PNHP

Repeat: Medicare Advantage & Other Private Investment Hurt Medicare

Repeat: Medicare Advantage & Other Private Investment Hurt Medicare

Summary: A September 2021 Health Affairs blog revealed how Medicare Advantage insurers use aggressive and fraudulent diagnostic coding practices to artificially boost revenues, with similar risks looming from Direct Contracting Entities. That blog was criticized as inaccurate by two corporate leaders in healthcare. The original blog authors responded this week, buttressing their case against Medicare Advantage and DCEs (now known as ACO Reach).

The Emperor Still Has No Clothes: A Response To Halvorson And Crane, Health Affairs Forefront, June 6, 2022, by Richard Gilfillan and Donald M. Berwick

Following our September 2021 Health Affairs Forefront articles on the “Medicare Advantage Money Machine,” the most common reaction of which we are aware has been that this was an “Emperor Has No Clothes” moment. Many knew the Medicare Advantage (MA) game, but few had called it what it was. Two responses to our articles … have been published in Forefront that find fault with our analyses. … For the most part, their arguments fail.

We count more than a dozen assertions in these critiques, some matters of opinion and others matter of fact. These can be grouped into … six categories … [see HJM Comment]

[Many] have documented that MA costs more than fee-for-service [largely due to the gaming of risk scores]. Every extra dollar paid to MA plans is, indeed, a transfer of taxpayers’ money to MA plans, which then benefit in terms of growth and higher profits. Those profits represent direct transfers of wealth from taxpayers to plans.

The impact of MA on the delivery of care goes well beyond the Risk Score Game. Traditional Medicare presents a relatively straightforward, highly standardized approach to coverage and the financing of health care. MA creates a highly fragmented coverage and financing system that brings complexity and additional cost for all segments of the industry, particularly the providers. The result is an expensive MA administrative superstructure that we have layered on top of, and that now permeates and distorts, the actual delivery of care. Estimates of administrative costs and profits for all health system parties vary significantly but the broadest definitions are in the range of 25 percent. MA is a major driver of those costs. We must ask what we are getting for that if, after 35 years of privatized Medicare costing more than fee-for-service, we cannot demonstrate real clinical outcomes improvement. The answer is, “We are not getting much.” The opacity that comes from the privatization of public payment confounds objective, scientific analysis.

Comment:

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

Gilfillan and Berwick logically and effectively counter the two published criticisms of their September 2021 “Medicare Advantage Money Machine” blog (discussed in HJM). In so doing, they solidify an appropriately harsh assessment of Medicare Advantage and ACO Reach (rebranded DCEs). Below is a structured summary, incorporating quotations from the blog.

Bottom line: Massive insurer profits achieved via widespread diagnostic upcoding deplete Medicare funds without evidence of added value for beneficiaries.

1) The Medicare Advantage Business Model

Snapshot: Model = diagnostic upcoding to raise capitation rates

Coding efforts are not just to inform clinical practice, as the critic argues; they are to drive up payment rates. “MA risk scores have for decades risen continually … now almost 2 percent per year faster than those in traditional Medicare. That is not a mark of … increasing relative severity of actual illness in MA compared with the fee-for-service population; it is the Risk Coding Game …”

The industry is so focused on this, it refers to a “risk score headwind” when COVID prevented home visits used to add more diagnoses.

Overall, an estimated 14 percent risk score excess will result in overpayments to Medicare Advantage of $600 billion from 2023-2031.

2) The Profitability of MA Firms

Snapshot: Huge profits and valuations

The critic proposes “Most businesses in most industries would see their stock prices dropping with only 4.5 percent profits [as seen with insurers].”

Yet “[T]he increases in plans’ stock prices and valuations [are extraordinary].” Why? I argue in HJM that the nominal 4.5% for insurers obscures a real return rate of 30%, and thus explains why the investment is so attractive.

“Profits are the product of profit margin multiplied by revenue. Risk Score Gaming positions plans to increase profits from both.“

And here’s the maximum profit strategy: if insurers buy up providers, as they are doing, the “Medical Loss Ratio” restriction on profits is easily evaded, dropping the real MLR from 85% to 70% and thus more than doubling actual profit margins.

3) The Effects of MA On Care and Underinsurance for Low-Income MA Beneficiaries

Snapshot: Lower upfront costs, but poor financial protection when sick

“Plans use some of the subsidies [overpayments] from CMS to offer products with improved benefits and lower premiums for members. … Zero-premium products, with less-rich benefits and more out-of-pocket costs, are targeted at cost conscious buyers, particularly those with limited disposable income. Lower-income individuals have little choice but to trade a known zero premium cost for an unknown likelihood of greater out-of-pocket costs. But that tradeoff leaves many low-income beneficiaries underinsured and possibly experiencing significant negative impacts on their health.”

The Kaiser Family Foundation found that “enrollees in Medicare Advantage do not generally receive greater protection against cost-related problems than beneficiaries in traditional Medicare with supplemental coverage, particularly for some enrollees, such as Black beneficiaries in relatively poor health…”

4) Financial Savings for MA Beneficiaries

Snapshot: Impossible to tell, with distorted comparisons

The critics claim that “MA members actually spend much less money each year on care.”

Gilfillan and Berwick explain why: a) MA plans are subsidized due to over-payment by Medicare, and they share the subsidies with members, and b) the plans use risk selection to enroll a healthier population than traditional Medicare.

In other words, apparent savings are artifact, meaningless.

5) The Quality of Care In MA

Snapshot: Mixed and ambiguous picture, with flawed data

The critics claim higher quality of care in MA. We just can’t know, say Gilfillan and Berwick.

For example, “[R]ecent studies document that MA plans are actively ignoring system-improvement efforts as they use lower-quality skilled nursing facilities and home health providers more, and high-quality hospitals less, than traditional Medicare.”

Claims that integrated care systems like Kaiser improve care (itself dubious, IMO) don’t carry over to the non-integrated Medicare Advantage norm.

MA plans actually artificially boost quality scores – “manipulating contracts to ‘move about 550,000 enrollees from non-bonus contracts to bonus-level contracts, resulting in unwarranted bonus payments in the range of $200 million in 2019.’”

“Understanding the effects of MA on quality is extremely difficult in part because MA operates in an information environment in which it is all but impossible to demonstrate better clinical outcomes for patients.” Data are missing, biased, or manipulated. [Stunning eg’s in the blog.]

Gilfillan and Berwick’s positive view of ACOs diverges from my deep skepticism. But I agree with them, the greatest danger lies in the growth of investor-controlled entities.

6) The Direct Contracting Model/ACO Reach Model

Snapshot: Investor control portends problems such as in Medicare Advantage

[W]e remain concerned that [ACO Reach] brings MA investor and insurer-controlled firms directly into the fee-for-service alternative payment model (APM) world. The 52 of 100 Reach ACOs that are investor-controlled operate in 49 states (including the District of Columbia and Puerto Rico) containing 99 percent of the 35 million fee-for-service beneficiaries.

