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MONDAY REPORT

Administration Focuses on Healthcare Fraud

The Trump administration last week announced that it would crack down on fraud in the Medicare and Medicaid programs, and President Trump during his State of the Union speech made specific mention of Massachusetts along with other states.

At a White House conference the day after the State of the Union, Vice President J.D. Vance and Administrator of the Centers for Medicare & Medicaid Services (CMS) Dr. Mehmet Oz announced a nationwide moratorium on Medicare enrollment for certain suppliers of durable medical equipment, prosthetics, orthotics, and supplies. The administration said some suppliers are suspected of more than $1.5 billion in fraudulent billing last year.

The administration also announced that it would defer $259 million in funding to Minnesota’s Medicaid program to counter “unsupported or potentially fraudulent Medicaid claims” and claims relating to people “lacking a satisfactory immigration status.” In his State of the Union, the president slammed “Somali pirates who ransacked Minnesota,” saying they were responsible for $19 billion in fraud. (An investigation by the U.S. Attorney in Minnesota said the potential fraud was closer to $9 billion.) The president went on to say, “And California, Massachusetts, Maine, and many other states are even worse.” During the White House press conference the following day, CMS Administrator Oz said similar announcements on funding freezes are in the works for other states.

The other major fraud effort from the administration involves establishment of the CRUSH Initiative – or Comprehensive Regulations to Uncover Suspicious Healthcare. CMS issued a CRUSH request for information that seeks input from states, providers, suppliers, payers, technology companies, patient advocates, beneficiaries, and others on ways to strengthen CMS’ ability “to prevent, detect, and respond to fraud, waste, and abuse, and program inefficiencies in Medicare, Medicaid, the Children’s Health Insurance Program, and the Health Insurance Marketplace.”

MassHealth conducts a number of program integrity efforts on a routine basis, and the state auditor routinely reviews MassHealth and other programs receiving state and federal funding. Last Wednesday, State Auditor Diana DiZoglio issued the legislatively mandated report from the auditor’s Medicaid Audit unit for the period from March 3, 2025, through February 27, 2026. That audit found potential cost savings of $8.4 million in MassHealth’s $22.1 billion budget, constituting .04% of the agency’s budget. DiZoglio said her office is currently conducting other MassHealth audits.

Wednesday: MHA Joins League and Legislators to Discuss 340B

On Wednesday, MHA, along with the Massachusetts League of Community Health Centers, and Senators Brendan Crighton (D-Lynn) and Pavel Payano (D-Lawrence) are hosting a discussion at the State House on the 340B drug pricing program.

340B has been in existence for 35 years and requires pharmaceutical manufacturers to sell outpatient drugs at discounted prices to healthcare organizations that care for uninsured and low-income patients. The benefits of this bipartisan federal program are drawn from pharmaceutical profits – at no additional cost to taxpayers.

But now, through intensive funding and advocacy from the pharmaceutical industry, 340B is under threat at both the state and national level. Wednesday’s open forum is meant to inform policy makers about how safety net providers actually use the savings they receive through 340B to help maintain critical patient services and free care offerings, especially at a time when federal policy changes are making their outreach to communities even harder.

“340B reduces overall healthcare costs by not only providing drug discounts to patients but also by supporting preventative health services known to decrease overall healthcare costs,” said MHA’s Vice President of Government Advocacy & Public Policy Emily Dulong. “Erosion of the 340B program results in savings to pharma not savings to patients.”

Senator Payano along with Rep. Daniel Cahill (D-Lynn) have co-sponsored An Act Prohibiting Discrimination Against 340B Drug Discount Program Participants (H.1107/S.819), while Senator Crighton and Rep. Kate Lipper-Garabedian (D-Melrose) have co-sponsored An Act to Protect 340B Providers in the MassHealth Program (H.779/S.845).

The discussion takes place on Wednesday from 11 a.m. to noon in Room 437.

MHA Letter Encourages DOE to Scrap Student Loan Caps

MHA recently wrote to the U.S. Department of Education (DOE) urging it to revise its definition of “professional degree programs” to include numerous essential healthcare professions. DOE is currently drafting the rules to implement provisions of the One Big Beautiful Bill Act that caps student loans but that provides higher limits for professional degree programs.

Under the proposed DOE rule, students entering critically important healthcare professional degree programs, such as nursing, social work, physician assistant, physical therapy, occupational therapy, respiratory therapy, and speech language pathology, among others, would no longer qualify for the higher borrowing limits available to professional degree programs.

“As a result, students pursuing these fields would be restricted to substantially lower annual and aggregate federal loan caps, creating unnecessary financial barriers to entering and completing programs that are essential to hospital operations and patient care,” MHA wrote to DOE Under Secretary Nicholas Kent. “We urge DOE to include a full range of healthcare post-baccalaureate professional degree programs in its definition of professional degrees. Healthcare – and hospital care in particular – requires a full team of highly trained healthcare professionals working together to provide high-quality, comprehensive, person-centered care.”

CHIA Report Confirms Common Healthcare Assumptions

The latest report from the state’s Center for Health Information and Analysis (CHIA) confirms some known healthcare “truths” while delving a bit deeper on the “whys” behind the data.

For example, CHIA found that people in communities with higher family incomes spend more on primary care and specialty doctors than those in less affluent communities. In communities where the population does not speak English well or where people have less than a high school education, those residents are likely to spend less per month on medical care. In short, the CHIA report is yet further proof of the inequities in the provision of healthcare that providers and state leaders have been working to address.

Some of the other findings include:

• Better internet access, car access, or computer access leads to greater spending on physician care;
• The less insured a community is, the less its members spend on physician services;
• Those over age 65 spend more than those 18 to 64 on hospital outpatient, total hospital, and member cost-sharing; and
• Communities with a higher proportion of non-U.S. citizens tend to have “lower total medical [per member, per month] spending, as well as lower physician and member cost-sharing PMPM spending.”

CHIA’s report covers 2023 data. While the results may not be terribly surprising, they help to build the foundation for future efforts to improve population health. As CHIA wrote in its executive summary, “Improving population health outcomes requires understanding how community sociodemographic characteristics affect an individual’s or family’s ability to access healthcare services. With medical spending varying across Massachusetts communities, higher spending may not reflect better health outcomes, but rather greater access to and utilization of care as well as higher costs of services. Higher spending on primary and specialty physician care also supports prevention and chronic disease management, reducing avoidable emergency department visits, hospitalizations, and overall healthcare costs. Correlations between community characteristics and medical spending can highlight areas that merit deeper examination, helping policymakers target efforts to improve access to care.”

John LoDico, Editor