantly impact many areas of the sprawling traditional program.
The proposed rule would make changes to Medicare accountable care organizations (ACOs), transition away from the physician Merit-based Incentive Payment System (MIPS) to an enhanced value-based care (VBC) pathways program, and update physician payment policies to better reflect modern clinical practice.
In part the ACO changes would establish more predictable spending targets to improve planning and participation as well as increase some shared saving rates and make benchmark and other calculation adjustments. Notable quality reporting changes are also proposed.
The MIPS successor would also have three new value-based pathways on diabetes, hypertension, and hospital-based care.
Physician reimbursement would generally shrink a bit in 2027. Remote patient monitoring would also be substantially reformed and reined in.
Additional articles: https://www.cms.gov/newsroom/press-releases/cms-proposes-transformational-medicare-reforms-expand-accountable-care-modernize-physician-payment and https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2027-medicare-physician-fee-schedule-proposed-rule-cms-1848-p-medicare-shared and https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2027-medicare-physician-fee-schedule-proposed-rule
(Some articles may require a subscription.)
#medicare #acos #physicians
https://www.modernhealthcare.com/politics-regulation/mh-cms-medicare-physician-pay-2027
CVS and FTC Settle Insulin Fraud Case
CVS Health’s Caremark pharmacy benefits manager (PBM) reached a settlement with the Federal Trade Commission (FTC) in the agency’s litigation against the three big PBMS. CVS is the second to settle, with United’s OptumRx remaining. CVS’ deal looks substantially like the earlier agreement, with a requirement to prefer the lowest-cost drugs on its standard formularies and pass through savings negotiated with drugmakers to clients.
Additional: https://www.fiercehealthcare.com/payers/ftc-cvs-unveil-settlement-ongoing-insulin-pricing-case and https://www.healthcaredive.com/news/cvs-caremark-ftc-settlement-insulin-suit/825224/
(Some articles may require a subscription.)
#ftc #pbms #drugpricing
https://www.modernhealthcare.com/insurance/mh-ftc-cvs-pbm-insulin-lawsuit-settlement
MA News
Alignment Healthcare lost its 2025 Medicare Advantage (MA) Stars lawsuit as a federal appeals court has ruled in favor of lower court rulings substantially in favor of the federal government.
Elevance Health received word that it will not face intermediate sanctions over risk adjustment practices in MA after it fulfilled all corrective actions.
Additional article: https://www.beckerspayer.com/payer/medicare-advantage/alignment-loses-2025-star-ratings-appeal-against-cms/
#medicareadvantage #regulations #stars #riskadjustment
https://www.cms.gov/files/document/elevancesanctioncompletion07132026.pdf
— Marc S. Ryan
