Speaker Archive - Page 10 of 1207

Excessive Corporate Control in Medicine

Summary: A valuable report lays out the harm due to a corporate takeover of medicine –deleteriously affecting the experience of both providers and patients. The American Medical Association is failing to fight this trend. Regulatory action and physician activism are needed.

The Corporate Practice of Medicine, TAKE MEDICINE BACK, October 2023, by Mitchell Li, Sailesh Konda, Robert McNamara

Conclusion:

[HJM bolding]

The corporate practice of medicine doctrine was integral in providing an ethical basis for the practice of medicine. Today, the American Medical Association (AMA) explicitly tolerates the corporate practice of medicine, and state prohibitions on CPOM are broadly unenforced. The vast majority of physicians are now employees of increasingly consolidated corporations, while moral injury and burnout among physicians are at unsustainable levels. Rapid horizontal and vertical consolidation of non-physician healthcare corporations that employ physicians not only increases monopoly power over consumers, which in return increases costs, but also increases monopsony power over physician labor. This has resulted in anti-competitive labor practices that lead to intimidation of, and retaliation against physicians who advocate for patients.

This places the public at risk through greater corporate influence over the practice of medicine. Corporations are increasingly replacing physicians with lesser-trained non-physician practitioners in order to maximize profits, while increasing costs to patients and taxpayers and eliminating remaining safeguards of physician expertise from the unfettered corporate practice of medicine.

A new era of robust antitrust enforcement in healthcare is needed. Past FTC actions against the AMA restricting the ability to impose ethical restrictions on its members should be re-examined in the context of unintended consequences of enabling corporatization and consolidation. A national prohibition on the corporate practice of medicine is necessary to accompany the strengthening, and enforcement of existing state-based prohibitions. Physician organizations must collectively reject non-physician corporate ownership of medical practices. Reclaiming the profession from corporate interests will take time, and greater protections for employed physicians are needed now in order to protect patients. In the face of legislative inaction at the state and federal level, employed physicians should use the tools available to labor and organize through unionization.

Comment:

By Don McCanne, M.D.

This very impressive 63-page report on the corporate practice of medicine explains very well how the monopoly (one seller) power over health care consumers has increased costs, and the monopsony (one buyer) power over physicians has led to intimidation of and retaliation against physicians who advocate for their patients, resulting in moral injury and burnout. And this is just the beginning of the harm being done.

Coincidentally, Sen. Bernie Sanders is currently holding hearings with the message that we need to expand union organizing in this country to rein in corporate greed if we are going to save the middle class and the workers in this country (https://www.theguardian.com/us-news/2023/nov/14/bernie-sanders-unions-middle-class-labor-movement).

This report on the corporate practice of medicine closes its Conclusion with the following two sentences: “Reclaiming the profession from corporate interests will take time, and greater protections for employed physicians are needed now in order to protect patients. In the face of legislative inaction at the state and federal level, employed physicians should use the tools available to labor and organize through unionization.”

Remarkably, the American Medical Association, at its interim meeting of its Congress of Delegates this week, actually brought this report up for consideration. However, the membership is down to 10% of US physicians, and they are predominantly politically conservative in my opinion (I’m a Life Member), so their Council on Legislation recommended that it not be adopted. But at least some more concerned members did have it pulled out of the “not for consideration” list of resolutions. There is some moral spark within the AMA such as those who attempted to have the AMA withdraw their long-standing opposition to single payer. Even though that effort failed this time, maybe the good guys and gals will eventually prevail.

Anyway, for those of us who care about our patients, we need to end the private corporate control of health care, and we need to take the immediate action of using the tools available to labor and organize through unionization.

This white paper is worth downloading and sharing with all who care.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Medicare for All Explained Podcast: Episode 105

Interview with Aija Nemer-Aanerud

November 15, 2023

Healthcare for All Campaign Director Aija Nemer-Aanerud (of People’s Action) invites anybody who cares about the state of health care in the U.S. to join the Care Over Cost campaign.

This nationwide campaign, which is carried out by a large network of local affiliates, encourages people to share their personal struggles with care denial at the hands of U.S. health insurers.

“Your community will have your back,” they say. “Your fight with the insurance company is my fight with the insurance company.”

Additional episodes will be uploaded monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

Ga.’s health care woes continue

Hospital closings show need for expanding Medicaid, following other states’ example.

By Vineet Raman and Isabela Pavkov
The Atlanta Journal-Constitution, November 14, 2023<

With the closing of Atlanta Medical Center (AMC) a year ago, 6 million people in metro Atlanta have been left with one Level 1 trauma center. It was the first time in recent history the mostly rural phenomenon — hospital closures — hit the state capital. Just like that, another hospital was gone, dealing another blow to the health of low-income Georgians after years of neglect by all branches of Georgia’s state government.

The state government’s response? A onetime infusion of pandemic relief funds into Grady Memorial Hospital to help absorb the influx, which resulted in 182 new beds and a new 16-bed psychiatric unit (AMC had a total 460 licensed beds, with 200 operational toward the end).

Let’s put AMC’s closing in context.

Since 2010, nine rural hospitals have closed in Georgia. These hospitals provided essential services, and their closures leave residents driving hours for life-saving treatment.

They were also keystones in their towns: providing jobs, a tax base for local government and an anchor for businesses like restaurants and grocery stores.

Serving largely uninsured, low-income patients, these hospitals closed because their base of patients were often older, required more expensive care and were uninsured or underinsured, making it difficult for facilities to remain financially viable. Many rural hospitals remain vulnerable, and while federal pandemic relief funds have helped some stay afloat, others have cut back on essential services like emergency rooms, labor and delivery wards and maternity care.

Fast forward to 2016: Tenet Healthcare Corp. sells a group of hospitals, including North Fulton, Spalding Regional Hospital and AMC to Wellstar. In April 2022, Wellstar cut services at AMC South, in East Point, shutting down a hospital and emergency room and leaving the property with only a single outpatient clinic. Four months later, Wellstar announced the closing of AMC.

AMC served a patient population that was about 70% Black and more than 15% uninsured.

However, as evidenced by the closure of two medical centers serving low-income communities and low rankings on equity measures, Wellstar seems to prioritize profit over patients. Wellstar’s flagship hospital, Kennestone, ranks as the least racially inclusive in Georgia and serves only 10% uninsured patients, while AMC ranked in the top 25 in the country for most racially inclusive before it closed. While Wellstar deserted intown Atlanta patients, it expanded Kennestone’s emergency room and strategized a partnership with Augusta University Medical (AUMC). Wellstar, a nonprofit, made $2.1 billion in revenue last year, and spent $91.8 million in expenses to keep AMC running for the fiscal year ending in October 2022.

So how do we solve the issue of uninsured care? We believe it begins with Medicaid expansion, which has been shown to reduce the likelihood of rural hospital closures. For years, Georgia Republicans in the legislature and governor’s office have declined to expand Medicaid. In October 2020, the Department of Community Health (DCH) had a Medicaid demonstration waiver passed (“Pathways”) that would offer Medicaid to certain low-income individuals who meet work requirements. It is the only Medicaid program in the nation with work requirements. However, in reality, this waiver omits coverage for about 430,000 people and costs the state more money. In its first few months, the onerous requirements of registration and work certifications have resulted in fewer than 2,000 enrolled beneficiaries.

Recent headlines also confirmed the post-pandemic redetermination process resulted in 215,000 vulnerable Georgians — mostly women and children — losing access to Medicaid due to bureaucratic reasons.

Other expansion states — including those in the South — have seen much of their population gain regular access to primary care. As physicians and medical students, we refuse to sit by idly and be a part of a system that invests as much time and money into denying and blocking access to care as it does providing care.

Our Nov. 12 rally sought to highlight the injustice committed by Wellstar to the community of South Fulton. Hearing from patients affected by the closure, it’s clear the hospital was key to the health of the community. Entire families saw their lives shaped by the care they received, in their own neighborhood.

The moral injury we deal with on a daily basis pushes us to advocate for a better health care system for our patients, one that is driven by neither profit nor bottom lines. It is clear to us that a publicly funded system of universal and comprehensive health care is necessary to combat the inequities patients face.

A full Medicaid expansion is a first step in improving Georgians’ access to care and keeping existing hospitals up and running.

While we advocate for this compromise, we haven’t lost sight of our goal of universal health care.

Vineet Raman and Isabela Pavkov are members of Students for a National Health Program, a group of allied health profession students pushing for a single-payer health care system in the U.S. Both grew up in Georgia and earned undergraduate degrees here. Raman is a third-year medical student at the University of Minnesota. Pavkov is a third-year medical student at the Medical College of Georgia.

https://www.ajc.com…

Fighting the Medicare Advantage scourge

By Brenda Gazzar
Code Wack Podcast, November 12, 2023

What can be done in light of Medicare Advantage overcharging taxpayers to the tune of around $140 billion a year? What’s the Medigap Trap and why should you worry about it? Why should we work to improve traditional Medicare while pursuing Medicare for All?

