PNHP

Cost-Sharing, Coverage Denials, Missed Care, & Medical Debt

Cost-Sharing, Coverage Denials, Missed Care, & Medical Debt

The Commonwealth Fund, a respected monitor of US health system performance, highlights how cost-sharing and coverage denials lead to widespread missed care and medical debt. The system is unfair and opaque. Administrative tweaks won’t resolve these problems for private insurance designed to benefit executives and shareholders at the expense of patients.

Unforeseen Health Care Bills and Coverage Denials by Health Insurers in the U.S., The Commonwealth Fund, August 1, 2024, by Avni Gupta, et al.

Americans are increasingly struggling to get their health insurance to work for them. High deductibles and copayments are causing nearly two of five working-age adults to delay visiting the doctor and filling prescriptions. Those who do get care can become burdened by medical or dental debt, something almost one-third of working-age adults report experiencing. Billing errors and denials of coverage by insurance companies may contribute to this problem. Media investigations have found that insurers are becoming increasingly adept in using technology to deny payment of medical claims and pressures their company physicians to deny care during prior authorization reviews. Doctors also report spending increasing amounts of time on the phone with insurance company physicians over denials of care for their patients.

In this brief, we report findings from a Commonwealth Fund survey on the extent to which working-age adults say their insurance provider charged for a health service they thought should have been free or covered or denied coverage for care recommended by their doctors. We examined whether people challenged such errors or coverage denials, the reasons why they didn’t, and the implications for their health and well-being.

From the Discussion:

The complexity of the health insurance system in the United States has left many people struggling to understand what services are and aren’t covered and their financial liabilities when they get care. On top of this complexity, insurers are motivated to avoid paying for care. Many insurers appear to be utilizing increasingly aggressive tactics to do so, deploying technology and applying pressure to company physicians to scrutinize services recommended by patients’ physicians and often to deny coverage, leaving patients with unexpected bills or delays in care.

When looking at people’s billing disputes and denials of coverage, what emerges is that many realize positive outcomes when they appeal decisions they perceive to be in error. Yet only half of those who believe they were erroneously billed or denied care actually challenged the decision or had a doctor challenge it on their behalf. The survey shows considerable consumer confusion among patients and their families about their right to appeal and who to contact. The responsibility of appealing may not be clear between patients and providers, or between employers and employees, and the documentation requirements to appeal can create additional barriers. The current system with its complicated appeals processes can be detrimental to patients who are most in need of services.

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

Americans often do not understand why, when we have the most expensive healthcare system in the world, so many people are left without the care they need, and are saddled with excessive medical debt for services that common sense would indicate insurance should cover. The answer is, simply, the system was designed to provide increased revenue and profits for insurers and other intermediaries by increasing administrative services, which often oppose the interests of patients – thus diverting funds from medical care to executives and investors.

If you read the full report, you will find that suggested corrections to the problem are primarily in adjusting administrative functions. This misses the big picture: Protecting superfluous administrative functions by adding even more administrative functions, supervised by an industry that thrives on (and is adept at) drawing off patient care funds, hardly seems like a satisfactory solution to the problems of inadequate patient care in an environment of rising medical debt.

Of course, we know what the answer is: a single payer financing system. We need to provide comprehensive health care to everyone, and fund the system with progressive taxes that everyone can afford. Administrative functions would be drastically simplified, and directed to making health care accessible for all and paying for it without rewarding a superfluous industry that is designed primarily to create wealth rather than preserve health.

https://healthjusticemonitor.org…

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Building power nationally for health justice

Interview with Dr. Ed Weisbart

Building Bridges, WBAI Pacifica Radio, August 5, 2024

PNHP national board secretary Dr. Ed Weisbart discusses his recent piece in Common Dreams, “To Win ‘Medicare for All,’ First Reclaim Medicare From Profiteers.”

Dr. Weisbart cites the corporate insurance industry’s indefensible overcharging of taxpayers—to the tune of up to $140 billion per year.

“If we could get that money back from them,” he says, “then we could use that money to help us pay for hearing, and vision, and dentistry for everybody in Medicare” along with other important health care priorities.

https://wbai.org…

How Harris Left Medicare For All Behind

Kamala Harris once championed a true universal health care plan, only to walk it back. Now, nobody knows where she stands.

By Amos Barshad
The Lever, August 2, 2024

On a chilly Monday night in January 2019, Kamala Harris was in Des Moines, Iowa for a CNN town hall. At the time, Harris was the junior senator from California and one of nearly 30 candidates vying to be the Democrats’ 2020 presidential nominee. A few minutes into the event, a self-employed local resident named Renee Welk asked a pertinent, inevitable question: “What is your solution to ensure that people have access to quality health care at an affordable price?”

Without hesitation, Harris answered, “We need to have Medicare For All.” Then, as the applause rang out, she riffed beautifully. “To live in a civil society, to be true to the ideals and the spirit of who we say we are as a country,” Harris said, “we have to appreciate and understand that access to health care” is not a “privilege” but a “right.”

“It is inhumane,” she continued, “to make people go through a system where they cannot literally receive the benefit of what medical science can offer because some insurance company has decided it doesn’t meet their bottom line in terms of their profit motivation. That is inhumane.”

This wasn’t Harris’s first time publicly backing universal government-sponsored health care: In 2017, she was one of the first co-sponsors of Sen. Bernie Sanders’ (I-Vt.) sweeping Medicare For All bill. But never before Des Moines had Harris spoken about the issue so forcefully, so passionately, and under such a bright spotlight.

When CNN’s moderator Jake Tapper pushed her on whether that meant she would “eliminate private insurance,” Harris seemingly stayed resolute. She described the painful process of filing an insurance claim, of dealing with all of the required paperwork, of facing delays in coverage, and then said: “Let’s eliminate all of that. Let’s move on.”

For supporters of universal health care, it was a stirring moment, a rousing defense from a senator whose state was then in the early stages of its ongoing fight for a single-payer system. For Harris, fighting to make herself known nationally, it was potentially definitive. On an issue of grave importance, she had spoken with a ringing moral clarity.

But within days, as opponents across the political spectrum launched attacks on her position, Harris and her campaign began walking it all back.

In confused, mealy-mouthed statements, campaign reps told the media that while Harris’s “preference” was Medicare For All, she was open to more than one “path” to providing universal coverage. By the summer of 2019, Harris had proposed a widely panned proposal that critics said would continue to enrich the private insurers who have fueled the country’s health care crisis.

Now that Harris is the Democratic Party’s presumptive 2024 presidential nominee, questions about her back-pedaling on Medicare For All have a new urgency. What does her retreat under pressure from powerful monied interests tell us about a potential Harris presidency’s agenda on issues that conflict with donors’ demands?

Medicare Privatization For All?

Throughout 2019, Harris stumbled repeatedly when prompted to express her views on Medicare For All. In May 2019, in another interview with CNN’s Tapper, Harris said that back in Iowa, when he’d asked her if she wanted to get rid of insurance companies and she said yes, that was actually “not what I meant.”

During a debate in June of that year, when the candidates were asked who would be in favor of eliminating all private health care insurance, Harris raised her hand. Days later, she again backed off the position. The next month, in a Medium post headlined “My Plan For Medicare For All,” Harris finally released the specifics of her health care plan.

“She called it Medicare For All,” said Adam Gaffney, an ICU doctor and the former president of the advocacy group, Physicians for a National Health Program. “But it really wasn’t. She did envision covering everyone and that is laudable and that is critical. But the plan maintained a central role for private insurers, and we’ve seen year after year is that private insurers are driving up the cost of care. They are a key problem in our crisis.”

Medicare For All is also known as single-payer health insurance because it would create one federal government entity that would oversee all health care spending. Its advocates believe the best way to provide health insurance to all Americans is by improving and expanding Medicare, a system that has successfully provided health care for millions of people for decades. Advocates also estimate a single-payer system would net $500 billion in savings by mimicking the efficiency of Medicare, which spends just two percent of costs on administrative tasks like billing.

Harris’s plan wasn’t a single-payer system. Instead, it aimed to give all Americans the choice of enrolling in Medicare while also likely expanding Medicare Advantage, the controversial for-profit insurance program subsidized by the federal government.