7) Resolution via Single Payer

Snapshot: They didn’t say this. They should have.

http://healthjusticemonitor.org…

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Don’t Hand Medicare to the Profiteers

Interview with Dr. Susan Rogers

By Patty Fahy, M.D.
Licensed to Lead Podcast, June 6, 2022

Listen to “042 – Dr. Susan Rogers Tells Senate: Don’t Hand Medicare to the Profiteers” on Spreaker.

Community, connection, purpose: these values are almost palpable even in a virtual conversation with Dr. Susan Rogers. Dr. Rogers is an internist, educator, and activist on behalf of those who suffer when profit motives bulldoze the institutions that are meant to serve the public. A neon example of a public good which has been targeted by profiteers is traditional Medicare. As president of Physicians for a National Health Program, Dr. Rogers is fighting back against the shape-shifting strategies launched by insurance companies and private equity firms to cash in on Medicare. She fills us in on the importance of preserving the choice of traditional Medicare, and talks about her work to inform the public and Congress about the “predatory DCEs” or Direct Contracting Entities.

She was shaped by growing up in a uniquely integrated community in Chicago as well as by the activism of the 1960s. When she was in middle school, her mom took her to a march led by Martin Luther King, Jr. protesting the state of the public schools in Chicago. She trained at Cook County Hospital in Chicago and then went on to hold leadership and teaching positions there as an attending. While she did defect temporarily to work in other settings in Chicago, she missed the camaraderie and like-minded passion of her Cook County colleagues. She emphasizes the importance of community with colleagues and the significance of a physician’s long-term relationships with patients.

Dr. Rogers is exasperated at the privatization of healthcare by people who know nothing about the practice and profession of medicine. She describes the total disconnect when decisions are made by financially-driven business people: “There should be no role for them.”

“Resources aren’t placed where they’re needed—they’re placed where they can generate more money.”

She compares the inroads of private equity firms in healthcare to the debacle of private equity firms and charter schools siphoning funds away from public schools in poor communities. As in healthcare, the motives are not to provide the needed services to the public—but to amass profits for investors. Rural hospitals that are acquired and then closed by large healthcare systems are another example of decision-making by those seeking to maximize profit, not community benefit.

Dr. Rogers and other representatives from Physicians for a National Health Program had success on Capitol Hill when they petitioned Congress and HHS to reject DCEs. While PNHP’s efforts were influential regarding DCEs, she describes how it didn’t take long for a new acronym and strategy to emerge. “Same shirt, different color,” she says about ACO REACH (ACO Realizing Equity, Access, and Community Health). She emphasizes the remarkable lack of oversight by Congress for this program that can be hoisted on patients without patients realizing that their traditional Medicare decision has been overruled.

Also in this episode:

  • The powerful impact of a high school biology teacher
  • Activism in the time of role model Angela Davis
  • A Tuskegee airman who exemplified the bond between physician and patient
  • She was able to see patients as people: “They shared their lives with me”
  • “Are you going to open your own office?” a question rarely posed to medical students now that 70%+ physicians are employed
  • Burgeoning full-service hospitals arising in close proximity are as logical as putting a town’s four fire stations on facing corners.

Meet Susan Rogers, M.D.

Dr. Susan Rogers is president of Physicians for a National Health Program, a national organization with over 23,000 physician members, whose mission is to advocate for Single Payer/Medicare for All.

Dr. Rogers received her medical degree from the University of Illinois College of Medicine and completed her residency in Internal Medicine at Cook County Hospital in Chicago. She spent most of her career at Cook County Hospital (now Stroger Hospital of Cook County), where she practiced internal medicine in a neighborhood clinic before becoming a hospitalist and Director of Medical Student Programs for the Department of Medicine. She has also worked at the Lakeside VA hospital in Chicago affiliated with Northwestern and was a prior Medical Director at Near North Health Services, an FQHC in Chicago.

She retired in 2014 but remains a voluntary attending at Stroger Hospital and continues as active faculty at Rush University in Chicago as an Assistant Professor of Medicine.

Dr. Rogers is a Fellow of the American College of Physicians, and a member of the National Medical Association.

Resources:

https://spreaker.com…

Beat cancer? Your Medicare Advantage plan might still be billing for it.

Firms mined patient records for outdated, irrelevant conditions to increase profits, Justice Department contends

By Christopher Rowland
The Washington Post, June 5, 2022

Kathy Ormsby’s work auditing medical case files uncovered an alleged scheme to defraud the federal government: The California health system that employed her was scouring health histories of thousands of elderly Medicare patients, then pressuring doctors to add false diagnoses it found to their current medical records.

The point of larding the medical records with outdated and irrelevant diagnoses such as cancer and stroke — often without the knowledge of the patients themselves — was not providing better care, according to a lawsuit from the Justice Department, which investigated a whistleblower complaint Ormsby filed. It was to make patients appear sicker than they were.

The maneuver translated into millions of dollars in inflated bills to the federal Medicare Advantage insurance program, the government alleged in its false-claims lawsuit filed in U.S. District Court in California.

The case was part of a broader government crackdown on abusive billing practices in Medicare Advantage, the privatized insurance option that by next year is expected to cover more than half of all Medicare beneficiaries. The Justice Department is pursuing civil lawsuits against multiple companies that participate in the privatized system, from huge insurers to prestigious nonprofit hospital systems, alleging they have cheated the system for unfair profit.

Ormsby’s former employer, the Palo Alto Medical Foundation, which has 1,600 doctors, and its parent affiliate, Sutter Health, which runs 24 hospitals in Northern California, settled the case with the government in August 2021 for $90 million. It admitted no wrongdoing or liability.

The government said its investigation confirmed that Palo Alto Medical and Sutter systematically added false diagnoses to patient records. In a sample of hundreds of cases Ormsby audited, the government’s lawsuit said, she discovered 90 percent of diagnoses for cancer were invalid, as were 96 percent for stroke and 66 percent for fractures.

“As we continued to audit, I started to see more things,” Ormsby said in an interview with The Washington Post, the only time she has spoken publicly since reporting the alleged misconduct in 2015. “I couldn’t believe how bad it was.”

In response to questions from The Post, Sutter indicated it was ready to move on. “The agreement brought closure to a long-running dispute and enabled Sutter to avoid the uncertainty and expense of protracted litigation,” it said in an email statement.

Medicare Advantage, which is run by outside companies under contract with the government, was added to traditional Medicare in 2003 with the support of Republicans in an effort to improve care and lower costs through privatization. But it is costing taxpayers increasingly more money to run than traditional fee-for-service Medicare, according to MedPAC, a government watchdog panel. The higher cost, what MedPAC labels “excess payments,” reached $12 billion in 2020 out of total program costs of $350 billion and are projected to top $16 billion next year, MedPAC said in March.