To find out, we spoke to Dr. Ed Weisbart, the national board secretary for Physicians for a National Health Program and president of the Consumers Council of Missouri.

Transcript

Dispatcher: 911, what’s your emergency?

Caller: America’s healthcare system is broken and people are dying!

Welcome to Code WACK!, where we shine a light on America’s callous healthcare system, how it hurts us and what we can do about it. I’m your host, Brenda Gazzar.

(music)

This time on Code WACK! What can be done in light of Medicare Advantage overcharging taxpayers to the tune of $140 billion a year? And what’s the Medigap Trap and why should you worry about it? Should we improve traditional Medicare or pursue Medicare for All as a solution? To find out, we spoke to Dr. Ed Weisbart, the national board secretary for Physicians for a National Health Program and president of the Consumers Council of Missouri.

Welcome back to Code WACK!, Dr. Weisbart.

Weisbart: Thanks Brenda.

Q: Last time we spoke about how Medicare Advantage companies are overcharging the government as much as $140 billion dollars through various ways, including upcoding or adding diagnoses so that people appear less healthy than they are. You also mentioned the No Upcode Act which would fight fraud and upcoding by restricting the use of old or unrelated medical conditions to determine the cost of care. I think that’s great and I hope the bill passes. What else can be done to fight these Medicare Advantage overcharges?

Weisbart: It’s tough. There aren’t any other legislative initiatives that I know of that would actually start to address this. So I think it’s incredibly important that as we expose problems with Medicare Advantage, we need to get people aware of this, but we need to simultaneously be fighting at least as hard to improve traditional Medicare. We need to eliminate or greatly reduce the out-of-pocket expense so that people can afford to go into traditional Medicare. We need to add those extra benefits so that you don’t have to give up your choice of doctors so that you can get a gym club membership. We need to level the playing field so that it’s fair. So we need to be working at the same time. If you just got rid of Medicare Advantage today, there’s a lot of people who wouldn’t have a place to land. I mean, because it is a lower premium. We need to do these two things in tandem.

Q: Yeah. So what do you think about single-payer Medicare for All and where does that fit into the differences between Medicare Advantage and Traditional Medicare?

Weisbart: What does single payer mean? It means one payer instead of a multitude of payers. So today we have a multi-payer model where we have all these dozens or I don’t know how many insurance companies and all these employers and all these, there’s a whole bunch of people that pay for insurance that’s called a multi-payer model and it fragments us and it makes it kind of crazy. It locks you into your job because you don’t want to give up your insurance because that means giving up your doctor.

It’s a crazy system having it the way it is today. So one payer instead of hundreds of payers would be great and we should all be in it. So what should that one payer be? And to me the most sensible one would be to build it on Medicare. You know, Medicare’s got decades of a track record showing that it rescues seniors from poverty, that it improves life expectancy, that it lowers death rates, you know, and that it gives you a peace of mind and gives you choice. You can pick almost any doctor in the country or any hospital. So if you live in Boise, Idaho, and you have your Medicare there, but you spend four months in the winter in Florida, if you have Medicare, regular Medicare, you can spend four months of the year in Florida and go to get any health care you need. If you have Medicare Advantage or any other insurance and you go to Florida, you wind up only being able to get emergency care paid for if you’re lucky.

Whoah, talk about taking a risk.

Weisbart: Yeah. A one single payer based on Medicare, fix the things that are wrong with Medicare and give that to everybody in the country and we would save money, the country would spend less on health care. We would stop having to, you know, every year rethink, ‘well, do I want Blue Cross? Do I want Humana? Do I want Cigna?’ You know, we just, you know, stop that.

What’s their one job? Their one job? The one thing the insurance companies get is they’re tasked with telling us which doctors and hospitals we can’t use . Who would do that? Who would set up a system like this? It’s nuts. So yeah, I think single payer Medicare for All, improved Medicare in the ways we were talking about is really the right way to go.

Right, because under a Medicare for All system, we could all go where we want for care because everyone would have the same coverage.

Weisbart: So there’s a bill in the House (of Representatives) and a bill in the Senate that would accomplish that. Hooray – and they’re actually increasing in popularity. They have more co-sponsors than they’ve ever had when they were brand new. So it’s huge and they’re growing, but I know that they’re not going to pass next week. They’re not going to pass in probably in the next two years. So instead, you know, to get there, let’s work on the things that we know we need. We need to improve traditional Medicare. We need to eliminate those copays and deductibles, or at least greatly reduce them. We need to add the missing benefits, improve traditional Medicare and that and a few other ways, and at least expose what’s going on with Medicare Advantage.

So think about it. You brought up that they’re now in the majority, you brought up that most people in Medicare are in Medicare Advantage, which is terrifying to me. But it’s true. This year we crossed the Rubicon and now 51% of people in Medicare this year are in Medicare Advantage. So they’re on track to keep on growing….Let’s say they’re on track to get to 60% in three years. I don’t know that, but let’s say they’re on track to get to 60% in three years. Well, if we could do things to keep them at 50% instead of 60% three years from now, that would be huge. I mean, these are usually for profit, publicly traded companies. They want to see growth. If we can stop their growth…

Q: How could we do that?

Weisbart: Well, you can’t get them from 60% down to zero unless you get Medicare itself improved. But you can get them to stop growing or maybe even shrink a little bit. If the people that could afford Medigap learned this. They don’t realize what’s happening. They sign up for Medicare Advantage and they, most of them don’t realize that they’re giving up their choice of doctor.

Q: Yes, and that’s usually what people care most about.

Weisbart: They don’t realize they’re taking a gamble on their future health. They don’t realize that their hospital may no longer be in-network. ’cause Hospitals are leaving Medicare Advantage left and right nowadays. So they don’t know this. They don’t know if they sign off for Medicare Advantage that they may have to start traveling 30 miles to get to the nearest hospital instead of going to the one that’s 10 miles away if you’re rural. They don’t know this stuff and they don’t know that once you’re in Medicare Advantage, there’s a really good chance that you’re trapped there.

Q: Oh? How so?

Weisbart: Yes, you can always get out of Medicare Advantage and go back to traditional Medicare. Absolutely you can do that. But there’s no guarantee that you can still buy Medigap, so the first six months that you’re in Medicare, or the first 12 months that you’re in Medicare Advantage, if you apply for that Medigap policy, the Medigap insurers are legally required to say yes. They’re legally required to sell you a policy and they’re legally prevented from asking you if you have cancer or diabetes or any of that stuff. They can’t send you a survey about your health.

They can’t ask you that stuff. They can’t look at your medical claims history. So for the first 6-12 months that you’re in Medicare, if you want to buy Medigap, and almost everybody does, ’cause otherwise you’re risking bankruptcy the first 6-12 months that you’re in Medicare, yeah, you can buy Medigap. But after that, there’s no guarantee about that. There’s I think four states that do guarantee it, but you know, 46 states don’t. So pretty much you can’t count on that.

So you go into traditional Medicare for a year, for two years, for five years, and then you get one of the cancers that I was talking about a few minutes ago. You get something bad and you try to go to the cancer center, the National Cancer Institute approved Cancer center, and you didn’t think to look that up when you signed up for Medicare Advantage cause you know you didn’t have cancer. You can’t look up everything. You didn’t think to look that up. So you didn’t know you signed up for Medicare Advantage. You didn’t realize you were taking a gamble.

You like the health club, you like having this, you know, you pick your six favorite teeth and you got the dental care for those. I’m overstating that. But you know, you got that stuff but then five years in, you get cancer and you want to go to the National Cancer Institute approved Cancer center and they say you can’t. And the Medicare Advantage company says, ‘sure, go there, but we’re not going to pay a penny for it.’ And then you’re in trouble, then you’re in trouble and your gamble isn’t paying off anymore.

And you can go back to traditional Medicare, but you’ve got to pay $1,600 every time they put you in the hospital for that cancer. Or you got to pay 20% for every office visit to your oncologist – 20% for every, every, every chemotherapy infusion and you are gonna go bankrupt.

Q: Yeah. So let’s say I’m in Medicare Advantage and want to switch to traditional Medicare. Did you say that in the first six months to a year I can buy supplemental policy?