People choose Medicare Advantage because it’s cheap: The upfront premiums average less than $20 a month. What they don’t know is that actually receiving treatment with their Medicare Advantage plan is costly in other ways: Critics say that Medicare Advantage insurers profit by denying patients care.

The Journal of Clinical Oncology has found that, in part due to inferior care options, cancer patients in Medicare Advantage have higher mortality rates immediately after surgeries than traditional Medicare enrollees. Researchers studying one large insurer’s data found a 15 year increase in denials over a five year period. One in three Medicare Advantage enrollees are denied at least one claim annually. The programs are being investigated by the Department of Justice for fraud.

This privatized version of Medicare has existed in previous versions since at least the nineties. In 2003, it was renamed Medicare Advantage. Under Trump, it ballooned. In 2018, his administration’s Department of Health and Human Services sent physical letters to millions of Americans saying things like “See if you can save money with Medicare Advantage.” Under the Biden and Harris administration, its growth continued. Last year, around half of all eligible patients were in Medicare Advantage plans rather than traditional Medicare.

As The American Prospect wrote in 2019, “what’s so insidious about Harris’ approach” is that it “would expand the commercial part of the system, falsely branded as a variant of Medicare, and take us further away from true seamless and universal coverage.” While that’s not good for patients, it’s also not good for the federal budget. As The Lever recently reported, “The federal government is losing as much as $140 billion per year by subsidizing private Medicare Advantage plans.”

As far as the GOP is concerned, Medicare Advantage should get even bigger. Project 2025, a broad package of policy proposals being pushed by the Heritage Foundation as the blueprint for a second Trump administration, wants to set Medicare Advantage as “the default enrollment option” for Medicare.

It’s been fourteen years since the Obama administration passed the Affordable Care Act and in many ways America’s health care crisis is worse than ever, as health insurance companies have taken advantage of its many loopholes. This year, the prices of health insurance premiums are estimated to reach record highs. By 2026, the number of uninsured Americans is predicted to spike to over 30 million.

By the end of 2019, in the wake of her flailing around Medicare For All, and as her support waned, Harris quit the Democratic primaries.

In the summer of 2020, Joe Biden — who, during his own successful campaign for the Democratic nomination, explicitly said he’d veto any Medicare For All bill as president — named Harris his vice president.

How Harris “Abandoned” Medicare For All

When Harris first began talking about her support for Medicare For All, she often told the story of her own mother who died in 2009 at 70 years old, due to complications from colon cancer. In a 2018 New York Times op-ed, Harris wrote touchingly of cooking “elaborate meals for her, filling the house with the smells of childhood,” and of finding time outside of her then-job as San Francisco district attorney to hold her mother’s hand “through the misery of chemotherapy.” She wrote, “I am so grateful my mother had Medicare, and I will fight for it to be guaranteed to all.”

In the fall of 2019, Harris sat down for an interview with Ady Barkan, the Medicare For All advocate who died last year, at the age of 39, from complications of ALS. At that point, Harris had already released her Medicare Advantage-boosting health care plan.

At first, the two speak in generalities about the importance of health care over the kind of crescendoing instrumentals that would sound right on a motivational YouTube sports highlights compilation. Barkan asks Harris about her late mother; Harris breaks down in tears. Then, to his credit, Barkan doesn’t let the opportunity slip to push back on the specifics of Harris’s plan.

“You philosophically believe the insurance companies play a useful role and should continue existing?” he asks her, using the augmentative technological intervention he needed to communicate toward the end of his battle with serious degenerative disease.

“I believe that those who abuse the system should be held accountable, but I am not trying to get rid of all private insurance,” she answers. “The problem is they have been writing the rules and they have been taking advantage of consumers.”

Michael Lighty, a longtime Medicare For All advocate, worked as the health care constituency director for Sen. Sanders’ 2020 presidential campaign. He was also the longtime single-payer expert for the California Nurses Association/National Nurses Union organization, which represents over 150,000 nurses nationwide.

He recalls being initially impressed with Harris’s thoughts on Medicare For All, both during the Des Moines event and on previous occasions, “It was very passionate, very sincere. Her framing was ‘we’re not getting a good ROI on health care,’ which was certainly unique, but she definitely seemed committed to the issue.”

The context for Harris’s eventual retreat, Lighty said, was that support for Medicare For All was making the Sanders campaign a target for huge attack ad spending. “Bernie was getting hit with about a million-and-a-half dollars in Iowa” ahead of the 2020 caucus, Lighty says. Meanwhile Pete Buttgieg, then best known as the former Mayor of South Bend, Indiana, “was claiming he had a better plan, some kind of public/private combination.” Sen. Ellizabeth Warren (D-Mass.) “felt compelled to prove how we pay for it in order to distinguish herself, which was not a smart move politically,” Lighty said. “You don’t wanna talk about what it’s gonna cost you, you wanna talk about what it’s gonna save.”

Harris, he explained, was trying to find something to make herself stick out while avoiding the ad spending being directed against Sanders for his support of Medicare For All.

“A majority of voters want the option to keep their plans,” Lighty said. “Primarily that’s because the situation is so bad, they’re desperate to keep what they have.” Political consultants “will tell candidates, ‘you don’t want to be out there telling people you’re taking away their plans.”’

When Harris finally did release her so-called version of Medicare For All, Lighty explained, she “backed off the fundamental principle — a single, publicly-administered plan that would eliminate the power of the commercial insurance companies.” For the Sanders campaign, Lighty says, Harris’s plan felt like an opportunity. “So, fine. Not ‘fine’ from a policy perspective, because she’s wrong.” But it distinguished Sanders as the sole champion for a true Medicare For All proposal.

“She had abandoned support for Medicare For All,” Lighty concluded. “We saw it as exactly that.”

In the long fight for universal healthcare, 2019 was “a very exciting time,” said Gaffney, the ICU doctor. “Single-payer activism had been going on for decades, but for many years had really been on the sidelines” of the political discourse.

Sanders’ 2016 presidential run energized the issue; with the ongoing efforts of progressive activists, and the broader pushback to the Trump administration, Medicare For All suddenly had real momentum. And Harris in Des Moines was a significant moment in the groundswell.

But despite bipartisan support, the movement faltered. “I think many politicians responded to the energy of their progressive constituencies,” Gaffney said. “But it’s one thing to sign on. It’s another thing to stay on.”

“I’ve Never Encountered Kamala”

Alex Lawson is the executive director of the advocacy organization Social Security Works, which aims to expand Social Security and Medicare. He’s an advocate for Medicare For All and has helped draft single-payer legislation introduced in the House of Representatives.

Of the plan Harris proposed in 2019, he said, “I totally reject the idea that the policy is terrible.” He understands why people might be alarmed at the plan’s potential to expand Medicare Advantage. But he said, “Harris’s goal is really clear. It’s to not allow corporate insurers to delay and deny care.”

He doesn’t agree with the people criticizing her approach as an expansion of Medicare Advantage, saying that was not her intention: ”I can tell you, I was right there.” As an activist in close communication with both the Sanders and the Harris teams, he saw that “Harris and her staff were looking to guarantee health care for Americans.’”

In her 2019 proposal, Harris writes, “Essentially, we would allow private insurance to offer a plan in the Medicare system, but they will be subject to strict requirements to ensure it lowers costs and expands services. If they want to play by our rules, they can be in the system. If not, they have to get out.”

Lawson points to the Biden-Harris administration’s health care track record, which includes, he says, “the largest expansion of Medicare since the creation of Medicare,” and the creation of price caps on a select handful of drugs for Medicare patients. Harris should be judged on what her administration has done, Lawson argued: “They beat pharma! The unbeatable pharma!”

For Lawson, Harris’s walkback on Medicare For All in 2019 is not as telling as its critics believe it to be. “That episode is not nearly as clarifying as the totality of what she did before, during, and up to now,” he said.

As President, Biden was very cozy with the insurance industry: He welcomed its lobbyists to his very first fundraisers, and he took its cues when crafting emergency relief policies during the pandemic.

What kind of relationship Harris will look to build with insurers is not yet known. According to Open Secrets, Harris now has over $800,000 in donations from the health services sector, which includes insurance giants like UnitedHealth and Blue Cross Blue Shield. (Donations to Biden’s campaign before he dropped out will now be transferred to Harris’s campaign, and so are included in that number.)