The aggressive billing tactics stem from incentives built into Medicare Advantage. Under the program, companies are paid a flat fee per month to provide whatever care is required for a patient based on age, gender, geography and health risk factors. To compensate plans and providers for potential costs of care for individual patients with conditions such as diabetes, heart disease or cancer, Medicare boosts the monthly payment to Medicare Advantage plans under a “risk adjustment” for each additional condition. The system differs from the traditional “fee for service” payment, in which Medicare pays hospitals and doctors directly each time they provide a service.

If companies add more risk adjustment codes to a Medicare Advantage beneficiary’s medical record to receive higher payment — but don’t spend money on the additional care — they make more money.

Industry officials broadly rebut the charge that companies game diagnostic risk codes for financial gain. They say Medicare Advantage firms adhere to Medicare’s rules and follow the system’s guidance on regulations that are not always clear. Moreover, the industry says that listing all health issues on medical records is a crucial part of Medicare Advantage’s promise to anticipate health problems, proactively manage disease and reduce hospitalizations.

But the government considers it improper — potentially even fraudulent — for providers to add codes for medical conditions that have been resolved or have no bearing on a patient’s current health.

For-profit insurance companies have typically been the primary target of these probes. More recently, unsealed whistleblower cases such as Ormsby’s against Sutter Health, and a pending case against Kaiser Permanente, reveal how such investigations have spread to prestigious, nonprofit physician and hospital groups.

Doctors, or sometimes even non-physician medical coders, updated patients’ current records without providing treatment and often unbeknown to the patients themselves, the government’s investigations have found.

Heart attack, stroke, cancer, vascular disease, depression, obesity and malnutrition were among diagnoses most often cited by the government in its false-claims lawsuits. In an example cited in the Sutter case, thyroid cancer was added as a current condition in a patient record even after the thyroid gland had been removed five years earlier and the patient had been free of cancer for years. None of the allegations has been fully tested in court, because they were settled by the companies without an admission of liability or, in the case against Kaiser Permanente, remain pending.

Some critics contend that a byproduct of these practices is that patients’ medical records, padded with false diagnoses, are inaccurate. That could unnecessarily stigmatize patients who were improperly deemed obese, or malnourished, or mentally ill. It introduces potential phantom influences on treatment decisions, critics say.

In addition to her shock over thousands of alleged false billings, Ormsby “was not comfortable with what she perceived as the complete divorce from the reality of what was in patient records” at Sutter Health, said Sarah “Poppy” Alexander, a whistleblower lawyer at Constantine Cannon, which represented Ormsby.

“The accuracy of patient records is critical for anyone’s health-care treatment,” she said. “Think about all the decisions that are made based on what’s in your health-care record. If that health-care record is not accurate, it’s extremely dangerous.”

Several doctors interviewed by The Washington Post said it was common practice for insurance companies and medical systems to search or data-mine the histories of patients covered by Medicare Advantage. Health systems were known to advise doctors on the most lucrative billing strategies, cajole them to document the maximum number of illnesses, and grade and rank them among their peers based on how they coded patients, they said.

“The emphasis is on how to code for more. It’s not ethical coding, it’s how to code for more money. That pressure is there,” said David Terry, a recently retired psychiatrist who worked within large health organizations in Kansas that are not part of any of the lawsuits.

The Justice Department said in February that Medicare Advantage investigations are an “important priority.” In federal whistleblower cases, the government investigates allegations brought by people with knowledge of alleged fraud against the government and then decides whether it will join the lawsuit, based on its findings. Whistleblowers are rewarded for stepping forward with a portion of any settlement or court awards. Justice Department whistleblower allegations and similar lawsuits also are playing out in federal courts against UnitedHealth Group, Cigna and Anthem. The government’s Office of Inspector General has audited Humana and found it overbilled the government. United Healthcare, which is under the umbrella of UnitedHealth Group, and Kaiser Permanente denied any improper conduct. Cigna, Anthem and Humana did not respond to requests for comment.

The health insurance industry’s trade group, AHIP, did not comment on allegations of false billings. MedPAC’s estimates of excess payments, when compared with traditional Medicare, are exaggerated, AHIP executives said, because its calculations do not factor in all differences between the two payment systems.

“The Medicare Advantage system is designed to promote accurate coding and support integrated care,” said Mark Hamelburg, AHIP senior vice president for federal programs. “Plans have to consider the entire patient, and know all their conditions, and how their conditions interact.”

Medicare Advantage plans cut costs using the tools of the private insurance industry. They control the use of MRIs and other costly tests, for instance, cutting down on waste. They restrict care to certain hospital and physician networks. Then they use a share of those savings to keep monthly premiums lower than traditional Medicare, while offering extra benefits traditional Medicare does not offer, such as dental and hearing and gym memberships.

“It is a vast, complicated system. It involves all these various components,” Hamelburg said. “Our view is that you shouldn’t just look at individual components, you need to look at the totality.”

An industry-backed study found that Medicare Advantage members pay $1,965 less in out-of-pocket costs, including premiums, than traditional Medicare beneficiaries. Beneficiary satisfaction is high. Membership in the plans grew by 10 percent last year; they are expected to cover more than 50 percent of all patients next year.

‘Something unseemly’

Ormsby, one of the Medicare Advantage whistleblowers whose case was investigated by the government, quit her job at Palo Alto Medical Foundation in 2015 after two years in her job as a risk adjustment project manager. An outside consultant had found 8,000 false codes for the years 2012 and 2013, the government alleged in the whistleblower lawsuit she initiated.

The government’s investigation of her complaint revealed how physicians received computerized “daily alerts” for their patients flagging “suspected” diagnoses unearthed via data-mining. When their risk-adjustment diagnosis numbers fell short, doctors were urged by higher-ranking colleagues to improve, the government lawsuit alleged. In some cases, the government said, coders would add diagnoses to patient records without participation of doctors.

Some doctors pushed back on the pressure to add diagnostic codes.

“With my patient on hospice, there is something that seems unseemly about pursuing a new diagnosis of PVD [pulmonary vascular disease] when she has weeks to live,” one physician, Joann Falkenburg, wrote to colleagues helping lead the pressure tactics. The email was obtained by Justice Department investigators. “I try to be pretty legitimate about how I diagnose, document and chart and want to avoid any possibility that it looks like I am working someone up just for the financial upside.”

The government’s lawsuit does not indicate how Palo Alto Medical responded to her email, and Falkenburg did not respond to a phone message requesting comment.

A Palo Alto Medical auditor reported in internal correspondence that another physician, Thomas Deetz, complained that “pre-populating diagnoses into his visit encounter is possibly fraud. … Does CMS know about what you all are doing?” Deetz also did not respond to a request for comment.

Ormsby maintains that her multiple warnings about the practices were ignored or rebuffed. She said she received a poor performance review in early 2015, but by then she had already sought out private lawyers, a step that led to her whistleblower suit.

“I was finding too many errors, and they didn’t want to send the money back,” Ormsby said in the interview. Under rules for federal whistleblower lawsuits, Ormsby, 56, will receive 15 to 30 percent of the $90 million Sutter Health settlement.

