Senate In A Quandary Over Spending Cuts
Conservatives and more moderate members are at odds in the upper chamber after President Trump and the House GOP held firm with a target of at least $1.5 trillion in spending cuts in the budget reconciliation process.
Commitments by Trump and Johnson to rightists in the House was the only reason the bill passed. But Senate Majority Leader John Thune says he has a number of moderates and pragmatic conservatives who have warned that deep spending cuts in healthcare and other areas could mean they are off any final budget bill. Two of the members are in tight re-election campaigns in 2026, which could significantly erode the Senate GOP majority if they lose.
That said, insufficient cuts could doom the bill in the House and perhaps even in the Senate.
#budgetreconciliation #spending #trump #congress
https://thehill.com/homenews/senate/5243579-senate-republicans-divided-budget-cuts/?tbref=hp
United Bullying Physicians To Pay Back Cyberattack Loans
The UnitedHealth Group appears to be bullying physician practices to pay back loans granted by the healthcare behemoth during the 2024 Change Healthcare cyberattack. United’s Change Healthcare subsidiary’s technology services systems had major tentacles throughout healthcare, touching health plans, physicians, and pharmacies. Some lost millions due to the service interruptions and still feel impacts to this day.
United’s approach is despicable, including one-size-fits-all demands for repayment and threats to withhold future claims. The government has done little so far to hold United accountable for the gross dereliction of duty to have been cyber-ready and for its total lack of a business continuity plan. Lawsuits against United are slowly moving through courts. The Trump administration should use its bully pulpit to pressure United to be more reasonable on its loan repayment approach, lay out reasonable repayment terms, and even forgive portions of loans given the huge costs to the healthcare system caused by United.
#changehealthcare #cyberattacks #providers #healthplans #unitedhealthcare
New Study Shows Reform Pilots Lose Money
A new Avalere Health assessment of 18 Center for Medicare and Medicaid Innovation models reaffirms other findings that, in the aggregate, the pilots cost and do not save. The study did find some that were effective in savings costs and improving quality.
The study found that the 18 reviewed models brought $6.4 billion in net model losses and $1.3 billion in model-specific operational costs. A third of the models brought “substantial” savings for the government, a third even greater losses and the remainder had “nominal financial impacts.”
I have argued that we cannot totally abandon such reform pilots as the fee-for-service systems will live on for decades in Medicare and to some degree in Medicaid. But the number of reform pilots should be reduced and standardized. More aggressive benchmarks and approaches should also be adopted.
#valuebasedcare #vbc #medicare #medicaid
CMS To Further Restrain Social Barrier Supports In Medicaid
Recently the Trump administration pulled the Biden administration’s model 1115 waiver process for social determinants of health benefits. Now, it is further restraining such investments. The Centers for Medicare and Medicaid Services (CMS) said in a letter to states it will end funding for so-called designated state health programs and designated state investment programs when their 1115 waivers end. And no new requests will be approved. CMS characterized the approvals as a creative interpretation of 1115 waiver authority.
States use this funding for non-medical benefits, such as housing, nutrition, and transportation assistance. All of this is an effort by Trump to refocus Medicaid on medical benefits. I am a believer in using Medicaid for some social barrier spending given such barriers can be a greater predictor of costs than underlying disease states. But I have to admit that states and the federal government liberally interpreted what Medicaid dollars should be used on.
In other news, a Health Affairs Forefront Blog discusses the potential impacts on population eligibility and benefits if Medicaid is reduced.
Additional articles: https://www.modernhealthcare.com/policy/cms-medicaid-designated-state-health-programs and https://insidehealthpolicy.com/daily-news/cms-cuts-federal-match-non-health-related-medicaid-initiatives and https://www.healthaffairs.org/content/forefront/rescinding-health-related-social-needs-guidance-undermines-trump-s-own-economic-goals and https://www.healthaffairs.org/content/forefront/state-medicaid-programs-face-decreased-federal-support-older-adults-and-individuals
(Some articles may require a subscription.)
#socialdeterminants #sdohs #medicaid
https://www.fiercehealthcare.com/regulatory/cms-end-federal-match-states-health-equity-requests
Rural Hospitals’ Challenges With Medicare Advantage
This Kaiser Health News (KHN) article published in Modern Healthcare recounts the ongoing saga of rural hospitals’ disputes with Medicare Advantage (MA) plans. Rural hospitals say that they have become more financially unstable as MA has expanded into rural areas. They complain of lower reimbursement.
The article did quote Better Medicare Alliance with some balancing arguments.
In my view, the allegation that MA reimburses less than the traditional program is likely not accurate. Overall revenue may be lower compared with traditional Medicare due to prior authorization (PA) requirements and greater scrutiny of services.
Regardless, MA plans seem to be losing the PA and claims denial fight on Capitol Hill.
(Article may require a subscription.)
#priorauthorization #ruralhealthcare #medicareadvantage #hospitals
https://www.modernhealthcare.com/insurance/medicare-advantage-contracts-rural-hospitals
MedPAC Laments Opaqueness Of Supplemental Benefits
In addition to calling out $83 billion in so-called Medicare Advantage (MA) overpayments, MedPAC, the congressional advisory group for Medicare, is again lamenting the lack of details to assess the benefit of the vast supplemental benefits funded by the rebates in the MA rate-setting program.
The Centers for Medicare and Medicaid Services (CMS) has taken steps to mandate better education on such benefits and mandatory encounter submissions.
#supplementalbenefits #medicareadvantage #riskadjustment #overpayments
https://www.medpagetoday.com/publichealthpolicy/medicare/115083
CMS Proposes 2026 Medicare Facility Rates
The Centers for Medicare and Medicaid Services (CMS) has announced rules to fund various hospital facilities, skilled nursing facilities, and hospice programs in 2026. In general, the increases are in the 2% to 3% range.
#medicare #providers #hospitals
Big PBM Leaders Defend Their Programs
Executives at big pharmacy benefits managers (PBMs) are on a campaign to defend their role in the healthcare systems, touting recent moves to go down the transparency road. Upstart transparency PBMs argue the moves are too little too late and their models are truly transparent. While the big three PBMs (68% to 80% of volume) continue to dominate, there are notable moves of health plans and employer groups to newer PBMs or solutions.
#pbms #drugpricing
— Marc S. Ryan
