Balanced patient reviews, required spending cuts, good marks for treatments — a Medicare roundup

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A new Medicare model aims to find the right balance of reviewing patient treatments, not necessarily adding to prior authorizations that are an administrative burden in U.S. health care.

Meanwhile, a Democratic leader in the House of Representatives said a new study shows Medicare cuts are inevitable under President Donald J. Trump’s One Big Beautiful Bill Act spending plan.

Health insurers also argued a separate analysis shows Medicare Advantage (MA) outperformed traditional Medicare fee-for-service (FFS) for patient screenings and medication adherence during the COVID-19 pandemic.

The developments were the latest in the continuing deliberation over the nation’s single largest health insurance plan.

More prior authorization burdens?

The U.S. Centers for Medicare & Medicaid Services (CMS) published a new frequently asked questions form outlining the goals and procedures of the new six-year Wasteful and Inappropriate Service Reduction (WISeR) Medicare model planned to start next year in six states.

House Democrats this month argued the model will increase the burden of prior authorizations (PAs) by introducing that process to traditional Medicare. Not so, according to CMS.

“WISeR targets a narrow set of items and services that have been a source of fraud, waste, abuse, and inappropriate utilization, and which can present a very real threat of patient harm,” the CMS update said. “Examples include skin substitutes, knee arthroscopy for knee osteoarthritis and electrical nerve stimulation. The list was derived through a careful review of existing National and Local Coverage determinations, clinical and academic literature, and reports from the U.S. Department of Health and Human Services (HHS) Office of Inspector General.”

The CMS information addressed by name HHS Secretary Robert F. Kennedy, Jr., and CMS Administrator Mehmet Oz, MD, MBA, and their pledge to work with insurers and fix the PA system.

“The Kennedy pledge is about the right balance for review: enough to protect patients but not so much that it interferes with their timely access to medically necessary care,” the CMS advisory said.

‘Budget time bomb’

The Associated Press reported the Congressional Budget Office (CBO) examined the effects of federal spending under the OBBBA and rules under the Statutory Pay-As-You-Go Act of 2010, known as S-PAYGO. As federal budget deficits increase, sequestration rules require a cut in Medicare spending — up to $491 billion from 2027 to 2034, according to the CBO letter to ranking members of House and Senate committees that oversee spending.

That could change if Congress acts, but there is no reason to believe Republicans “will disarm this budget time bomb,” Rep. Brendan Boyle (D-Pennsylvania) said in a statement. Boyle is ranking member of the House Committee on the Budget.

“For months now, I have been sounding the alarm on the devastating Medicare cuts caused by Trump’s Big Ugly Law,” Boyle said in a statement. “Republicans knew their tax breaks for billionaires would force over half a trillion dollars in Medicare cuts — and they did it anyway. American families simply cannot afford Donald Trump’s attacks on Medicare, Medicaid, and Obamacare.”

Strong performance

As for patients receiving treatment, Medicare Advantage had the advantage over traditional Medicare for more than 3.19 million beneficiaries. AHIP, the trade group for America’s health insurance plans, touted the results of “Care Quality Metrics in Medicare During COVID-19 Pandemic,” a study published in The American Journal of Managed Care.

Researchers examined a dozen clinical quality measures, including four screening measures requiring in-person visits, and eight medication management and adherence measure. The study group had more than 3.19 million beneficiaries from 2017 through 2021. In 2019 to 2021, Medicare Advantage “performed significantly better than TM (traditional Medicare) across the 12 clinical quality measures,” the study said.

That finding affirmed some earlier studies, but the authors noted much of the current literature largely was based on data from before 2020 and the start of the COVID-19 pandemic.

“In line with previous literature, our study finds that MA plans continue to outperform TM across various preventive and chronic condition care measures both before and during the COVID-19 pandemic,” the study said. “These findings demonstrate that MA plans continued to provide greater value than TM even during the public health emergency.”

AHIP noted the results in an emailed newsletter sent to subscribers.

“Nearly 35 million seniors and individuals with disabilities nationwide choose MA for their health coverage because it provides them with better care at lower costs than FFS,” the AHIP statement said. “The new study’s findings add to a growing body of evidence that MA’s coordinated, value-based approach delivers superior quality and better health outcomes — while saving beneficiaries an average of more than $3,400 per year versus FFS.”