‘Coding parties’

The practices at Sutter were not isolated, according to the government. Kaiser Permanente, a nonprofit health-care organization that treats patients in California, Colorado and elsewhere, including Virginia and Maryland, is accused in a separate Justice Department lawsuit of similar tactics that allegedly brought in about $1 billion in improper billings from 2009 to 2018. The case, which is pending, was consolidated from six whistleblower complaints against the company.

“As each year drew to a close, some employees referred to Kaiser’s rush to capture as many diagnoses as possible as the ‘dash for cash,’ ” the government said in its lawsuit. It alleges that at Kaiser Permanente, doctors were invited to “coding parties,” where physicians would be gathered in a room after hours and be expected to add diagnosis codes found in data-mining operations to current patient records.

Kaiser Permanente said in response to the government’s allegations that it was following the rules.

“We are confident that Kaiser Permanente is compliant with Medicare Advantage program requirements and we intend to strongly defend against the lawsuits alleging otherwise,” the company said in a statement sent to The Washington Post. “Our medical record documentation and risk adjustment diagnosis data submitted to the Centers for Medicare and Medicaid Services comply with applicable laws and Medicare Advantage program requirements. Our policies and practices represent well-reasoned and good-faith interpretations of sometimes vague and incomplete guidance from CMS.”

Internally, some doctors questioned the company’s practices, the lawsuit contends. Among the diagnoses Kaiser Permanente physicians were frequently asked to add to patient medical records was aortic atherosclerosis, according to the government’s lawsuit.

The condition, a hardening of the aorta wall, could often be observed incidentally in a chest X-ray or scan for some other ailment. Radiologists were instructed to record the presence of the condition if they detected any calcium in the aorta, “regardless of significance,” according to the government’s complaint.

Physicians would then be pressured via computerized queries to amend the patient records retroactively to include aortic atherosclerosis, which Kaiser had identified as having a “high rate of reimbursement” in the Medicare Advantage risk adjustment formula, the government alleged.

Some Kaiser Permanente doctors objected, saying the disorder was typically not serious in their elderly patients.

According to the government’s lawsuit, one physician, Matthew James Sena, observed in internal correspondence that “Aortic atherosclerosis is nearly ubiquitous in patients this age. It is not a clinically relevant diagnosis and doesn’t require treatment. Isolated [chest X-ray] interpretations are not grounds for clinical diagnosis in this case. … [It’s] clinically inconsequential in almost all cases.”

A coding administrator for Kaiser Permanente is quoted in the complaint as saying “[n]o one believes it is a real diagnosis,” and since “it is non-compliant to tell people to code for money, we need to really sort out a way to package this.”

Medicare Advantage programs are touted by industry as a way of ensuring that chronic conditions are carefully monitored through disease-management programs. But Kaiser Permanente’s increased diagnoses of aortic atherosclerosis threatened to create so many new patients with the condition that its disease management program for cardiovascular disease threatened to buckle.

Kaiser Permanente managers in 2011 came upon a solution, the government said: stop automatically enrolling aortic atherosclerosis patients in the cardiovascular disease management program.

After the change, the lawsuit alleges, medical leaders continued to pressure doctors aggressively to code for the disorder, identifying it as worth an additional $40 million in annual billing opportunity at one physician practice.

“How do we rally the herd?” a physician executive director wrote to colleagues at Kaiser’s Northern California Medical Group, in an email quoted in the lawsuit. “Everybody join in the discussion. $40m is no chump change.”

‘Where’s follow-up care?’

Minnesota-based United Healthcare, the largest health-insurance company in the country, quotes a founding father on the homepage of HouseCalls, its program that dispatches clinicians to Medicare Advantage beneficiaries’ homes: “Benjamin Franklin said it best, ‘An ounce of prevention is worth a pound of cure.’ We agree.”

Under such initiatives, companies routinely send clinicians, often nurse practitioners, into patients’ homes to conduct “health risk assessments.” Companies say the assessments are intended to identify any risks to beneficiary health that their physicians may have overlooked or that have developed since their last doctor visit.

But government reports have questioned whether the practice is intended to improve or capture more lucrative diagnosis codes. The visits often result in new codes added to patient bills without any evidence of doctors’ having considered or treated the newfound diagnoses, the Office of Inspector General of the Department of Health and Human Services found in a report last year.

A Connecticut primary-care physician, Kenneth Dardick (whose spouse is the executive director of the Center for Medicare Advocacy, a nonprofit that advocates for patients), said he routinely receives copies of United Healthcare’s in-home risk assessments and never learns anything about his patients that he did not already know.

He does notice that new patient codes are added to the reports, documenting conditions he already knew about or were irrelevant, he said.

He shared a copy of one assessment, with identifying information of the patient removed, that was sent to him by HouseCalls in April. He was already treating the patient, a man in his 70s, for diabetes. But the health risk assessment, in a section called “new diagnosis,” had added a different code, diabetes with complications. The new diagnosis section also listed a personal history of a type of skin cancer. Dardick said a precancerous growth was removed from the patient’s skin nine years ago and is no longer being treated.

“My sense is they are doing that just to game the system,” Dardick said, citing the “new” diagnosis codes as “irrelevant.”

United Healthcare stood out among Medicare Advantage companies for its aggressive use of risk assessments without evidence new risk codes were related to ongoing medical care, according to the Office of Inspector General report last year. (OIG did not identify the company in its report, but it did confirm its identity after a records request from the Minneapolis Star-Tribune.)

United Healthcare has the largest share of Medicare Advantage patients in the country, with 7.2 million beneficiaries, or 27 percent of the total.

United Healthcare did not respond directly to the OIG report’s findings. In response to questions from The Post, spokesman Matt Wiggin emailed a brief statement. “Simply stated, compared to fee-for-service Medicare, Medicare Advantage costs less (for beneficiaries), is more equitable, has better quality, access, and outcomes with greater coverage and benefits and nearly 100% consumer satisfaction,” he said.

Jacqualine Reid, a government research analyst who led the review, said the findings about United Healthcare raised red flags. Of the $9.2 billion in risk adjustment payments in 2016 based on health risk assessments with no other records to support the diagnosis, United received $1.38 billion, Reid and her team found in their review.

The three top diagnoses generating those payments were peripheral vascular disease, major recurrent depressive disorder and Type 2 diabetes with peripheral angiopathy.

“These are serious medical conditions. If they are getting payments for in-home visits, but we do not see any other evidence of services being provided to them, it raises concern,” Reid said. “If they are appropriate, where’s the follow-up care that in most cases you would expect to see?”

https://www.washingtonpost.com…

What is Single Payer?

Summary: Today we take a step back to review a fundamental issue – the definition of single payer. Also its typical features and options. Why? Because sometimes we get lost in technical details, and forget the big picture. And too often experts get confused, and thus confuse others.

