House Passes Reconciliation Bill; On To An Uncertain Fate In Senate
(UPDATED 5/22 AM)
The House threaded the needle and passed the budget reconciliation bill on a tight 215-to-214 vote. Two Republicans voted against the bill, and one voted present to get the bill to pass. The vote was a result of a marathon session and backroom arm-twisting by President Trump, House Speaker Mike Johnson, and other House GOP leaders. President Trump met with the caucus this week and laid down the law, telling moderates to drop their SALT demands (they did to some degree) and conservatives not to “f—” with Medicaid.
The House leaders thread the needle by a mix of further concessions and appealing to party unity. The conservatives wanted additional Medicaid structural changes and accelerated reductions. They were conceded acceleration of work requirements from 2029 to essentially 2027. It is likely impossible for states to do so that quickly.
House moderates cut a deal to further raise the state and local tax (SALT) deduction limit put in place in 2017, but watering down of Medicaid reductions did not occur. The conservatives received some more spending cuts to close the increase in the deficit created by the last-minute SALT change.
Each side was told that was it and they must support the bill given the importance to the GOP and the nation. Further, the president gave commitments to issue additional executive orders to address some spending and Medicaid concerns.
Now the Senate must grapple with passing the bill. It is philosophically opposed to the mammoth nature of the bill. The GOP likely has a solid no vote in deficit hawk Rand Paul of Kentucky. He will hate the deficit impacts. And there are between 5 and 7 moderates or pragmatic conservatives who right now are very concerned about the level of Medicaid cuts. Most can stomach work requirements, but others are concerned about the impact to reimbursement to states and the impact to coverage, especially related to provider tax reform.
The sequestration provisions hidden in the bill could trigger future healthcare cuts beyond what are strictly outlined, including in Medicare.
There is still a long way to go, but the House shockingly got its business done by the self-imposed Memorial Day deadline.
Additional articles: https://thehill.com/homenews/senate/5312796-thune-may-fight-medicaid-cuts/ and https://insidehealthpolicy.com/daily-news/house-gop-meets-wh-over-reconciliation-issues-johnson-strives-wednesday-night-vote and https://www.beckerspayer.com/policy-updates/gop-budget-bill-could-slash-medicare-by-45b-in-2026/ and https://thehill.com/homenews/house/5312712-house-gop-bill-medicare-cuts/ and https://thehill.com/business/5309473-trump-tax-policies-national-debt/?tbref=hp and https://thehill.com/homenews/house/5313019-salt-medicaid-house-republicans-trump-bill/ .
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#budgetreconciliation #trump #congress #medicaid #coverage #spending
https://thehill.com/homenews/house/5313198-house-passes-trump-big-beautiful-bill
CMS To Audit All Plans On Risk Adjustment
In a bombshell announcement, beginning immediately the Centers for Medicare and Medicaid Services (CMS) will audit all eligible Medicare Advantage (MA) plans for each payment year in all newly initiated audits and invest additional resources to expedite the completion of audits for payment years (PYs) 2018 through 2024.
MA opponents and a bipartisan group of lawmakers have raised issues with what they view as immense overpayments, some of which are tied directly to risk adjustment scoring. CMS says overpayments are about $17 billion a year on scoring. CMS’ completed audits for PYs 2011–2013 found between 5% and 8% in overpayments. The Medicare Payment Advisory Commission (MedPAC) estimates the risk scoring figure could be as high as $43 billion per year. MedPAC says total overpayments are $84 billion or more, which is over-inflated.
I have made the case that some scoring above the traditional program is fair, but that a small group of plans have aggressive and aberrant behavior in terms of risk adjustment submissions.
CMS has had a very poor track record on carrying out risk adjustment audits and recouping revenue.
CMS has a plan to complete all remaining RADV audits for PY 2018 to PY 2024 by early 2026. Key elements of the plan include enhanced technology for medical record review and workforce expansion in this area (from 40 to 2,000 for medical coders!). CMS says it will be able to increase its audits from ~60 MA plans a year to all eligible MA plans each year in all newly initiated audits (approximately 550 MA plans). It will increase from auditing 35 records per health plan per year to between 35 and 200 records per health plan per year, based on size.
In other news, a bipartisan bill aiming to reform prior authorization has been reintroduced in the Senate. The Improving Seniors’ Timely Access to Care Act has been in a number of Congresses and failed to gain traction to pass. The bill of late has had a zero-cost score from budget scorers because much of the bill has been implemented administratively. Still, passage would etch reforms into law. These include electronic submission and various prior authorization transparency and reform.
Additional articles: https://www.fiercehealthcare.com/regulatory/senators-reintroduce-bill-seeks-reform-prior-auth-ma and https://www.cms.gov/newsroom/press-releases/cms-rolls-out-aggressive-strategy-enhance-and-accelerate-medicare-advantage-audits and https://insidehealthpolicy.com/daily-news/admin-significantly-expand-ma-audits
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#medicareadvantage #riskadjustment #priorauthorization
https://www.modernhealthcare.com/policy/medicare-advantage-audits-cms
UnitedHealthcare Now Hit With Kickback Allegations
After rallying for several days in a row, UnitedHealth Group’s shares are taking another downturn following media reports that it paid kickbacks to nursing homes to reduce patient transfers to hospitals. The report in The Guardian, alleges that bonuses were paid to facilities based on metrics like “admits per thousand,” which tracked how many patients were sent from a nursing home to the hospital. The program aimed to reduce costs, but put patients at risk.
#unitedhealthcare #nursinghomes #fwa
Cigna Moves To Control And Lower GLP-1 Costs
Cigna rolled out another weight-loss drug initiative to control costs and bolster access to GLP-1 weight-loss medications. The program caps monthly copayments for Wegovy and Zepbound at $200 and counts the spending toward annual deductibles. This is about a 50% to 60% lower cost than so-called direct-to-consumer pricing the brand drug makers have launched recently. At the same time, the costs are prohibitive for most Americans.
In other news, the Food and Drug Administration (FDA) announced it will take additional steps to help states get their drug importation programs approved.
Further, Senate HELP Committee Ranking Member Bernie Sanders, I-VT, reintroduced his bill on most favored nation drug pricing, but Chairman Bill Cassidy, R-LA, blocked immediate consideration. Cassidy says he has alternatives.
Additional articles: https://www.modernhealthcare.com/insurance/cigna-evernorth-wegovy-zepbound-copayment and https://insidehealthpolicy.com/daily-news/fda-aims-streamline-state-drug-importation-approvals and https://insidehealthpolicy.com/daily-news/sanders-reintroduces-mfn-bill-cassidy-blocks-fast-track-vote
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#drugpricing #branddrugmakers #glp1s #weightlossdrugs #pbms #mfn
— Marc S. Ryan
