PNHP

Don’t weaken Medicare

Don’t weaken Medicare

By Ed Weisbart, M.D.
St. Louis Beacon, Dec. 21, 2012

As I sit in the waiting room for my 83-year-old mother-in-law’s cardiac MRI, I realize I’m not a good health-care consumer. I didn’t try to find the best deal; I didn’t ask any prices; I didn’t check to see if this were “in network.”

I did the only thing I wanted to do – I found the doctors we wanted and flew her to St. Louis from Daytona, Fla. I am incredibly grateful to have found these terrific physicians.

But I’m also incredibly grateful that my mother-in-law has Medicare. She lives on her meager Social Security check; and without Medicare, the cost of dealing with her heart problem would otherwise bankrupt her.

She’d have had to sell her condo in Florida and move in with us in St. Louis, moving away from all of her friends and into our colder winters. We’d love to have her with us, but not because she’s forced to be with us.

Thankfully, she does have Medicare. She’s “entitled” to it, having paid into it for 40 years, working full-time to earn that and her Social Security check.

Medicare gives her control over her own health-care decisions. Unlike my own “private” health insurance, Medicare lets her pick from virtually every doctor and hospital in the country. That’s the kind of choice she wants.

Frankly, it’s the kind of choice we all want. We’re not so interested in selecting one insurer’s restrictive network over another’s. We want and need access to quality health care, period.

We all want the fire engines to come when our house is on fire. When we all want the same thing, it just makes sense to provide it for everybody.

That’s exactly why we should just fix the problems with Medicare (end the deductibles and co-pays; correct the inadequate physician reimbursement, etc.) and provide it to all Americans, regardless of their age. That’s essentially what every other modern nation does, typically at half the cost and with far better health outcomes.

Instead, our precious Medicare is under attack.

Some propose increasing the eligibility age from 65 to 67. Because life expectancy has increased since Medicare was passed, they believe the age of eligibility should go up, too.

They ignore the fact that life expectancy hasn’t gone up the same for all of us. While the wealthiest have added five years to their life expectancy since 1977, the bottom half of us saw an average increase of barely one year. A significant number of people would get less, not more, years of Medicare since the bill was passed. Aside from the fundamental lack of fairness, more of us would die early preventable deaths.

Our 65- and 66-year-olds would either have to keep working or use the Affordable Care Act’s new insurance exchanges. They would choose from several insurance options, each with different premiums, deductibles, copays, networks of physicians and hospitals, etc. Thanks to the ACA, insurance companies will not be able to refuse to offer a policy, but few if any of the choices would be as affordable and robust as Medicare.

Second, some lawmakers have proposed to “means test” Medicare, creating an administratively complex system that would test the fortitude of patients, providers and even the IRS. Making wealthier patients pay more for Medicare will only motivate them to look for private insurance elsewhere, undermining the original program.

Others in Congress suggest turning Medicare into a voucher toward the purchase of private insurance. Healthier seniors would start picking the cheapest, but least robust, health plans and end up in dire financial trouble if they became seriously ill.

Each of these strategies undermines Medicare’s social contract, the message that “we’re all in this together.”

Now just imagine if we had an “improved Medicare for all.” By replacing our wasteful, profit-seeking private insurance industry with a streamlined single-payer system, we could save more than $400 billion in administrative costs – enough to provide high-quality care to everyone, mothers-in-law included.

Don’t throw our mothers-in-law over the fiscal cliff. Don’t cut Medicare – protect it, improve it, and expand it to cover everyone!

Dr. Ed Weisbart is the chair and a founding member of the St. Louis chapter of Physicians for a National Health Program.

https://www.stlbeacon.org/#!/content/28562/voices_weisbart_medicare_122012?coverpage=2395

Guns and health

Press Conference

Wayne Lapierre, CEO & Executive Vice President
NRA (National Rifle Association), December 21, 2012
The ONLY thing that stops a BAD guy with a gun is a GOOD guy with a gun.
http://home.nra.org/#

BANG! BANG!
(There is a not-so-subtle message here about the health of the nation.)

Ron Pollack and Celinda Lake: carnival hawkers for big insurance

Next Challenge for the Health Law: Getting the Public to Buy In

By Abby Goodnough
The New York Times, December 19, 2012

On its face, the low-key discussion around a conference table in Miami last month did not appear to have national implications. Eight men and women, including a diner owner, a chef and a real estate agent, answered questions about why they had no health insurance and what might persuade them to buy it.

