Clay’s Weekly Medicaid RoundUp: Week of September 17th 2018

Soundtrack for today’s RoundUp pessimist readers-

For optimist readers-


IOWA PER-MEMBER MEDICAID COSTS TRIPLED IN SIX YEARS- Luddite MCO-bashers think it’s the MCOs’ fault. You guys may want to look at the impact of a little thing called taking the “expansion” money as well. The costs of the newly-eligibles surprised the heck out of all of us in every expansion state.

ONE REASON MAINE EXPANSION COULD GO THRU DESPITE LEPAGE’S PROTESTATIONS- It’s a state plan amendment, not a waiver. So the state is basically saying “can we please follow existing law” vs “can you give us permission to get an exception to the law.” Good catch by Michael Shepherd @ Bangor Daily. Roundup readers know all about Mr. LePage. After years of successfully blocking expansion, his agency finally submitted a request to CMS for it- with a catch. LePage sent it along with a memo that said – hey please don’t approve this thing.

SUPER SECRET OHIO PBM REPORT A DUD- Well it ended up being “heavily” redacted, anyway. A judge had considered releasing the report, rich with inside scoop on CVS drug pricing, in all its unredacted glory.

CMS APPROVES 6 NEW FINANCIAL EXPERIMENTS FOR 2019- The Big House approved a new set of APMs (Alternative Payment Models) for next year. MA ACOs, OH episode-based payments, TN retro-episodes, and 2 Washington MCO-based projects.

DEMS TRY TO SUBPOENA CMS DOCS ON WORK REQUIREMENTS– They say it hasn’t been thought-through enough, and inquiring minds in Congressional Lefty Land want to know (do you remember the old National Enquirer tag?). Two of our modern statesmen-luminaries, Elijah Cummings (D-MD) and Raja Krishnamoorthi (D-IL) are leading the subpoena charge. They claim the impact of work requirements on Americans is not being vetted, and they want to see projections, spreadsheets, etc. (keep in mind dear readers, they don’t really care- its all for the cameras. Cummings is set to easily be a part of the “Blue Wave” this November. And while Cummings will probably never lose in ultra-blue MD ((he took 75% of the vote last time)), Mr. K is not as safe and needs to appeal to his Big Healthcare industry buddies, who account for his largest campaign donors by far). Back to the story, though- if we can now subpoena CMS docs for policies impacting Americans that we don’t agree with (apply the “that” either to the policies or the Americans, reader choice), I would love to see the analysis done about 9 years ago on the impact of ACA on Americans. How many Americans with non-Medicaid coverage would lose their coverage? How many Americans would be priced out by absurd deductibles and premiums? How much will the taxes need to go up (i.e. the impact on taxpayers)?


CONGRATS AND WELCOME TO KEITH WISDOM- He’ll be the new CEO of Aetna Better Health in KS. Aetna was a recent winner in the MCO awards, and Keith will be the first Aetna KS CEO.


OREGON SOS ASKING FOR MONEY TO AUDIT MEDICAID – Sec. of State Richardson wants about $780k to staff up an audit team to figure out just what the heck is going on in the Medicaid program.


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 time/ space this week, dear, dear fraudsters. Get your fix in the twitter feed. (There’s some big ones in there- I’d say at least $22M in total provider fraud, and a dee-lish $200k member! fraud).


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 (plant mums, soon) and keep running the race (you know who you are).

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