Follow the money: More room for improvement in Medicare policy

Changing Medicare policy for payment for skin substitutes is a good start. But government regulators could do more to help accountable care organizations (ACOs) that aim to improve patient care. What is proper accountability when providers engage in fraud that may be beyond the control of the ACO? Advocacy group Accountable for Health CEO Mara McDermott, JD, discusses additional policy recommendations.

Medical Economics: Accountable for Health has suggested at least four other steps to protect ACOs and their patients. Can you discuss those and why those are needed?

Mara McDermott, JD: In terms of our thinking about Accountable for Health and accountable care organizations — and I should say this isn't limited to accountable care organizations. There are others like, kidney care is one that comes to mind, that take risk on their populations that are in a similar situation, holding the risk or holding that financial accountability for these fraudulent claims. So the couple of areas where we have focused, we are again super thrilled about the payment policy going forward for 2026. Our accountable care organizations, our kidney care organizations, are still left holding the bag on $15 billion of fraud for 2025. So a lot of our work now with the administration has focused around, how can you hold accountable care entities responsible for financial spend that is fair, while not holding them accountable for fraud, waste and abuse. And I think in particular in the case of fraud, where we know that the provider should not have billed, but that was completely outside of the control of the accountable care entity, really asking CMS to take some steps to ensure that there's kind of like a right-sizing of accountability. So we have focused on asking the agency to either remove beneficiaries with spend over a certain threshold from the ACO math, like, from the calculations, or otherwise truncate, apply a stop loss policy, something like that, to provide financial protection to those organizations. The other area where we've been really interested is, like, how can we get in front of this in the future? ACOs had their hands up for a long time, waving that red flag saying something weird is going on here. CMS, can you please move faster, investigate, shut it down? And as evidenced in the data, it has taken years to get to a resolution on the payment policy. So we are working with the agency to uncover ways to more quickly, address fraud, waste and abuse, and in particular, in the case of providers, where we have a strong suspicion of fraud and data to back it up, is there a way to stop payment on those claims faster? So we're not left holding accountability for it on the back end, but stopping the payment of those claims in the first place.