But this focus group, along with nine others held around the country in November, was an important tool for advocates coming up with a campaign to educate Americans about the new health care law.

The sessions confirmed a daunting reality: Many of those the law is supposed to help have no idea what it could do for them.

There lies the challenge for Enroll America, a nonprofit group formed last year to get the word out to the uninsured and encourage them get coverage, providing help along the way. With the election over and the law almost certain to survive, the group is honing its fund-raising and testing strategies for persuading people to sign up for health insurance — a process that will begin in less than a year.

The group has raised only about $6 million so far — but financial backers include some major players in the medical industry: insurers like Aetna and Blue Cross Blue Shield, associations representing both brand name and generic drug manufacturers, hospitals and the Catholic Health Association.

Over the next two years, the group hopes to raise as much as $100 million for advertising, social media and other outreach efforts. “There are so many different groups that can play some role in this: hospitals, community health centers, pharmacies, tax preparers,” said Ron Pollack, chairman of Enroll America’s board. “Our job has got to be to try to galvanize each of those sectors, so there is a wide variety of ways people potentially can hear about this.”

In addition to holding focus groups in Miami, Philadelphia, San Antonio and Columbus, Ohio, Enroll America commissioned a nationwide survey to help hone its message. The survey, conducted in September and October by Lake Research Partners, a Democratic polling group, found that the vast majority of uninsured people are unaware of the new coverage options provided by the law.

They are also skeptical. Many who participated in the focus groups or survey reported bad experiences trying to get health insurance, and doubted that the law would provide coverage that was both affordable and comprehensive.

“It’s two major mountains that need to be climbed,” Mr. Pollack said. “People are unaware of the benefits that could be provided to them, and they have to overcome skepticism, based on their past experiences with trying to obtain insurance.”

But the survey found that even with federal subsidies, many uninsured people may balk at the cost of coverage. Only about a third of respondents leaned toward thinking monthly premiums of $210 for a single person earning $30,000 a year, for example, were affordable.

Those amounts became more acceptable when respondents were told it would “protect you from thousands of dollars of medical debt if you got sick” or “cover all of the basic care you need.”

In the end, Lake Research Partners recommended that Enroll America not cite specific dollar amounts at all when they talk to the uninsured about new coverage options. “Talking about ‘free or low cost’ plans may be more motivating,” the survey authors wrote in a report.

http://www.nytimes.com/2012/12/20/us/officials-confront-skepticism-over-health-law.html?ref=us&_r=0&pagewanted=all

Comment:

By Don McCanne, MD

From the days of the Clinton effort to reform health care, Ron Pollack of Families USA has opposed single payer reform as not being politically feasible, supporting instead reform based on private insurance plans. Likewise, Celinda Lake of Lake Research Partners has actively rejected single payer while using her polling and focus group activities to push the rhetoric of “Choice” to promote private insurers, glossing over the fact that private insurers take away choice of health care professionals and institutions. Both Pollack and Lake have had considerable influence in Democratic administrations.

Now that they got their wish and we have reform based on private insurance plans, they have a new hurdle and that is to try to sell the program to the public. They have formed a new organization, “Enroll America,” to do just that, and the private insurance industry is front and center in financing the organization.

Just as they concocted the “Choice” campaign to sell the legislation, they are now concocting the “Free or Low Cost” campaign to sell the uninsured on the new coverage options. When the survey found that many people may balk at the cost of coverage even with the subsidies, Lake recommended that Enroll America not cite specific dollar amounts at all when they talk to the uninsured about new coverage options.

Can you imagine? Just as they sold the nation on legislation using “Choice” for a program that takes away choice, they now are selling the nation on “Free or Low Cost” plans that the uninsured cannot afford to pay for. What chutzpah!

Where is the Occupy movement? Maybe we should occupy Enroll America and use it instead to enroll everyone in a single payer national health program – an Improved Medicare for All.

Our ever-evolving health care system

By Nathaniel H. Murdock, M.D.
St. Louis American, Dec. 20, 2012

The great American healthcare experiment is continuing to develop. The next stage is starting, so this is a good time to look back before we look ahead.

How did our healthcare get so tied up with our employment? In World War II, to preserve funds for the war effort, the government froze wages. To compete for workers, employers began to pay for health insurance, supported with business tax deductions. This quickly became an unfettered marketplace, with virtually no regulation on price or quality.