The Harris campaign recently told The New York Times that Harris “no longer supported a single-payer health insurance program.”  In a statement to NBC News on July 31, a campaign official said, “The VP will not push single payer as president.” When reached for comment, a Harris campaign official confirmed that to The Lever, adding, “The VP won’t push her 2019 health care plan. She will continue to build on the successes of the Biden-Harris Administration — lowering prescription drug costs and making health care more affordable and accessible.” The campaign official declined to elucidate Harris’s vision any further than that.

On July 30 of this year, Harris commemorated the anniversary of the creation of Medicare, signed into law by Lyndon B. Johnson 59 years ago, with a post on X, formerly Twitter: “Trump’s Project 2025 plans to cut Medicare and roll back our progress on Medicaid. As Vice President, I have worked to expand these programs—and we are not going back.” Once, she was clear and bold on the issue; these days, she is a cipher.

RoseAnn DeMoro, the former executive director of National Nurses United, is widely known as one of the most effective union leaders in recent American history. Before retiring in 2018, she helped create real and ongoing momentum for single-payer health care in California and remains an activist for Medicare For All in the state and nationwide. When asked about Harris’s shifting positions on Medicare For All, she first offers a preamble: “I really want her to win, and I hope you say that. She has to win.”

Then she said of her former neighbor in the Golden State, “I’ve been in the political world forever. And I cannot tell you what she advocates. In all my years doing political work in California, in terms of our issues, I’ve never encountered Kamala.”

https://www.levernews.com…

Every time corporate insurers spend money on our health care—that’s a financial loss

Interview with Dr. Ed Weisbart

The Attitude with Arnie Arnesen, August 1, 2024

PNHP national board secretary Dr. Ed Weisbart discusses his recent piece in Common Dreams, “To Win ‘Medicare for All,’ First Reclaim Medicare From Profiteers.”

Despite the need for improvements such as additional benefits and lower out-of-pocket costs, Dr. Weisbart reminds us that “Medicare is a spectacular public health program, [but] Medicare Advantage is completely different from that.”

After all, the corporate insurers that sell Medicare Advantage plans have financial priorities that are incompatible with public health. “Every time they spend money on our health care,” he says, “that’s a loss.”

https://www.podomatic.com…

What Happens to American Healthcare After November?

While Trump’s platform is a serious threat, Harris’s remains uncertain.

By Adam Gaffney, M.D., M.P.H.
The Nation, July 31, 2024

President Biden’s exit from the Democratic ticket and Vice President Kamala Harris’s emergence as the presumptive nominee has, perhaps, escalated the stakes of the November election for healthcare. Trump’s schemes are, of course, unchanged: A unified Republican government could shred the nation’s healthcare safety net, accelerate the (ongoing) privatization of Medicare, and further restrict or even ban abortion nationwide. In contrast, like a second Biden administration would have, a Harris administration might mostly mean continuity—allowing her to consolidate some real gains (like Biden’s landmark Medicare drug negotiation reform) without confronting the broader injustices and galloping corporatization of US healthcare. But in some quarters, hopes are rising that a Harris administration could go a step beyond Biden—and even open the door to a progressive shift on health policy.

Harris has been to Biden’s left on abortion, supporting a measure in 2019 that would have gone beyond Roe by curtailing state-level abortion restrictions; she is also the first vice president to visit an abortion provider. As a California senator, she endorsed Senator Bernie Sanders’s landmark 2017 Medicare for All bill, a far more expansive reform than anything Biden has put his name on. Yet Harris backtracked on Medicare for All, and the political pressure her administration would face in any major reform effort from both right and center would be daunting, particularly without a powerful grassroots movement pushing the cause, once again, to center stage. Such a mobilization is precisely what we need regardless of the election’s outcome—to advance progressive reform if possible and to fight calamitous policies if necessary.

Forecasting the impact of a second Trump administration requires distinguishing his rhetoric from the reality of his rule. Recall that in the 2016 presidential primary, Trump ran on vaguely popularist promises to protect public health insurance programs, while maligning Obamacare and promising to replace it with something better. “They’re gonna cut Social Security, they’re gonna cut Medicare, they’re gonna cut Medicaid,” Trump said of his Republican primary competitors in 2015. “I’m the one saying that’s saying I’m not gonna do that!” He also famously accused pharmaceutical companies of “getting away with murder” in how they priced their products, causing pharma stocks to briefly tumble.

Given the popularity of Medicare and Social Security even among Republican voters, such claims may well have helped pave the road to the White House for Trump. But as we know, once in office, he governed as a hardened healthcare right-winger, joining congressional Republicans’ nearly successful campaign to dismember Medicaid and dismantle preexisting conditions protections. Even after the Obamacare repeal effort failed, Trump’s budgets continued to call for devastating Medicaid cuts.

A second Trump administration could well give us something of a rerun. As in the past, Trump continues to deride Obamacare, but his platform’s healthcare provisions are reminiscent of his prior popularist claims. “FIGHT FOR AND PROTECT SOCIAL SECURITY AND MEDICARE WITH NO CUTS,” it promises, along with nebulous words about competition and transparency and some virulent threats to “protect” Medicare from immigrants. But if history is any guide, once in office, Trump will again serve as a right-wing standard-bearer on healthcare. Indeed, though he has distanced himself from the Heritage Foundation’s Project 2025 blueprint, his administration’s actions seem more likely to be guided by this conservative wish list—whose contributors include numerous members of his last administration, including six cabinet secretaries—than by his hazy populism. The document calls for sweeping conservative change, including gutting cuts to Medicaid via block grants and lifetime caps on benefits (i.e., kicking people out of the program even if they remain poor) “to disincentivize permanent dependence.” The Center for American Progress estimated that as many as 18.6 million enrollees could be at risk of losing coverage if the latter provision were to become reality. Project 2025 also proposes making privatized Medicare Advantage the “default enrollment option” for seniors, which would no doubt be the death knell for public Medicare.

Yet if Trump’s designs seem plain as day, the meaning of a Harris administration for healthcare seems underdetermined. “We believe in a future…where every person has affordable health care,” Harris said at a recent speech, without further details. The party’s platform has yet to be released, and Harris’s prior stances on healthcare issues have varied significantly. Her aforementioned cosponsorship of Sanders’s 2017 Medicare for All bill was no small thing; the senator’s last single-payer bill prior to the 2017 bill was launched with precisely zero cosponsors. But the progressive energies unleashed by his campaign, years of single-payer activism, and the galvanizing effect of Trump’s ascent to the White House (along with his attack on Obamacare) brought not just Harris but a historic 16 senators on board for the 2017 bill. (Similarly, Representative Pramila Jayapal’s 2019 Medicare for All bill, reintroduced last year, was ultimately cosponsored by two-thirds of House Democrats.) Yet, after endorsing Sanders’s bill, Harris backtracked, putting out her own plan that would give insurance companies a major role in providing universal coverage—an approach many of us criticized at the time for its accommodation of corporate interests. On Wednesday, a Harris spokesperson told NBC News that “The VP will not push single payer as President.”

Those years were something of a high watermark for M4A: The arrival of the Covid pandemic and the end of the Democratic primaries saw the issue’s prominence fade. But as we look ahead to the November election, it’s critical to realize that the dynamics that drove it to the forefront of the national political discussion are no less pressing today. A Trump administration would cruelly degrade healthcare coverage for the sick and working class, while accelerating the corporate corruption of care. Yet, even without such a regressive shift, US healthcare remains deeply inequitable and under siege from corporate power: The number of uninsured fell during the pandemic but is predicted to rise 32.8 million by 2032; one in four adults go without needed medical care, and one in five without a prescription drug, because they cannot afford it; private equity firms are strip-mining the nation’s hospitals; private insurance companies are gobbling up Medicare; and vertically integrated insurer-pharmacy-provider behemoths like UnitedHealth are increasingly subordinating the healing mission of medicine to their corporate bottom lines.