Weisbart: Yes. The first six months that you’re in Medicare Part B or the first 12 months that you’re in Medicare Advantage, the federal law requires every Medigap insurance company to sell you a policy at the same price they would sell it to anybody else in your community. They have to say yes. They can’t ask you why you want to buy the policy. They can’t exclude you for preexisting conditions. None of that stuff….But after that, that protection against preexisting conditions disappears. Disappears.

Q: So after 12 months, I won’t be able to get the Medigap policy, which protects people against medical bankruptcy?

Weisbart: You might be able to, but there’s no guarantee. And the sicker you are, the less likely they would sell it to you. It’s insurance that disappears when you need it. Well, that’s not insurance, that’s theft . I’m paying my premium and not getting what I’m paying for. That’s a really inferior way to set up a healthcare system. Which goes back to your question. Yeah. Single payer Medicare for All is absolutely the smart way to do this.

Q: Got it, And it sounds like it would solve the affordability problem that so many people in Medicare Advantage have because they won’t have to worry about paying premiums or deductibles under Medicare for All.

Weisbart: No, like I said, there’s a bill in the house and a bill in the Senate that, a state that is called the Medicare for All Act of 2023, each one. They’re not identical, but they’re very, very similar and both of them say exactly what you just said. The proposed bills eliminate copays, eliminate deductibles, eliminate co-insurance, don’t charge a premium at all. They’re publicly funded in the same way we publicly fund everything else that’s important for the whole country to have. They’re publicly funded through a progressive tax model the same way we do for clean drinking water and for the clean air and for the military and for most schools and the roads and sewage and the handful of things for which, you know, everybody left and right, you know, the most progressive to the most libertarian or the most conservative everybody thinks yeah sewage collection, you know, that should be tax funded. The military.

Yeah. We don’t want to each have our own military and maybe we don’t like everything the military does, count me into that camp, but we all think there needs to be a military. Not too many people don’t want that. So there is a handful of things that across the political spectrum, people agree, yeah, this is what progressive tax model should fund. And I submit to you that health care should be one of those things. It’s to my advantage to have you be healthy. I want you to have health insurance because if you’re here in this country, you know, I don’t want you coughing up an infectious disease on the bus, you’re not able to go to work ’cause your diabetes is out of control. You know, I want you healthy if you’re here. I think everybody that’s living in this country should have access to health care without financial barriers and then fund it the way we fund other things that are necessary for the public good, like a progressive income tax.

And it turns out that that increase in your tax is smaller than what we would save by not having to pay premiums or copays or co-insurance or any of that stuff. … So yeah, most of us would save a lot of money.

Q: That would be wonderful. Is there anything else you wanted to say, Dr. Weisbart?

Weisbart: Yeah, take action. Go to our website which we built called ProtectMedicare.net and there’s a bunch more resources. Our report is going to be up there by the time the podcast airs. There’s a petition there that you can sign to say that you don’t like this and you want to stop these overpayments, you want to fix this, you want to stop, you know, letting our Medicare program be so drained. We have a survey that we’d like you to fill out talking about your experience with Medicare or Medicare Advantage. And if you’re a physician, there’s a physician centric survey about what’s, what it’s like treating patients. So we’d like you to fill that. And there’s tools (at) ProtectMedicare.net that can help you write letters to the editor and help you be more articulate about this. … So go to ProtectMedicare.net for all this stuff and more.

Thank you Dr. Ed Weisbart of Physicians for a National Health Program.

Do you have a personal story you’d like to share about our wack healthcare system? Contact us through our website at heal-ca.org.

Don’t forget to subscribe to Code WACK! wherever you find your podcasts. You can also find us on ProgressiveVoices.com and on Nurse Talk Media.

Code WACK! is powered by HEAL California, uplifting the voices of those fighting for healthcare reform around the country. I’m Brenda Gazzar.

https://heal-ca.org…

Physicians gather in Atlanta to march for Medicaid expansion, AMC site

Demonstrators marched from Martin Luther King Jr. National Park to the former Atlanta Medical Center site in Old Fourth Ward

By Donovan J. Thomas
The Atlanta Journal-Constitution, Nov. 12, 2023

A national group of doctors gathered Sunday for a march in downtown Atlanta, pushing for the expansion of Medicaid, while also urging Wellstar Health System to donate the former Atlanta Medical Center site to the city.

Some carried signs with tombstones of closed hospitals in Georgia, and others of the over 100 people in attendance chanted in support for a single-payer health system, while decrying the actions of Georgia state officials and Wellstar Health System as detrimental to the health of Georgians.

The effort was a collaboration between Physicians for a National Health Program, a group of doctors that advocates for Medicare for All, elected officials, community members, patients and advocacy groups such as the New Georgia Project, Georgians for a Healthy Future and Georgia Equality.

Dr. Anwar Osborne, a member of Physicians for a National Health Program and an emergency medicine physician in Atlanta, spoke to concerns around proximity to care for underserved community members. He also talked about the stress being put on Atlanta’s now sole safety-net hospital and Level 1 trauma center, Grady Memorial Hospital.

“We’re here to say that closing this building, regardless of the forces that allowed that to happen, improve nothing here,” he said. “Those of us who are still left in the health care space are just fighting to make it to the next day.”

Organizers cited Georgia’s high rate of uninsured patients and lack of health care access as drivers for the march. Additionally, the closure of hospitals across the state, including two hospitals in Atlanta by Wellstar in 2022, were cited as a cause for alarm for underserved communities with dwindling health care options.

Georgia is one of 10 states to not expand Medicaid, the state-federal program that pays for health care for the poor, people with disabilities and many elderly patients. Because the state did not expand Medicaid, which was part of the Affordable Care Act, billions of federal dollars that are meant to support the state’s health systems are going unused.

Many doctors, other providers and health policy experts believe the lack of expansion leads to worsening health outcomes and will harm the state’s poor residents for years to come.

“We know that the lack of Medicaid expansion and the governor’s attempt to come up with a contrived system is an opportunity for him to eliminate people, just like attempts at eliminating voters,” said Sandra Lee Williams, president of the Atlanta North Georgia Labor Council.

Of Georgia’s 370,000 poorest uninsured adults, less than 2,000 have been enrolled in Georgia Pathways to Coverage, which has work or activity requirements. Many say the program is costing more than expanding Medicaid would and hurting those most in need.

“The fair thing would be for the governor to fully expand Medicaid,” Dom Kelly, co-founder of the New Disabled South, the first regional group focused on disability rights in the country, said. “It’s really beyond time. People are dying.”

Wellstar’s plans for hospitals in affluent suburbs of Cobb and Columbia counties were also called to question.

“They’ve left a lot of our community behind,” said Dr. Mindy Guo, a family medicine physician in Atlanta and co-chair of the Georgia chapter of Physicians for a National Health Program. ” We want them [Wellstar] to start acting like a nonprofit and actually benefiting the community instead of just not paying taxes.”

Demonstrators marched from Martin Luther King Jr. National Park to the former Atlanta Medical Center site in Old Fourth Ward.

Atlanta City Councilmember Liliana Bakhtiari and Georgia State Senator Nan Orrock spoke at the rally, pushing for the health needs of the community, while also condemning the acts of Wellstar and state officials for not expanding Medicaid.

Physicians for a Nation Health Plan demanded a meeting with Governor Brian Kemp to discuss full Medicaid expansion, for the state legislature to sign a bill fully expanding Medicaid in the next session, for Wellstar to donate the Atlanta Medical site to the city of Atlanta and for Atlanta Mayor Andre Dickens to reclaim the land to provide for the unmet health needs of the community.

“This is not done,” Bakhtiari said. ” We have the ability to turn this around.”

https://www.ajc.com…

California Seeks Federal Waivers for Unified Health Care Financing

Summary: In October, California enacted SB 770, establishing a formal process to explore federal waivers necessary for state-level “unified financing.” Insurers vehemently opposed it, and some single payer advocates bemoaned the lack of a single payer plan. This is a potent mechanism to advance single payer, the gold standard in unified financing.

California Senate Bill 770 Health care: unified health care financing, signed into law By Gov. Gavin Newsom, October 7, 2023

[HJM bolding]

1000 (i) … the Legislature endorses a health careb> system with unified financing, such as a single-payer health care system, to provide accessible, affordable, equitable, and high-quality health care for all Californians.

1001. The Secretary of the California Health and Human Services Agency shall research, develop, and pursue discussions of a waiver framework in consultation with the federal government with the objective of creating a health care system that incorporates the following features and objectives:

(a) A comprehensive package of medical, behavioral health, pharmaceutical, dental, and vision benefits, which includes primary, preventive, and wellness care services.

(b) A package of long-term care supports and services, including measures to support health and well-being while Californians age.

(c) Services that will not vary by age, employment status, disability status, income, immigration status, or other characteristics.