Premiums began rising and problems emerged. Employers could no longer afford to fully cover their employees. The elderly became increasingly unable to afford medical care. Many of our parents and grandparents fell into medical poverty, and even more were simply unable to afford any care. Diseases went untreated, often with disastrous consequences.

The next experiment was proposed in the 1960s: the government would provide health care coverage, called Medicare, to all Americans beginning at age 65. No longer would our elderly need to sell their homes to scrape together the resources for life-saving medical care, living in poverty for their final years. It was a humane and compassionate solution to an unacceptable social injustice, and has saved countless millions of lives.

While the senior population immediately embraced Medicare, many medical organizations lobbied extensively against it, perceiving a threat to their autonomy.

One of the few groups that immediately took a strong leadership position in favor of Medicare was the National Medical Association (NMA). I should disclose to you that I am a Past President of the NMA. We supported Medicare when it began, and continue to proudly support it today.

Although Medicare did not pay physicians well, costs continued to escalate. In response, insurance companies developed the “managed care” experiment. They promised physicians that if we discounted our fees, they would direct more of their patients toward us.

The insurance companies could not possibly deliver on this promise. Discounted fees became the new normal. As reimbursement fell, physicians began to spend less time with each patient. Patients found it increasingly difficult to find care. Medical care was arbitrarily cut to reduce costs. Managed care became rationed care, and America didn’t like it.

The next major step is the Affordable Care Act, an important step forward, but much remains to be done.

When picking a doctor, we will still need to look to our insurance company to determine if that doctor is “in network.” Prevention may soon be free, but treatment will continue to bankrupt many. Despite Massachusetts’ health care reform, they have more citizens than ever declaring bankruptcy due to illness.

Most Americans, including most doctors, now feel that a plausible strategy to achieve universal health coverage is to improve Medicare and provide it to all Americans. This is often called a “single-payer” model as the only payer of health care services would be our government, not our employers or insurance companies. Coverage would be for everyone, young and old, in sickness and in health.

Most economists tell us that this solution would actually cost less than we spend today. We’d spend more to cover today’s uninsured, but we’d save even more through simplification and coordination. People could afford to go to their physician for regular maintenance and preventive care. We should be able to decrease many causes of preventable sickness and death. We would save lives.

Those who argue against a single-payer plan claim it would bankrupt the country. They’re wrong; almost every industrialized country provides universal health coverage from birth to death, at a fraction of what we spend.

Insurance companies claim that single-payer will not work. I wonder if their skepticism is related to the fact that this plan would marginalize their role. We need to keep this in mind when we hear their fears. We need to remind them that most other modern countries already do this. Of course it would work; it already does.

I would like to see us have a single-payer with universal comprehensive health coverage for all Americans. This is an idea whose time has come.

Dr. Murdock is a founding member of Physicians for a National Health Program – St. Louis.

http://www.stlamerican.com/news/columnists/article_601d28bc-4a42-11e2-b061-0019bb2963f4.html

Ron Pollack and Celinda Lake: carnival hawkers for big insurance

Next Challenge for the Health Law: Getting the Public to Buy In

By Abby Goodnough
The New York Times, December 19, 2012
On its face, the low-key discussion around a conference table in Miami last month did not appear to have national implications. Eight men and women, including a diner owner, a chef and a real estate agent, answered questions about why they had no health insurance and what might persuade them to buy it.
But this focus group, along with nine others held around the country in November, was an important tool for advocates coming up with a campaign to educate Americans about the new health care law.
The sessions confirmed a daunting reality: Many of those the law is supposed to help have no idea what it could do for them.
There lies the challenge for Enroll America, a nonprofit group formed last year to get the word out to the uninsured and encourage them get coverage, providing help along the way. With the election over and the law almost certain to survive, the group is honing its fund-raising and testing strategies for persuading people to sign up for health insurance — a process that will begin in less than a year.
The group has raised only about $6 million so far — but financial backers include some major players in the medical industry: insurers like Aetna and Blue Cross Blue Shield, associations representing both brand name and generic drug manufacturers, hospitals and the Catholic Health Association.
Over the next two years, the group hopes to raise as much as $100 million for advertising, social media and other outreach efforts. “There are so many different groups that can play some role in this: hospitals, community health centers, pharmacies, tax preparers,” said Ron Pollack, chairman of Enroll America’s board. “Our job has got to be to try to galvanize each of those sectors, so there is a wide variety of ways people potentially can hear about this.”
In addition to holding focus groups in Miami, Philadelphia, San Antonio and Columbus, Ohio, Enroll America commissioned a nationwide survey to help hone its message. The survey, conducted in September and October by Lake Research Partners, a Democratic polling group, found that the vast majority of uninsured people are unaware of the new coverage options provided by the law.
They are also skeptical. Many who participated in the focus groups or survey reported bad experiences trying to get health insurance, and doubted that the law would provide coverage that was both affordable and comprehensive.
“It’s two major mountains that need to be climbed,” Mr. Pollack said. “People are unaware of the benefits that could be provided to them, and they have to overcome skepticism, based on their past experiences with trying to obtain insurance.”
But the survey found that even with federal subsidies, many uninsured people may balk at the cost of coverage. Only about a third of respondents leaned toward thinking monthly premiums of $210 for a single person earning $30,000 a year, for example, were affordable.
Those amounts became more acceptable when respondents were told it would “protect you from thousands of dollars of medical debt if you got sick” or “cover all of the basic care you need.”
In the end, Lake Research Partners recommended that Enroll America not cite specific dollar amounts at all when they talk to the uninsured about new coverage options. “Talking about ‘free or low cost’ plans may be more motivating,” the survey authors wrote in a report.
http://www.nytimes.com/2012/12/20/us/officials-confront-skepticism-over-…