Harris is no doubt aware of these issues: As attorney general of California, she helped block a merger between two massive insurance giants, and, though she backtracked, her endorsement of Medicare for All demonstrated that she was responsive to the progressive constituencies that mobilized behind it. A Trump victory, make no mistake, would be a deadly disaster for our nation’s health—and something we must be prepared to fight. But it is important to be clear-eyed about a Harris victory: It will be an opening if and only if a progressive grassroots movement is able, once again, to put real universal healthcare back on center stage.

Dr. Adam Gaffney is a critical care physician and an assistant professor at Harvard Medical School, and past president of Physicians for a National Health Program.

https://thenation.com…

The experiment of Medicare privatization has failed

For its 59th birthday this year, let’s protect Medicare from the corporate raiders

By Priya Pal, M.D., Ph.D.
Missouri Independent, July 30, 2024

It may seem like it’s always been a part of America, but Tuesday is Medicare’s 59th birthday. We should pause, celebrate its success and commit to stopping the corporations who are pilfering it for their own profits.

Health care in the United States remains unaffordable and inaccessible despite costing Americans $4.7 trillion a year.  Medical costs are the leading cause of personal bankruptcy for Americans, and the problem is even more dire among seniors.

Those older than age 55 represent 31% of our country but account for 55% of health care spending. When Medicare was signed into law 59 years ago in Independence, it offered the hope that our population’s elderly and disabled could access health care and age with dignity. It’s lived up to that promise for generations now.

The attack on Medicare began in the 1970s with a proposal to turn the nation’s best public health program over to profit-centric corporations and privatize Medicare. The false premise was that the free market would create competition that could drive down health care costs and turn a profit for the investment community.

That strategy works in many parts of the economy, but not in health care.

Health care by nature cannot be a free market good. It isn’t like purchasing a cell phone where you can identify prices, compare specs of different models, read reviews and ultimately choose to walk away if you don’t like the options. Patients don’t wake up in the morning and choose to take medications because they want to, but because they need to.

Health care emergencies like heart attacks and strokes don’t afford patients or their families the luxury to price shop, compare facilities or reviews. Health care can only turn a profit at the expense of quality care. This is exactly what so-called Medicare Advantage (“MA”) plans have demonstrated every year since their creation in 2003.

MA corporations restrict access to care through small networks, ghost networks, limited out of network coverage, and referral requirements for specialty care — none of which exist in Traditional Medicare.

MA plans typically refuse access to more than half of the physicians in a community, sometimes excluding up to 70% of providers, and cover only half of hospitals in a county. Because these plans force patients with many types of cancer to delay their care and block them from going to “Centers of Excellence”, these critically ill patients are more likely to die after their cancer surgery than similar patients in traditional Medicare.

No one warns patients about these barriers to care, and in fact MA plans grossly mislead people about what they cover. MA network directories frequently include providers who are retired, deceased or simply don’t exist. These limitations are even worse for those living in rural areas where access is already limited.

Even when patients go to in-network providers, they are then faced with prior authorizations and claims denials that further delay access to care.

In 2018 the Office of Inspector General (OIG) published a report showing 75% of appealed claims denied by MA plans were overturned on first repeal. Analysis by KFF found that in 2021, 82% of appealed denials were approved. These high successful repeal rates suggest that many of the denials should have never happened in the first place.

Unfortunately, the appeals system for claims denials is so convoluted that only 1-6% of claims are ever attempted to be appealed, allowing companies to reap massive profits just by denying care. These coverage restrictions have also extended to physician administered medications; in reviewing the 20 most commonly prescribed medications between 12-17 of 20 had access restricted with prior authorizations in 2018.

By 2020, CVS/Aetna and Humana only retained four of the 20 most commonly used physician administered medications on their formularies, Kaiser covered 6 and United Healthcare covered only 2.

One of the shiny selling points for an MA plan over traditional Medicare plans is the inclusion of vision, hearing and dental benefits that aren’t part of traditional Medicare, but on closer look most of these plans have dollar limits that result in thousands of dollars in out-of-pocket costs, making it hard to see much true benefit.

With all the harms noted for MA plans over traditional Medicare plans, one might expect that if the plan were truly bad in a free market, patients would switch away from MA plans. Unfortunately, consumers don’t get a choice, since health care is not a true free-market commodity.

Those with higher health care needs do in fact switch out of MA plans at significant rates, but this option isn’t accessible to everyone. Protections against pre-existing conditions in pricing of Medigap policies only exist for the first 6-12 months in most states, including Missouri. Switching out of MA plans after the first year can be cost prohibitive, trapping patients in a vicious cycle of care delays and denials.

The experiment of privatization of Medicare is a failed one. In addition to the actual patient harms that have come from privatized Medicare, MA plans are inefficient, have high administrative burden and more costly to taxpayers. The government pays more per person in MA plans than in TM plans, at a conservative estimate of 140 billion dollars a year in excess payments.

If that money instead went towards improving traditional Medicare, we could eliminate the need for people in traditional Medicare to purchase Medigap (a $5,000 out-of-pocket maximum would cost $39 billion); we could include hearing, dental, vision for everyone in Medicare and Medicaid ($84 billion), or free people from having to pay a premium for Medicare Part B ($131 billion).

For its 59th birthday this year, let’s protect Medicare from the corporate raiders, call for an end to the subsidies and make the best thing (Medicare) even better.

Dr. Priya Pal is an instructor within the Division of Infectious Diseases at Washington University School of Medicine.

https://missouriindependent.com…

To Win ‘Medicare for All,’ First Reclaim Medicare From Profiteers

If we want to build on the promise of Medicare, then we’re going to have to grapple directly with the power of corporate health insurance: That starts with taking on the so-called “Medicare Advantage” program.

By Ed Weisbart, M.D.
Common Dreams, July 30, 2024

Fifty-nine years ago today, President Lyndon Johnson signed Medicare into law—a high-water mark in the fight for universal healthcare that had started decades before and that continues to this day.

Ever since Medicare became law, it has been a shining example of what is possible in U.S. healthcare: a truly public, truly universal program that has saved countless lives and prevented untold financial ruin among America’s seniors. But alongside this success, corporate health interests have also grown immeasurably more powerful. Insurers like UnitedHealthcare and Blue Cross Blue Shield have erected cruel barriers to care and are laughing all the way to the bank.

If we want to build on the promise of Medicare—and win the best possible version of Medicare for All—then we’re going to have to grapple directly with the power of corporate health insurance. That starts with taking on the so-called “Medicare Advantage” program.

The Strategic Importance of Medicare Advantage

Single-payer advocates understand that there can’t be “Medicare for All” if there is no “Medicare.” And no, Medicare Advantage (MA) doesn’t count as Medicare. The health insurance corporations that run these plans have a business imperative to prioritize profits above all else; this is anathema to any public health program.

Physicians for a National Health Program (PNHP) has compiled overwhelming evidence that MA insurers are harming patients, physicians, and hospitals by delaying and denying care—harms that are virtually unseen in Traditional Medicare. Nor is this cruelty even a trade-off for lowering the cost of healthcare. In fact, these corporations are paid far more than what is spent for similar patients in Traditional Medicare—up to $140 billion per year, or as much as 35% above the funding levels of Traditional Medicare.

There is no road to Medicare for All that ignores this existential threat.

Thankfully, support for eliminating overpayments to MA extends far beyond those who are already committed to single payer. This fight builds our movement by mobilizing a wide range of people who understand, or can be educated about, the damage insurance companies are doing to patients. When we find common ground, we should walk together.

For that reason, PNHP is exposing MA overpayments and demanding a more fiscally responsible approach from policymakers. We are working closely with several organizations to change the national conversation and provide a badly needed counterweight to the lobbying might of big insurance.

When MA was created, way back in 2003, corporate insurers promised to reduce the cost of healthcare by improving care coordination and health outcomes. A healthier population, they claimed, would be less expensive. We should demand that MA corporations live up to these lofty promises without billions of dollars in overpayments.

We’d like to see them try.

Improved Medicare … for ALL

Winning back $140 billion in annual overpayments begs a tantalizing question: How can we use those funds to improve Medicare for all seniors?

