Clay’s Weekly Medicaid RoundUp: Week of June 18th 2018

Soundtrack for today’s RoundUp pessimist readers-

For optimist readers-

 WELL YOU SAID IF THE LEGISLATURE FUNDED IT… If you’ve been following LePage vs Expansioners, you know that the Good Guvn’r of Maine has sworn to not submit an expansion request to the federalis unless the legislature came up with the money to pay for it (seems logical, but I know desire/emotion trumps logic in our world…). On Wednesday a judge upheld LaPage’s right to not be forced to submit an expansion plan against his will. Then (also on Wednesday) the ME Senate and House approved $60M to expand the state’s program. Your move, Mr. Governor.

 NEW REPEAL / REPLACE EFFORT VIA APPROPRIATIONS? The House GOP budget teed-up on Tuesday includes $1.5T in cuts to Medicaid and “other healthcare programs.” There may also be hooks in the bill to allow for repealing ObamaCare without the Dem votes normally needed (I think this is the “reconciliation” maneuvering but not sure yet). GOP leaders are sounding the alarm over mounting debt and related fiscal crises if we don’t reduce spending. Where are my Medicaid #Resistance Fighters? Shouldn’t you be freaking out / yelling right now? By the way, the new legislation is called “A Brighter American Future.”


MEDICAID FRAUD UP 157% SINCE 2013 AND SENATE LEADERS SHOW CONCERN- A new report from the Senate Homeland Security and Governmental Affairs Committee shows Medicaid fraud skyrocketing since 2013 (and it was already ridiculously high). The report claims $36B is lost to Medicaid fraud each year. Some members are laying the blame at CMS’s feet for not “taking basic steps to fight Medicaid fraud.” It doesn’t help CMS’s case that GAO has been sounding the alarm for years. Of the 11 anti-fraud recommendations GAO has made in the last 3 years, guess how many CMS has implemented. Zero. I have been tracking and trying to bring emphasis on the disgrace that is Medicaid fraud for 15 years now.. Not getting my hopes up this report will change much.


DEMOCRATS OPPOSE FUNDING NEW OPIOID TREATMENTS VIA MEDICAID- The House passed a bill on Wednesday to cover new treatments for opioid addiction in Medicaid programs. The legislation will allow for funding for addiction treatment to go to facilities with more than 16 beds (this

gets at the IMD exclusion for those familiar with this part of the space). States have been asking – and receiving- waivers to allow exactly this funding. But proponents say the waiver process is taking too long and this law would speed up access to treatment. Opposing dems said it didn’t go far enough.

HOW MUCH DID YOU PAY IN STATE TAXES LAST YEAR? 17% OF THAT WAS FOR MEDICAID – Up from 13% in 2000, according to a new Pew study. All 50 states spent a higher percentage of their funds on Medicaid in 2016 compared to 2000. LA had the highest surge, going from 11% in 2000 to 24% in 2016 (they also expanded Medicaid in 2016).


PA AMBULANCES GET 33% MEDICAID PAY RAISE- Standard rates for Advanced Life Support went from $200/trip to $300 in the Keystone State. The Ambulance Lobby (usually its one dude in the state with most of the marketshare) is a real thing. I have seen it in multiple markets over the years.


MAJOR CHANGES FOR MDRP? MACPAC (the Medicaid and CHIP Payment and Access Commission) is recommending 2 changes: 1) stop letting pharma set Avg Manufacturer Price using brand and generics, and instead use the prices actually available to wholesalers. This matters because rebates set off of generic prices are lower (and using the generics in the calculation dilutes the amount states can get back). And #2) MACPAC wants HHS to be able to punish manufacturers that don’t provide good enough data to monitor compliance.

MOLINA GETS FLORIDA LOSS OVERTURNED- The MCO had lost its business in 2 regions as part of the recent procurement cycle. After a successful protest, Molina will now continue to serve members in 2 of the 11 FL regions. The new decision is important for Molina – at $550M / year in revenue, the 5-year contract now secures $55M in profits (assuming a 2% profit rate).

FARRIS’S FANTASTIC FRAUD FOLLIES– And now for everybody’s favorite paragraph. Let’s start the ticker and see who wins this week’s award – er, not so fast. Not enough space this week. Get your fraud fix in the twitter feed (I put 20 or so fraud news items in there this week).

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 (pick tomatoes!) and keep running the race (you know who you are).

FULL, FREE newsletter@ . News that didn’t make it and sources for those that did: twitter @mostlymedicaid . Trystero: Pityānē putrālā jagācyā tāraṇāsāṭhī pāṭhavilē

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