By Matthew DeCamp, M.D., Ph.D., Lois Snyder Sulmasy, J.D., for the American College of Physicians Ethics, Professionalism and Human Rights Committee
Annals of Internal Medicine, March 16, 2021

Abstract

The environment in which physicians practice and patients receive care continues to change. Increasing employment of physicians, changing practice models, new regulatory requirements, and market dynamics all affect medical practice; some changes may also place greater emphasis on the business of medicine. Fundamental ethical principles and professional values about the patient–physician relationship, the primacy of patient welfare over self-interest, and the role of medicine as a moral community and learned profession need to be applied to the changing environment, and physicians must consider the effect the practice environment has on their ethical and professional responsibilities. Recognizing that all health care delivery arrangements come with advantages, disadvantages, and salient questions for ethics and professionalism, this American College of Physicians policy paper examines the ethical implications of issues that are particularly relevant today, including incentives in the shift to value-based care, physician contract clauses that affect care, private equity ownership, clinical priority setting, and physician leadership. Physicians should take the lead in helping to ensure that relationships and practices are structured to explicitly recognize and support the commitments of the physician and the profession of medicine to patients and patient care.

Business Practices, Employment, and Ethics: Recommendations

• ACP Recommendation 1: Ethics and professionalism must be emphasized and explicitly addressed in the implementation of business practices and employment relationships, including in the face of external motivators for clinicians, such as financial incentives.
• ACP Recommendation 2: Contract provisions affecting practice should align with the ethical commitments of physicians and be subject to negotiation that recognizes that alignment.
• ACP Recommendation 3: Confidentiality clauses should not interfere with patient well-being, respectful professional relations, or the individual and collective responsibility of physicians to promote patient best interests, community health, and quality improvement.
• ACP Recommendation 4: Physicians should consider carefully whether to sign an employment contract that permits termination without cause. Provisions related to termination should be reciprocal and time-limited.
• ACP Recommendation 5: The net value of private equity investment in physician practices for patients, physicians, and medicine is unclear. Systematic studies of this trend on patients, medicine, and society are needed.
• ACP Recommendation 6: Organizations and employers should recognize and appropriately value time for patient–physician encounters and engage patients and physicians in priority setting across all aspects of health care.

Conclusion

Business practices can challenge the ethics and professionalism of individual physicians and the collective responsibility of the medical profession to patients. The social mission of institutions can be challenged as well.

Physicians, whether in training, newly graduated, or with decades of experience, must be aware of the effect business practices, employment terms, and contracts can have on ethics and professionalism. National organizations, such as the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education, and medical schools and residency programs should develop strategies for and educational materials on these issues. Because details matter, physicians must be prepared to ask questions about arrangements and feel empowered to advocate for practices that promote patient health and the patient–physician relationship. If a practice or policy harms or has the potential to harm patient care, the physician should speak out and “resist and even refuse to carry it out”.

It is also important for physicians to inform patients when these arrangements affect practice. Doing so preserves trust in the patient–physician relationship and helps make patients and society more aware of forces shaping the practice of medicine. Physicians should be actively involved as a major force.

The practice of medicine must be defined by the ethics of medicine. Efficiency and productivity are important but secondary to serving the needs of patients. Intrinsic motivations of service, professionalism, and clinical integrity must guide physicians and be respected by institutions and health systems. Trust in systems, individual clinicians, and the patient–physician relationship demands no less.

The challenges to care and medical practice during and after the COVID-19 pandemic underscore the need to reemphasize the ethical foundation of medicine. The commitment to ethics in the response of clinicians to COVID-19 has helped sustain the profession and society in the emergency. Some see in COVID-19 an important “lesson that the system can be reset” to better serve both patients and clinicians. Looking anew at the environment in which care is delivered, physicians should lead in ensuring that business relationships explicitly recognize and support the fundamental and timeless commitments of physicians and medicine to patients.

https://www.acpjournals.org…

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Comment:

By Don McCanne, M.D.

The excerpts posted here for this policy paper include the abstract, the recommendations, and the conclusion. But they do not begin to adequately address today’s ethics and professionalism considering the dramatic changes taking place in medicine, especially in the business of medicine. The American College of Physicians has made the full policy paper available for free at the link above, and it should be read in its entirety.

The policy paper is still inadequate because it fails to reject some of the approaches that fall more under the heading of business rather than medicine, although they do stress the primacy of the patient and the patient-physician relationship. As you read the paper, you will be able to identify some of the areas for which they suggest ethical principles that should be applied, but some of these are structural issues that should be rejected.