Instead of the paltry benefits that MA plans offer, those funds would help us add robust hearing, vision, and dental benefits; totally eliminate Medicare Part B premiums; and fold in the Medicare Part D prescription drug benefit. Imagine the relief a senior on Medicare Advantage would feel when enrolling in a plan that actually covers the full range of dental care, while also freeing themselves from the narrow provider networks and prior authorization requirements imposed by MA plans.

Most critically, we need to establish a low out-of-pocket maximum for Medicare. Insurance corporations lure seniors and people with disabilities into the MA trap by selling lower up-front costs while hiding substantial barriers to care. It’s a classic bait and switch. Eliminating the need to purchase Medigap would level the playing field and allow everybody to remain in Traditional Medicare.

Well, not everybody—but that’s our ultimate goal. PNHP advocates for a national single-payer health insurance program, and what better way to get there than through an improved version of the already popular Medicare program?

Where we see middlemen standing between patients and the care they need, we should remove them. Where we see limited provider networks, we should expand them. Where we see piles of pre-authorization paperwork, we should shred them.

We should also expand benefits to include all medically necessary care, and ultimately eliminate out-of-pocket costs that deter people from seeing a doctor. Once these improvements are in place, we will have a program that’s truly worthy of the name Medicare for All.

The advocacy work for these priorities—ending MA overpayments, improving Traditional Medicare, and realizing our vision for single payer—overlap and build on one another.

Let’s work to build a movement of seniors, physicians, students, people with disabilities, and everybody else who cares about Medicare. Together, we can take on the corporate insurers that are wreaking so much havoc in our lives and lay the groundwork for winning a single-payer program that brings everybody in and leaves nobody out.

Dr. Ed Weisbart is a retired family physician in Missouri and board secretary of Physicians for a National Health Program.

https://commondreams.org…

Not-for-Profit Care Begets Profits

In our profit-permeated health care system, even charitable care often covers for raking in massive profits and exorbitant CEO salaries.

Why Many Nonprofit (wink, wink) Hospitals Are Rolling in Money, The Washington Post, July 22, 2024, by Elisabeth Rosenthal

One owns a for-profit insurer, a venture capital company, and for-profit hospitals in Italy and Kazakhstan; it has just acquired its fourth for-profit hospital in Ireland. Another owns one of the largest for-profit hospitals in London, is partnering to build a massive training facility for a professional basketball team, and has launched and financed 80 for-profit start-ups. Another partners with a wellness spa where rooms cost $4,000 a night and co-invests with “leading private equity firms.”

Do these sound like charities?

These diversified businesses are, in fact, some of the country’s largest nonprofit hospital systems. And they have somehow managed to keep myriad for-profit enterprises under their nonprofit umbrella — a status that means they pay little or no taxes, float bonds at preferred rates and gain numerous other financial advantages. Through legal maneuvering, regulatory neglect and a large dollop of lobbying, they have remained tax-exempt charities.

To be sure, many hospitals’ major source of income is still likely to be pricey patient care. Because they are nonprofit and therefore by definition can’t show that thing called “profit,” excess earnings are called “operating surpluses.”

The truth is that a number of not-for-profit hospitals have become wealthy diversified business organizations. Seven of the ten most highly paid nonprofit CEOs in the United States run hospitals and are paid millions, sometimes tens of millions, of dollars annually.

Today’s big hospital systems do miraculous, lifesaving stuff, but they are not channeling Mother Teresa.

A California Medical Group Treats Only Homeless Patients – And Makes Money Doing It, KFF Health News, July 19, 2024, by Angela Hart

“The biggest population of homeless people in this country is here in Southern California,” said Sachin Jain, CEO of SCAN Group, a Medicare Advantage insurance plan. Jain’s organization created Healthcare in Action, a medical group that sends practitioners into California’s streets solely to care for homeless people.

Street medicine in most of the country is practiced as a charitable endeavor. “It’s really innovative and entrepreneurial to take all this energy and grit to try and improve things for a population that is too often ignored,” said Mark Duggan, a professor of economics at Stanford University. “Financial incentives matter massively in health care. It’s everything.”

Healthcare in Action and SCAN’s Medicare Advantage generate revenue in multiple ways: billions of dollars in Medicaid money, charitable donations from some hospitals and insurers, partnering with cities and hospitals to provide services, and enrolling low-income, older people in SCAN’s Medicaid and Medicare programs.

Jim Withers, who coined the term “street medicine,” cautioned against a model with financial motives. “I do worry about the corporatization of street medicine and capitalism invading what we’ve been building, largely as a social justice mission outside of the traditional health care system. But nobody owns the streets, and we have to figure out how to play nice together.”

Comment:

By Don McCanne, M.D.

One of the beauties of a well-designed single payer system is that everyone can receive the health care that they need, and it is automatically paid for through an equitable financing pool that is affordable for everyone.

Sadly, even though we have the most expensive healthcare system, many are not adequately covered and are dependent on charitable sources, whether or not the government is a source of that charity. Even though we could have fixed that through adoption of single payer, we did not.

Instead, we allow business interests to divert even more of our healthcare dollars to their own interests. Examples above of so-called charity care include allowing nominally non-profit hospitals to divert public health care dollars to profit-making ventures, fattening their coffers & salaries … or converting the social justice mission of street medicine into a business opportunity to divert public funds to passive investors.

Rather than avoiding “channeling Mother Teresa,” we can “play nice together” by advocating for the establishment of a single payer system which would provide comprehensive, affordable health care for all of us. What is stopping us?

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.

How UnitedHealth harnesses its physician empire to squeeze profits out of patients

Investigation: Health Care’s Colossus

By Bob Herman, Tara Bannow, Casey Ross, and Lizzy Lawrence
STAT News, July 25, 2024

UnitedHealth Group started out as a small, Minnesota health insurance company and has since morphed into a modern-day Standard Oil, exerting unmatched dominance over health care in the United States.

It’s no secret that UnitedHealth is a colossus: It’s the country’s largest health insurer and the fourth-largest company of any type by revenue, just behind Apple. And thanks to a series of stealthy deals, almost 1 in 10 U.S. doctors — some 90,000 clinicians — now either work for UnitedHealth or are under its influence, more than any major clinic chain or hospital system.

But behind those statistics, there’s a lot UnitedHealth doesn’t want you to know. A STAT investigation reveals the untold story of how the company has gobbled up multiple pieces of the health care industry and exploited its growing power to milk the system for profit. UnitedHealth’s tactics have transformed medicine in communities across the country into an assembly line that treats millions of patients as products to be monetized.

Central to these tactics is UnitedHealth’s unrivaled leverage over physicians, whose diagnoses help determine how much private insurers get paid for covering older adults. Dozens of former doctors and employees at UnitedHealth medical practices told STAT how they became enmeshed in UnitedHealth’s strategy to make their patients seem as sick as possible. Doctors said the company had a fixation with medical coding to generate more revenue — encouraging clinicians through bonuses and performance reviews to identify more health problems in patients, even if those conditions seemed dubious.

By controlling doctors, UnitedHealth can lean on them to practice in ways that benefit the insurer, and use its insurance arm to funnel cash back to its clinicians — similar to how Standard Oil amassed power as both the buyer and seller in oil refining. Through these efforts, and by adeptly navigating the Medicare Advantage payment system, UnitedHealth has squeezed potentially tens of billions of extra dollars from taxpayers over the past decade, according to STAT estimations based on federal data. The relationship between UnitedHealth’s insurance company and physician practices is the focus of an ongoing Department of Justice antitrust probe.

Doctors interviewed by STAT said they were initially seduced by the company’s sales pitch that it would be hands-off and help them provide high-quality care, but they quickly became disillusioned. UnitedHealth has required some physicians to see as many as four patients per hour, a difficult task if any of those patients are new to a clinic, they said. Patients, meanwhile, are wondering why their doctors are rushing through their appointments — if they can get seen at all — and have expressed alarm when concerning diagnoses pop up in their medical records, many of which were never mentioned by their physicians.

Susan Baumgaertel experienced the shift firsthand. She is an internal medicine physician who spent 25 years — almost her entire career — at The Polyclinic, a large multispecialty group in Seattle. After UnitedHealth took over in 2018, Baumgaertel said the company pressured her and her colleagues to code patients for certain conditions, including some that the doctors didn’t think applied. She quit in 2021.

