Government shutdown averted until November 17, but threat is far from over
Congress passed a last-minute stopgap funding measure late Saturday to keep the government running for the next six weeks. Hours before the government shutdown was set to take effect, the House of Representatives and the Senate passed a continuing resolution to fund the government at current levels through November 17. The measure briefly extends funding for community health centers, National Health Service Corps, Special Diabetes Program, and the Teaching Health Center Graduate Medical Education Program. It also delays cuts to Medicaid Disproportionate Share Hospital payments. The bipartisan agreement has come at a cost for House Speaker Kevin McCarthy, who lost his speakership Tuesday because of his work with Democrats. In the meantime, it’s unclear whether lawmakers can agree on a new speaker and resolve their differences on long-term government funding by mid-November and prevent a shutdown.
Report: Despite its potential, CMS innovation center has failed to save money
Although the Congressional Budget Office (CBO) projected in 2010 that the Center for Medicare & Medicaid Innovation (CMMI) would produce savings, a recent report from the federal agency finds that it actually increased spending during its first decade and likely will cost more money than it saves in the future.
CMMI was established in 2010 by the Affordable Care Act to develop payment models for Medicare, Medicaid, and the Children’s Health Insurance Program that would reduce spending or improve the quality of care. The innovation center’s activities increased direct spending by $5.4 billion between 2011 and 2020, according to the CBO report. CMMI spent $7.9 billion to operate models and the models reduced spending on health care benefits by $2.6 billion.
CBO projects that CMMI will also increase net federal spending by $1.3 billion, or 0.01 percent of net spending on Medicare, over its second decade, which extends from 2021 to 2030.
OIG audit: Aetna received $25.5M in MA overpayments
An Office of Inspector General (OIG) audit has recommended Aetna refund Medicare $632,070 in overpayments it received in 2015 and 2016 for submitting high-risk diagnosis codes not supported in medical records. OIG's audit focused on 210 sampled enrollee-years and found 155 of the records didn’t comply with federal requirements for use in the Center for Medicare & Medicaid Services’ (CMS) risk adjustment program. Based on the sample results, OIG estimated that Aetna received at least $25.5 million in Medicare Advantage overpayments for 2015 and 2016.
In addition to reimbursing the federal government for the sampled year’s overpayments, OIG recommends that Aetna determine, for the remaining 159 enrollee years in the sample, whether the medical records in each case support the diagnosis for an unrelated condition not reviewed during the audit and refund any resulting overpayments. The watchdog also recommended that Aetna identify similar instances of noncompliance for the high-risk diagnoses that occurred before or after the audit period and refund any resulting overpayments to Medicare.
The audit noted that Aetna didn’t concur with OIG’s recommendations or agree with the findings for five enrollee-years sampled. Aetna did not state whether it agreed or disagreed with the findings for the remaining enrollee-years. The insurer also disagreed with the audit methodology, medical record review process, and use of extrapolation. As a result, OIG revised the number of enrollee-years in error from 156 to 155 for the final audit report. OIG also has recommended a refund of only the overpayments for the sampled enrollee-years because CMS has updated regulations for audits in its risk adjustment program to specify that extrapolated overpayments could only be recouped beginning with payment year 2018.
Lawmakers want feds to scrutinize proposed UnitedHealth-Amedisys acquisition
Sen. Elizabeth Warren (D-Mass.) and Rep. Pramila Jayapal (D-Wash.) have called on the Federal Trade Commission and the Justice Department to inspect the UnitedHealth Group’s proposed acquisition of Amedisys, a home and hospice care provider. The lawmakers said the $3.3 billion is the latest example of “massive health care conglomerates using anticompetitive mergers to increase their market dominance, reducing competition, hurting patients, and increasing health care costs.”
In their announcement about the letter, Warren and Jayapal urged the federal agencies to scrutinize similar deals, reject behavioral or structural remedies, and oppose any health care acquisition that would threaten competition, increase prices, and reduce quality of care. They raised concerns about how profiteering, including in Medicare Advantage, is driving vertical consolidation in health care.
HHS seeks input on coverage of OTC preventive services
The Departments of Health and Human Services, Labor, and the Treasury are seeking public input on how best to ensure coverage and access to over-the-counter (OTC) preventive services, including the benefits of requiring most health insurance plans to cover these services at no cost and without a prescription by a health care provider. This new Request for Information (RFI) solicits comment on access to a range of OTC items recommended by experts for preventive care that can be purchased without a prescription, including contraceptives, tobacco smoking cessation products, folic acid during pregnancy, and breastfeeding supplies. Comments are due by December 4, 2023.
Under the Affordable Care Act, most plans and issuers must cover certain recommended preventive items and services at no cost. Several of these recommended preventive items and services are currently available to consumers OTC without a prescription but are not required to be covered without cost sharing unless prescribed by a health care provider. The goal of the RFI is to understand the potential challenges and benefits for various interested parties, including consumers, plans, issuers, pharmacies, and health care providers, to provide coverage at no cost for recommended OTC preventive products without requiring a prescription.
“All Americans deserve access to quality health care. We know that making preventive care available over the counter can improve access–but there may still be cost barriers. That’s why we are working with the Department of Labor and Department of the Treasury to better understand how a policy change that could further increase access to affordable, preventive care might affect consumers, pharmacies, and health insurance providers,” said HHS Secretary Xavier Becerra, in the announcement.