Matt Fiedler

Full piece on the House bill is here: healthaffairs.org/content/fore.... I’ll release an updated analysis once final numbers on the Senate bill are available.

What will the Senate bill mean for health coverage? We don’t yet have final CBO estimates, but it’s clear they’ll be pretty similar to the House bill. That puts the U.S. on track for an unprecedented increase in the uninsured rate that will wipe out ~3/4 of post-2013 declines.

The Senate reconciliation bill, at least in its current form, appears likely to reduce coverage about as much as the House bill. If it becomes law, that would mean reversing most of recent years' insurance coverage gains:

bsky.app/profile/matt...

How Medicaid Work Requirements Betray Work and Waste Money I Oversaw Work Requirements in Michigan - Here is What I Told Congress

New-to-me nugget on work requirements implementation in here:

Pinging Equifax's The Work Number — which states are likely to rely on to get recent-enough employment data — "sometimes costs over $20 per person per query"

Full piece is here: www.healthaffairs.org/content/fore...

Clever new piece from Kennah Watts and Jack Hoadley takes a first look at how decisions under the No Surprises Act arbitration process vary across arbitrators. Lots of interesting findings here, including that provider win rates vary a lot by arbitrator.

From a first look at the Senate drafts, the cuts to Medicaid & the Marketplaces are similar to the House’s, maybe even a bit deeper on net. Upshot: these drafts, like the House bill, would put the US on course for an unprecedented rise in the uninsured rate.
bsky.app/profile/matt...

My new piece @healthaffairs.bsky.social Forefront finds that if the House bill becomes law and enhanced premium tax credits expire on schedule, the US will see an unprecedented increase in the uninsured rate, wiping out about ~3/4 of the post-2013 decline.

Taking Stock Of The Health Coverage Impacts Of The House Reconciliation Bill | Health Affairs Forefront The US uninsured rate has never risen as far, as fast as it will if the House bill and other looming policy changes affecting insurance coverage take effect; the resulting increase would erase almost ...

"...the US uninsured rate has never risen as far, as fast as it will if the House bill and other looming policy changes affecting insurance coverage take effect"

-- @mattafiedler.bsky.social www.healthaffairs.org/content/fore...

Read the full piece here: www.healthaffairs.org/content/fore...

If lawmakers want to change the House bill to avoid this, they’ll have to change the provisions with big coverage impacts. Notably, the bill's provider tax changes, which seem to be attracting the most ire from Senators so far, are a fairly small part of the overall picture.

My new piece @healthaffairs.bsky.social Forefront finds that if the House bill becomes law and enhanced premium tax credits expire on schedule, the US will see an unprecedented increase in the uninsured rate, wiping out about ~3/4 of the post-2013 decline.

Ok folks, we know work requirements reduce benefits without increasing work (cc: @chloeneast.bsky.social)

But who loses benefits and what happens if work requirements are reversed?

New evidence from linked SNAP-Medicaid data and a natural experiment in CT tell a concerning story...

Thread below 👇

Read the full paper here: www.nber.org/papers/w33856

The authors then show that fall birthdays are, correspondingly, least likely to have a doctor’s office or emergency department visit for flu (green line/dots), indicating that higher vaccination rates do indeed translate into greater protection against flu.

The authors leverage the fact that kids typically have a wellness visit around their birthday. For fall birthdays, the flu vaccine is typically available at that visit, resulting in higher vaccination rates than for kids a bit older/younger, esp. around 3rd & 4th birthdays.

Interesting new paper providing clear evidence that the flu vaccine is effective at reducing both office and emergency department visits for flu in kids.

Second, a Twitter thread from back when CMS finalized the RADV rule explaining why CMS should audit more contracts and why that could substantially reduce risk scores and, in turn, generate significant savings:
x.com/MattAFiedler...

Two other closing notes. First, while reporting of invalid diagnoses is part of why risk scores are higher in MA, more intensive coding of *valid* diagnoses is more important. Addressing coding intensity differences attributable to valid diagnoses requires tools beyond audits.

#3: Litigation. The final RADV rule is already the subject of litigation, and this step will raise the stakes in that litigation considerably.
litigationtracker.law.georgetown.edu/litigation/h...

In recent guidance, CMS has indicated that it intends to retain a fairly broad sampling frame, but CMS’ choices in this area also bear watching going forward.
www.cms.gov/files/docume...

If CMS followed through on that, it would greatly reduce the impact of this step since the audits (and subsequent extrapolation from those audits) could only address inappropriate coding associated with the targeted sub-sample.

#2: Sampling strategy. In the RADV final rule, CMS suggested that it might shift from a sampling strategy aimed at measuring the level of inappropriate coding for a contract as a whole to a strategy aimed at fairly narrow subsets of enrollees.

It’s hard to assess how large sample sizes need to be without access to actual audit data. But I would not be at all surprised if CMS needs to be at the top end the 35 to 200 record sample size they envision (or beyond) for this to work well.

The underadjustment will be larger when CMS' estimate of the error rate is noisier since a noisier estimate means a wider confidence interval. Thus, for audits to address overpayments due to inappropriate coding, adequate sample sizes are essential.

While it’s easy to understand why CMS adopted this approach, it will very likely lead CMS to systematically underadjust payments since the payment adjustment will always be smaller than what CMS’ best estimate of the error rate would justify.

In later guidance, CMS indicated that the payment adjustment would be based on the bottom of a 90% confidence interval for the error rate (at least for the 2018 plan year).
www.cms.gov/files/docume...

Achieving the planned increase in audit sample sizes may be especially important. In keeping with the RADV final rule, CMS (appropriately!) plans to “extrapolate” from audit results to make a payment adjustment for the audited contract as a whole.

#1: Execution. Can CMS actually achieve the planned increase in audit volume & audit sample sizes on the planned timeline, especially during a period where it’s been actively slashing its workforce? Possibly, but bears watching.

Important step from CMS to begin conducting risk adjustment data validation (RADV) audits for *all* MA contracts each year. If implemented well, this could, in effect, reduce MA risk scores by a few percentage points. But a few things to keep an eye on:
www.cms.gov/newsroom/pre...