Paragon Says Improper Medicaid Payments Could Be Over $1 Trillion
The Paragon Health Institute is an extremely powerful think tank with the ear of the Trump administration and some in Congress. Its newest report, in conjunction with the Economic Policy Innovation Center, says that improper payments under Medicaid could be as much as $1.1 trillion over ten years. The Centers for Medicare and Medicaid Services (CMS) estimated improper payments at $543 billion over ten years, but Paragon says that does not include eligibility check errors.
The report urges Congress to cut funding to states found with greater than 3% erroneous payments based on eligibility errors. Many of the errors are tied to the suspension of eligibility checks during the COVID pandemic. The ineligible population includes people over income limits and illegal immigrants.
The report gives hope that the GOP Congress can reduce Medicaid spending and perhaps certain Medicare spending without fundamentally impacting coverage. This is a promise made by the president and congressional leaders in the House.
(Article may require a subscription.)
#medicaid #fwa #improperpayments
Second Judge Grants Preliminary Injunction On Spending Freeze
A second federal judge granted a preliminary injunction against the Trump administration that bars the ongoing spending freeze. Judge John J. McConnell, Jr., of the U.S. District Court for the District of Rhode Island, sided with states in saying that “the Executive put itself above Congress” with late January’s “temporary pause” of congressionally appropriated and obligated federal disbursements.
He added: “Federal agencies and departments can spend, award, or suspend money based only on the power Congress has given to them – they have no other spending power. … The Executive has not pointed to any constitutional or statutory authority that would allow them to impose this type of categorical freeze.”
The administration argues it has a duty to run government efficiently and to root out fraud, waste, and abuse. There is concern that funds continue to be frozen or the time to allocate funds is still very long.
#spending #trump #doge
Will Clean CR Pass the House?
Government money runs out for FFY 2025 (through September 30) on March 14 and there is a big question about whether House Speak Mike Johnson will have enough Republican votes to pass a continuing resolution (CR) to continue funding the government. Do not expect any Democratic votes on the bill. And some members of the GOP Doctor’s Caucus could vote against a so-called clean CR (with funding at current levels through the end of the FFY) if there is no fix for the Medicare physician reduction that took effect on January 1.
Some health extenders will be included in the CR, so Rep. Greg Murphy is asking why the huge injustice to physicians cannot be addressed. While it costs money ($3.8B), it should be done. We have a primary care crisis in America. We cannot lose more doctors in Medicare. Murphy wants the almost 3% cut to be converted into a modest increase. Murphy says there are offsetting cuts that could be included, including pharmacy benefit manager (PBM) reform and Medicare Advantage (MA) overpayment reform. He may vote against the CR if no resolution to the doc fix happens. There is also the chance that some rightists will object to what they would characterize as continuing high spending.
(Some articles may require a subscription.)
#crs #governmentshutdown #congress #trump #healthcare #physicians #medicare
https://insidehealthpolicy.com/daily-news/clean-cr-still-most-likely-outcome-docs-rally-help
Becker’s Reports on BCBS Losses
At least six Blue Cross Blue Shield companies reported a financial loss in 2024, citing rising medical utilization and drug costs.
#margins #healthplans
https://www.beckerspayer.com/payer/6-bcbs-plans-reporting-losses-in-2024.html
Democrats Push PBM Reform
Senate Democrats on Thursday introduced a standalone package of health policies, including changes to the pharmacy benefit manager (PBM) industry that was left out of December’s government spending bill.
#pbms #drugpricing
https://thehill.com/policy/healthcare/5180391-senate-dems-introduce-pbm-reform
Confusion Abounds Over RFK Jr. Comment Changes
Nearly one week after Health and Human Services (HHS) Secretary Robert F. Kennedy Jr.’s move to eliminate certain public comment on regulations, the agency has done little to clarify the extent of the changes. Advocates, patient groups, and lawmakers are pushing back and asking for clarification. I have taken the position that the move is fairly limited to direct administration of the agency, but clarification is needed.
#rfkjr #hhs #cms #regulations
https://www.statnews.com/2025/03/06/rfk-jr-public-comment-patient-groups-richardson-waiver/
Telehealth Companies Team UP With GLP-1 Makers
Teladoc and LifeMD are partnering with drugmaker Eli Lilly to offer the weight loss drug Zepbound directly to self-paying patients. The telehealth companies said they are working with Gifthealth, the pharmacy partner of Eli Lilly’s direct-pay, direct-to-consumer website LillyDirect.
Both Eli Lilly and Novo Nordisk have taken steps to set up direct-to-consumer operations that reduce the ultimate costs of GLP-1 weight-loss drugs each month. But costs still are $349 to $499 per month. While these prices are much lower than list prices of $1,000 or more, they are still well above other developed nations’ prices.
On Wednesday, a federal judge ruled that compounding pharmacies must stop selling versions of Eli Lilly’s Zepbound and Mounjaro. The FDA removed its active ingredient, tirzepatide, from a shortage list last fall. The brand drug makers are looking to capture the telehealth market with their lower prices and telehealth partnerships.
In other news, a Modern Healthcare article discusses the tremendous success of Mark Cuban Cost Plus Drug Co. and the growing alliances it has with providers and health plans.
Additional articles: https://www.healthsystemtracker.org/brief/prices-of-drugs-for-weight-loss-in-the-us-and-peer-nations/ and https://www.modernhealthcare.com/insurance/mark-cuban-cost-plus-drug-clients
(Some articles may require a subscription.)
#drugpricing #glp1s #weightlossdrugs #branddrugmakers #cuban
https://www.modernhealthcare.com/digital-health/teladoc-lifemd-partner-eli-lilly-glp-1s
— Marc S. Ryan
