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There is a shortage of primary care doctors, and KFF Health News reported on some organizations' attempts to integrate technology to address that shortage. The newer aspect of this movement is to use artificial intelligence (AI) to interview patients and automatically suggest diagnoses and treatment plans, streamlining some work for primary care providers. The second step is that patients can meet primary care providers virtually, expanding geographic reach. The person who was profiled in the article noted that "I think I got an appointment the next day or two days later... It was just such a difference from being told I had to wait two years." Interestingly, researchers have found AI "to be slightly better at identifying 'critical red flags' and recommending care based on clinical guidelines, though the physicians were better at adjusting their treatment recommendations as they spoke more with the patient."

This solution seems to alleviate some short-term challenges, but the current state seems inadequate for long-term care. The technology could improve, or society in general could invest more into primary care. It is perhaps not surprising that some of the primary care doctors who were interviewed wanted organizations to adopt a different approach: "they want less spent on AI and more used to attract and increase pay for primary care staffers". As self-serving as their proposal might sound, it is probably the case that the pay disparity between physician specialists and generalists should be narrowed.

KFF Health News reported on a recent plan by the federal government to slow the growth in Medicare Advantage spending. The rates for 2027 remained virtually unchanged. Additionally, in an effort to reduce excessive billing, the Centers for Medicare & Medicaid Services (CMS) has proposed restricting a practice known as "chart reviews," which can result in extra cost ("estimated $6.7 billion in payments for 2017"). Medicare Advantage plans purportedly engage in this practice for more accurate billing, but a "December 2019 report by the Department of Health and Human Services inspector general found that the health plans 'almost always' used chart reviews to add, rather than delete, diagnoses." Medicare Advantage plans have an incentive to do so because Medicare will compensate more for sicker patients.

Unfortunately, people familiar with this space have noted that "it is 'quite common' for CMS to partially backtrack when faced with opposition from the industry" and "even a minor change to Advantage payments has led the industry to protest that 'the sky will fall as a result, and the proposal is usually dropped.'" It is unclear, therefore, whether this proposal will actually take effect, and even if it does, whether Medicare Advantage plans will find a way of circumventing its intention.

In the spirit of value-based care, Medicaid is tying payments to the effectiveness for some gene therapies, as reported by KFF Health News. Paying only when a treatment is successful is one way of reducing risk as a payer, especially if the treatment is expensive. The details of the program are confidential, so it is unclear whether the performance-based payments are meaningful. Additionally, the program stipulates "discounts and rebates," which could reduce the appeal of the arrangement.

Nevertheless, when these treatments can cost millions of dollars, a performance-based compensation scheme makes a lot of sense. A health insurer might be willing to pay a large number if the treatment successfully avoids larger ongoing costs over the long term. In return, the participating pharmaceutical companies might be able to enjoy a more streamlined process for patients to be approved, which could lead to more sales. This arrangement could be a win-win for Medicaid and for companies that offer effective treatments.

KFF Health News reported on how one large Medicare Advantage insurer settled with the federal government in a case about "upcoding" (exaggerating how sick patients are in order to gain more compensation). Interestingly, even though a whistleblower (an insider physician) brought forth one of cases against this insurer, the case took over eleven years to resolve, and the insurer still did not admit wrongdoing. The case alleges that over a time period of 2009 through 2018, the insurer received roughly a billion dollars of improper payments. Although other Medicare Advantage insurers have faced similar accusations, the article did not discuss why Medicare Advantage might be particularly susceptible to this type of fraud.

Cases against other insurers appear to be ongoing. Unfortunately, this type of fraud drives up the cost of health care.

The reduction in Medicaid funding signed into law last July will have significant impacts on the state and local levels. KFF Health News reported on how California, for example, could lose $30 billion each year in Medi-Cal funding, which could account for 15% of the state program's budget. On a local level, that means that millions of people will likely be losing health insurance ("estimated 10 million"). One researcher noted: "This is the moment where a lot of hard decisions have to be made about who gets care and who doesn't... The number of people who are going to lose coverage is large, and a lot of the systems that were in place to provide care to those individuals have either gone away or diminished."

The expansion of Medicaid coverage as part of the Affordable Care Act made sense in many ways. When states and counties come to rely on that funding, and that funding is abruptly reduced, it is no surprise that the change can be a devastating shock to the system.