Health Care Matters | June 26
A Holiday Pause for America’s 250th Birthday
As the country prepares to mark its 250th birthday, Health Care Matters will pause publication next week for the 4th of July holiday. We will return the following week with our regular coverage of health care policy, payment, and delivery developments.
Medicare Fraud Cases Draw Attention to High-Cost Wound Care Billing
Federal officials announced charges against 455 defendants in connection with alleged health care fraud schemes totaling more than $6.5 billion in false claims across Medicare, Medicaid, and other federal programs. A significant portion of the cases involved wound care products, an area that has also drawn attention following a sharp increase in Medicare spending on skin substitutes and subsequent CMS payment changes. Together, the developments highlight growing federal attention to high-cost services where utilization and reimbursement have expanded rapidly. Read more here and here.
Why It Matters
CMS’s recent enforcement activity reinforces its broader focus on fraud, waste, and abuse, particularly in high-cost areas where utilization has grown quickly and payment rules may not be keeping pace. Wound care and skin substitutes are a clear example of the issue: rapid spending growth, evolving clinical use, and complex reimbursement dynamics have created pressure for both payment policy changes and stronger program oversight. Looking ahead, CMS may increasingly look beyond traditional enforcement and payment rule changes to approaches that create stronger incentives for organizations to identify and address questionable billing patterns earlier. That could include more robust data monitoring, stronger accountability in value-based payment arrangements, and program designs that reward plans, providers, or accountable entities for preventing inappropriate utilization before it becomes widespread.
CMS Keeps Close Watch Over Rural Health Transformation Funding
The Rural Health Transformation (RHT) Program was framed as a state-led opportunity to invest in new approaches to rural care, but the early implementation process is showing a more tightly managed federal role. CMS has rejected or redirected some state proposals, including efforts to use funding to offset the effects of broader federal health program cuts, and states are being reminded that approved plans come with conditions. The agency has authority to withhold or recover funding if states do not follow their approved applications or meet program expectations, turning the $50 billion rural health fund into something more structured than a flexible block grant. Read more here and here.
Why It Matters
The clawback language gives RHT a different feel than a typical state funding opportunity. The program still leaves room for state-specific approaches, but that flexibility now sits inside a more closely managed federal process, where approved plans may be harder to change once implementation begins. That matters because rural health transformation rarely moves in a straight line. Workforce realities, local partnerships, provider capacity, and community needs can all evolve between application and execution. As states move into implementation, much will depend on how CMS handles requests to pivot when local market needs change, especially if those pivots require states to move away from the priorities or activities outlined in their approved applications.
Look for the Helpers: Family Caregivers Step Into a Role Many Do Not See Coming
When William Morrison’s father was diagnosed with cancer, he quickly became an intermediary between his family and the medical staff, helping ask questions, navigate conversations, and support care decisions. His experience reflects how caregiving often begins before people formally recognize themselves as caregivers and how embracing that role can help people seek support, better understand the systems they are navigating, and prepare for the emotional, financial, and practical demands of caring for a loved one. Read here.
New Resource
Coral Health Advisors’ Rural Health Transformation Program Tracker
Coral Health Advisors has launched a new tracker to help organizations monitor RHTP activity across states. The tracker brings together state updates, procurement opportunities, webinars, deadlines, and other key developments in one easy-to-navigate dashboard, with filters and preferences that allow users to focus on the states and topics most relevant to their work.
With the purchase of the RHTP Tracker, subscribers will also receive complimentary access to Coral’s grant toolkit. The toolkit provides practical guidance to help organizations prepare for RHTP-related opportunities, including eligibility considerations, proposal development, budgeting, and post-award readiness.
Learn more about the RHTP tracker in this product demo.
If you have any questions or would like to learn more about subscription options, please don't hesitate to reach out at info@coralhealthadvisors.com
What We Are Reading
Guiding Principles for Cultivating a Sustainable Culture for Policy Innovation
Milbank Memorial Fund outlines lessons from former CMS Innovation Center leaders on building policy innovation that can hold up across shifting priorities, operational constraints, and real-world implementation demands. Read here.
Considerations For Integrating Chronic Condition Episodes Into Value-Based Payment Models
A Health Affairs Forefront article examines how chronic condition episodes could be incorporated into value-based payment models, with a focus on engaging specialists in more coordinated, longitudinal care. Read here.
Developing a Primary Care-Specific Risk Adjustment Model: Lessons from MassHealth
CHCS shares how MassHealth developed a Medicaid risk adjustment model for primary care sub-capitation, including what the state learned about chronic conditions, behavioral health, and social risk. Read here.
From Pledge to Practice: Outcomes-Based Payment for Tech-Enabled Care
Manatt Health explores the operational decisions health plans will need to make as they move from broad commitments on outcomes-based payment for tech-enabled chronic care to model design and implementation. Read here.
The Human Side of Medicaid Work Requirements: United States of Care Launches Two-Year Enrollee Study
United States of Care announced a two-year study following Medicaid enrollees in five states as work requirements take effect, with attention to coverage, compliance, and administrative barriers. Read here.
Pop Health Podcast
Rethinking Rural Access: How Truentity’s ANCHOR Model Connects Pharmacies, Data, and Care
In this episode of Bright Spots, Coral’s Kate Freeman speaks with Beth Blaise, MPA, Director of State Programs at Truentity Health, about how Truentity’s ANCHOR model is expanding access to care in rural and underserved communities. Their conversation explores the role of community pharmacies, connected health infrastructure, and coordinated care in addressing gaps in chronic disease management and rural care access.