From the days of the Clinton effort to reform health care, Ron Pollack of Families USA has opposed single payer reform as not being politically feasible, supporting instead reform based on private insurance plans. Likewise, Celinda Lake of Lake Research Partners has actively rejected single payer while using her polling and focus group activities to push the rhetoric of “Choice” to promote private insurers, glossing over the fact that private insurers take away choice of health care professionals and institutions. Both Pollack and Lake have had considerable influence in Democratic administrations.
Now that they got their wish and we have reform based on private insurance plans, they have a new hurdle and that is to try to sell the program to the public. They have formed a new organization, “Enroll America,” to do just that, and the private insurance industry is front and center in financing the organization.
Just as they concocted the “Choice” campaign to sell the legislation, they are now concocting the “Free or Low Cost” campaign to sell the uninsured on the new coverage options. When the survey found that many people may balk at the cost of coverage even with the subsidies, Lake recommended that Enroll America not cite specific dollar amounts at all when they talk to the uninsured about new coverage options.
Can you imagine? Just as they sold the nation on legislation using “Choice” for a program that takes away choice, they now are selling the nation on “Free or Low Cost” plans that the uninsured cannot afford to pay for. What chutzpah!
Where is the Occupy movement? Maybe we should occupy Enroll America and use it instead to enroll everyone in a single payer national health program – an Improved Medicare for All.

Get serious about mental health care

By Aaron E. Carroll, M.D.
CNN, December 18, 2012

In the wake of last week’s tragedy in Newtown, I have been asked a million questions about gun control. I’ve seen pictures of the weapon the killer used. I’ve heard stories about the number of bullets in the clip and the number of guns in his mother’s home. I’ve even heard politicians argue that school officials should be armed with semiautomatic weapons.

I’ve also heard about mental health.

We should be careful not to blame the mentally ill for all crimes. But we should also be prepared to accept that we might be able to prevent some tragedies if we did a better job of caring for them.

I’ve seen mental health illness in children, and our system is ill-equipped to handle it. I’ve seen families struggle with it. One of my greatest frustrations with clinical practice is that there are far too many times when I lack the tools necessary to care for children who need help. It’s relatively easy to cure an infection or an acute physical ailment. It’s so much harder to take a mental health issue. There are rarely pills that will do the job. Even when they are, they almost never work perfectly to eradicate the problem.

Studies show that more than 10% of children in the United States might benefit from some sort of mental health treatment. Most don’t get it. We often don’t have the research to tell us how best to care for these problems. Even when we do, we often lack the capacity. There is a shortage of resources and services available to serve children. Furthermore, even when those resources exist, a lack of coordination often prevents they’re being used effectively.

It doesn’t help that the upcoming fiscal cliff will likely cut National Institutes of Health research funding by $2.4 billion. That would mean 2,300 fewer grants in the coming year, which represents about 25% of grants that might otherwise be offered. It doesn’t help that we keep talking about cuts to services such as Medicaid and the Children’s Health Insurance Program, which cover the health care for about one in every three children in the United States.

