Medicare Tightens Rules After Alleged $3 Billion Fraud Scheme

A $3 billion suspected scam involving urinary catheters has exposed vulnerabilities in Medicare and prompted calls for reform, according to the Washington Post. For over a year, a dozen companies allegedly submitted fraudulent bills for tens of millions of catheters using patient and doctor information. Experts say this isn't a new problem. Medicare is a prime target for fraud, and combating claims for unnecessary durable medical equipment has been a longstanding challenge. Health care providers and lawmakers are urging the government to crack down on the companies and improve antifraud efforts. The National Association of Accountable Care Organizations (ACOs), which advocated for a policy remedy to the catheter billing issues, issued a statement that it “applauds CMS for implementing stakeholder recommendations to hold ACOs harmless for significant anomalous and highly suspect catheter expenditures in 2023.”

New Alzheimer Criteria: Progress or Profit?

Amid the approval of donanemab for early Alzheimer disease, the Alzheimer Association has published new criteria for doctors diagnosing the disease, according to CNN. The criteria suggest that rather than relying on memory and thinking tests, doctors should diagnose the disease based on biomarkers: pieces of β-amyloid and tau proteins picked up by lab tests or on brain scans. However, some experts have argued that some people can have β-amyloid proteins in their brains and blood without ever developing dementia symptoms. There is concern within the medical field that the new diagnosis criteria will expand the number of people eligible for the new Alzheimer disease drugs, generating huge profit margins for manufacturers. The Alzheimer Association clarified that the new criteria should serve as a bridge between research and doctor diagnosis.

Loss of Medicaid Tied to Health Care Struggles

A study on low-income adults in 4 southern US states found that losing Medicaid coverage after COVID-19 protections ended led to struggles affording health care and prescription drugs for many, according to CIDRAP. Nearly half of those disenrolled from Medicaid were uninsured in late 2023. This could widen a gap that had narrowed during the time when governmental benefits were expanded; for instance, adults with low incomes were less likely to delay or forgo health care due to cost during the pandemic vs before.