RISE summarizes recent regulatory-related headlines and reports.
5 factors that cause Medicare beneficiaries to switch between MA and FFS plans
A new article published by Health Affairs Forefront analyzes the enrollment patterns between Medicare Advantage and fee-for-service and the factors that influence enrollment decisions.
William V. Padula, Ph.D., an assistant professor in the Department of Pharmaceutical and Health Economics in the School of Pharmacy at the University of Southern California, writes that the patterns that influence switching between Medicare Advantage and fee-for-service plans may ultimately restrict access to novel medications and therapies.
Factors that may influence those who switch between plans include networks of providers, Medicap coverage, risk adjustment policies, quality bonuses, and a change in health status. Padula says fee-for-service plans over broader network coverage, but moving from Medicare Advantage to original Medicare may reduce financial protections because Medicare doesn’t place a limit on out-of-pocket spending. In addition, Medicare Advantage members who opt into fee-for-service plans need to enroll in several plans to access Part D benefits. Each prescription drug plan offers different coverage, premium costs, formulary restrictions, and cost-sharing mechanisms, Padula explains.
While switching from original Medicare to Medicare Advantage can streamline coverage under a single plan, he says that members may face challenges accessing medications, network restrictions, use management practices and increased-cost sharing obligations.
Lown Institute: Billions of Medicare dollars spent on unnecessary back surgeries for older adults
Physicians performed more than 200,000 unnecessary back surgeries on older adults, according to a new study from the Lown Institute based on three years of Medicare claims.
The surgeries took place despite medical research showing they provide little to no clinical benefit and come with serious risks, Lown Institute said in an announcement. Complications of spinal fusion, one of the procedures studied, can occur in up to 18 percent of patients and include the risk of developing infection, blood clots, stroke, pneumonia, heart, and lung problems, and even death.
The report estimates these unnecessary procedures cost Medicare $1.9 billion.
The findings come as the Centers for Medicare & Medicaid Services (CMS) launches efforts targeting overuse of medical services, like its introduction of the WISeR (Wasteful and Inappropriate Service Reduction) Model. WISeR’s list of 17 services includes vertebroplasty, a surgery that Lown’s study confirms is extensively overused on patients.
“The fact that CMS is launching an effort to curb overuse is a welcome and important step toward improving health care safety and reducing unnecessary federal spending,” said Vikas Saini, M.D., president of the Lown Institute.
Washington Post investigation explores the financial impact of veteran disability fraud claims
A new investigative report from the Washinton Post that analyzed 25 years of government data on disability claims found military veterans are submitting fraudulent disability claims totaling millions of dollars. The publication said taxpayers will spend $193 million in 2025 for the Department of Veterans Affairs to pay nearly seven million disabled veterans. The majority of the disability claims are legitimate, according to the VA, but the newspaper said it found millions of claims for minor issues, such as hair loss, eczema, acne, and toenail fungus that shouldn’t impact employment. Although the individual costs for the conditions aren’t costly, collectively they add up to billions of dollars, the Washington Post found. However, fewer veterans receive compensation for combat-related injuries. And when they do receive payment, the VA will compensate veterans diagnosed with sleep apnea more than a combat veteran who had a leg amputated below the knee.
Disabled American Veterans (DAV), an organization that supports the rights and benefits of all veterans, contested the findings and called the report misleading “Nothing could be farther from the truth and the Post should be ashamed of publishing such an inaccurate and distorted piece,” wrote Coleman Nee, national commander. The rising number of claims is because of the country’s efforts to keep the promise to veterans who served during multiple wars. He said the increase in claims is driven by the PACT Act, bipartisan legislation enacted in 2022 to acknowledge, compensate, and care for veterans who suffered toxic wounds from burn pits, Agent Orange, and other hazards in the line of duty.
“While the Post story focuses only on whether a disabled veteran can hold a full-time job, it totally disregards how service-connected injuries and illnesses can impact every aspect of a veteran’s life, and in many cases, even shorten it,” Nee said. “They do not even consider how these lifelong wounds, both visible and invisible, impact the families, caregivers, and survivors of those who defended our freedom."
Government shutdown forces MedPAC to cancel October meeting
The failure of Democrats and Republicans to come to an agreement to fund the government has had an impact on the daily operations of The Medicare Payment Advisory Commission (MedPAC). The organization has had to cancel its October public meeting. The next meeting is scheduled for November 6-7.
AHA calls for MedPAC to refine recent analysis of MA enrollment
The American Hospital Association (AHA) disagrees with MedPAC’s recent analysis of the financial impacts of Medicare Advantage enrollment growth on hospitals, which determined that increased enrollment is not statistically associated, on average, with changes to hospital profit margins. Molly Smith, group vice president public policy for AHA, wrote in a letter to MedPAC Chair Michael Chernew, Ph.D., that certain Medicare Advantage plans have created barriers to care access and provider payment. MedPAC’s focus on all-payer profit margin as an aggregate can obscure the financial pressures imposed by MA plans’ administrative practices and reimbursement structures, particularly in hospitals with high or growing Medicare Advantage enrollment. She urged the commission to refine its analytic approach to its analysis to address the AHA’s concerns.