If a child is actively suicidal or homicidal, an emergency room can spring into action and admit him or her for inpatient care. But that’s often all inpatient care will do. Once a child is no longer actively threatening harm to himself or others, he or she will be released. That’s what the hospital system does. It cares for the acute problem, leaving the long term, and often much harder, work to a system ill-equipped to handle it.

It’s natural to try and blame poor parenting when kids don’t turn out as well as we’d hope. And, certainly, in many instances such parenting can lead to a misbehaving child, or even a child we don’t necessarily like. But mental illness really does exist, and a lot of it can’t be cured by good parenting and isn’t caused by bad parenting. We don’t have a good system for dealing with it.

I want to stress that I don’t think that all violence is associated with mental illness. In fact, it’s quite the opposite. But the problems with guns and injuries go so far beyond school shootings, and a lot of that is amenable to a more focused health care system.

One of the things I do as a pediatrician is “anticipatory guidance.” We ask questions about issues that have not yet occurred but might occur in the future. A lot of anticipatory guidance focuses on injury prevention. We might ask about bike helmets, or swimming, or fire alarms in the house. I even ask about guns in the home.

I don’t ask this question because I’m eager to lecture patients or parents on the morality of owning guns, or the rights of individuals under the Second Amendment. I’m asking because I’m trying to prevent injury or death. The No. 3 killer of children age 10-14 is suicide; the fourth is homicide. The No. 2 killer of children age 15-19 is homicide; No. 3 is suicide.

I have been trained to ask parents if they have a gun in the home. If they do, I ask how it’s stored. I strongly recommend that they keep it unloaded, locked up, and that they store the bullets separately. I do this because guns are part of almost 85% of homicides and more than 45% of suicides in kids 5 to 19 years old. This doesn’t even account for injuries not resulting in death.

Yet recent laws have attempted to stop pediatricians from doing even this.

I don’t know what the best outcome is from a tragedy like this. I imagine much of the focus will be on banning the weapon used or on limiting the number of bullets that could be fired without reloading. I think that’s somewhat missing the point. The vast majority of injuries or deaths due to guns are carried out on a small scale.

While what happened in Newtown is a horrific occurrence, it represents the exception, not the norm, with respect to gun violence in the United States. While I welcome the opportunity for us to address the problem, I hope we focus on how we might best help all our children, not just those who make the national news.

Editor’s note: Aaron E. Carroll, M.D., M.S., is an associate professor of pediatrics at the Indiana University School of Medicine and the director of the university’s Center for Health Policy and Professionalism Research. He blogs about health policy at The Incidental Economist and tweets at @aaronecarroll.

http://www.cnn.com/2012/12/18/opinion/carroll-mental-health/index.html

Cleveland Clinic CEO Cosgrove on single payer

Cleveland Clinic Diagnoses Health-Care Act

By Anna Wilde Mathews
The Wall Street Journal, December 18, 2012

Just over a year from now, the Affordable Care Act is set to unleash enormous change in the health-care sector, and Cleveland Clinic Chief Executive Delos “Toby” Cosgrove is preparing his institution by expanding its reach and striving to make caregivers more cost-conscious.

WSJ: Do you think employers will stop providing health insurance, even though they can pay a penalty under the health overhaul law?

Dr. Cosgrove: The first ones will be the small companies… Every CEO I’ve talked to knows how much he’d save between insuring his people and paying the federal penalty.

WSJ: What does that tell you?

Dr. Cosgrove: The first time some big player does that, it’s going to fall like dominoes. What that does is drive everybody to the exchanges.

WSJ: What does that mean to you?

Dr. Cosgrove: It’s going to be a faster move towards one payer. Increasingly, people think that in 10 years you’re going to have 75% of the health-care costs paid by the federal government.

WSJ: You think we’re moving toward a single-payer system?

Dr. Cosgrove: Well, the question is how long…I don’t think in the next 10 years, but I think it probably is going to head in that direction.

http://online.wsj.com/article/SB10001424127887324677204578187613286882532.html?mod=health_newsreel

Comment:

By Don McCanne, MD

Cleveland Clinic President and CEO Delos “Toby” Cosgrove confirms what Physicians for a National Health Program has been saying all along. It’s not whether we’ll ever have single payer, it’s how long.

It’s our job to expedite it.

