Clay’s Weekly Medicaid RoundUp: Week of August 20th 2018

Soundtrack for today’s RoundUp pessimist readers-


For optimist readers-


CMS SPEAKS ON DEMO WAIVER BUDGET NEUTRALITY- CMS rolled out new guidance this week on how states can prove 1115s are budget-neutral. Looks like there hasn’t been much tracking of this until now (and not even a formal calculation method if I am reading the stories right). Moving forward, these things may actually get evaluated for whether the demonstration waiver “demonstrated” its “innovation.” Good luck to all the DSRIP programs out there. If you are opposed to fiscal responsibility and transparency, I recommend fighting this one with all you’ve got.


OKLAHOMA TO PAY FOR DRUGS THAT WORK (AND NOT PAY FOR ONES THAT DON’T)- OK is now greenlighted by the federalis to negotiate prices with drug manufacturers based on whether or not super-expensive drugs actually do anything to help the patient. 1st contract is with Alkermes for a schizophrenia injectable. Its an interesting approach – price keeps going down as long as the prescription keeps getting refilled (the metric for whether its helping, I guess).


HOSPITALS STAND TO LOSE LOTS AND LOTS OF CASH IF KY MEDICAID EXPANSION NIXED; COME UP WITH THEIR OWN PLAN TO FIX IT- Hospital execs in KY have put together a “group” called Balanced Health of KY. It’s big idea? Wait for it… Up the provider-tax magic money scheme to pay for expansion if the whole KY vs Lefties court case doesn’t allow expansion to keep going. For new readers, these schemes allow hospitals to happily pay a “tax” that then gets matched with federal dollars, which then go back to the hospitals. But of course, its mean-spirited to question the ethics of this (like GAO and other investigators have been doing for decades).


ADD IL TO LIST OF MEDICAID REIMBURSEMENT FOR MH/BH TELEHEALTH- The Good Guvn’r Rauner just signed a bill allowing Medicaid to pay behavioral health providers for telehealth. Probably easier now that IL got $2B from feds to address the opioid crisis. IL already allowed psychiatrists and FQHCs to get paid for telehealth; the new bill opens up payment for clinical psychologists, social workers, anps and other mental health professionals.


“MEDICAID IS THE ONE FOR OLD PEOPLE, RIGHT?”: SENATE WANTS TO HEAR FROM CMS ABOUT FRAUD- Senators (those wise old, Medicaid policy experts making all the big funding decisions) heard from Ms. Veerma on Tuesday. They were particularly interested in her thoughts on fraud in the program, as well as insights into possible recoveries against TX for its uncompensated care financing scheme (prob a magic-money/provider tax scheme but I don’t have the details). Senators also heard from GAO officials the same day. GAO shared insights from its recent reports about CMS not having enough data to perform effective fraud monitoring. Coming out of the hearings, all Senators unanimously agreed to with-hold 10% of federal funds until somebody actually did something about fraud. Just kidding! Everyone agreed that Medicaid fraud is clearly Mr. Trump’s fault and should be included in the scope of Mr. Mueller’s investigation. #Impeach! #Resist! #1984!


GRANDMA GOT RUN OVER BY A PRIOR AUTH SYTEM: AFTER COURT BATTLE OVER WHO IS FINAL SAY ON COVERAGE, UNITED HEALTHCARE HAS TO BUY WHEELCHAIR FOR GRANDMA- UHC Iowa repeatedly denied a nursing home resident a request for a special wheelchair after 3 court cases where it took the unusual step of fighting it. Anyone know why? Seems like not worth the PR, but maybe I am missing something…


FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph-  Not enough time this week, my dear, dear fraud junkies. Check the twitter feed for a lot of shared cases, though (at least 20 cases).

That’s it for this week. As always, please send me a note with your thoughts to or give me a buzz at 919.727.9231. Get outside (get up early – the cool morning breezes will remind you of things forgotten) and keep running the race (you know who you are).

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