“We were not truly caring for patients anymore,” Baumgaertel said. “We were just micromanaging their care to bring in money. It just felt so unconscionable.”

She’s become an unofficial therapist for dozens of her colleagues who still work at UnitedHealth practices, dispensing advice and words of comfort over hours-long walks or coffee dates. Recently, Baumgaertel was on the phone with another physician who worked at a UnitedHealth-owned clinic at the time, and had just pulled up in front of her house.

“She was crying in her car. She said, ‘Susan, I can’t leave. I’m the breadwinner. I have to have insurance. My husband is a stay-at-home dad,’” Baumgaertel recalled. She could hear her friend’s kids knocking on the car window. “She felt trapped. I hear this over and over again.”

STAT’s reporting is based on interviews with more than two dozen current and former UnitedHealth doctors and executives conducted over the past six months. STAT also spoke with health policy experts and patients, examined court records, and read UnitedHealth’s 600-page medical coding bible. Many of the UnitedHealth doctors and executives, and even some patients, asked for anonymity — expressing concerns the company could take them to court, derail their careers, or alter their care.

Accounts from clinicians like Baumgaertel challenge UnitedHealth’s stated rationale for its increasing control over health care. The company says owning medical groups, while also being the insurer, will allow for better preventive care that is “value-based.” Why wait for people to show up in the emergency room with serious, costly issues when you can keep an eye on them in the clinic and intervene earlier?

UnitedHealth declined to make executives available for interviews and did not answer a detailed list of questions. In a statement to STAT, spokesperson Eric Hausman said the company’s “providers and partners make independent clinical decisions, and we expect them to diagnose and document patient information completely and accurately in compliance with [federal] guidelines. We provide training and other practice support to providers because it leads to better care management, coordination, and patient follow-up. Regulators routinely audit this documentation.”

From the start, the takeover of physician practices by the nation’s largest health care company has been carefully choreographed.

UnitedHealth’s leadership team is filled with people who have stayed at the company a long time, and have enriched themselves by doing so. Those executives have leveraged a system that has put patients’ medical charts at the center of how companies get paid. They have lobbied the government over policies that further entrench UnitedHealth’s market power. Several executives have held powerful federal health care positions of their own. And they have capitalized on the government nudging more older adults to enroll in privatized Medicare Advantage plans. UnitedHealth’s clinics and outpatient centers now provide care for about 103 million Americans, according to the company’s own estimates.

In 2007, at a Wall Street conference in a posh midtown Manhattan hotel, UnitedHealth’s then-CEO Stephen Hemsley telegraphed that UnitedHealth — already a rapidly expanding health care company — saw itself as much more than just an insurer. “I would ask you to begin to think about UnitedHealth Group and the construct of its business, its capabilities, its reach in the marketplace, as a health care system unto itself,” he said.

That same year, UnitedHealth struck a deal for an insurance company that owned Southwest Medical Associates, a group of clinics located throughout Nevada — the company’s first large medical group. This happened as the health care industry was on the cusp of its biggest transformation since the advent of Medicare nearly five decades earlier — changes that would ultimately reinforce UnitedHealth’s new direction and spur it to double down on doctors.

The Affordable Care Act, which President Barack Obama signed into law in 2010, limited the amount of profit insurers could make on health insurance. That encouraged many insurers to branch into other lines of business where profit wasn’t capped — such as providing medical care. The law also sought to tweak how doctors and hospitals got paid by adding incentives for keeping patients healthy instead of just paying for every visit or procedure. That meant, of course, more collaboration between providers and insurers.

The result was consolidation across all corners of the industry: Insurers bought insurers. Hospitals bought hospitals. And doctors — many of them overwhelmed by new rules around documentation and using electronic health records — flocked to hospitals, private equity firms, and insurers that could handle the administrative burden. UnitedHealth’s Optum subsidiary was one of the biggest players in the feeding frenzy, bringing tens of thousands of doctors under its umbrella. Today, less than half of the country’s doctors work at physician-owned practices, according to the American Medical Association.

As for UnitedHealth, Hemsley, along with former Optum CEO Larry Renfro and several other top executives, positioned themselves as architects of the company’s physician empire. Hemsley still serves as UnitedHealth’s board chair and has his own investment firm. Renfro, who led Optum from its reorganization in 2011 until 2018, now works at UnitedHealth’s venture capital firm.

While UnitedHealth expanded in patient care, it also grew its dominance in Medicare Advantage, the alternative to traditional Medicare that is run by private insurers and now covers more than half of all Medicare beneficiaries. UnitedHealth has had the biggest slice of enrollment in the program for more than a decade, growing from 20% of Medicare Advantage enrollees in 2010 to almost 30% in 2023.

That simultaneous growth was no accident. Medicare Advantage insurers depend on clinicians to enter diagnosis codes into patients’ medical records. Those codes turn into risk scores that explain how sick the patient is and, in turn, how much money the government pays their insurer for their medical care.

Medicare Advantage insurers have gamed the system by excessively coding their members, resulting in massive overpayments to the companies. Overpayments based on coding alone are expected to total $50 billion this year, more than the Department of Justice’s entire budget, according to the Medicare Payment Advisory Commission, a group of experts that advises Congress on Medicare. Since 2007, MedPAC estimates Medicare Advantage insurers have reaped $217 billion in coding overpayments from the federal government.

As the country’s biggest Medicare Advantage insurer and its biggest physician group, nobody is better positioned to extract massive sums from the program than UnitedHealth. The company is still facing a federal lawsuit alleging it continued to collect government money based on millions of patient diagnoses it knew were incorrect. UnitedHealth has disputed the allegations and continues to contest them in court.

While UnitedHealth operates in a completely different industry than did Standard Oil, they have unmistakable similarities, starting with their ambitions to stealthily expand. When Standard Oil was acquiring competing oil refineries in the 1860s and 1870s, the conglomerate did so with little trace. Under its founder John D. Rockefeller, Standard Oil scooped up nearly all the refineries in the Cleveland area, but few newspapers were aware of the growing monopoly.

“It had all been accomplished in accordance with one of Mr. Rockefeller’s chief business principles — ‘Silence is golden,’” journalist Ida Tarbell wrote in “The History of the Standard Oil Company.”

UnitedHealth rarely announces its takeovers of physician clinics and outpatient centers. In part, that’s because the acquisitions are small compared with its overall size and therefore don’t have to be disclosed to financial regulators. It also has downplayed the number of physicians it controls through employment and other financial agreements.

Of UnitedHealth’s 90,000 physicians, 10,000 are employed, and the others are affiliated through “value-based care arrangements,” the company said. It’s unclear what the financial parameters of those affiliations are, and UnitedHealth declined to clarify. In a statement, UnitedHealth’s Hausman said, “The vast majority of the physicians we work with are independent and choose to work with us,” reiterating CEO Andrew Witty’s remarks to Congress.

But UnitedHealth has clearly targeted specific, important medical groups and outpatient surgery centers in markets where it also has the most Medicare Advantage enrollees. The company’s strategy goes like this: If UnitedHealth could get more of its insurance members to go to its own physicians, the company would get to pay itself with money that previously would have gone out the door.

“Controlling the physicians is incredibly lucrative for maximizing risk-coding payments. It’s hard to overstate just how lucrative this can be,” said Hayden Rooke-Ley, an Oregon-based attorney and senior fellow for health care at the American Economic Liberties Project. He has written about the risks of insurers owning physician groups. “This is the singular explanation for why insurance companies are getting into the business of care delivery, particularly of primary care.”

At the core of amassing its doctor empire was luring physicians. UnitedHealth quickly found the surest approach: Money, and a lot of it.

Some groups needed cash to invest in new electronic health records and other technology, or were facing financial distress. Physicians who bought into the idea of less wasteful care and more prevention opted to sell to UnitedHealth rather than to private equity or their local hospital systems. Plus, physicians nearing retirement were looking for a golden parachute, and UnitedHealth in some cases dangled huge sums of cash, according to multiple former physicians who sold practices to UnitedHealth and other employees.

“The doctors wanted the moolah, especially the older physicians,” said a former employee of a UnitedHealth clinic in the western U.S.

