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House GOP Wants MedPAC To Be More Favorable To MA

A new bill from Ways and Means Republicans that passed on a party line vote would require the Medicare Payment Advisory Commission (MedPAC) to study the topic of overpayments in Medicare Advantage (MA) more favorably for insurers. I support the bill as MedPAC has shown major bias against MA over the years, undertaking twisted analyses and citing dubious research studies to further the idea that MA is markedly over reimbursed.

#medicareadvantage #overpayments #riskadjustment

https://www.statnews.com/2026/09/16/medicare-advantage-overpayments-analysis-medpac-change-apples-to-apples-act/

PBM Law Could Impact Drug Entities In The Shadows

A new law with restrictions on and reforms to pharmacy benefit managers (PBMs) will have a major effect throughout the drug channel. The law requires greater transparency and will likely expose various transaction fees between PBMs and rebate aggregators, group purchasing organizations, and others related entities.

#pbms #transparency

https://www.modernhealthcare.com/insurance/mh-pbm-reform-drug-rebate-aggregators

ACCESS Program To Expand

The new tech-based chronic disease management ACCESS program will expand the diseases and conditions eligible for enrollment. The Centers for Medicare and Medicaid Services (CMS) announced that new clinical tracks will be added next Spring, including heart failure and substance use disorders. CMS Administrator Dr. Mehmet Oz also said he eventually wants the model adopted in Medicare Advantage (MA) and Medicaid. Right now, it services traditional Medicare enrollees.

The initiative has CMS contracting with technology organizations, which team up with Medicare physicians to use tech to track and improve outcomes for people with certain cardio-kidney-diabetes disease states, anxiety and depression, and musculoskeletal conditions. The new disease states include health failure, chronic obstructive pulmonary disease, substance abuse, and tobacco cessation.

Additional article: https://www.modernhealthcare.com/health-tech/mh-cms-access-model-chronic-care-tracks/

#medicare #chronicdisease #caremanagement #access

https://www.beckershospitalreview.com/finance/cms-expanding-access-model-4-things-to-know/

Trump Rejects Amodei’s Call

President Donald Trump rejected Anthropic CEO Dario Amodei’s call to slow the pace of advanced artificial intelligence development. Trump said that existing federal authority and presidential oversight are sufficient. “The only control or ‘guardrails’ that AI needs is a STRONG AND SMART (High IQ!) PRESIDENT,” President Trump wrote in a Truth Social post.

Of course, neither is true and the nation does not have a true game plan to control the roll out of AI across industries.

Amodei published an essay last week where he argued that AI capabilities are advancing faster than safety measures designed to govern them. He called for slowing development, implementing new safeguards, and allowing third-party evaluators to verify measures undertaken. Anthropic will implement the evaluator safeguard unilaterally.

Check out my blog published today on AI and regulation: https://www.healthcarelabyrinth.com/ai-in-healthcare-innovate-but-with-guardrails/

#healthcare #ai #regulation

https://www.beckershospitalreview.com/healthcare-information-technology/innovation/trump-rejects-anthropic-ceos-call-for-more-ai-guardrails/

Does PDP Program Need A Fallback Plan?

I have made much of the politically motivated Democratic Inflation Reduction Act’s (IRA) provisions to reduce cost-sharing for seniors in Part D. It was a terrible piece of public policy that has led to a huge increase in costs and risk to plan sponsors. While Medicare Advantage (MA) has survived, it certainly led to benefit reductions. But in the standalone Part D (PDP) world (which largely serves the traditional Medicare beneficiaries), the IRA changes have led to benefit reductions, rising premiums, fewer choices and coverage, and a financially untenable system.

A Health Affairs Forefront blog makes the case that a government-facilitated fallback plan may need to be introduced now before the financial situation gets worse.

The author traces the failures to growing MA and its payment and benefit advantages, which means the PDP market gets smaller and riskier. The capping of cost-sharing and elimination of costs in the catastrophic phase are big costs for plans. The author argues the program is headed for a death spiral, which is a case I have made.

The Centers for Medicare and Medicaid Services (CMS) has demonstration authority for a fallback on a regional basis but not yet a national one. The author argues a federally-facilitated PDP — with core benefits defined by CMS — would strengthen competitive conditions and exert downward pressure on premiums across remaining private sponsors.

I am not a big fan of a government plan running in parallel. It would clearly have advantages and could even make things worse. But the point about reform now rather than later is an important one. And as noted by the author, a federally-facilitated plan should be viewed as a complement to broader structural reform.

