With Friends Like These: No Love From GOP For Medicare Advantage
At a House Ways and Means Committee’s joint oversight and health subcommittee hearing, GOP lawmakers declared that the Medicare Advantage (MA) program needs an overhaul and private plans need to be reined in. The primary complaints were risk adjustment upcoding and prior authorization abuses. They also argued MA is not saving money as promised.
The hearing was contentious and could lead to either accelerated reforms from the Centers for Medicare and Medicaid Services (CMS) or possible inclusion of cuts in a future budget bill. But admittedly, so far Congress has not wanted to pull the trigger on MA reforms given the popularity among seniors.
In other news, a good article on the Trump administration proposal to begin some site neutral payment reform in Medicare. Some hospital-owned outpatient facilities (just off-campus outpatient facilities) would be paid the same to administer medications as physicians. CMS projects that Medicare would save $210 million and that beneficiaries would save $70 million in out-of-pocket costs next year. Clinic visits at on-campus outpatient departments could be the next area of reform.
These are baby steps. Congress is working on broader measures. Congressional policy arm MedPAC proposes very deep changes. Of course, hospitals will fight all site neutral measures because they simply do not want to reform and be efficient. But the time seems to be coming – finally.
Site neutral on Medicare fee-for-service (FFS) would help MA and commercial products as well.
(Some articles may require a subscription.)
Additional articles: https://www.modernhealthcare.com/politics-regulation/mh-medicare-advantage-house-hearing-upcoding/ and https://www.modernhealthcare.com/politics-regulation/mh-site-neutral-payment-cms-2026/
#hospitals #medicare #siteneutral
https://www.healthcaredive.com/news/medicare-advantage-house-hearing-upcoding-prior-auth/753726
Molina Reports Weak Q2 Financials
Molina Healthcare reported its Q2 financial news after earlier pulling back on guidance to investors, warning medical cost pressures would affect adjusted earnings. Molina cited a misalignment of rates with medical expense in the Medicaid program. Medicaid medical expense is over 91% of premiums. Molina executives say this is temporary. It says the company is performing near to long-term forecasts, but that is hard to imagine given its concentration in Medicaid and the Exchanges and what the budget bill, expiration of enhanced premium subsidies and a new Exchange enrollment rule will bring.
In other news, healthcare policy group KFF updated its allocation of state Medicaid reductions from the budget reconciliation bill. It has a good breakout too of the savings for each Medicaid measure and spending reduction impacts globally by year over the 10-year horizon.
Becker’s also details what you should know about the expiration of premium subsidy enhancements.
Additional articles: https://www.fiercehealthcare.com/payers/cost-pressures-limit-molina-healthcare-during-q2-earnings-stock-dips-4 and https://www.kff.org/medicaid/issue-brief/allocating-cbos-estimates-of-federal-medicaid-spending-reductions-across-the-states-enacted-reconciliation-package/
#budgetreconciliation #medicaid #exchanges #molina
No Surprises Act Favors Providers And Is Driving Healthcare Costs
Foolish lawmakers from both sides of aisle backed the provider-tilted No Surprises Act and it is clear providers are winning big and costs are being driven higher.
A study in Health Affairs finds that providers won around 83-88% of arbitration cases in the first half of 2024. More importantly, they secured much higher amounts than insurers, with the median prevailing provider offer in some cases reaching 447% of the qualifying payment amount.
#pricetransparency #nsa #nosurprisesact
https://www.beckerspayer.com/payer/5-no-surprises-act-updates
— Marc S. Ryan