Six former UnitedHealth doctors said that when UnitedHealth took over medical groups, nothing would immediately change. But as the weeks and months passed, UnitedHealth would begin to overhaul their schedules: They were expected to see more patients, perform more physicals, and conduct more annual wellness visits. Some said they were required to see three or even four patients per hour.

In 2022, UnitedHealth acquired Atrius Health, then the largest independent doctor group in Massachusetts. Eleanor Hobbs, an urgent care physician, soon began dreading her shifts because her new corporate owner required her to see patients every 20 minutes. Previously, she saw a patient every 30 minutes. Hobbs, 76, had planned to work longer, but instead retired earlier this year.

“When I retired, my feeling was: I feel just like an Amazon warehouse worker, where all I’m doing is 20 minutes, 20 minutes, 20 minutes, 20 minutes,” Hobbs said. “Just do it. Don’t ask how the patient feels about it. Don’t ask what kind of a moral injury it feels like to me. It was awful.”

The pressure to treat patients as if they were fields of medical codes to be harvested, instead of people who have complex histories, soon followed. More than a dozen former doctors and employees from seven different practices nationwide described how UnitedHealth pushed its clinicians to document as many ailments as they could by offering bonuses or reviewing the performance of those who were not coding as much as their peers.

“If your numbers aren’t great, they meet with you individually. It just felt like at every avenue possible, you were reminded of it,” a former Polyclinic provider said.

Nine clinicians told STAT they were instructed to document conditions they didn’t believe applied. Six former UnitedHealth physicians said the shift has been most apparent since the Covid-19 pandemic, as they’ve been encouraged to catch up on coding after patients stayed at home instead of going in for routine checkups.

“It’s very frustrating to me as a physician to see something that was really intended to be a way to pay primary care doctors to do good, preventive risk assessment,” a physician formerly at UnitedHealth’s New West Physicians group in Colorado said of risk scores and coding. “And it’s turned into this coding vehicle where, ‘How do we drop as many codes as we can?’”

Potentially improper coding routinely came up in the same categories, such as peripheral vascular disease and chronic kidney disease, former UnitedHealth doctors said. One study from 2022, crafted by UnitedHealth’s own physician researchers, shows that UnitedHealth’s physicians coded Medicare Advantage patients as having lung disorders, vascular conditions, and kidney disease at more than two times the rate of those in the traditional Medicare program.

A separate review of provider data suggests the trend was broader than just UnitedHealth. It shows the rate of vascular disease testing and diagnosis across providers in a national dataset more than doubled between 2018 and 2023 among patients aged 50 and older. The analysis, based on electronic health record data and conducted by the health analytics company Truveta for STAT, also showed the rate of testing and diagnosis decreased in spring 2024, after Medicare eliminated a particularly lucrative code for patients with peripheral vascular disease without complications.

Part of the issue is the difference in the federal programs. Traditional Medicare pays doctors for each service they provide, while the government pays Medicare Advantage insurers based on how sick their members are, as determined by codes from doctors. Health policy experts say traditional Medicare undercounts older adults’ ailments. Coding and documentation also can be more of an art than a science at times, especially for complex patients who have a lot of medical problems. But within Medicare Advantage, conditions that can be open for interpretation can be exploited.

“There are probably a subset of diagnostic codes that are kind of squishy. They’re kind of subjective. They’re kind of game-able,” said Chris Pope, a senior fellow at the Manhattan Institute, a conservative think tank, who has studied Medicare Advantage coding.

Four doctors told STAT it was common to get panicked calls from patients. They wanted to know why their online medical charts said they had chronic kidney disease or vascular disease even though their doctors hadn’t mentioned it during their visits. When Baumgaertel got those calls, she said she always tried to tell patients the truth, as uncomfortable as it was: I don’t really think you have that condition, but I’m supposed to code you as having it so that I get paid more.

“It was almost to the point of being embarrassing,” she said. “These are people I’ve known for a long time, and they’re like, ‘Susan, what’s going on?’”

Doctors said that UnitedHealth medical directors and administrators pressured them to increase codes for a variety of different ailments, even if they thought those codes didn’t fit patients’ conditions. As one example, more than a half dozen clinicians said UnitedHealth used an unreliable device to screen nearly all of its Medicare Advantage patients for peripheral arterial disease as a way to boost vascular disease diagnoses.

Another example is chronic kidney disease. It’s normal for people’s kidney function to decline as they age, but five doctors said UnitedHealth pushed them to code for that condition even if they felt the patients’ diminished kidney function was appropriate for their age and unlikely to cause harm.

“The number of elderly patients I had who had legit panic episodes when they went to their chart and found out they had chronic kidney disease,” a former Polyclinic doctor said. “I’d have to have this whole conversation with them about like, ‘No, your kidney function is actually not that abnormal for your age, but because of this coding thing, blah blah blah.’ That was awful.”

Daniel Weiner, a nephrologist at Tufts Medical Center, said many older adults meet the technical definition of having chronic kidney disease based on tests that examine their kidney function. The problem is there’s a limited number of codes for chronic kidney disease that cover a large group of people.

“There are clearly financial reasons to code people with chronic kidney disease, as some of these patients have extremely complex medical issues, but others, with the same code, are far healthier,” he said.

Nick Jones, a primary care physician who joined Oregon Medical Group in Eugene just before UnitedHealth bought the practice, said the inaccurate code he saw most frequently in patients’ records was long-term management of insulin. In some cases, he said, this code was applied to patients who received insulin once to lower their blood sugar before a surgery, but who never needed the drug again.

Jones said he finally got fed up when the Oregon Medical Group’s electronic health record started making it mandatory that doctors attest to whether patients’ Medicare Advantage codes had been checked off before they could close out a visit. The system gave the option to deny the codes, but that was more labor-intensive because it required an explanation for why the codes were wrong, he said.

UnitedHealth would regularly host educational sessions where company representatives spent hours teaching Oregon Medical Group doctors how to code Medicare Advantage patients, Jones said. He found it frustrating because the sessions never covered new research into specific conditions or resources available for patients, like nutritionists or case managers.

“I don’t give a damn about what reimburses for what,” said Jones, who now runs a practice called Clear Health Direct Primary Care. “I’m just going to code what I addressed during that visit.”

Even surgeons were roped in, according to one who used to work at The Polyclinic.

“It just didn’t make a lot of sense for a surgeon to talk to patients about chronic illnesses that didn’t necessarily have a lot to do with their presenting complaint,” he said. “We’re not frankly specialized or qualified to do it.”

Nine doctors reported being rewarded with bonuses if they met UnitedHealth’s coding expectations. One former Polyclinic surgeon said it could be upwards of $30,000 per year. But if doctors didn’t comply, it affected their entire department, that surgeon said. UnitedHealth declined to respond to questions about whether it encouraged coding through bonuses and performance reviews, and whether it encouraged doctors to use specific codes that exaggerated patients’ conditions.

“So are you going to be the turd — sorry — are you going to be the doctor, who is not compliant and causing your partners to lose thousands of dollars? No. And ultimately, that’s what got me to be compliant,” the former Polyclinic surgeon said. Eventually, he and his colleagues left for a different medical group.

Top UnitedHealth executives have gushed to investors over the past 15 years that thoroughly documenting patients’ conditions is an untapped line of recurring revenue. UnitedHealth has become such an expert on the topic that it sells a coding bible to the medical community for $165.95. The 592-page book explains how the government’s payment system works and provides advice on how to “capture” more conditions.

The tips give a sense for how the company views coding and documentation: as a way to distill patients to a series of numbers and decimals that translate into big dollar figures. Coders are taught that every 0.1 in coding equates to $1,000, more or less, from the government per year.

Does a patient have diabetes? That adds 0.166 to the risk score, according to the government’s 2024 risk adjustment system, equating to $1,700 in annual Medicare payments. Congestive heart failure? That’s another 0.36 to the patient’s score, or $3,600. Severe obesity, cocaine use, Medicaid eligibility — all descriptors that lead to more money.

Some may assume Medicare Advantage insurers push for more documentation of these diagnoses because of a “desire to make a profit,” UnitedHealth’s 2024 coding guide reads. “This is a half-correct assumption,” the guide concedes, before saying coding also ensures companies get enough money from the government to cover care.

