Clay’s Weekly Medicaid RoundUp: Week of October 17th, 2016

Soundtrack for today’s RoundUp pessimist readers- ( bonus song- )


Or you can click the one for optimist readers –


RUH-RO IN OR: Looks like OR Medicaid may be un-invited to all the nice parties again (for those of you that remember the scandalous Medicaid-coverage-leads-to-worse-outcomes stories a few years back). New, long term studies have confirmed that the 40% ER spikes seen after expansion are sustained. The “pent-up demand” theories that assured us it would go down after initial uptake were proven false.

SHOW ME STATE SHOWED US THIS WEEK: Who the new MCO winners are, anyway. Centene, WellCare and UHC – Congratulations! The new contracts include a significant expansion (adding 61 counties). Aetna lost out on this one – and lost 270,000 monthly cap payments as well.

HUGE PROPS TO AMERIHEALTH CARITAS OF PA- The MCO achieved what only 14 others did nationwide – a 2016-2017 NCQA rating of 4.5. Keep up the good work!

VIRGINIA IF FOR (DEFICIT) LOVERS- VA has a $1.5B deficit, resulting in layoffs, agency cuts and other measures. Despite all this (but of course he argues because of all this), the Good Guvn’r McAuliffe is nagging/lobbying for VA to expand Medicaid again. Trot out the “but it’s free money from the federal government – they get it from the money trees in DC!” argument. Thinking people know that its not free, and it does add hundreds of millions more in the state share of Medicaid costs.

GET THOSE WAIVER APPS IN QUICK, PEOPLE- Seems like CMS is thinking there might be some sort of change that impacts federal healthcare policy happen in November? Any idea what that could be? For waiver apps that are in line with CMS desires, there is a fast track lane. Case in point- WA just got preliminary (helps us have something to latch onto post-November) approval of a new $1.5B Medicaid reform waiver. The WA deal will include monies to revamp LTC (among other things, most of them focused on shifting to value based care and out of FFS). Now if you’re KY and wanting to dial back expansion, well you’re request somehow made it to the bottom of the pile.

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. “Dr” Stanley Marable plead guilty to Medicaid dental fraud in Valdosta, GA this week. He stole $789k from GA Medicaid for tooth extractions that didn’t happen. OmniCare, the largest institutional pharmacy in the U-S of A (it’s a nationwide nursing home pharmacy) has agreed to pay back $28M to various state Medicaid programs over allegations it conspired with Abbot labs in a kickback scheme to increase Depakote sales. Robert Novy, and elder-law attorney of Brick, NJ was charged this week for defrauding clients out of $1.2M. He presented himself as an elder advocate, “helping” clients navigate Medicaid financing issues (think estate recovery), but in reality he was (allegedly) taking control of their finances and stealing their savings. OmniCare- you win this week’s award. I would make some witty quip about seeing you in orange and in jail, but it seems like more and more powerful people / corporations are above the law these days.


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 (do a rain dance for AL- we need it!) and keep running the race (you know who you are).


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