Weekly Medicaid RoundUp: Week of August 29th, 2016

Soundtrack for today’s RoundUp pessimist readers- http://bit.ly/2c6pb2c

Or you can click the one for optimist readers – http://bit.ly/2ahXf8T

A BETTER WAY TO LOOK AT FRAUD IN MEDICAID- RoundUp readers and now show watchers know I can’t stand it when people essentially defend the huge disgrace of Medicaid fraud with the “I know its billions but that’s just a drop in the bucket in overall spending” or “but there is fraud in commercial and in Medicare, too!” A great article coming out of Illinois makes the (obvious) connection between Medicaid fraud (which we look the other way on) and Medicaid cuts (which we go bonkers about). Guess what- if you lose $12M on payments for dead people, you may have to cut some provider rates next year. (That article actually follows one family with a child who was counting on services and was directly impacted by Medicaid cuts that had to be made in part because of some large fraud losses). In other news, CMS released data on the improper payment rate for Medicaid (fancy way of saying fraud and stuff we can’t exactly call fraud). 2015 was 9.8% – that’s right, 10% of all Medicaid payments are “improper”, even by CMS’s own numbers – and it is projected to be 11.5% for 2016. For comparison, 2013’s rate was around 5%.

DON’T LOOK AT THIS CUP OVER HERE, LOOK AT THAT ONE OVER THERE! It was a rough month for ACA. The news of way higher than expected pmpm costs for those “healthier” expansion bennies was a punch to the gut, and the news of mass exchange exodus by the plans (I’m looking at you, Aetna) was the subsequent uppercut to the chin while ACA was bent over from the gut punch. Keep in mind some of the smartest people on our planet are investing their entire careers in ACA, so damage control was impressive (related vocabulary word – “sophistry”). Still hard to cover up some it, though. My favorite last week was an article that claimed expanding Medicaid keeps premium rates down on the exchanges. It’s a garbage argument, but works if you don’t ask too many questions. On a more positive note – if you are not following Slavitt on twitter yet, you need to. The head of CMS is tweeting constantly, and he’s honest, brilliant and engages people who disagree with him respectfully.

RUH-ROH IN ALASKA- After the fun sideshow that we all got to watch with Alaska’s expansion drama last year, a completely unexpected thing has happened. Expanding Medicaid has cost AK $30M more than projected. AK is now in the first stage of grief (denial), so consultants are trotting out the same old worn-out consolation theories: pent-up demand (previously known as the “woodwork” effect, until someone realized that was sort of a rude way to put it), costs will go down next year, et cetera.

KEYSTONE STATE SELECTS MLTSS MCO WINNNERS (FINALLY!)- Judging from all the calls I got on this one, a ton of RoundUp readers have been watching the procurement. Winners were AmeriHealth Caritas, Centene, and UPMC for You. 14 total bidders gave it a go, so expect some protests. In the meantime, congrats to the winners!

OK MEDICAID DIRECTOR LEAVING- Nico Gomez announced plans to leave the agency this week. Gomez has been at the helm during one of the toughest chapters in all of Medicaid history, with a particularly challenging budget reality in OK. Good luck, Mr. Gomez! Let us know where you end up.


FARRIS’S FANTASTIC FRAUD FOLLIES– Just not enough space this week. A few good ones in the twitter feed. Head on over there and get your fix.


That’s it for this week. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (leaves are starting to change) and keep running the race (you know who you are).


FULL, FREE newsletter: http://eepurl.com/ep81Y


News that didn’t make it and sources for those that did: twitter @mostlymedicaid | Otec poslal Syna, aby zachránil svět