Comment:

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

It drives me to distraction when health policy researchers, journalists, medical journals, and critics misrepresent single payer. This has come up several times in recent months. I guess it’s understandable, with all the misinformation that’s floating around. But I’m eager to settle on a single, correct definition. Here’s my attempt…

DEFINITION:

  • One entity (a public agency) pays for health care. This agency receives all funding and disburses all payments for standard comprehensive coverage. Private insurers are prohibited from this role.
  • All patients and providers deal with just one payer for the standard coverage. This is especially important for providers, offering the simplicity of a single payment source.

TYPICAL FEATURES:

These elements are typical in single payer, if not in the definition, in order to achieve overall goals of universal, equitable, efficient, and affordable access to care.

  • Everyone is covered. Universal, lifelong – meeting a fundamental human need, and part of single payer’s efficiency.
  • Everyone has identical comprehensive coverage / benefits. This is hugely different from our current system, with myriad and varied restrictions on benefits according to health plan.
  • Payment rates are the same for everyone. Again, this is vastly different from today, with up to 10-fold differences in payment levels for the same services, creating strong economic forces for unequal access.
  • Cost-sharing is minimal. No deductibles, and co-pays either not used or small with low-income exemptions. This avoids financial barriers to care.
  • Capital spending (investment) decisions are made by the payer, not by providers. This assures that capacity is increased where most needed.
  • Negotiated drug & medical equipment prices. A single payer negotiates a single set of prices, directly with manufacturers. Currently prices vary widely across insurers and plans, and intermediary PBMs distort the market and extract profits.
  • Long-term care. In most single payer plans, long-term care (both institutional and community-based) is included as an essential care need.
  • A single electronic health record, focused on clinical care rather than billing. With much simpler billing, a universal EHR would reduce the burden on providers and facilitate exchange of medical information and enable effective public health tracking and intervention.

DO WE HAVE SINGLE PAYER NOW? NOT MUCH

  • Veterans Affairs (the VA) has a single payer (the federal government). With full-time staff, the VA resembles a national health service. Access to and quality of care is better than average. Some patients have private insurance as well, and recently more VA funds have been used for community providers, but still, a single payer.
  • Medicare is not a single payer, even though it’s the predominant payer for seniors. This is a common misunderstanding. Medicare is not a single payer because from the perspective of providers, it’s just one of many payers, losing the efficiencies and equity enhancements of single payer. The large role of private insurers in Medicare Advantage further distances Medicare from single payer.

CHOICES UNDER SINGLE PAYER:

  • Provider payment mechanisms. Fee-for-service is the most common proposed approach for individual providers, but they can also be paid with salaries. Hospitals and other institutions may be paid via global budgets. Indeed, capitated provider groups (without intermediaries, and not-for-profit) may be possible, though controversial and require very strong rules to prevent undertreatment and gaming.
  • Supplemental or complementary insurance. Many nations permit focused (small scope) additional insurance, e.g. to speed access to specialty care. These are fraught, potentially undermining standard coverage, but satisfying demand for service enhancements. In other countries, they take many forms and work acceptably (not materially reducing access for the broad population) … but can they in the US?
  • Parallel single payer systems. A single payer approach may permit having a second system in tandem, such as the VA. Two independent systems, each meeting the definition of single payer from the perspective of participating providers and patients.
  • Opting out. Providers can practice outside of the single payer system, accepting direct payments for services. But they are not permitted to both participate in single payer and accept payment for the same services. That is: either fully in or fully out.

So, now that we’ve clarified, let’s get back to winning the long-running battle for an efficient and equitable system to pay for health care – single payer (you know what I mean!).

http://healthjusticemonitor.org…

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Medicare for All Explained Podcast: Episode 78

Interview with Dr. Anthony Spadaro

June 1, 2022

Former Students for a National Health Program leader Dr. Anthony Spadaro talks about the importance of public health and celebrates the recent American Public Health Association endorsement of Medicare for All.

“Having groups like APHA support single payer helps build momentum,” he says. “We have to build our support and our political power to make this a reality.”

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

https://medicareforallexplained.podbean.com

Private Equity Takes Aim at Primary Care

Summary: If private equity firms have their way, traditional primary care will disappear, replaced by corporate skeletons stripped of financial assets and the most skilled practitioners, with investors sitting on billions in extracted profits. That’s the private equity model, now targeting front-line providers. We must stop them before they destroy our health system.

Ethically Challenged: Private Equity Storms US Health Care, by Laura Katz Olson, Johns Hopkins University Press, 2022

The advent of the neoliberal order and its restructuring of the US political economy coincided with the emergence of private equity in its shadow. Financialization took root and surged during the 1980s, and PE has been riding on that wave ever since. Buttressed through eased regulations and preferential tax treatment, the financiers have steadily advanced their tentacles into ever more market sectors, from manufacturing and retail to business and monetary products, energy, and information technology. Eventually, they gravitated toward human services, such as health care, where in some cases they created markets that had not previously existed.

Private equity’s business model can be characterized as a later stage of neoliberalism, one that takes its rationale to greater extremes; it is neoliberalism on steroids. Supersized earnings for PE and its shareholders are front and center, with no pretense otherwise. Nothing else matters. The profit motive guides everything in both word and deed. At a PE conference I (Laura Olson) attended in 2019 hosted by the Wharton School, the entrepreneurs discussed their buyout priorities, value-enhancing strategies, return on investment, and other metrics; not once did anyone mention the impact of their playbook on individuals or society, at least not at the sessions I joined.

The PE industry – capitalism in overdrive – weighs down its health companies with enormous debt while pushing for extra large earnings. Faceless PE shops take an oversized bite into US health dollars, transferring substantial public and private money for medical needs into the pockets of financiers who do not provide any health services per se.

PE firms are on a roll, pushing full steam ahead in the physician practice, urgent care, and medical staffing domains. What will be the next niche? It seems that the indispensable but long-neglected primary care doctors are on their radar, as are other relatively unclaimed health care spaces. If the trend continues – and I’m sure that it will – medical decisions will be less and less between you and your doctor.

Other Resources: Brief article about / summary of the book | Interview with Laura Katz Olson

Comment:

By Don McCanne, M.D.; David Himmelstein, M.D.; Steffie Woolhandler, M.D., M.P.H.; Jim Kahn, M.D., M.P.H.

We have been worried about the injustices of our current health care financing using a fragmented, inequitable system of health insurance, but, behind the scenes, private equity has been taking over the health care system, using various economic tools to divert massive amounts of health care dollars to its own industry. In her book, “Ethically Challenged,” Laura Katz Olson explains the surprising degree to which this has already occurred and how we are losing control of our health care system as a result.

Examples of some of the tools used by private equity include leveraged buyout using other people’s funds, dismissing expensive personnel and using less qualified individuals, establishing creative management fees and newly structured real estate payments for nominally owned facilities, “improving productivity” by slashing benefits for labor, raising prices and reducing product quality, extracting all funds available from the captured entities, pre-planned use of Chapter 11 to dismiss negotiated debts, early selloff of captured enterprises drained of assets in order to achieve maximum return on investment, etc., etc.

