OIG report to Congress highlights watchdog’s work to combat health care fraud
The U.S. Department of Health and Human Services’ (HHS) Office of Inspector General (OIG) recently released its semiannual report to Congress that outlines the work the watchdog has conducted for the six-month period ending on March 31. Inspector General Christi A. Grimm wrote that the OIG has identified more than $200 million in expected recoveries and $277 million in questioned costs during the reporting period, which began October. The OIG has issued 62 audit reports and 19 evaluation reports in which it has made 213 recommendations to improve HHS programs, including Medicare and Medicare Advantage oversight. The 100-page report noted that despite the accomplishments, the watchdog has had to turn down hundreds of criminal and civil health care fraud cases each year due to a lack of resources. Indeed, Grimm said the OIG currently has about two cents to oversee every $100 of HHS spending and each case it turns down means unaddressed potential fraud.
Avalere study: MA risk adjustment model accuracy differs by race and ethnicity
A recent Avalere analysis funded by Arnold Ventures found that the Centers for Medicare & Medicaid Services (CMS)-Hierarchical Condition Category (HCC) model used may inaccurately estimate health care costs for beneficiaries depending on their race or ethnicity.
The CMS-HCC model, on average, closely predicts costs for Black and non-Hispanic white, according to the study. However, it overpredicts for beneficiaries who are Asian/Pacific Islander and Hispanic and underpredicts for those who are American Indian/Alaska Native.
To conduct the study, Avalere partnered with Inovalon Inc. to access CMS data and identify beneficiaries who were enrolled in both Medicare Fee-for-Service (FFS) Part A and Part B for at least one month in 2019. Analysts also identified all HCPCS codes in 2018 that could be risk adjusted as well as claim spending and then estimated the CMS-HCC community model, which includes enrollees who had 12 months of Part B enrollment in 2018. Avalere then compared the predicted costs of the sample using the CMS-HCC community model in use for plan year 2023 and assigned a ratio to the results.
The research findings indicate that the CMS-HCC risk-adjustment model may incorrectly predict costs for certain subpopulations, which might perpetuate disparities by overpaying for some low-cost populations and underpaying for some high-cost groups of beneficiaries.
CMS outlines plans for availability of new Alzheimer’s drugs if FDA gives full approval
The Centers for Medicare & Medicaid Services (CMS) has announced plans to broadly cover a new class of Alzheimer’s drugs if the Food and Drug Administration (FDA) grants traditional approval. Currently two drugs in this class have received accelerated approval from the FDA, but no product has received traditional approval.
The FDA could make a potential decision on approval of a new Alzheimer’s drug within weeks following the results of a confirmatory trial of the Eisai product Leqembi. Broader Medicare coverage would begin on the same day the FDA grants traditional approval.
Medicare will cover drugs with full FDA approval when a physician and clinical team participates in the collection of evidence about how these drugs work in the real world (more commonly known as registries). Clinicians will be able to submit this evidence through a nationwide, CMS-facilitated portal that will be available when any product gains traditional approval. The approach is consistent with CMS’ National Coverage Determination. To get Medicare coverage people will need to be enrolled in Medicare Part B, be diagnosed with mild cognitive impairment or early dementia caused by Alzheimer’s disease, and have a qualified physician participating in a registry, including the options above, with an appropriate clinical team and follow up care. These criteria are in addition to any label requirements the FDA specifies.
CMS said that other registries for drugs that may slow the progression of Alzheimer’s disease may soon become available. The agency will make information available here as studies come online.
New CMS model aims to improve access and quality of primary care
CMS has also announced plans to test a new primary care model in eight states. The Making Care Primary (MCP) model aims to improve care for patients by expanding and enhancing care management and care coordination, equipping primary care clinicians with tools to form partnerships with health care specialists, and leveraging community-based connections to address patients’ health needs as well as their health-related social needs. CMS expects the model will lead to downstream savings over time through better preventive care and reducing potentially avoidable costs, such as repeat hospitalizations. MCP will run for 10.5 years, from July 1, 2024, to December 31, 2034, in Colorado, Massachusetts, Minnesota, New Jersey, New Mexico, New York, North Carolina, and Washington. Primary care organizations within participating states may apply when the application opens in late summer 2023.
Jha to step down as White House COVID-19 czar
In the wake of the end of the COVID-19 public health emergency, the White House announced Ashish Jha will leave his role as its COVID-19 response coordinator next week to return to his job as dean of the Brown University School of Public Health. His last day is June 15.
“When I took office, our nation was facing a once-in-a generation pandemic, hit with a virus that changed everything. Thanks to my Administration’s whole-of-government approach, we now have the tools to manage COVID-19 and the virus no longer controls our daily lives,” President Biden said in a statement. “For the last year, I have relied on Dr. Ashish Jha to help me do just that as the White House COVID-19 Response Coordinator. As one of the leading public health experts in America, he has effectively translated and communicated complex scientific challenges into concrete actions that helped save and improve the lives of millions of Americans.”