The first 100 days of the current administration have focused heavily on reforms to the Affordable Care Act (“ACA”) and the Centers for Medicare and Medicaid Services (“CMS”), bringing a series of executive orders, focusing on expanding healthcare competition and reducing regulatory interventions. With the administration's promised intention to reduce the role of the federal government in healthcare delivery, today's systems must prepare for changes in redemption structures and competition. Creative strategic and budgeting adjustments are required to navigate change and scale operations efficiently to maintain competitiveness in the market while maintaining access to healthcare and patient safety. This article focuses on proposed Medicare changes and how they affect the private and public health systems as a whole.
Medicare Part C: Transition to privatized healthcare
In recent years, there has been a push to deregulation. In the current administration, this trend continues to make further efforts to reduce regulatory oversight. Medicare Advantage (Part C) will likely be a key focus of the administration, as CMS administrator Dr. Mehmet Oz previously advocated for the expansion of Medicare advantage (“MA”) and the traditional Medicare exchange of private MA plans. include:
Decrease in professional care and access to specialized providers has resulted in a shift in service line demand and the use of specialized care. Traditional Medicare offers wide range of access to providers accepting Medicare, but MA plans have limited provider networks that are limited to designated service areas. MAs encourage aggressive health care and develop expensive interventions. With increasing demand for preventive and care coordination services, health systems should focus more on value-based care (“VBC”) models and prepare to adjust delivery models to focus on preventive and care coordination services. Reduced use of services from providers that do not employ the Medicare Advantage Network. Shifts in payer mix observed in the healthcare system. This can have a significant impact on operations and revenue cycles. Health systems need to be prepared for more complex refund processes by adapting to competent payment models and complex risk adjustment systems.
Medicare Part D: Cancellation and delay of proposed policies
Changing prescription drug pricing can have a significant impact on Medicare Part D. No direct action has been taken and uncertainty surrounds federal efforts, but the reversal of Executive Order 14897 on October 14, 2022 (reducing prescription drug costs for Americans) could lead to potential changes. For example, on March 12, 2025, CMS announced that it would not implement the Medicare High Value Drug List Model, a model under development that proposed limiting Part D sponsors to co-payments of up to $2 for certain high value generic drugs. Limiting the cost cap may have effects including, but not limited to:
Affordable prices concerns and potential confusion over beneficiary treatment plans. A decrease in the amount of prescriptions in the healthcare system that operates pharmacies on the premises. Changes in prescribing behavior as providers are forced to rely more heavily on preventive care and alternative therapies.
The Uncertain Future of Telehealth
The impact on telehealth coverage may also be seen as a result of actions taken by the administration. Currently, Telehealth's compensation bill, licensed during the Covid-19 pandemic, allows Medicare beneficiaries to receive telehealth services from anywhere. 9 Although coverage was set to expire on March 31, 2025, Congress passed a law extending coverage until September 30, 2025, as it is eligible for the most eligible facility, since September 30, 2025. Or you are seeking help from one of the following: Monthly treatment for end-stage renal disease. Diagnosis, evaluation, or treatment of an acute stroke. or diagnosis, evaluation, or treatment of mental and/or behavioral health disorders. 11, 12
Another bill (HR 7623) has been reintroduced to permanently extend telehealth flexibility, but there is uncertainty over whether it will pass.
Decline in access to care for many Americans. This is particularly harmful to people with disabilities that affect mobility to physically visit providers. An increase in the need for transportation services provided by medical institutions. The growing demand for critical access hospitals must be strategically prepared to meet care needs. Increased costs for patients who have to seek more expensive in-person care rather than relying on telehealth services. It increases the need to hire an in-person provider rather than relying on contracted Locum Tenens Telehealth Providers.
Where are you going now?
With the aforementioned changes in Medicare on the horizon, it is important to ensure that quality of compliance care is maintained while hospitals, physicians, insurance companies and other providers survive in a competitive market. Healthcare leaders must be agile, staying behind with disputed legislative decisions and obtaining strategic planning initiatives while educating providers and patients.