Many health care niches have already been occupied by behind-the-scenes private equity entities, and much damage has been done, as Laura Olson explains. If you don’t already know how this is happening, you should read her book or a similar source to understand. Then the reason for the following statement will be clear.

URGENT WARNING: Primary care, the basic infrastructure of health care in America, is about to be taken over by private equity. Although the appearance of having your own health care professionals will continue, your health care will actually be under the control of invisible (to the public) private equity entities whose sole interest in you is to generate more wealth for themselves with absolutely no regard for your personal health, except to avoid blemishes to the market value of your primary care facility.

Again, read “Ethically Challenged” to learn how trillions of dollars are going to be milked out of our compromised health care system, and we will be unable to do much about it once the changes are in place. Single payer Medicare for All won’t be able to help us then. We urgently need to educate ourselves on what is transpiring, and then we urgently need to elect a Congress that understands and will take the appropriate measures.

http://healthjusticemonitor.org…

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

Honor Those Who Died for Our Country by Honoring Truth on Civilian Guns

Summary: On Memorial Day we mourn and thank the legions who fell in battle for the US. This Memorial Day we also mourn civilians who fell in recent mass killings, perpetrated with military-style assault rifles obtained by mentally unstable individuals. Sensible gun sale regulation would slow this bloodshed, say studies. Yet opponents once again are distorting the evidence. We offer resources to pursue honest debate.

Fact-Checking Trump and Cruz at the N.R.A. Convention, New York Times, May 27, 2022, by Linda Qiu

“Gun bans do not work. Look at Chicago. If they worked, Chicago wouldn’t be the murder hellhole that it has been for far too long.” — Senator Ted Cruz, Republican of Texas

This is misleading. …

There were more gun murders in Chicago than in any other U.S. city in 2020, fueling the perception that it is the gun violence capital of the country. But Chicago is also the third-largest city in the country. Adjusted by population, the gun homicide rate was 25.2 per 100,000, the 26th highest in the country in 2020 …

The three cities with the highest gun homicide rates — Jackson, Miss.; Gary, Ind.; and St. Louis — had rates double that of Chicago’s or more. All are in states with more permissive gun laws than Illinois.

Chicago’s reputation for having the strictest gun control measures in the country is outdated. Mr. Cruz cited the city’s handgun ban — without noting that the Supreme Court nullified the ban in 2010. An appeals court also struck down a ban on carrying concealed weapons in Illinois in 2012, and the state began allowing possession of concealed guns in 2013 as part of the court decision. …

Gun control proponents have also argued that the patchwork nature of gun laws in the country makes it difficult for a state like Illinois with tough restrictions on the books to enforce them in practice. A 2017 study commissioned by the city of Chicago found, for example, that 60 percent of guns used in crimes and recovered in Chicago came from out of state, with neighboring Indiana as the primary source.

How To Arm Yourself (With Facts) To Win the Gun Debate, Podcast (9 min), May 28, 2022, by Ben Glieb

[Practical suggestions on how to effectively counter fact twisting.]

Is It Time To Bring Back The Assault Weapons Ban?, Statista, Feb. 16, 2018, by Niall McCarthy

According to [Louis Klarevas], gun massacres fell 37 percent during the ban period and in the ten years after it lapsed in 2004, they went up an alarming 183 percent. Klarevas points out that the ban on high-capacity magazines holding more than 10 rounds made a huge difference. He says that if that is regulated, there will be a considerable drop in massacres and fatalities.

Presence of Armed School Officials and Fatal and Nonfatal Gunshot Injuries During Mass School Shootings, United States, 1980-2019, JAMA Network Open, Feb. 16, 2021, by Jillian Peterson et al.

Controlling for … location and school characteristics, the rate of deaths was 2.83 times greater in schools with an armed guard present.

The well-documented weapons effect explains that the presence of a weapon increases aggression. Whenever firearms are present, there is room for error, and even highly trained officers get split-second decisions wrong. Prior research suggests that many school shooters are actively suicidal, intending to die in the act, so an armed officer may be an incentive rather than a deterrent.

Comment:

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

We designate holidays to honor those who fought and who died in US wars. Although I am highly critical of many US wars, I am not a categorical pacifist. I believe that some of our wars were for necessary and admirable causes. Regardless, we should not blame the soldiers for terrible choices made by our leaders. I honor our veterans, especially my father, who served in a World War II German-Jewish immigrant military intelligence program.

But military weapons in the hands of civilians who are too young and/or mentally unstable and/or criminal is a horrendous mistake. In my view, it is an insult to those who wielded such weapons in service to their country. I recognize that the current interpretation of the Constitution’s 2nd Amendment means private ownership of guns cannot be banned. (Until 1959, the “well-regulated militia” clause was interpreted to mean that private ownership was not protected.) But even today, guns can be regulated. For example, universal background checks could be implemented, and high capacity bullet cartridges could be banned. More than 75% of Americans would like such reasonable regulation. It would reduce deaths. Yet the gun industry stymies action.

The GOP-proposed solutions have not been shown to work. Indeed the study cited above finds that having an armed school official worsens the problem.

Whenever a massacre occurs, Democrats and a few moderate Republicans push for regulation. Reliably, the GOP blocks legislation, and cites “data” in their defense. The data are distortions. The excerpts and links above give you a starter kit for arguing back. Here’s another – the reductions in gun killings in Australia after its 1996 gun buyback.

Please use these resources. Let’s implement the will of the vast majority. Let’s honor military service with honest debate about civilian guns.

http://healthjusticemonitor.org…

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During COVID Insurers Collected Full Premiums But Paid Less for Care, Forcing Government to Bail Out Providers

Summary: In 2020, private insurer profits – largely from Medicare Advantage and Medicaid managed care – jumped 20-30% because they collected full premiums even as claims from health care providers fell due to decreases in elective care. Meanwhile, the government also compensated providers for revenue shortfalls. So taxpayers paid two-fold for the care dip.

Taxpayers Paid Twice for Healthcare: Private insurers are profiting more than ever during the pandemic, MedPageToday, May 25, 2022, by Steffie Woolhandler, M.D., M.P.H. and David U. Himmelstein, M.D.

While 2020 may have been a bad year for Americans, it was a great one for America’s health insurance firms. Profits at UnitedHealthcare, the nation’s largest private insurer, shot up 20%, reaching more than $12 billion. The second biggest, Anthem, collected $16.1 billion more in premiums than it paid out in benefits, a 30% jump over 2019, and CVS/Aetna’s take from its insurance business rose 29%.

It turns out that taxpayers footed the bill for this explosion in profits by, in effect, paying twice for healthcare.

. . . what could justify the nearly $65 billion increase in private insurers’ overhead? And how is it that two thirds of that increase came from private insurers’ subcontracts with Medicare and Medicaid?

