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CMS Quality Conference Opens

The Centers for Medicare and Medicaid Services (CMS) Quality Conference began today with some major addresses by CMS Administrator Dr. Mehmet Oz and other top officials. I will have a blog on the major addresses soon. In the meantime, some key points that were addressed:

At the HIMSS conference in Las Vegas last week, 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.

Oz also noted the following:

• Bad quality care is our biggest problem.
• Digital expansion models have been approved, including ACCESS, ELEVATE, and TEMPO, but such tech models must show outcomes.
• Rural health can be transformed with technology.
• Reducing drug costs and expanding GLP-1s are a key goal.
• Fraud will remain center stage.
• Payment transformation is necessary.
• The Exchange benefits are being transformed.
• He called out prior authorization reform across all lines of business as an achievement.

In related news, announced grant applications for the ELEVATE Model in Medicare. The model will offer Medicare coverage to functional and lifestyle medicine providers. Interested participants seeking grants under the model must submit a Letter of Intent by April 10, with the final application deadline set for May 15. CMS is planning to select 30 participants for the model to receive a collective $100 million of funding. CMS said that these participants will be split into two cohorts, one for the 2026 model year and one for 2027.

Further, CMS has announced that all brand drug makers that manufacture the fifteen drugs selected for Medicare drug price negotiations in the third round have chosen to participate.

Additional article: https://www.cms.gov/newsroom/fact-sheets/cms-announces-manufacturer-participation-third-cycle-medicare-drug-price-negotiation

#cms #quality #primarycare #technology #maha #digitalhealth

https://www.fiercehealthcare.com/regulatory/cms-unveils-new-model-aimed-functional-lifestyle-medicine

CMS All In On AI and Digital Health

Centers for Medicare and Medicaid Services (CMS) Administrator Dr. Mehmet Oz championed the use of AI, agentic AI, and digital health at a recent healthcare tech conference. CMS is rapidly endorsing models to use such technology, and CMS is starting to use the technology too.

Oz argued that such tech could help reduce rural healthcare gaps and that digital health and remote patient monitoring also could reduce costs by focusing care further upstream before diseases become acute. Oz argued: “I can win the battle for health, not in the ER or in the ICU, but in your home, in your kitchen, your bedroom, in your living room, with remote patient monitoring and better tools to validate that.”

Seniors appear to be endorsing the technology too. A recent healthcare policy group KFF survey found that the vast majority of seniors are using digital health tools and are interested in making greater use of them. About eight in 10 Medicare beneficiaries ages 65 and older used a healthcare app or website in the last year. A sizeable majority said it made it easier to use the health system. Some lack of trust of AI must be overcome, however.

Additional article: https://www.fiercehealthcare.com/ai-and-machine-learning/himss26-dr-oz-cms-officials-push-agentic-ai-adoption

#ai #digitalhealth #cms #healthcare

https://www.healthcaredive.com/news/cms-artifical-intelligence-ai-fraud-mehmet-oz-himss/814650

New Poll Finds Unaffordability Having Consequences

As we enter the midterms, healthcare affordability remains a significant challenge. A new poll finds that one in three Americans had to cut back on daily living expenses to afford care. A new West Health/Gallup survey says about a third of those surveyed cut back on at least one daily expense to afford healthcare last year. That is the equivalent of about 82 million Americans. For those that did not have insurance, about 62% said they made a cutback. For those with income of $24,000 or less, the tradeoff rate was about 55%. About 48% of those earning between $24,000 and $48,000 in annual household income said the same.

In other news, a Modern Healthcare analysis finds that healthcare revenue rose faster than all other services categories in 2025. Increased prices and growing demand from an aging population drove much of this. Revenue tied to the delivery of healthcare services increased 8.6% year-over-year – higher than the 6.1% increase for all other categories in the services sector. This is down from 10.1% and 11.2%, in 2024 and 2023, respectively for healthcare.