(d) The identification of disparities among Medicare, Medi-Cal, employer-sponsored insurance, and individual market coverage, with the goal to eliminate those disparities to the greatest extent possible in the new system.

(e) The elimination of the adverse impacts within the health care system of attempts to avoid covering the sick or providing the benefits patients need.

(f) The absence of cost sharing for essential services and treatments covered under the program, including primary, preventive, and wellness care services. …

(h) A program to implement a just transition for members of the health industry workforce whose jobs may be disrupted.

(i) Assurances that no individual will pay more than a specified percentage of their income on a progressive sliding scale for the cost of financing the health system.

(j) Unified financing that delivers health care more effectively, efficiently, and equitably.

(k) Cost-effectiveness by systemwide pooled purchasing to negotiate rates with providers.

(l) Freedom for patients to choose providers and for primary care providers to choose practice models.

(m) Greater investments in public health, primary care, and health equity efforts to address the social determinants of health through an improved mix of health care and human services. …

(s) Methods of payment, delivery, and oversight implemented under the unified health care financing system that will continue to allow California the ability to receive the full benefit of federal expenditures and tax credits that currently underwrite the full scope of health services.

1002. (a) (1) Stakeholder engagement shall include representatives of consumers, patients, and community-based health care service providers, community organizations, health care professionals, labor unions, employers, and health policy experts, as well as representatives of government agencies and philanthropic organizations focused on health care.

Kaiser Permanente Voice, (not online, but can sign up here), Nov. 8, 2023, Teresa Stark, Vice President, California Government Relations

Universal coverage and affordability: The legislature and governor advanced a modest proposal to have the state explore what steps at the federal level would be required to implement a single-payer health care system in California. Such a system would be costly, disruptive, and detrimental to Kaiser Permanente and our members. While this bill was not ideal, it could help answer some important questions about whether the federal government fundamentally would or could ever take some of the quite radical actions likely needed to move single-payer forward in California. In 2024, we will continue to stress to the legislature how critical it is to refocus on achieving universal, affordable coverage for all Californians through more sensible means and address the root causes of high health care costs, like prescription drug prices and lack of well-integrated and coordinated care, free of harmful financial incentives.

Comment:

By Jim Kahn, M.D., M.P.H.

California SB 770, now law, requires the State to convene discussions with the federal government on waivers required to deliver “unified financing” of health care in the state. This represents a practical step in pursuit of the recommendations of the Healthy California for All Commission, which in turn was Governor Gavin Newsom’s first major step in pursuit of his campaign pledge for single payer.

SB 770 is not a single payer plan. CalCare AB 1400 was a single payer plan, and failed to pass out of the Assembly (very disappointing). But SB 770 is a huge opportunity to move toward single payer, by seriously pursuing the details necessary to design a technically and politically feasible plan. A review of its provisions highlights how closely aligned it (and the Commission report) is with single payer. Note for example comprehensive, consistent benefits across the population, long-term care, protection from financial burdens, and freedom to choose providers. Note too that “insurers” are not among the stakeholders to be consulted. I confess I’m not a huge fan of item 1001 (d), since the cited programs shouldn’t exist in a single payer system, but eliminating insurance-related disparities is a goal I heartily endorse.

The Voice excerpt reiterates Kaiser management’s longstanding opposition to single payer. It’s unsurprising, since insurers (and Kaiser is in part an insurer) have lined up against SB 770. But they have key facts wrong. They’re right that single payer would be “disruptive” – that’s what our fragmented insurance system needs. They’re wrong that it would be costly; indeed, the Commission like all previous studies found tens to hundreds of billions in savings over 10 years. And they’re wrong about effects on Kaiser as a health care delivery system – it could prosper, which is exactly what its members want and deserve.

SB 700 passed despite loud controversy among single payer advocates. Now is the time to take the process seriously, assuring excellent technical work, discussions, and stakeholder input. So much is at stake; so much is possible.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Medicare recipients should look beyond ‘benefits’ of Medicare Advantage plans

By Jeffrey Belden, M.D.; Robert Blake, M.D.; Steve Calloway, R.Ph.; Linda Headrick, M.D.; David Mehr, M.D.; Bill Parks, M.D.; Margie Sable, Dr.P.H.; and Mahree Skala, M.A.
Columbia Missourian, November 6, 2023

An increasing number of Medicare beneficiaries are enrolled in heavily advertised Medicare Advantage plans. These plans, which interpose an insurance company middleman between the Medicare program and patients, are superficially attractive. They offer such benefits as coverage for some vision, hearing and dental services and gym memberships.

However, a recently published investigation has found that Medicare Advantage overcharges American taxpayers by a minimum of 22% or $88 billion a year with no clear evidence of better health outcomes.

Strategies used by Medicare Advantage to overcharge taxpayers include:

Targeting healthy beneficiaries who generate less costs for the plans. Medicare Advantage plans receive capitated payments from Medicare. They are paid a certain amount per enrollee. Healthier enrollees generate less expense and thus allow insurance companies to retain more of the capitated payments as profit. This “favorable selection” is well documented.
Limited networks. In contrast to traditional Medicare, Medicare Advantage plans frequently only cover health care provided by specified doctors and hospitals; thus, limiting patient choices.
Patients who need health care when traveling may be forced to pay for it out of pocket.
Prior authorization. With prior authorization, the insurance company must approve treatment before the company will pay for it. The company could refuse to pay for treatment that a physician has recommended, overruling a physician’s judgment. Far more frequently than traditional Medicare, Medicare Advantage plans require prior authorization of certain medications, surgical procedures and other forms of care. This can create serious obstacles to receiving essential medical care, frustrating patients, and potentially putting them at risk. A 2022 investigation of Medicare Advantage organizations by the Inspector General of the Department of Health and Human Services documented “widespread and persistent problems related to inappropriate denial of services.” One of the signers of this letter experienced adverse effects of a prior-authorization requirement of a Medicare Advantage plan.
Because of these hassles — limited networks, prior authorization, and other practices that decrease access to necessary care— patients tend to switch from Medicare Advantage to traditional Medicare as they get sicker and need more medical care. Sicker patients generate higher costs and thus erode corporate profits. Downloading such patients to traditional Medicare benefits Medicare Advantage companies. In addition, patients who switch from Medicare Advantage to traditional Medicare may encounter obstacles.
Upcoding of diagnoses. The capitation that Medicare Advantage plans receive from the government is affected by the severity of the medical problems enrollees have. While Medicare Advantage plans seek healthy enrollees, there is an incentive to make the enrollees appear to be sicker when seeking taxpayer money. The well-documented propensity for Medicare Advantage plans to amplify the illness severity of patients by manipulating diagnostic coding is clearly fraudulent.
Underpayments to hospitals to boost profits. This has serious consequences for patients. USA Today reports that an increasing number of hospitals around the country are ending contracts with Medicare Advantage plans because of inadequate reimbursement for services provided. The CEO and president of Scripps Health describes Medicare Advantage strategy as “delay, deny or don’t pay” and concludes “They’re in the business of making money.” This trend further narrows choices available to patients and increases the danger that patients are stuck with huge medical bills.

A major appeal of Medicare Advantage plans is the added benefits provided. These benefits were a result of intense lobbying by insurance companies for an “advantage” of their feeding at the Medicare trough. However, these benefits should be included in traditional Medicare. The cost of adding them to traditional Medicare would be at least $4 billion less than the annual overcharges from Medicare Advantage. In other words, beneficiaries could receive dental, hearing and vision care through traditional Medicare at less taxpayer expense.

Taxpayers and Medicare recipients should look beyond the slick, heavy promotion of Medicare Advantage to see the serious negative consequences. Those enrolled in Medicare Advantage should raise these issues with their plan.

https://www.columbiamissourian.com…

Four Ways Medicare Advantage is ripping you off

By Brenda Gazzar
Code Wack Podcast, November 6, 2023

Medicare Advantage is overcharging the federal government – and you won’t believe by how much! How’s this affecting taxpayers like you and me and what can be done about it?

To find out, we spoke to Dr. Ed Weisbart, the national board secretary for Physicians for a National Health Program and president of the Consumers Council of Missouri.

Transcript

Dispatcher: 911, what’s your emergency?

Caller: America’s healthcare system is broken and people are dying!

Welcome to Code WACK!, where we shine a light on America’s callous healthcare system, how it hurts us and what we can do about it. I’m your host, Brenda Gazzar.

(music)

This time on Code WACK! Medicare Advantage is overcharging the federal government – and you won’t believe by how much! How’s this affecting taxpayers like you and me and what can be done about this? To find out, we spoke to Dr. Ed Weisbart, the national board secretary for Physicians for a National Health Program and president of the Consumers Council of Missouri.

