As DOGE Works, Evidence Of FWA Emerges
Even as Democrats excoriate Elon Musk and the Department of Government Efficiency (DOGE) commission for its far-reach and tactics, more word is coming out about the depth of improper payments made through Medicare and Medicaid. While the estimate is down since the COVID pandemic, a new report says there was $88.5 billion in improper payments in 2024, more than 5% of outlays last year.
A Centers for Medicare and Medicaid Services (CMS) fact sheet says improper payments from federal programs can include payment errors or fraudulent payments but most often involve insufficient or missing documentation in reporting by states, providers, or contractors.
My view: fraud, waste, and abuse (FWA) is much higher. Latest estimates suggest FWA is more like 25% of all healthcare costs, up from a traditional 10% norm used before. That would mean FWA accounts for over $1 trillion in the entire healthcare system. With Medicare and Medicaid closing in on $2 trillion, that is about $500 billion a year in these programs.
DOGE efforts have met some injunctions in federal court, but President Trump reiterated his support for the evaluation process so as to reduce wasteful spending.
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#medicare #medicaid #medicareadvantage #managedcare #trump #doge #spending
https://www.modernhealthcare.com/politics-policy/hhs-cms-improper-payments-2024
Rural Hospitals Want Exclusions From Cuts
Rural providers are pushing for exemptions from any spending reductions enacted impacting Medicaid and Medicare. Rural hospitals do need some exemptions given their critical role. They worry most about overall reductions in Medicaid as well as site neutral payments in Medicare. Site neutral payments are important and some allowances can be made for rural providers.
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#medicare #medicaid #providers #ruralhealthcare #siteneutral
https://www.modernhealthcare.com/providers/medicaid-cuts-rural-closures-layoffs
PhRMA Outlines Drug Negotiation Process Concerns
The Trump administration has already stated it plans to continue Medicare drug negotiations but it is soliciting input on transparency and stakeholder concerns. As such, the brand drug lobby, PhRMA, has already begun outlining its issues. They include:
- Information on the application of the bona fide marketing standard to determine when generic competition is available.
- The selection of studies and data sources used to determine the maximum fair price (MFP) for selected drugs.
- The evaluation of real-world evidence.
- Clarity on how therapeutic alternatives are selected that factor into CMS’ negotiation of prices for the brand drugs.
- The role of patient-listening sessions in shaping CMS’ price calculations.
- Which effectiveness and safety outcomes were prioritized.
- The role of patient-centered outcomes.
- The strategy for monitoring formulary placements and the utilization management (UM) tools that could affect drug access.
Separately, generic makers worry the MFP set could lower the prices that generic drug manufacturers can charge for their versions of the drug.
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#trump #ira #drugpricing #branddrugmakers
House Continues To Plot Budget Strategy
While the House GOP made some progress plotting a budget strategy this week in a meeting with President Trump, the House will work throughout the weekend to nail down the actual process and settle open issues. In addition, the Senate will meet with President Trump in Florida tonight to try to convince him to go with the Senate strategy of two bills versus the one bill approach of the House GOP and Trump.
#congress #budgetreconciliation #trump #healthcare
— Marc S. Ryan