In Monday’s blog here I gave you my views on the midterm congressional races: https://www.healthcarelabyrinth.com/a-look-at-the-status-of-congressional-midterm-elections/ .

Additional articles: https://www.fiercehealthcare.com/finance/gallup-poll-one-three-americans-cutting-back-daily-expenses-pay-healthcare and https://www.modernhealthcare.com/providers/mh-healthcare-revenue-services-2025-census-bureau/

(Some articles may require a subscription.)

#healthcare #coverage #affordability

https://thehill.com/policy/healthcare/5780428-americans-cutting-expenses-healthcare

Aetna Settles MA Risk Adjustment Case

Aetna will pay $117.7 million to resolve False Claims Act allegations that it overbilled the Medicare program. The agreement settles claims related to past risk adjustment submissions in Medicare Advantage (MA). The Department of Justice said some diagnostic codes were not fully supported but were still submitted to secure higher payouts. Aetna also failed to withdraw some inaccurate diagnoses.

Additional articles: https://www.modernhealthcare.com/insurance/mh-aetna-medicare-advantage-upcoding-claims/ and https://www.beckerspayer.com/payer/medicare-advantage/aetna-to-pay-118m-to-resolve-medicare-advantage-upcoding-allegations/

(Some articles may require a subscription.)

#medicareadvantage #riskadjustment #overpayments #fwa

https://www.fiercehealthcare.com/payers/aetna-pay-1177m-settle-medicare-advantage-false-claims-case-doj

Oz Says Exchanges Have Major Fraud Problem

Centers for Medicare and Medicaid Services (CMS) Administrator Dr. Mehmet Oz claimed in his strongest terms yet that he believes major fraud exists in the Exchange enrollment process. He says millions could be inappropriately enrolled.

Conservatives say the enhanced Exchange subsidies that have now expired led to millions being enrolled due to zero or near-zero premiums. A number of brokers have been accused of fraudulently enrolling Americans. In January, enrollment in the Exchanges dropped about 1 million, which is far less than estimates. Conservative groups, including the Paragon Institute, have argued that so-called “shadow enrollees” remain in the program. Oz did say he expects enrollment to drop throughout the year to around 19 million. In part this is because of affordability issues due to premium hikes and people being unwilling to pay any premium.

#exchanges #coverage #fwa

https://thehill.com/policy/healthcare/5776734-oz-claims-aca-fraud-millions

Balance And Bridge Proposed For GLP-1s

The Centers for Medicare and Medicaid Services (CMS) has issued requests for applications for Medicare Part D plans and Medicaid agencies to join the BALANCE model that would bring GLP-1 weight-loss drugs to Medicaid and Medicare in 2026 and 2027, respectively, for those with obesity but not other qualifying disease states for the drugs.

CMS will negotiate prices for such drugs with brand drug makers. Participating plans and Medicaid agencies must cover all model drugs from the included manufacturers, and the existing Part D weight-loss coverage exclusion would not apply. The drugs must fall under a plan’s basic benefit structure. In Part D, at least 90% of a plan’s eligible population must be included.

Narrower risk corridors are available to plans. Enhanced alternatives and employer group waiver plans must cap beneficiary spending at $50 for a month’s supply during the initial coverage phase. For basic alternative and actuarially equivalent plans, the cap is $125 per month supply. Prior authorization would also be standardized across the model. The documents outline body mass index thresholds, provider attestation, and confirmation that patients are pursuing lifestyle modification.

CMS is also proposing a pilot in Medicare known as the Medicare GLP-1 Bridge to begin providing coverage as early as mid-2026. Wegovy and Zepbound would be provided to eligible beneficiaries enrolled in Medicare Part D for a $50 copayment. The short-term program will operate outside the Part D benefit for its duration from July 1 to December 31, 2026. Providers will submit GLP-1 prescriptions and prior authorization requests to a central processer managed by CMS.