Welcome back to Code WACK! Dr. Weisbart.

Weisbart: Thanks, Brenda. How nice to see you again.

Q: So it’s Medicare open enrollment where people age 65 and older, and those with certain disabilities, are deciding whether they want traditional Medicare or Medicare Advantage. Today over half of Medicare beneficiaries have Medicare Advantage. What are a couple of key differences between these two programs for consumers?

Weisbart: So Medicare is the program that, you know, we know and love started in 1965. It covers your hospital stuff, it covers your doctor stuff. If you buy Part B and it’s traditional. We’ve had it for forever, and it’s seamless. They never say no, they never get in your way. You can go to almost any doctor in the country and there’s nobody trying to make a profit off of it. They operate with like a 2% overhead. It’s a terrific program.

Medicare Advantage is really neither Medicare nor an advantage. So instead of having the Medicare program just pay for your doctors and hospitals for you, instead of that, now, Medicare prepays insurance companies, like the insurance companies that do most of the employer kind of health care. So they prepay the insurance companies for every person that’s in there.

Pre-paid? Lucky them.

Weisbart: And of course, you know, once the insurance companies are prepaid for you, they don’t want to let go of that money. It’s in their bank account. They want to, they want to keep it. … So they have all sorts of games to kind of get in the way. They keep you from going to certain doctors and hospitals. They delay paying for your care, even just stand in the way for a week or two of being able to get care. That’s money that’s still in their bank that they can make a profit off of.

So they don’t want you to go get care, and they don’t want you to get it quickly, and they want you to go to the places that they pick.

And so that’s different from Traditional Medicare…

Weisbart: Medicare Advantage is completely different from Medicare. The only real advantage to Medicare Advantage is if you’re the CEO, you know, or the shareholders, the investment companies. I mean, nobody looks at Medicare and says, ‘gee, you know, what we really need are more bankers involved’ and that’s what you get with Medicare Advantage.

Q: And yet, more and more seniors are getting Medicare Advantage. Why is that?

Weisbart: It’s not because it’s any better, so it’s cheaper on the front end. What people don’t really realize is that although it may be cheaper initially, it’s not a lot cheaper and then they have somebody saying, ‘no, you can’t get the health care you want.’

So people in Medicare Advantage actually have more trouble accessing health care than people in good old traditional Medicare. People in Medicare Advantage have longer delays. Actually a new study came out recently that shows people in Medicare Advantage don’t go to the better hospitals as often. They have a longer time getting diagnosed. They have a longer time getting treated once they’re diagnosed with cancer, and they actually have higher death rates postoperatively if they have cancer surgery.

So, you know, you’re kind of taking a gamble when you’re going into Medicare Advantage. You’re gambling that spending a bit less money up front on premiums isn’t going to kill you. And sadly there’s evidence that it just might so it’s not a good choice.

Q: I see. So the single-payer advocacy group Physicians for a National Health Program recently released a bombshell report about Medicare Advantage overcharging titled “Our Payments, Their Profits: Quantifying Overpayments in the Medicare Advantage Program.” What were the key findings of this report?

Weisbart: The bottom line is that we overpay or they’re allowed to be overpaid by at least $140 billion.

Q: $140 billion?

Weisbart: I think the analysis is fair to say $140 billion and that’s just looking at the legal things. That’s not looking at fraud and abuse. That’s just looking at what’s legal. So I said $140 billion a year. It’s so hard to figure out. Is that a big number? You know, everybody in Medicare – just about – has to pay a part B premium, right? We spend about $170 out of pocket a month on our Part B premium so that we can get the Part B benefits, you know, go to the doctor and stuff.

But it usually comes out of your Social Security check… If you add up those $170 a month across everybody in Medicare, it comes to $131 billion. So we’re spending $131 billion on our Part B premiums, but the Medicare Advantage companies are getting $140 billion in overpayments.

Wow. So it sounds like the overpayments to Medicare Advantage plans could more than cover Medicare’s Part B premiums for doctor visits, outpatient hospital services and other medical services.

Weisbart: When I realized that that’s how the numbers work out, that all of my premium dollars for Part B and more are being diverted into Medicare Advantage companies for no reason, for worse outcomes. So all of our money is going to them and that just makes me mad that that should be happening.

And that’s one comparison to Part B premiums. You know, one of the things that is really troublesome in Medicare is the out-of-pocket costs. We have to pay 20% of our outpatient care. We have to pay, you know, $1,600 for a hospitalization, and if you have to go to the doctor once a year, 20% of one visit is probably something most can afford.

But if you’re sick and that’s why you have insurance and you have to go to a doctor once a month or once a week or two or three times a week, 20% of that is bankruptcy town and there’s no limit on that or $1,600 for a hospital stay, that’s already stuff that you need to take a loan out for and if you have to be hospitalized two or three times a year… So because of that, it’s a problem that Medicare doesn’t have a limit on how much those out-of-pocket costs can go to and this is directly relevant to our study because we found an analysis from the Urban Institute that looked at what would it cost to change Medicare and limit it so that nobody has to spend more than $5,000 out of pocket – $5,000’s still a lot, but it’s way the heck better than 20% of everything, you know?

Q: Interesting. And how much would it cost Medicare to implement a $5,000 out-of-pocket maximum for people?

Weisbart: $39 billion dollars. … So if we weren’t squandering our money, if the Medicare Advantage companies weren’t allowed to pilfer our money, we could do that.

Or the last piece, and then I’ll, you know, stop my little tirade here is if you look at the things that people also really want, they want dental insurance, right? They want hearing, they want vision. If you add that up, it comes up to, for everybody in Medicare and Medicaid together, it comes up to about $80 billion a year, $80 billion.

So that’s less, way less than what we give away to the Medicare Advantage companies.

In other words, we could have really nice things here. We could afford to have really good health insurance through the Medicare program and make it available to everybody in the country, but we have to stop the bleeding. You know, we have to stop letting these Medicare Advantage companies drain our funds, take it directly out of us. That’s not right. We shouldn’t be doing that. They’re giving us worse health care and we’re not getting anything for it.

Q: So you’re saying Medicare could have a $5,000 annual out-of-pocket cap, plus cover dental, vision and hearing for about what we’re paying the Medicare Advantage companies?

Weisbart: Yeah, we could fix all the things that are wrong with Medicare if we would just stop letting the Medicare Advantage corporations rip us off like this.

Q: Wow. So what are some of the ways that Medicare Advantage is grossly overpaid for the care and services it provides to beneficiaries?

Weisbart: Yeah, it comes down to four main ways.

The first is the way that’s sort of gotten the most attention, which is called upcoding. Upcoding means that they’re paid for the average person and then they get actually paid more if you’re sick. So Medicare Advantage companies long ago came to Congress and said, ‘Hey, you know, we have these really sick patients, you know, we deserve to be paid more than the average.’

So yeah, Medicare put in a program that said if your people are sicker, then we will pay you more and so it seemed to make sense. You know, maybe that makes a lot of sense, I don’t know. But it created this opportunity for the Medicare Advantage companies to pretend you’re sicker so they’ll send a nurse out to your house once to pick up diagnoses that your doctor didn’t think was clinically important.

They won’t send you out for home care, you know, you’re less likely to get home care, but they will send somebody to your house to get extra codes. They will very seriously pressure physicians to add diagnoses that are not of any real medical purpose so they can submit their claims to Medicare and say, ‘ see how sick people are here? And it’s really just not true. That’s called upcoding. And that one piece is pretty significant. That one piece is worth $20 billion. They’re overpaid by 5% just for that one piece and that’s actually the smallest of the ways.

A second way that they get overpaid is what’s called favorable selection, which is, as I said, they’re paid on the average with that little quirk of upcoding, but they’re paid on the average, but they don’t want you if you’re actually sick. So they have these ways of attracting healthier people, and it’s called favorable selection by attracting healthier people in all the ways I started to hint at. That gets them another $44 (billion) to $56 billion extra.

So that’s two key ways.

Q: So we’ve got upcoding and favorable selection. What are the other two ways?

Weisbart: And then the third way is a whole series of weird sort of benchmarks and bonuses that they have. And there’s a lot of those. But one in particular, I’ll just point out, ’cause it just really kind of is outrageous. They’re paid more, if they hit these quality targets, right? If it’s a better Medicare Advantage company, they’ll get paid more. That makes sense, except that the measurements of getting paid more don’t have anything to do with death rates and mortality rates and, and denials and delays in care. They’re kind of goofy things that aren’t that important.

And most interestingly, when a new Medicare Advantage company enters, they’re paid assuming that they’re going to be high quality, and even without any data at all, they’re given a three and half percent bonus for high quality when they haven’t done that yet.