UnitedHealth’s guide emphasizes how coders should scour physicians’ notes to see if there are other illnesses that aren’t being captured. For example, it says doctors should mark down a patient’s cancer diagnosis when they come in for an unrelated issue like a high cholesterol reading if that patient’s records show they are actively seeing an oncologist and on cancer medication.

Richard Lieberman, a medical coding expert who helped develop the government’s risk adjustment system, said there is “far too much gaming of risk coding, but also of documentation.” Big companies like UnitedHealth have insulated themselves from more sweeping government investigations by justifying everything in medical charts, even if the diagnoses are wrong or based on flawed diagnostic tools, he said.

“It becomes sort of like a ‘Catch Me If You Can’ kind of scenario,” Lieberman said. “Only when you get audacious is your number often up.”

One doctor who used to work at UnitedHealth’s WellMed practice in Florida told STAT that managers set a troublesome expectation that risk scores could only go up, not down. UnitedHealth’s guide also explains how doctors and coders can “recapture” as many prior health conditions as possible. Things like fractures that have healed will fall off, but chronic conditions are expected to carry over. The assumption is that as people get older, they will have more diseases.

“There are a lot of targets that are just set to meet some obvious financial endpoint. They were unrealistic,” the former WellMed physician said. “People like me didn’t feel comfortable that these targets are the ones that we are getting our bonus based on, or people will even chase you and get you out of the company if you’re not producing like other physicians.”

UnitedHealth’s coding book attempts to help people determine if conditions are appropriately documented. All they have to do is remember this mnemonic device: treatment, assessment, monitor, plan, evaluation, and referral — or TAMPER.

Hundreds of people across the country have taken to Yelp and Google to gripe about longer waits for appointments and doctors quitting after UnitedHealth assumed control of their clinics. It became tough to get a real person on the phone, even after waiting for hours on hold. Billing mistakes became more common and difficult to resolve. Appointments felt rushed.

At the Polyclinic in Seattle, patient Todd Anderson said that after UnitedHealth took over, it became clear the company was trying to cut costs in every way possible. Check-in became centralized in a way that created a lot of confusion. Then came easily avoidable mistakes. The clinic sent the Seattle retiree’s bill to the wrong health insurer, so it was rejected. Despite Polyclinic’s repeated promises to fix the problem, Anderson was sent to collections. Then he was told if he wanted to stay on as a patient, he’d have to switch from his Aetna Medicare Advantage plan to a UnitedHealthcare one.

“Things changed rather dramatically, and it was pretty visible,” Anderson said.

For some patients, waiting longer to be seen had serious consequences. Connecticut resident Sharon Maloney believes her husband might still be alive if he’d been able to see his doctor right away, as he’d been able to before UnitedHealth took over ProHealth Physicians in 2015. In the past, she said, ProHealth had reserved time for sick patients to be seen the same day.

Maloney’s husband had several health issues, and he was taking medications for ulcerative colitis, chronic inflammation of the large intestine or rectum, that made him more susceptible to infections. In October of 2022, Maloney’s husband had all the telltale signs of a UTI, but ProHealth couldn’t get him in for three days. The day after he called ProHealth, his symptoms got so bad, Maloney took him to the hospital. By then, the infection had spread into his kidneys, leading to sepsis, antibiotics, a hospital-acquired infection, and, ultimately, his death last year.

“If he had been able to get a visit that day, if they had been able to identify the culture, and if they had gotten him on the antibiotic in the first couple of days, this slope would not have even started,” Maloney said.

UnitedHealth didn’t respond to questions about the care of Maloney’s husband.

Former longtime Polyclinic patient Mary Woodbery said things that used to be simple now require a maze of specialist referrals and seemingly unnecessary tests. One time, her teenage son had a tiny cyst on his neck that she suspected was an ingrown hair. Instead of letting him see a dermatologist straight away, The Polyclinic first made him see a radiologist who performed an ultrasound and then a neck specialist. Finally, a dermatologist confirmed it was an ingrown hair. Woodbery was exasperated.

“They have answers. They just don’t want to give them to you because they want to drag you through this endless chain of referrals so they can make sure all their departments are utilized,” said Woodbery, a speechwriter living in Seattle who had seen the same Polyclinic doctor for over two decades before that doctor left.

UnitedHealth continues to absorb medical groups, including a contentious battle over The Corvallis Clinic in Oregon. Regret is starting to set in for some physicians who took UnitedHealth’s offer. The coding dictates became too much for many to handle. For one former ProHealth physician in Connecticut, remorse builds even more after hearing from longtime patients who are wondering why they can’t get an appointment or why they have been mistakenly billed.

“Everybody thinks it was a catastrophe,” the former ProHealth physician said. “They destroyed our practice.”

https://statnews.com…

Dr. Diljeet Singh on “HEALTH CARE un-covered”

PNHP Vice President Dr. Diljeet Singh spoke with Wendell Potter’s “HEALTH CARE un-covered” for a video that was posted on July 24, 2024. Dr. Singh discussed how so-called “Medicare Advantage” plans are fleecing taxpayers to the tune of $140 billion each and every year—and routinely delaying or denying care, with often deadly results.

“I try to help people understand Medicare Advantage will make it hard for them to get health care,” said Dr. Singh. “They have a very good chance of having prior authorizations lead them to getting their care delayed unnecessarily—or even just denied.”

Medicare for All Prospects in a New Presidential Administration

Medicare for All received partial and ambiguous endorsement in the past by one presidential candidate. The major challenge ahead is achieving overwhelming and irresistible public support for the pure single payer system we need.

Where Kamala Harris stands on health care issues, The Hill, July 22, 2024, by Nathaniel Weixel

While running against Biden in the 2019 Democratic primary, Harris tried to present herself as someone between moderates like Biden and progressives like Sens. Elizabeth Warren and Bernie Sanders. She endorsed the Medicare for All bill introduced by Sanders, but also backed an array of moderate alternatives, including a “private option” plan that would transition to Medicare for All by allowing private insurance plans to compete with public plans.

Still, experts agree, she Is a staunch supporter of expanding ObamaCare and making health care more affordable for millions of Americans – something that is likely to be one of the biggest health care fights in Congress in 2025.

“Harris’ previous support for Medicare for All with a private insurance option is suggestive of her values, but I doubt it will be a big emphasis for her in the current campaign,” Larry Levitt, executive vice-president for health policy at KFF, said in an email. “I think Harris will lean much more into the Biden-Harris record on health care than policies she proposed in the 2019 primary. The political and policy context have changed quite a bit since 2019.”

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

So does Kamala Harris support single payer / Medicare for All strongly enough to move it forward were she elected president? Many politicians include Medicare for All in the list of policies they support, but, after they are elected, it is moved off their desks as they deal with other pressing policies.

We must also note that including a private insurance option has major downsides. First, if private plans recruit and retain lower cost individuals while avoiding costly ones (in geek speak, risk selection), the system might split into a financially challenged public system for the sickest, and a highly profitable private system for the healthier. In addition, the added billing and insurance-related burden on providers and insurer profits would deprive our health care system of the efficiency we need and deserve to cover everyone while still controlling costs. So, from a technical perspective, all-in public insurance is best, as seen in many wealthy nations. Finally, a split system attenuates public insistence on an optimally functioning public system.

There is also an advocacy challenge. The enthusiasm for single payer in 2019, and still today, is high, about 2/3 of adults in fair polling questions. But under assault it is not as robust as we advocates would like. As an example, a panel debate including former PNHP president Adam Gaffney and the Pacific Research Institute’s Sally Pipes showed that, in spite of an excellent presentation by Gaffney, the audience support for Medicare for All declined significantly (YouTube video and transcript). This type of debate + polling is tricky to generalize, but is nonetheless a harbinger of fights ahead of us when single payer is under serious consideration.

We still have a lot of work ahead to persuasively convince the public of the clearcut advantages of properly public health insurance that would provide comprehensive care equitably to absolutely everyone, at a lower cost than the vast majority of us are paying now, thanks to progressive financing. Once these ideas are fully grasped by the public – which then raises voices in unison demanding its enactment and implementation – a President Harris would very likely respond positively.

https://healthjusticemonitor.org…

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