Additional https://www.kff.org/quick-take/what-medicares-temporary-program-covering-glp-1s-for-obesity-means-for-beneficiaries/

#glp1s #weightlossdrugs #medicare #partd

https://www.beckerspayer.com/policy-updates/cms-invites-medicare-part-d-plans-medicaid-agencies-to-apply-for-glp-1-affordability-model/

Health Systems Report Financial Strength

Large health systems are on the upswing financially right now, with improved margins, higher volumes, investment returns, technology-driven efficiency, and better cash flow. In addition to the positives cited, health systems are also investing in alternative revenue streams, such as specialty pharmacy and outpatient care.

But storm clouds are moving in. Pharmaceutical and supply costs have posted sharp increases. And health systems face financial hits from the Medicaid and Exchange cuts in the One Big Beautiful Bill Act (OBBBA).

(Article may require a subscription.)

#hospitals #margins #obbba

https://www.modernhealthcare.com/providers/mh-health-system-earnings-kaiser-mayo-clinic

Other PBMs May Settle With FTC On Insulin Suits

The Federal Trade Commission (FTC) may be close to settlement in its insulin suits with CVS Caremark and OptumRx, two of the remaining big 3 pharmacy benefits managers (PBMs). Express Scripts has already settled and any future settlements are expected to be as far-reaching in terms of impacting existing business practices.

The FTC said in a court filing that it is making “significant progress” in talks with the two PBMs,

Additional article: https://www.fiercehealthcare.com/payers/ftc-seeing-progress-discussions-optum-caremark-insulin-case

#pbms #drugpricing #ftc

https://www.healthcaredive.com/news/optumrx-caremark-progress-ftc-settlement-insulin-case/813834

Study Finds Multiply Comorbid Drive Inpatient Admissions

A new report by Vizient finds that 11% of the U.S. population has multiple chronic conditions but these patients account for 52% of inpatient admissions, 35% of emergency department visits, and 32% of office visits. Patients with at least one chronic condition make up nearly 8 in 10 inpatient admissions. 

Among Medicare beneficiaries, more than half of those aged 65 to 74 have at least one chronic condition, and the same is true among nearly two-thirds of those 75 and older. This creates huge cost challenges in Medicare as America ages. Controlling chronic disease states is key.

#aging #medicare #hospitals #chronicconditions

https://www.beckershospitalreview.com/quality/patient-safety-outcomes/11-of-us-population-accounts-for-52-of-admissions-vizient/

Plans Oppose Flat 2027 MA Rates

In comments on the proposed 2027 Advance Notice of rates, Medicare Advantage (MA) plans say a flat rate will mean reduced benefits and services and increased out-of-pocket costs for seniors. UnitedHealth Group estimates the proposed rate increase would lead insurers to reduce benefits by more than $600 a year. AHIP says its actuary Wakely determined no-premium plans could face a 50% cut to supplemental benefits and increased out-of-pocket costs by $1,000. Premiums could increase $23 per month, resulting in a jump of more than $550 for a couple each year.

The plans also argue rising utilization and costs are being ignored.

In addition, Humana, insurer trade group AHIP, and the Blue Cross Blue Shield Association want the proposed changes to risk adjustment regarding chart reviews not linked to encounters to be delayed until 2028. UnitedHealth Group and the Better Medicare Alliance recommend that CMS implement this change gradually rather than all at once next year. AHIP and the Alliance of Community Health Plans say plans should be able to use chart reviews to score new members.

I expect final rates to increase by between 2% and 3%.

Additional article: https://www.beckerspayer.com/research-analysis/benefits-coverage-for-no-premium-plans-could-drop-50-under-2027-ma-rule-ahip/

(Some articles may require a subscription.)

#medicareadvantage #rates #riskadjustment

https://www.modernhealthcare.com/politics-regulation/mh-cms-2027-medicare-advantage-proposal-unitedhealth