So anyway, if you add all these crazy extra bonuses and benchmarks, that’s another $24 (billion) to $28 billion. So $20 billion on the upcoding, $44 (billion) to $56 (billion) on the favorable selection, $24 (billion) to $28 billion on the quality benchmarks and the quality bonuses and stuff that I’m talking about, if you add just those three factors together, you get to $88 (billion) to $104 billion that they’re overpaid.

And then there’s a fourth way, which is a little bit trickier. So we pay the Medicare Advantage companies as if they eliminate the financial barriers to care and as if therefore people could use health care more. But that’s not the case. They are not, they do not eliminate that.

In fact, we know the people in Medicare Advantage have more financial barriers to care than do people in traditional Medicare, but they’re paid as if they’ve eliminated them. That’s called induced utilization.

And that’s another 9%, and that’s $36 billion more. So if you add up the $44 billion to $56 billion from the favorable selection and the $20 billion from upcoding and the $24 to $28 billion from these benchmarks, and the $36 billion from induced utilization, that’s $124 to $140 billion.

And I think that’s very conservative and then, like I said, that doesn’t even begin to count the fraud and abuse and the illegal things that they do. So it’s a lot of money and it’s a lot of games. They’ve created an industry around maximizing how much they get out of each one of these games.

Q: What is the impact of these insurance company overcharges on taxpayers and Medicare beneficiaries, and why should we all be concerned about this?

Weisbart: And so here we are wasting, as I say, probably around $140 billion a year of our taxes … going to healthcare companies that actually make health care worse, not better.

So it’s a terrible impact on the taxes which we could fix. It’s interesting to note that Senators (Jeff) Cassidy and (Bill) Merkley, I believe, have submitted a bill called the No Upcoding Act, which would actually not deal with the $140 billion. It would deal with just the one that I was mentioning, the upcoding piece, which was about $20 billion.

If that bill that’s in the Senate got traction it would at least deal with that one piece. And that is actually like I told you four factors, and that was the smallest of the four factors. But if that bill got passed and became part of law, it would start the trend of reversing the tide of these overpayments. So I think, you know, the bill’s imperfect. It’s not anywhere near as strong as I would like it to be, but it’s still pretty darn good and it’s interesting to note that it’s sponsored by Senator (Jeff) Merkley, who is a Democrat and Senator (Bill) Cassidy, who’s a Republican.

So it’s literally got bipartisan appeal, and it’s not by an accident. The reason for that is because, frankly, you know, our fractured political landscape agrees in general that we don’t like wasting money, you know. This upcoding is a game that should not be allowed to steal our Medicare funds. So I think there’s hope for it.

Thank you, Dr. Ed Weisbart of Physicians for a National Health Program. Stay tuned for next time when we continue our discussion with Dr. Weisbart about Medicare Advantage overcharges and what can be done about them.

Do you have a personal story you’d like to share about our wack healthcare system? Contact us through our website at heal-ca.org.

Don’t forget to subscribe to Code WACK! wherever you find your podcasts. You can also find us on ProgressiveVoices.com and on Nurse Talk Media.

Code WACK! is powered by HEAL California, uplifting the voices of those fighting for healthcare reform around the country. I’m Brenda Gazzar.

https://heal-ca.org…

KFF Highlights the Harms of Insurance Complexity

Summary: Leaders of the Kaiser Family Foundation – a leading tracker of US health care – published a blog in JAMA identifying system complexity as the “enemy of access and affordability”. Exactly right. How can we streamline our way out of complexity? Single payer.

Complexity in the US Health Care System Is the Enemy of Access and Affordability, JAMA Forum, October 26, 2023, by Larry Levitt and Drew Altman

[bolding by HJM]

A recent survey by KFF [discussed in HJM] … provides some hints at the scope of the problem for US consumers with various types of health coverage …

Almost 6 in 10 people with insurance reported a problem with using their health insurance during the past year. The share increases to two-thirds for people in fair or poor health, three-fourths for those who need mental health services, and almost 8 in 10 for people who use the health system the most. The result is that many delay or skip care or accumulate bills they cannot afford. …

The idea of making the health care system simpler and more transparent certainly sounds good, at least in concept. Who could disagree with the principle that everyone should be able to learn which physicians and hospitals are in their network and taking patients, or that patients should get easily understandable explanations of benefits, statements, and medical bills? And does anyone want an artificial intelligence algorithm to deny claims without any review by real medical professionals?

Yet, any push for health care simplification inevitably clashes with commercial interests. The health insurance system is structured to simultaneously maximize profits, control costs, and serve consumers, which are competing goals that add to the challenge of simplifying it. For instance, limiting denials of claims or prior authorization requests will make the system more consumer friendly, but could also raise costs and might lead to care that is less grounded in evidence.

Although mechanisms already exist to protect patients and consumers, oversight and enforcement has been uneven. A federal law passed in 2021 requires private insurers to keep clinician directories up to date even though regulations implementing that requirement have not yet been issued.

Comment:

By Jim Kahn, M.D., M.P.H.

Let’s review the key (bolded) points:

Each year, 60% of insured individuals have a problem with their insurance. Even higher for those with greater need. As we discussed recently, unaffordability of care is now pervasive. With single payer, insurance is simple and care is affordable.

Everyone should be able to learn which providers they can use, and understand their benefits and bills. Indisputable, and essential given how the current system uses networks, along with highly varied benefits and coverage rules. Single payer makes this moot — with free choice of providers, standard comprehensive benefits, and full coverage.

Any push for health care simplification inevitably clashes with commercial interests. Correct – complexity and confusion reduce costs and thus raise profits for insurers, hence their resistance to simplicity. Single payer removes commercial interests from insurance. Costs are controlled through administrative efficiencies, lower prices, and global budgets.

A federal law requires private insurers to keep clinician directories up to date and the corresponding regulations are pending. Why should a law be required to keep provider directories current?? And why are the regulations still pending three years later?? Single payer would remove private insurers and the games that they inevitably play to avoid compliance with rules to protect patients.

The blog and associated survey also discuss denied claims and how consumers don’t know how to appeal them.

Our fragmented, profit-motivated health insurance system contradicts every reasonable and real world-proven principle of health insurance design. Single payer is sane, humane, and efficient. Let’s get on with it!

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Medicare Advantage is a money grab by big insurers

By Kip Sullivan, J.D.
Minnesota Reformer, November 3, 2023

The Sunday, Oct. 15 issue of the Minneapolis Star Tribune arrived on my door step wrapped in a four-page advertisement for something called Allina Health-Aetna. Allina is a 12-hospital multi-clinic chain; Aetna, which was bought out by the drug chain CVS for $69 billion five years ago, is a health insurance company.

The purpose of the ad was to urge the 20% of Minnesotans who are eligible for Medicare — the nation’s health insurance program for the elderly and the disabled — to enroll in Allina-Aetna’s “Medicare Advantage” plan.

“Medicare Advantage” is the misleading name given to the privatized portion of Medicare — the portion in which tax dollars are funneled through insurance companies so they can take 15% off the top to pay for administrative costs and profit before sending the other 85% to doctors and hospitals with strings attached. The traditional Medicare program — the unprivatized portion – does not funnel money through insurance companies; it pays doctors and hospitals directly, and it devotes around 2% of its expenditures to administrative costs. Today half of all Medicare beneficiaries are insured by insurance companies and the other half are insured by traditional Medicare.

Allina-Aetna’s ad boasted about extra services their “advantage” plan covers that Congress has never allowed the traditional Medicare program to cover. The upper half of the first page of the ad was taken up with these words: “Can I get dental, vision and hearing benefits in a Medicare plan?” Just below the fold were the words, “Yes, yes, and yes!”

What the ad didn’t explain was how health insurance companies not only survive within Medicare but make big profits. After all, Congress enacted Medicare in 1965 because the health insurance industry didn’t want to insure the elderly and the disabled. How is it that today insurance companies offer extra services and still make an outlandish profit despite their high administrative costs? American health insurance companies make 2.5 times as much profit per enrollee on Medicare as they do on their private-sector customers, according to a 2021 KFF paper on health insurer financial performance.

The answer: They are vastly overpaid. According to a report released earlier this month by Physicians for a National Health Program, which I helped write, the overpayment in 2022 was somewhere between 22% and 35%. In other words, the cost of insuring Medicare beneficiaries through Medicare Advantage was 22% to 35% higher, or somewhere between $88 billion and $140 billion more, than it would have been had those beneficiaries remained in traditional Medicare. Those are astronomical figures. That’s far more, for example, than the $75 billion the U.S. spent on humanitarian and military aid for Ukraine between February 2022 and October 2023.