Cleveland Clinic CEO Cosgrove on single payer

Cleveland Clinic Diagnoses Health-Care Act

By Anna Wilde Mathews
The Wall Street Journal, December 18, 2012
Just over a year from now, the Affordable Care Act is set to unleash enormous change in the health-care sector, and Cleveland Clinic Chief Executive Delos “Toby” Cosgrove is preparing his institution by expanding its reach and striving to make caregivers more cost-conscious.
WSJ: Do you think employers will stop providing health insurance, even though they can pay a penalty under the health overhaul law?
Dr. Cosgrove: The first ones will be the small companies… Every CEO I’ve talked to knows how much he’d save between insuring his people and paying the federal penalty.
WSJ: What does that tell you?
Dr. Cosgrove: The first time some big player does that, it’s going to fall like dominoes. What that does is drive everybody to the exchanges.
WSJ: What does that mean to you?
Dr. Cosgrove: It’s going to be a faster move towards one payer. Increasingly, people think that in 10 years you’re going to have 75% of the health-care costs paid by the federal government.
WSJ: You think we’re moving toward a single-payer system?

Dr. Cosgrove: Well, the question is how long…I don’t think in the next 10 years, but I think it probably is going to head in that direction.
http://online.wsj.com/article/SB1000142412788732467720457818761328688253…

Cleveland Clinic President and CEO Delos “Toby” Cosgrove confirms what Physicians for a National Health Program has been saying all along. It’s not whether we’ll ever have single payer, it’s how long.
It’s our job to expedite it.

PacifiCare's massive Medicare Advantage fraud

Risk Adjustment Data Validation of Payments Made to PacifiCare of California for Calendar Year 2007

Department of Health and Human Services
Office of Inspector General, November 2012

Under the Medicare Advantage (MA) program, the Centers for Medicare & Medicaid Services(CMS) makes monthly capitated payments to MA organizations for beneficiaries enrolled in the organizations’ health care plans. Subsections 1853(a)(1)(C) and (a)(3) of the Social Security Act require that these payments be adjusted based on the health status of each beneficiary. CMS uses the Hierarchical Condition Category (HCC) model (the CMS model) to calculate these risk-adjusted payments.

The diagnoses that PacifiCare submitted to CMS for use in CMS’s risk score calculations did not always comply with Federal requirements. For 55 of the 100 beneficiaries in our sample, the risk scores calculated using the diagnoses that PacifiCare submitted were valid. The risk scores for the remaining 45 beneficiaries were invalid because the diagnoses were not supported by the documentation that PacifiCare provided.

As a result of these unsupported diagnoses, PacifiCare received $224,388 in overpayments from CMS. Based on our sample results, we estimated that PacifiCare was overpaid approximately $423,709,068 in CY 2007. The confidence interval for this estimate has a lower limit of $288 million and an upper limit of $559 million.

The following are examples of HCCs that were not supported by the documentation that PacifiCare submitted to us for medical review:

*  For one beneficiary, PacifiCare submitted the diagnosis code for “spinocerebellar disease, other cerebellar ataxia.” CMS used the HCC associated with this diagnosis in calculating the beneficiary’s risk score. However, the documentation that PacifiCare provided described an evaluation for fever and cough. The documentation did not mention cerebellar ataxia or indicate that cerebellar ataxia had affected the care, treatment, or management provided during the encounter.

*  For a second beneficiary, PacifiCare submitted the diagnosis code for “malignant neoplasm of the prostate.” CMS used the HCC associated with this diagnosis in calculating the beneficiary’s risk score. However, the documentation that PacifiCare provided appeared to describe suture removal and left shoulder bursitis/tendonitis. The documentation did not mention prostate cancer or indicate that prostate cancer had affected the care, treatment, or management provided during the encounter.

*  For a third beneficiary, PacifiCare submitted the diagnosis code for “unspecified septicemia” (commonly referred to as “blood poisoning”). CMS used the HCC associated with this diagnosis in calculating the beneficiary’s risk score. However, the documentation that PacifiCare provided noted that the patient was admitted for a “left total knee revision arthroplasty.” The documentation did not mention blood poisoning or indicate that blood poisoning had affected the care, treatment, or management provided during the encounter.

http://www.scribd.com/doc/116760242/RISK-ADJUSTMENT-DATA-VALIDATION-OF-PAYMENTS-MADE-TO-PACIFICARE-OF-CALIFORNIA-FOR-CALENDAR-YEAR-2007

Comment:

By Don McCanne, MD

It has long been recognized that the private Medicare Advantage plans (offered as an option to the traditional Medicare program) have been cheating the taxpayers, initially by selectively enrolling the healthy while being paid at rates that include a mix of the sick, and, more recently, by gaming the process of risk adjustment (which seeks to correct for the health status of the beneficiaries actually enrolled by the private plans). This new report from the HHS Office of Inspector General is helpful because it provides a perspective of the enormity of the problem.

