November 20, 2023

Improper Payments Detailed By CMS

CMS touts that improper payments were under 10% in traditional Medicare and in Medicaid, but it is nothing to be proud of. The traditional estimator of 10% for fraud, waste, and abuse (FWA) is a misnomer. Recent studies suggest that true FWA is perhaps 25% of all healthcare expenditures. In 2021, healthcare expenditures were $4.3 trillion. That means almost $1.1 trillion is true FWA.

#fwa #medicare #medicaid

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Providers Impacted As Well When Star Ratings Fall

Good article describing how providers suffer too when Star ratings fall in Medicare Advantage. Many have entered into partial or global risk-sharing arrangements with health plans and share in bonus revenue. (May require subscription.)

#medicareadvantage #providers #stars

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New Speaker’s Healthcare Advisor Named

New House Speaker Mike Johnson (R-LA) has named Drew Keyes, a former Republican Study Committee staffer, as his senior health policy advisor. He led the healthcare task force in 2019 that proposed the dismantling of the Affordable Care Act subsidies and Medicaid expansion in favor of state grants. As well, other private sector reforms were promoted, including health savings accounts (HSAs), association health plan growth, and more.

I am a Republican, but don’t favor these changes. Ensuring we close affordable coverage holes will yield more savings and quality over time than these approaches. (May require subscription.)

#speakerjohnson #healthcarereform #aca #medicaid

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Series on Long Term Care Crisis

The second of many articles from the Kaiser Family Foundation and the New York Times on our long-term care crisis. Two key points. First, the article notes that most states do not cover assisted living as part of Medicaid long-term care. So higher cost nursing home coverage can be obtained but not some cheaper forms of community-based care. The article also features the numerous costly add-ons that drive the cost of assisted living very high and out-of-reach for most. My book (The Healthcare Labyrinth — available on this site) goes into the need for an aging agenda in the U.S. and creative ways to offer care.

#medicare #medicaid #assistedliving #ltc #longtermcare #nyt #kff

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Opinion Piece On Urgent Care

Good opinion piece in MedPage Today on the need to re-examine urgent care and build adequate primary care. Many of my health plan friends tell me that the abuse of urgent care is real. Costs are rising for health plans and there are little to no offsetting reductions on ER.

#urgentcare #primarycare

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Great Summary of ACA Proposed Rule

Excellent article on the recently announced proposed rule amending the Affordable Care Act (ACA). The ACA is intricate and this Health Affairs Forefront blog does a good job of breaking the rule down and explaining it simply. Areas covered include: marketplace operations standards, web broker and other enrollment changes, standardizing open enrollment periods and additional special enrollment periods, changes to network adequacy and essential benefits, website requirements, changes to the basic health benefit program, and much more. The rule keeps standardized plan requirements and reduces the number of non-standardized options that can be marketed (but does not eliminate them and also allows additional plan designs if a benefit can be shown). The link below is to the main article. A separate blog discusses risk adjustment changes: https://www.healthaffairs.org/content/forefront/proposed-2025-payment-rule-risk-adjustment. (May require subscription.)

#aca #exchanges #obamacare

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Problems With Medicare Part B Drugs In Negotiation Law

Good Health Affairs Forefront blog on potential issues with Medicare Part B drugs in the Inflation Reduction Act (IRA). As the author notes, medical drug costs are obscene and are driving a great deal of spending. Called out are two problems: (1) The Drug Price Negotiation Program will begin to include Part B therapies in its pool of eligible drugs in 2026, but few will be subject to the program because they hit exclusion criteria. (2)  The law doesn’t address annual Part B out-of-pocket spending for patients, only those in Part D. (May require subscription.)

#drugpricing #partbdrugs #partd #medicare

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— Marc S. Ryan

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