The PNHP report documented five causes of these overpayments:

“Favorable selection,” which means insurance companies lure healthier-than-average beneficiaries away from traditional Medicare, but Medicare pays them as if they enrolled beneficiaries in average health (overpayment of 11% to 14%);
“upcoding,” the name given to the insurance companies’ practice of making their enrollees look sicker (and therefore warranting higher reimbursement) by adding diagnoses to patient medical records that are either false or irrelevant to the treatment given to the patient (5%);
pointless bonuses Congress requires Medicare to give to Medicare Advantage plans for high scores on a score card that is so inaccurate the Medicare Payment Advisory Commission has called for its termination (4%);
gratuitous bonuses Congress ordered Medicare to give to plans that sell insurance in more rural parts of the country that plans tend to avoid (2% to 3%);
and, a subsidy created by Medicare’s use of the average cost of insuring a traditional Medicare beneficiary as the baseline to determine plans’ payments, uncorrected for the portion of traditional Medicare costs paid for by supplemental (Medigap) coverage (9%).

PNHP’s estimate of the total overpayment does not take into account “favorable deselection” — driving sicker Medicare Advantage enrollees back to traditional Medicare by denying them necessary services. We have abundant evidence indicating Medicare Advantage plans deny necessary services to tens of thousands of their enrollees every year. But we don’t have any research on how much that adds to the overpayments. This abuse of enrollees is just one of the reasons research indicates Medicare Advantage plans have had, at best, a mixed effect on quality.

The Allina-Aetna four-page ad that now sits in my recycling bin made no mention of the overpayments, nor of the reasons why Medicare beneficiaries should consider avoiding enrolling in a Medicare Advantage plan (narrow networks and frequent denial of services being the most important).

Congress should put an immediate stop to the overpayments and, at the same time, authorize traditional Medicare to cover dental, vision and hearing services.

Kip Sullivan is a member of the policy committee of Health Care for All Minnesota. He has written extensively about health care reform.

https://minnesotareformer.com…

History of U.S. Medical Debt Collection

Summary: U.S. medical debt structure has substantially evolved from amounts negotiated among care participants in the 1980s, to commoditized assets and aggressive collection today. With sky-high deductibles and other cost-sharing, debt magnitude is rapidly growing. Single payer would end this painful complication of our health insurance.

Debt Collection in American Medicine – A History, New England Journal of Medicine, October 26, 2023, by Luke Messac

A historical lens reveals that since the 1980s, medical debts have shifted from obligations negotiated by doctors, patients, and hospitals to assets bought and sold by people with no role in patient care. In part because of the proliferation of insurance plans with higher copayments and deductibles, hospitals have faced more delinquent payments. Hospital administrators have turned away from charity care and have opted instead for aggressive debt collection.

Comment:

By Don McCanne, M.D.

This report discusses the all-too familiar topic of medical debt in the United States. Sections in the report include: “Debt in the Doctor-Patient Relationship,” “The Rise of the Collection Industry,” and “The Criminalization of Debt.” The concluding section is “The Physician’s Responsibility.”

The message that should come across today is that The New England Journal of Medicine recognizes that this topic of medical debt is not only important enough to feature in their journal, but the closing sentence of the article demonstrates that PNHP can be a part of the solution! The closing statement (bold type added for emphasis): For their part, doctors who seek to be a part of the solution can join ongoing grassroots efforts, including organizations such as Physicians for a National Health Program and the Debt Collective, to make medical debt, and its destructive consequences, a thing of the past.

Now let’s mobilize to get the politicians on board.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

‘Deny, deny, deny’: By rejecting claims, Medicare Advantage plans threaten rural hospitals and patients, say CEOs

Medicare Advantage plans "are taking over Medicare and they are taking advantage of elderly patients," said the CEO of one Mississippi facility.

By Gretchen Morgenson
NBC News, October 31, 2023

For decades, Rose Stone counted on the Alliance HealthCare System in rural Holly Springs, Mississippi, for her medical needs. But after she retired and signed up for a Medicare Advantage plan, she was surprised to learn it didn’t cover her visits to nonprofit Alliance, the only health-care provider within 25 miles. Stone had a choice: use her own money to keep seeing her regular doctor or drive out of town to see a physician she didn’t know but whose costs were covered.

“It was a mess,” Stone told NBC News. “I didn’t go to the doctor because I was going to have to pay out-of-pocket money I didn’t have.”

Some 31 million Americans have Medicare Advantage plans, private-sector alternatives to Medicare introduced in 2003 by Congress to encourage greater efficiency in health care. Just over half of Americans on Medicare are enrolled in one of the plans offered by large insurance companies, including UnitedHealthcare and Humana.

Problems are emerging with the plans, however. Last year, a federal audit from 2013 was released showing that 8 of the 10 largest plans had submitted inflated bills to Medicare. As for the quality of care, the Medicare Payment Advisory Commission, a non-partisan agency of Congress, said in a March report that it could not conclude Medicare Advantage plans “systematically provide better quality” over regular Medicare.

Even worse, because the plans routinely deny coverage for necessary care, they are threatening the existence of struggling rural hospitals nationwide, CEOs of facilities in six states told NBC News. While the number of older Americans who rely on Medicare Advantage in rural areas continues to rise, these denials force the hospitals to eat the increasing costs of care, causing some to close operations and leave residents without access to treatment.

“They don’t want to reimburse for anything — deny, deny, deny,” Dr. Kenneth Williams, CEO of Alliance HealthCare, said of Medicare Advantage plans. “They are taking over Medicare and they are taking advantage of elderly patients.”

Williams is something of a local hero in Holly Springs. When the area hospital was in danger of closing in 1999, he marshaled resources and bought it to keep it open. Alliance serves a county with 38,000 people.

Still, this spring he had to shut down a long-time geriatric psychiatry program that had served the community for over eight years. Coverage denials from Medicare Advantage plans killed the program, Williams said.

Medicare Advantage plans are sold assiduously by celebrity pitchmen — one is Joe Namath — as a better way for Americans who qualify for Medicare to get insurance coverage. Many plans add services such as dental and hearing care and wellness programs not offered under traditional Medicare, for which beneficiaries pay extra.

The U.S. government pays most of beneficiaries’ premiums to the insurers offering the plans.

If the government hoped Medicare Advantage plans would reduce the costs of care, that has not been the outcome. Medicare pays the plans 6 percent more than it would spend if plan enrollees were covered under regular, fee-for-service Medicare, the MedPAC report found. Medicare payments to the plans will total $27 billion more in 2023 than if patients were enrolled in traditional Medicare, the report projected.

A new enrollment period for the plans began this month. State insurance commissioners told NBC News they, too, receive many complaints from customers saying they were sold Medicare Advantage plans without understanding their limitations. A major complaint, said Mike Chaney, the Mississippi Insurance Commissioner: “Consumers are not aware their doctors are likely to change under the Medicare Advantage plans.”

‘We can’t pay our bills’

Medicare Advantage plans have grown in popularity in recent years, with enrollment more than doubling nationwide since 2013. One explanation: The plans are often cheaper than paying for a Medicare supplement, sometimes referred to as Medigap.

Another reason for the growth may be the significantly larger commissions the government pays to brokers selling Medicare Advantage plans. In 2024, the Centers for Medicare and Medicaid will pay brokers a commission of between $611 and $762 for the first year of a Medicare Advantage plan, depending on the state, and roughly half that on annual renewals. On Medicare supplements, by contrast, brokers receive around $300 on average in year one.

Brokers selling the so-called advantage plans aren’t the only ones making money on them. UnitedHealth Group, the largest Medicare Advantage provider with 7.6 million people in its plans, generated $257 billion in premium revenues in 2022, some 13% over the previous year. A significant driver of that growth was its Medicare Advantage plans, the company’s financial filings said. Humana, the next largest provider, counts 5.3 million Medicare Advantage customers; during the six months that ended June 30, almost 80% of Humana’s $51 billion in premium revenues came from individual Medicare Advantage plans, its filings show.

Meanwhile, CEOs of rural nonprofit hospital systems in Arkansas, Colorado, Mississippi, Missouri, South Dakota and Texas told NBC News that Medicare Advantage plans repeatedly refuse to reimburse them for the care they provide. Some 170 rural hospitals are at risk of closing in those six states alone, according to a report from the Center for Healthcare Quality and Payment Reform, a nonprofit advocacy organization.

While there are multiple reasons for rural hospitals’ financial woes, coverage denials from Medicare Advantage plans play a big part, said Harold Miller, president of the Center that conducted the study. For years, Medicare Advantage plans had been rare in rural areas, now they are becoming ubiquitous. In 2022, enrollment in Medicare Advantage plans grew 13 percent in rural areas versus 7 percent in urban zones, according to the MedPAC report.