In one year alone (2007), one California insurer – PacifiCare (acquired by UnitedHealth Group in 2005) – used their Medicare Advantage program to cheat taxpayers out of almost half a billion dollars! Extrapolate that to all Medicare Advantage plans in all states for all years, and think of the impact this must have had on our Medicare budget.

The private insurers pride themselves on their innovations. Based on their past behavior, we can be assured that they will continue to innovate in opaque ways that cheat not only the taxpayers, but also the health professionals and institutions, and, most importantly, the patients. Without transparency, they will get away with it for extended periods of time, with new innovations introduced as they get tripped up on the old.

Although the Affordable Care Act calls for a reduction in overpayments to these plans, the legislation leaves them in place. That is a terrible mistake.

We need to shut down the Medicare Advantage plans, and, while we’re at it, shut down all private insurers and replace them with an improved Medicare for everyone. We may not be able to do that before we reach “The Cliff,” but we should start working on it immediately.

PacifiCare’s massive Medicare Advantage fraud

Risk Adjustment Data Validation of Payments Made to PacifiCare of California for Calendar Year 2007

Department of Health and Human Services
Office of Inspector General, November 2012

Under the Medicare Advantage (MA) program, the Centers for Medicare & Medicaid Services(CMS) makes monthly capitated payments to MA organizations for beneficiaries enrolled in the organizations’ health care plans. Subsections 1853(a)(1)(C) and (a)(3) of the Social Security Act require that these payments be adjusted based on the health status of each beneficiary. CMS uses the Hierarchical Condition Category (HCC) model (the CMS model) to calculate these risk-adjusted payments.

The diagnoses that PacifiCare submitted to CMS for use in CMS’s risk score calculations did not always comply with Federal requirements. For 55 of the 100 beneficiaries in our sample, the risk scores calculated using the diagnoses that PacifiCare submitted were valid. The risk scores for the remaining 45 beneficiaries were invalid because the diagnoses were not supported by the documentation that PacifiCare provided.

As a result of these unsupported diagnoses, PacifiCare received $224,388 in overpayments from CMS. Based on our sample results, we estimated that PacifiCare was overpaid approximately $423,709,068 in CY 2007. The confidence interval for this estimate has a lower limit of $288 million and an upper limit of $559 million.

The following are examples of HCCs that were not supported by the documentation that PacifiCare submitted to us for medical review:

*  For one beneficiary, PacifiCare submitted the diagnosis code for “spinocerebellar disease, other cerebellar ataxia.” CMS used the HCC associated with this diagnosis in calculating the beneficiary’s risk score. However, the documentation that PacifiCare provided described an evaluation for fever and cough. The documentation did not mention cerebellar ataxia or indicate that cerebellar ataxia had affected the care, treatment, or management provided during the encounter.

*  For a second beneficiary, PacifiCare submitted the diagnosis code for “malignant neoplasm of the prostate.” CMS used the HCC associated with this diagnosis in calculating the beneficiary’s risk score. However, the documentation that PacifiCare provided appeared to describe suture removal and left shoulder bursitis/tendonitis. The documentation did not mention prostate cancer or indicate that prostate cancer had affected the care, treatment, or management provided during the encounter.

*  For a third beneficiary, PacifiCare submitted the diagnosis code for “unspecified septicemia” (commonly referred to as “blood poisoning”). CMS used the HCC associated with this diagnosis in calculating the beneficiary’s risk score. However, the documentation that PacifiCare provided noted that the patient was admitted for a “left total knee revision arthroplasty.” The documentation did not mention blood poisoning or indicate that blood poisoning had affected the care, treatment, or management provided during the encounter.

http://www.scribd.com/doc/116760242/RISK-ADJUSTMENT-DATA-VALIDATION-OF-PAYMENTS-MADE-TO-PACIFICARE-OF-CALIFORNIA-FOR-CALENDAR-YEAR-2007

Comment:

By Don McCanne, MD

It has long been recognized that the private Medicare Advantage plans (offered as an option to the traditional Medicare program) have been cheating the taxpayers, initially by selectively enrolling the healthy while being paid at rates that include a mix of the sick, and, more recently, by gaming the process of risk adjustment (which seeks to correct for the health status of the beneficiaries actually enrolled by the private plans). This new report from the HHS Office of Inspector General is helpful because it provides a perspective of the enormity of the problem.