#medicareadvantage #partd #pdp #ira

https://www.healthaffairs.org/content/forefront/old-idea-whose-time-has-come-why-medicare-needs-federal-backstop-part-d

— Marc S. Ryan

MA Star Cut Points Rise

Good Healthcare Dive article on the release of Plan Preview 2 information for Medicare Advantage Stars and the new cut points. As the article discusses, assessing what will happen to overall Star ratings is hard to do. Tougher cut points can or cannot be a sign that things will go up overall.

My companion blog tends to think that some of the increases tie to true initiatives on performance improvement and others to MA plan exits. I think if things do go up overall, it will be modest. That blog is here: https://www.healthcarelabyrinth.com/two-star-blogs-in-one-what-will-cms-do-next-on-stars-and-despite-cut-point-moves-widespread-overall-ratings-hikes-unlikely/

#medicareadvantage #partd #stars #quality

https://www.healthcaredive.com/news/medicare-advantage-stars-cutpoints-2027-cms/829963

Impact Of OBBBA Cuts

Two new analyses describe the looming impacts of the Medicaid and Exchange cuts in the One Big Beautiful Bill Act (OBBBA).

Upcoming statutory limits on providers’ state-directed payments (SDPs) in Medicaid are expected to cost states tens of billions of dollars for state match and lower spending by double that or more. The analysis published in Health Affairs says 17 hard-hit states could see impacts of 10% to 25% of total annual Medicaid spending. The analysis outlined at least $51.8 billion in reductions across 36 states. A proposed rule would expand reductions beyond what is outlined in the OBBBA to all such SDPs.

Federal policy changes and budget cuts are forcing states to scale back Medicaid benefits for immigrants. Because of looming cuts, California, Colorado, Illinois, Minnesota, New York, Washington and the District of Columbia have scaled back state-funded coverage for immigrants. The changes will also have major impacts on revenue of Medicaid-dominant health plans Molina and Centene, among others. Insurers project losing more than $1 billion in Medicaid revenue.

Additional article: https://www.modernhealthcare.com/insurance/mh-molina-centene-state-medicaid-cuts-immigrants/

#medicaid #exchanges #obbba

https://www.fiercehealthcare.com/providers/obbbas-state-directed-payment-caps-will-trim-some-states-medicaid-spend-quarter-study

States Turning To Managed Care For Medicaid Long-Term Care

An excellent Modern Healthcare article on Medicaid long-term care. Twenty-four states contract with Medicaid managed care organizations to cover people who need long-term services and supports. This is a remarkable shift from decades ago when managed care covered largely only TANF welfare and related populations. States have turned to private delivery to save costs and reduce trends.

However, some states are actually rolling back long-term managed care. Indiana and Nebraska recently ended insurer contracts amid provider concerns.

#medicaid #longtermcare #managedcare

https://www.modernhealthcare.com/insurance/mh-medicaid-managed-care-long-term-services

Cuban Offers Ideas On Affordability

Entrepreneur Mark Cuban, founder of Cost Plus Drugs, appeared before the Texas Legislature with affordability and reform ideas. They include:

• Patients should be able to access drugs at the lowest possible cost, even if that’s outside of their health plan. Laws should allow such cash pay expenses to count toward deductibles or out-of-pocket maximums.
• Standardized contracts should be adopted for both pharmacy benefits managers and third-party administrators.
• Transparency in pricing is key and must be mandated. That includes transparency into rebates, fees, affiliate compensation, and any other guarantees.
• Elimination of gag clauses that may prevent employers or other plan sponsors from speaking more openly about their contracts. This would also drive transparency and better contract terms.
• And government of laws and regulations enforcement should have teeth.

#healthcare #healthcarereform #cuban

https://www.fiercehealthcare.com/regulatory/mark-cubans-recipe-affordable-healthcare-includes-these-5-policy-changes

Hospitals Say Revenue Losses Will Mount With More Changes

Hospital lobbies are turning up the heat on lawmakers given multiple funding reductions that threaten hospital finances. Impacts of the One Big Beautiful Bill Act will be $340 billion through 2034. But new rules proposed by the Trump administration would reform site neutral payments for imaging and enact reductions to drug reimbursement in Medicare for those with 340B status. That would mean another $681 billion loss over ten years.

While I favor site neutral payments and some 340B reforms, it seems clear that all the reductions threaten to undermine providers.

#hospitals #obbba #340b #siteneutral #medicaid #exchanges

https://www.politico.com/news/2026/09/02/hospitals-say-coming-regulations-worse-than-medicaid-cuts-01060086