Payment Integrity & Affordability

Payment integrity and affordability pressures intensified around Medicare: new fraud enforcement involving a $328M Medicare scheme and laundering tied to a Russian crime ring reinforces why CMS, under the Trump administration, is likely to keep tightening program-integrity analytics, prior authorization scrutiny, and payment controls across Medicare FFS, MA, and ACO arrangements. At the same time, churn among high-need Medicare Advantage members is undercutting plans’ ROI case for long-term care and complex-care investments, creating a direct tension for VBC leaders between investing in longitudinal population health and managing member instability (MA churn analysis). Affordability remains a political accelerant: rising household healthcare costs are being framed as a driver of voter activism, while hospitals are being urged to prepare now for 2027 H.R. 1 impacts that could reshape Medicaid/coverage economics and safety-net risk exposure (Keckley on spending activism).