In one year alone (2007), one California insurer – PacifiCare (acquired by UnitedHealth Group in 2005) – used their Medicare Advantage program to cheat taxpayers out of almost half a billion dollars! Extrapolate that to all Medicare Advantage plans in all states for all years, and think of the impact this must have had on our Medicare budget.

The private insurers pride themselves on their innovations. Based on their past behavior, we can be assured that they will continue to innovate in opaque ways that cheat not only the taxpayers, but also the health professionals and institutions, and, most importantly, the patients. Without transparency, they will get away with it for extended periods of time, with new innovations introduced as they get tripped up on the old.

Although the Affordable Care Act calls for a reduction in overpayments to these plans, the legislation leaves them in place. That is a terrible mistake.

We need to shut down the Medicare Advantage plans, and, while we’re at it, shut down all private insurers and replace them with an improved Medicare for everyone. We may not be able to do that before we reach “The Cliff,” but we should start working on it immediately.

True reform remains elusive

By Arthur J. Sutherland III, M.D.
The Commercial Appeal (Memphis, Tenn.), Letters, Dec. 17, 2012

Dr. Scott Morris’ Dec. 13 Viewpoint guest column “Jesus, prophets couldn’t get health care” was quite clever, but we need to look “upstream” at the roots of our problems to figure out why Jesus couldn’t get care in our current health care “system.” The Patient Protection and Affordable Care Act of 2010 was just another symptom of the chaotic, costly and dysfunctional delivery system that we have lived with since World War II. We are an outlier among developed nations who all have more efficient and less costly national health programs that do a better job of delivering quality health care to all their populations.

Attempts to block implementation of the PPACA or opt out of parts of it just reflect the myopic vision our nation has in dealing with the cost and access issues in health care. The political rhetoric is one of fear and talk about the scarcity of wealth and other resources needed to transform our nation’s health care into one of the world’s best systems. That type of talk is just not true. We have an abundance of wealth, talent and medical resources, plus we already spend more than twice as much per capita as any other developed country. But we have the wrong system in place to get the job done.

Our current supply-driven health care market has no brakes on it. All the stakeholders have no incentives to control costs and improve quality. What we need is a well-thought-out and debated national health program with true national goals based on “best evidence” preventive and medical treatment standards, regional planning, and local implementation. We can best achieve these goals by improving and expanding Medicare for everyone in our country.

In a just society even those made poor have a right to health care. The PPACA will not cover everyone in America or make health care more affordable. The law just makes health insurance more affordable through a voucher system and supplements, but health insurance is not health care.

Even though the Church Health Center has done an outstanding job treating the working poor, we have a bigger problem than all the charity care in communities across the nation could possibly fix. It will require a national will to find the solution. Please look up H.R. 676, the Improved and Expanded Medicare for All Act.

Dr. Arthur J. Sutherland III resides in Memphis.

http://www.commercialappeal.com/news/2012/dec/17/letter-true-reform-remains-elusive/

Consider Medicare for everyone

By John Sytsma, M.D.
Sun Journal (Lewiston, Maine), Letters, Dec. 5, 2012

I am responding to a column by Matt Miller of the Washington Post, printed in the Sun Journal Nov. 30. He suggests that President Obama appoint a panel of experts, chaired by Mitt Romney, to solve the serious problems the nation faces in financing health care.

Rather than asking Romney to chair a panel, Obama should listen to the majority of U.S. physicians and many others who have studied the problem for years and come up with the only system that makes sense — a single-payer national health policy.

Yes, the U.S. health care system is extremely dysfunctional, with 20 to  30 percent of health care spending going into corporate pockets, while more and more dollars are being taken away from beneficiaries.

The U.S., with its profitized system of health care, is spending twice as much on health care as other industrialized countries, yet stands in 17th place in quality of care. The death toll is higher among the uninsured than among the insured. Medical bankruptcy abounds, even among the insured.

The U.S. needs to take a serious look around and consider Medicare for all — the most efficient, not-for-profit system, with administrative costs similar to those in other countries.

Dr. John Sytsma resides in Farmington.

http://www.sunjournal.com/news/letters/2012/12/05/j-sytsma-consider-medicare-everyone/1288823