Mary Beth Donahue, president of the Better Medicare Alliance, an advocacy group that supports Medicare Advantage plans, said in a statement: “We acknowledge the challenges facing some health systems, but we need to ensure coverage is maintained for millions of seniors. As Medicare Advantage continues to grow, it is essential that hospitals provide access for seniors and people with disabilities who rely on this program.”

A UnitedHealthcare spokeswoman said in a statement, “Over 6,000 hospitals participate in our UnitedHealthcare network, and we have built collaborative relationships with them to help ensure we are meeting our shared goal of providing quality care to the people we serve.”

By law, Medicare Advantage plans are supposed to base their reimbursements on Medicare rules. But there’s room for interpretation, says the Department of Health and Human Services. For example, insurers can use their own clinical criteria to determine whether to authorize or pay for care. A report last year by the department’s Inspector General found that in June 2019, the 15 top Medicare Advantage plans denied authorization for 13 percent of claims that had met Medicare rules. The plans also denied payment for 18 percent of claims that met Medicare coverage and billing rules, the report said.

Even when the plans pay, they reimburse providers far less than traditional Medicare, rural hospital CEOs and doctors told NBC News. The plans are effectively rationing health care, these providers said.

For example, the hospital officials cited specific cases in which plans take a week to approve care but agree to pay only for a three-night stay; deny coverage after approving it, clawing money back from hospitals; or contend a provider is “out of network” when it isn’t. They also deny routine tests and refuse to pay for rehabilitation, saying patients should go home before their doctors think it’s wise.

“Any study we order — X-ray, CT scan, MRI, stress tests — they’re going to deny,” said Craig Pendergrass, a doctor at Ozarks Community Hospital, a nonprofit critical access hospital in Gravette, Arkansas, in the northwest corner of the state. “With straight Medicare we just schedule it.” He estimated that his staff spends one-quarter of each week trying to persuade the plans not to deny the tests or treatment.

Large hospital systems with big staffs can dedicate time and energy to fighting claims denials, the American Hospital Association says. Small rural hospitals cannot. In response, some smaller systems are starting to reject Medicare Advantage plans. This summer, Jason Merkley, chief executive of Brookings Health System, a highly rated nonprofit hospital chain in South Dakota, stopped accepting the plans because of coverage denials and pre-authorization problems. Only a small percentage of the system’s patients had Medicare Advantage plans, Merkley told NBC News, but the effort required to battle the denials was considerable.

A Humana spokesman provided this statement: “In our Medicare Advantage hospital contracts, Humana pays rates, on average, that are above fee-for-service Medicare rates. Moreover, the fee-for-service Medicare reimbursement model is focused on patient volume and the quantity of services provided, whereas we are focused on delivering better outcomes for patients.”

In mid-September, Samaritan Health Services, a five-hospital system in Oregon, said it ended its contract with UnitedHealthcare, including its Medicare Advantage plans. “United Healthcare’s processing of requests and claims has made it difficult for Samaritan to provide timely access to the appropriate care to United’s members,” the system said.

Refusing to accept Medicare Advantage plans is not an option for hospitals with many plan customers and whose facilities are the only ones in their rural areas, the CEOs say. If they stopped accepting the plans, their communities would have to forego local health care.

“We’re a system with a proud history of taking all patients, insured or not,” said Paul Taylor, CEO of the 25-bed Ozarks Community Hospital. “But this makes it really difficult for us to continue to care for at-risk patients. We can’t pay our bills.” Medicare Advantage plans make up 40% of his reimbursements now, up from 20% a few years ago, he said.

Taylor recently conducted a two-year study of what his hospital received treating traditional Medicare patients versus what it received from Medicare Advantage plans. He found that the plans paid $4.5 million less than he received under Medicare for the same treatments. That’s roughly what his facility generates in revenues each month.

Ozarks Community, which serves approximately 30,000 people, narrowly averted a bankruptcy filing this spring, Taylor said. He is selling assets to stay afloat.

$29,458 of care denied

In late August, a patient with chronic obstructive pulmonary disease and Covid arrived at San Luis Valley Health Regional Medical Center, a 49-bed, level 3 trauma center in Alamosa, Colorado. The nonprofit hospital serves a six-county region in south central Colorado that’s home to about 50,000 people. Roughly the size of Delaware, the area is one of the poorer in the state, said Konnie Martin, San Luis Valley Health’s chief executive.

The doctor handling the patient recommended admitting her to the hospital, but her UnitedHealthcare Medicare Advantage plan balked. They agreed to pay only for “observation” of the patient, a lower standard of care that generates much smaller reimbursements.

The facility went ahead and treated her as an inpatient for two weeks, a stay that cost $29,458, all of which San Luis Valley Health absorbed, it said. Had the Medicare Advantage plan agreed to cover the claim, it would have paid one-third, the hospital estimated.

“This is the norm — they push back on people to try to keep them out of the hospital or delay their hospital care,” Martin said. The hospital’s staff has to spend time resubmitting claims, she added, saying: “It costs us 2 or 3 times the amount of labor and investment to collect on one claim.” Her staff provided documentation of four recent denials of coverage by United Healthcare in one week.

The coverage denials the CEOs described to NBC News are similar to those found in last year’s Health and Human Services report. They included erroneous rejections of MRIs and CT scans, paying only for “observation” rather than inpatient care, denials of long-term acute care, rehab, lab tests and medical equipment.

The Inspector General said that “human error” and “system processing error” caused most of the denials by Medicare Advantage plans. But the hospital executives NBC News spoke with say they believe the denials are a strategy by insurers to improve their profits by refusing to pay claims.

“This world of medical billing is so automated if you’re denying a claim, you’re doing it intentionally,” said Martin, of San Luis Valley Health.

UnitedHealthcare declined to comment.

The Cuero Regional Health System, a small hospital in Cuero, Texas, serves a population of 22,000. Its officials say Medicare Advantage plans often deny care based on the insurers’ internal determinations about the type of care required, overruling the physicians handling the cases. When the hospital questions a determination — called a peer-to-peer review — officials often have to argue with a physician who doesn’t specialize in the care the patient requires, said Lynn Falcone, its chief executive.

A Medicare Advantage plan recently denied a referral to long-term acute care for a patient with sepsis, Falcone said. When the family practice doctor overseeing the case asked for a peer-to-peer review, the insurance company physician defending the denial was an ob-gyn specialist. “A surgeon that delivers babies maybe isn’t used to handling sepsis,” Falcone said.

‘It had to be extreme’

Sandra Tate of Cuero, Texas, said her family’s Medicare Advantage plan created problems for her family in Feb. 2022. Her husband required physical and respiratory therapy after a 10-day stay in the ICU at Cuero Regional Health, she said; although a previous plan from Humana had paid for this treatment four years earlier, the second request for reimbursement was denied under her new plan from United Healthcare. After arguing with the insurer for 30 minutes, Tate, a former school nurse, said she was never told why.

“I pay my Medicare premiums and also my insurance premiums,” Tate told NBC News. “I don’t understand why Medicare Advantage is not wanting to pay the rural hospitals that are taking care of you.”

The UnitedHealthcare spokeswoman said the company could not comment on Tate’s experience unless she signed a waiver; Tate declined to do so.

In its financial filings, United Healthcare describes how rates paid by the government on Medicare Advantage plans can fall below what the insurer calls its “cost trends.” To combat these profit pressures, the insurer said, it “can seek to intensify our medical and operating cost management” and “adjust member benefits.”

For eight-and-a-half years, Alliance HealthCare System’s inpatient geriatric psychiatry program helped older patients in Holly Springs, Mississippi, with depression and other mental health issues. The 15-bed facility offered group and family therapy as well as an inpatient program that could run from one to three weeks, said Ejerra J. Selma Dukes, its former director.

Medicare always paid for the services, Dukes said. But a few years ago, she started seeing more patients with Medicare Advantage plans declining to pay. The insurers would reject claims for patients with depression and dementia, she said, agreeing to reimburse only for those who were suicidal, paranoid or homicidal. “It had to be extreme for them to say we will allow you all to bring them in,” Dukes told NBC News.

On March 28, the program closed its doors, Dukes said, a result of the denials. “It was heartbreaking, especially with those who had been dealing with us a long time,” she recalled. “You know you can help, but you can’t bring people in for free.”

Meanwhile, Rose Stone is once again receiving care at Alliance HealthCare System. She junked her Medicare Advantage Plan and returned to Medicare, with a supplement. “Everything is fine now,” she said.

https://www.nbcnews.com…

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‘We can’t pay our bills’

$29,458 of care denied

‘It had to be extreme’

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