. . . In setting 2020 payment rates to Medicare Advantage plans, federal officials boosted payments by nearly $49 billion, anticipating the usual annual increases in medical care use and costs. But with many doctor visits and non-urgent surgeries during the pandemic cancelled, Medicare Advantage plans pocketed most of that increase. Their overhead rose to $2,256 per enrollee. Meanwhile, the overhead of private Medicaid managed care plans also surged.

The flip side of insurers’ windfalls were financial shortfalls faced by many hospitals and doctors. Even hospitals full of COVID-19 patients hemorrhaged money, because the reimbursement for a case of COVID-19 was far lower than they would have gotten for the knee or hip replacements that were cancelled.

Private insurers’ payments to hospitals actually fell in 2020, even as hospitals faced sharp increases in costs for the staff and equipment needed for the tsunami of COVID-19 patients. The financial distress of hospitals and health professionals triggered congressional bailouts — the Provider Relief Fund and Paycheck Protection Program — that totaled about $165 billion in 2020.

In essence, government paid twice for care: once through premiums paid to private insurers for Medicare Advantage and Medicaid managed care, and a second time to fill the hole in hospitals’ and doctors’ budgets caused by falling reimbursements from private insurers.

Comment:

By David Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.

This article traces the spectacular increase in insurance overhead in 2020, which was attributable mostly to their Medicare Advantage and Medicaid managed care businesses.

While insurers’ profiteering from taxpayers in 2020 was extreme, Medicare Advantage plans have been fleecing the taxpayers for years, and look set to continue doing so. Indeed, the Biden Administration recently granted them a huge payment increase for 2023.

MedPAC estimates that between 2008 and 2019, Medicare Advantage plans’ upcoding raised Medicare’s costs by $132 billion, costs borne both by taxpayers and by Medicare enrollees’ as higher Part B premiums. And Medicare Advantage overcharges are projected to add as much as $355 billion to Medicare’s costs by 2030.

Medical spending should pay for care, not to line the pockets of insurance executives and shareholders.

http://healthjusticemonitor.org…

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Social Harms Induced by Private Financial Gain

Summary: As we grieve the latest horrific mass shooting of school children, this and other recent stories highlight a broad societal challenge: untrammeled focus on profit that undercuts basic social values. We see this with guns, corporate norms, foreign policy, and US health care. It’s time to elevate values over profits.

Letters from an American – Heather Cox Richardson

Now a player in national politics, the NRA [National Rifle Association] was awash in money from gun and ammunition manufacturers. By 2000 it was one of the three most powerful lobbies in Washington. It spent more than $40 million on the 2008 election. …

Increasingly, NRA money backed Republican candidates. In 2012 the NRA spent $9 million in the presidential election, and in 2014 it spent $13 million. Then, in 2016, it spent over $50 million on Republican candidates, including more than $30 million on Trump’s effort to win the White House. This money was vital to Trump, since many other Republican super PACs refused to back him. The NRA spent more money on Trump than any other outside group, including the leading Trump super PAC, which spent $20.3 million.

New York Times – The Ransom – The Root of Haiti’s Misery: Reparations to Enslavers

[W]e tabulated how much money Haitians paid to the families of their former masters and to the French banks and investors who held that first loan to Haiti, not just in official government payments on the double debt but also in interest and late fees, year after year, for decades.

We found that Haitians paid about $560 million in today’s dollars. But that doesn’t nearly capture the true loss. If that money had simply stayed in the Haitian economy and grown at the nation’s actual pace over the last two centuries — rather than being shipped off to France, without any goods or services being provided in return — it would have added a staggering $21 billion to Haiti over time, even accounting for its notorious corruption and waste.

For perspective, that’s much bigger than Haiti’s entire economy in 2020.

New York Times – Jack Welch CEO of General Electric

He closed factories and fired employees by the tens of thousands, unleashing a series of mass layoffs that destabilized the American working class. He devised systems like “stack ranking,” which mandated that the bottom 10 percent of workers be fired each year, and took root at other companies. And he embraced offshoring and outsourcing, sending labor overseas and turning to other companies to provide back-office functions like accounting and printing.

… Mr. Welch’s obsession with finance allowed him to steadily inflate G.E.’s valuation in the public markets. … the company derived much of its profit from GE Capital, which was essentially a giant unregulated bank. Mr. Welch called it “the blob” — it was an amorphous, ever-changing collection of financial assets, capable of delivering whatever adjustments were most advantageous to the parent company in a moment’s notice.

Comment:

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

We are shocked and saddened by the latest mass murder of school children enabled by easy access to powerful assault weapons. Gun regulation has failed repeatedly despite vast public support. This is due to the immense influence of the NRA, achieved via massive political donations – funded by gun and ammunition manufacturers in pursuit of maximum profits. NRA leaders also hugely profit personally.

What struck me in other stories this week is the recurring theme of how financial gain, when elevated to the driving objective, shifts policy to unconscionable extremes. The newly liberated nation of Haiti was forced into perpetual economic distress by the French and then US government and bankers. The US middle class was enfeebled by a generation of corporate leaders worshipping at the cost-cutting-&-finances-manipulating alter of Jack Welch. This list is not exhaustive, just what caught my attention in recent days.

And, of course, there is widespread compromise to health care access, and the imposition of increased mortality, by profit-obsessed insurers, provider conglomerates, and drug companies.

The answer is not “let market forces decide our values.” The answer is, “let the market thrive within admirable social values.”

http://healthjusticemonitor.org…

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Dr. Ana Malinow on “Rising Up With Sonali”

PNHP past president Dr. Ana Malinow appeared on “Rising Up With Sonali” on Free Speech TV and Pacifica radio stations on May 25, 2022. Dr. Malinow described the dangers of Medicare Direct Contracting and REACH, which allow third-party (often corporate) middlemen to “mange” the care of Traditional Medicare beneficiaries.

Dr. Malinow was especially critical of the claim that these programs would do anything to advance equity: “We cannot possibly trust corporations, which created inequality in the first place, to achieve health equity.”

Taxpayers Paid Twice for Healthcare

Private insurers are profiting more than ever during the pandemic

By Steffie Woolhandler, M.D., M.P.H. and David U. Himmelstein, M.D.
Medpage Today, May 25, 2022

The Biden administration rewarded private insurers with an 8.5% hike in Medicare Advantage payments in April, despite new evidence that these companies profiteered at Medicare’s expense during the first year of the pandemic.

While 2020 may have been a bad year for Americans, it was a great one for America’s health insurance firms. Profits at UnitedHealthcare, the nation’s largest private insurer, shot up 20%, reaching more than $12 billion. The second biggest, Anthem, collected $16.1 billion more in premiums than it paid out in benefits, a 30% jump over 2019, and CVS/Aetna’s take from its insurance business rose 29%.

It turns out that taxpayers footed the bill for this explosion in profits by, in effect, paying twice for healthcare. This only came to light in December 2021 when federal actuaries released their official tabulations of 2020 health spending.

