Read today’s Kaiser Health News
In other news:
Inside Operation Gold Rush, largest health care fraud bust in U.S. history Among the articles highlights: The two-year investigation, dubbed Operation Gold Rush, uncovered a conspiracy to purchase more than 30 small health care supply companies that were already enrolled with Medicare, officials said. Conspirators then used those companies to submit a flood of claims for urinary catheters, continuous glucose monitors and other supplies that were not medically necessary, law enforcement officials allege.
The numbers were often eye-popping. Beginning in late 2022, the companies collectively submitted fraudulent claims to Medicare for more than 1 billion urinary catheters, officials said.
About health insurance/insurers
Wasteful and Inappropriate Service Reduction (WISeR) Model From CMS:
The Wasteful and Inappropriate Service Reduction Model (WISeR) will harness enhanced technologies like Artificial Intelligence (AI) and Machine Learning (ML) to streamline the review process for certain items and services that are vulnerable to fraud, waste and abuse, helping people with Medicare receive safe and appropriate care and protecting federal taxpayers. The model is voluntary and will run for six performance years from January 1, 2026 to December 31, 2031…
WISeR will aim to:
• Focus health care spending on services that will improve patient well-being
• Apply commercial payer prior authorization processes that may be faster, easier and more accurate
• Increase transparency of existing Medicare coverage policy
• De-incentivize and reduce use of medically unnecessary care
Comment: The prior authorization feature is interesting in light of federal pressure on private plans to scale back or eliminate this process. Also, Medicare beneficiaries’ right to freedom of choice of providers may conflict with these provisions, depending on how these rules are implemented.
Medicare Advantage in the headlines: 10 recent updates A good summary of recent events.
About hospitals and healthcare systems
Joint Commission cuts standards by 50% in sweeping overhaul: The Joint Commission is transforming its accreditation process by reducing the number of requirements by 50% — from 1,551 to 774 standards — in its most significant rewrite since Medicare was established in 1965…
The redesign, called Accreditation 360: The New Standard, features an updated manual with clearer definitions of CMS conditions of participation and the Joint Commission’s national performance goals, now distilled into 14 critical categories.
UCI Health to open nation’s 1st all-electric acute care hospital: The UCI Health-Irvine hospital is a 144-bed facility expected to open in December, according to a June 26 system news release.
“This building is different from a traditional medical center in that we don’t use any carbon fuels for our normal operations,” Joe Brothman, director of UCI Health General Services, said in the release. “All of the electricity we use is either generated onsite or procured through sustainable sources.”
The facility is powered by solar panels on the roof and uses recycled water.
760 hospitals at risk of closure, state by state FYI
FYI9 hospital projects worth $1B+ in 2025 FYI
About pharma
Optum Rx removes reauthorization requirements for an additional 60-plus drugs FYI
CVS Caremark selects Wegovy as preferred GLP-1 for commercial formularies: CVS Caremark has selected Novo Nordisk’s Wegovy as the preferred GLP-1 medication for its largest commercial template formularies, effective July 1.
In March, Novo Nordisk launched NovoCare Pharmacy to provide direct-to-patient doses of Wegovy for $499 per month. Eligible self-paying patients can also get the $499-per-month price at their local pharmacy.
The new formulary change is a blow to Eli Lilly, which began selling higher doses of Zepbound, a weight loss drug, for $499 at first fill in late February.
AbbVie to pay $2.1 billion for immunology drug developer: AbbVie announced this morning it would buy clinical-stage biotech company Capstan Therapeutics for up to $2.1 billion in cash, picking up the company's in vivo CAR-T therapy candidate.
FDA eliminates barrier to CAR-T accessibility: The FDA will no longer require healthcare facilities be specially certified to administer currently approved CAR-T cell therapies, a move intended to make the potentially curative cancer treatments more accessible to patients.
The change, announced this week, was made because the FDA determined that the risk evaluation and mitigation strategy (REMS) required of CAR-Ts "is no longer necessary to ensure that the benefits… outweigh their risks."
About the public’s health
Moderna's mRNA-based flu vaccine superior to traditional jab in pivotal study: Moderna said Monday that its investigational seasonal influenza vaccine mRNA-1010 demonstrated superior efficacy to a standard-dose flu shot in adults aged 50 years and older. The results from the Phase III study set up filings not only for the mRNA-based flu vaccine, but also the company's combination influenza/COVID-19 vaccine mRNA-1083.
Food contact articles as source of micro- and nanoplastics: a systematic evidence map: Micro- and nanoplastics (MNPs) in foodstuffs lead to widespread human exposure and are often linked to environmental contamination. However, the role of plastics in food contact articles (FCAs) has received less attention, despite being a known source... We conclude that the normal/intended use of FCAs can lead to the migration of MNPs. Further research is needed to systematically characterize MNP migration related to materials and use. To better protect human health, regulations could mandate MNP migration testing for FCAs.
Fast-food Intake Among Adults in the United States, August 2021–August 2023:
Data from the National Health and Nutrition Examination Survey
During August 2021–August 2023, about one-third of adults age 20 and older (32.0%) consumed fast food on a given day.
Overall, adults consumed 11.7% of calories from fast food on a given day, and the percentage decreased with age: 15.2% for ages 20–39, 11.9% for 40–59, and 7.6% for 60 and older.
Adults with some college education generally consumed more calories from fast food than those with a high school diploma or less or a bachelor’s degree or more.
The percentage of daily calories from fast food increased with increasing weight status.
The percentage of calories consumed from fast food among adults decreased from 14.1% during 2013–2014 to 11.7% during August
2021–August 2023.
About healthcare personnel
Schools of Nursing See Enrollment Increases Across Most Program Levels, Signaling Strong Interest in Nursing Careers: New data released…by the American Association of Colleges of Nursing (AACN) show increases in the student population across most undergraduate and graduate programs at U.S. nursing schools, reversing some recent downward trends. While enrollment increased from 2023 to 2024 in baccalaureate, master’s, and practice doctorates, fewer students entered research-focused doctoral programs (PhD) last year, further challenging efforts to prepare enough researchers, faculty, and leaders to meet workforce needs. Click here to see highlights from AACN’s 2024 Annual Survey.
About health technology
FDA Authorization of Therapeutic Devices Under the Breakthrough Devices Program: Findings In this cross-sectional analysis of 75 FDA-authorized breakthrough-designated therapeutic devices from 2016 to 2024, the FDA reviewed 57% of devices within statutory performance timelines. Although 89% underwent premarket clinical testing, nearly half of primary effectiveness end points used surrogate measures and 19% lacked statistical testing; the FDA did not require postmarket studies for 60% of devices, including 7 of 11 devices that did not meet premarket study effectiveness end points.
Meaning Results of this study suggest that the FDA authorizes most breakthrough-designated devices before statutory target timeframes, but often with considerable uncertainty about risks and benefits.