The actuaries’ report documented a nearly 10% increase in overall health spending between 2019 and 2020 — more than double the average yearly increase over the previous decade. Two expenditure categories accounted for half of the 2020 cost growth, and almost all of the acceleration over past years: 1) government public health spending to combat the pandemic, and 2) private insurance overhead costs.

It’s obvious why public health spending would surge during a pandemic. But what could justify the nearly $65 billion increase in private insurers’ overhead? And how is it that two thirds of that increase came from private insurers’ subcontracts with Medicare and Medicaid?

Since the 1980s, federal and state governments have funneled a growing share of their reimbursement to healthcare providers through private insurers’ Medicare Advantage and Medicaid managed care plans. In effect, private insurers serve as middlemen between the government and care providers.

The enlarging stream of government dollars has been a godsend for private insurers. As enrollment in employer-sponsored insurance stagnated, private insurers have relied on this funding to grow their businesses. By 2020, public dollars accounted for the majority of private insurers’ premium revenues.

But much of that money never reaches a medical provider. It stays with the insurance companies as overhead. In the year before the pandemic, overhead for private Medicare Advantage plans averaged $1,824 per enrollee — 15% of their revenues and more than five times higher than Medicare’s 2% overhead.

In setting 2020 payment rates to Medicare Advantage plans, federal officials boosted payments by nearly $49 billion, anticipating the usual annual increases in medical care use and costs. But with many doctor visits and non-urgent surgeries during the pandemic cancelled, Medicare Advantage plans pocketed most of that increase. Their overhead rose to $2,256 per enrollee. Meanwhile, the overhead of private Medicaid managed care plans also surged.

Private insurers’ payments to hospitals actually fell in 2020, even as hospitals faced sharp increases in costs for the staff and equipment needed for the tsunami of COVID-19 patients. The financial distress of hospitals and health professionals triggered congressional bailouts — the Provider Relief Fund and Paycheck Protection Program — that totaled about $165 billion in 2020.

In essence, government paid twice for care: once through premiums paid to private insurers for Medicare Advantage and Medicaid managed care, and a second time to fill the hole in hospitals’ and doctors’ budgets caused by falling reimbursements from private insurers.

Insurers fleecing taxpayers in 2020 was in some respects a one-off event caused by the unexpected fall in non-COVID-19 care. But the Medicare Advantage rip-off began before 2020 and continues today.

By exaggerating how sick their enrollees are, private plans have extracted extra payments from Medicare, which pegs its funding of Medicare Advantage plans to the severity of enrollees’ illnesses. Congress’ official Medicare watchdog estimates that between 2008 and 2019, Medicare Advantage plans raised Medicare’s overall costs by $132 billion.

And even before the recent payment increase Medicare Advantage overcharges were on track to increase — costing Medicare and seniors (whose Medicare Part B premiums are deducted from their Social Security checks) as much as $355 billion by 2030.

Medicare Advantage plans use a fraction of that overpayment to entice enrollees with extra benefits like eyeglasses and discounts at fitness clubs. But most of it funds their exorbitant overhead, including PR campaigns and lobbying to prevent a crackdown that might derail this money train.

Some in Congress claim they can’t find the money to continue funding COVID-19 vaccinations and care, child tax credits, or green energy. Reclaiming the hundreds of billions wasted by subcontracting Medicare and Medicaid coverage to private insurers would be a good place to look.

Steffie Woolhandler, M.D., M.P.H. and David U. Himmelstein, M.D. are both distinguished professors at the City University of New York at Hunter College, research associates for Public Citizen’s Health Research Group, and long-time advocates for national health insurance.

https://www.medpagetoday.com…

St. Louis takes healthy step of endorsing Medicare for All

‘It’s time to reform our health care system’

By Alvin A. Reid
The St. Louis American, May 24, 2022

St. Louis is now among more than 90 American cities whose governing bodies have passed Medicare for All People resolutions of support.

Alderwoman Pam Boyd introduced the proposal as Resolution 25. After clearing the Board of Aldermen Health and Services Committee, it was passed by the full board on May 13.

People in St. Louis are hurting. They can’t afford to see a doctor, and they really can’t afford to get sick,” Boyd said.

“With Medicare for All, everyone can get the healthcare we need, the prescription drugs that can keep us alive, and the peace of mind to not worry about deciding between our medicine and the roof over our heads.”

Dr. Ed Weisbart, Physicians for a National Health Program – Missouri chapter chair, said during the committee hearing that America spends double on healthcare than any other country.

“[Medicare for All] would reduce that. This comes down to plain, old morality. It makes me furious to see the moral injustice,” said Weisbart, who also serves on the national board.

Angela Brown, St. Louis Regional Health Commission CEO, said “access to health care continues to be a public health crisis.”

“We have developed ‘sick care system’ that prevents our most vulnerable populations from accessing health care until there is an extreme crisis. We recognize it’s time to transform our health care system into a system everyone can access when needed.”

Brown said the pandemic illuminated discrepancies in health care, which could be reduced if Medicare for All became mandated by Congress.

“Medicare for All is the most valid means of insuring health care coverage for all Americans and a step toward achieving zero health disparities in our region,” she said.

U.S. Rep Cori Bush is among the original cosponsors of HR 1976, a proposed bill that would create Medicare for All. It now has 121 cosponsors.

“Medicare for all is a transformational policy change that would implement a national, single-payer universal health care system that guarantees comprehensive health care coverage to every person in America and end the for-profit, privatized, broken system we have in place now,” Bush said during a House Oversight Committee hearing on March 30, 2022.

“I have personally borne witness to the stark inequities faced by uninsured and under-insured patients during my tenure as a registered nurse. For some people, it’s hard to imagine rationing expensive medication like insulin; skipping dialysis appointments; forgoing surgical procedures; or refusing medical care entirely. People are having to choose between their life or a lifetime of medical debt.”

According to Physicians for a National Health Program, Medicare for All could:

  • Expand Medicare’s benefit design to include coverage of hearing, vision, dentistry, prescription drugs, and long-term care
  • Include a full choice of physicians and hospitals and eliminating narrow “networks”
  • Eliminate copays, deductibles, and need to purchase supplemental policies
  • Eliminate individual premiums, which would be funded through an equitable tax model

The benefits of Medicare for St. Louis include improved health and health equity of residents and a lessened financial burden on the city’s budget

Many St. Louisans depend on emergency rooms as the only realistic healthcare option, at significant cost to the city and local business community, according to Weisbart.

“Medicare for All improves health equity by ensuring everyone has affordable access to needed healthcare throughout their life.”

Medicare for All is also endorsed by: Missourians for Single Payer Physicians for a National Health Program; Mound City Medical Forum; Students for a National Health Program-St. Louis University Chapter; Consumers Council of Missouri Green Party of St. Louis; Missouri Health Care for All; National Nurses United at St. Louis University Hospital; Democratic Socialists of America-St. Louis Chapter; League of Women Voters-Metro St. Louis Chapter; Missouri Jobs with Justice; and the Ethical Society of St. Louis.

https://www.stlamerican.com…