You’ve heard it many times before and we’ll say it once again, we need to begin with a comprehensive restructuring of our health care financing system by enacting and implementing a model that automatically has ethical principles built in. Of course, that model is a single payer, improved Medicare for All national health program. It’s a system built around the patient, and that’s where you want to begin. If we finally get the model right, the ethics will follow.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By David Engel, J.D., Gary Azorsky, J.D., Jeanne Markey, J.D., and Ray Sarola, J.D.
MedPage Today, March 13, 2021

Can a patient have and not have diabetes at the same time? According to private insurers participating in the Medicare Advantage program, the answer is yes. The data architecture of Medicare Advantage is vulnerable to fraud perpetrated by the Medicare Advantage Organizations (MAOs) who administer Medicare Advantage plans. These MAOs stand to collect inflated profits if they determine that their beneficiaries have complicating diagnoses for certain purposes but not for others.

Why does it matter?

The stakes for the new administration – and the country as a whole – are enormous. Over 23 million Medicare beneficiaries are enrolled in Medicare Advantage plans, for whom the federal government paid out $264 billion in 2019 alone. It is increasingly clear that these public funds are vulnerable to fraud. The HHS Office of Inspector General recently reported that in just one year $2.6 billion was paid to MAOs based on their reports of patient diagnoses that lacked supporting data from providers. It is widely anticipated that investigations and prosecutions of corporate fraud will increase under the Biden administration, and given the dollars at issue and the critical importance of our national healthcare system, fraud in the Medicare Advantage program should be a particular focus of this renewed enforcement effort.

Why is the program so vulnerable to fraud?

To illustrate Medicare Advantage’s vulnerability to fraud, consider how it relies upon two independent data systems to pay for a beneficiary’s inpatient hospital care.

The first system determines the amounts MAOs pay hospitals. This system uses the same MS-DRG prospective payment methodology as traditional Medicare, under which payment for each episode of care is a fixed fee. This fee is based on the procedures performed and the patient’s current diagnoses as reported by the hospital to the MAO.

The second system determines the capitated amount the government pays the MAO for insuring all of a beneficiary’s covered care during the relevant period. The government estimates the cost of this care by calculating a Risk Adjustment Factor (RAF) for each beneficiary. The RAF is based on information regarding each beneficiary’s demographic information and current diagnoses as reported to the government by the patient’s MAO. The higher the RAF, the greater the payment the MAO will receive for that beneficiary.

In the first system, the data flow is between the hospital and the MAO. In the second, it is between the MAO and the government. The problem arises because the government does not have real-time access to hospital claims data in the first system, and hospitals do not have access to the MAO’s reports to the government in the second system.

Our diabetes example demonstrates the consequences of this lack of integration and transparency, particularly in the context of secondary diagnoses. For instance, suppose that a Medicare Advantage member with type 2 diabetes is admitted for surgery, and the hospital later codes this secondary diagnosis on its bill to the MAO. This diagnosis may move the episode of care into a more heavily weighted DRG, which can increase by thousands of dollars the amount the MAO must pay the hospital. These increased payments incentivize MAOs to challenge the propriety of such secondary diagnoses by contending that they are inactive conditions or otherwise irrelevant to the episode of care. Some MAOs have initiated programs to routinely delete certain diagnoses in order to downgrade DRGs and reduce payments to hospitals.

Whether a patient has type 2 diabetes is also an important datum in the Medicare Advantage risk adjustment system. A beneficiary with a current diabetes diagnosis will receive a higher RAF score, and the government will pay the MAO more to insure that beneficiary. While the MAO has an incentive to delete this secondary diagnosis to reduce its payment to the hospital, it can increase its own payments from the government by including this diagnosis in the risk adjustment reports it transmits to the government. If the MAO does not synchronize its provider payment determinations with its risk adjustment reports, our patient will both have and not have diabetes at once. The MAO will improperly profit by being paid to insure a diabetic patient while not paying a hospital to care for one.

How can we prevent this fraud?

It is unfortunate that the current Medicare Advantage data reporting systems are vulnerable to this type of fraud and do not have real-time policing mechanisms. MAOs are likely to continue to take advantage of a system that lets them act as though a patient is less sick when paying for their care, and more sick when seeking money from the government to cover that same patient. The most effective tool to deter and remedy this type of fraud is the federal False Claims Act, which imposes treble damages and significant monetary penalties on companies that defraud the government. Prosecuting those who engage in this fraud under the False Claims Act, including through cases brought by whistleblowers, is the most effective remedy and deterrent.

David Engel, J.D., is a health care attorney admitted to the New York Bar. Gary Azorsky, J.D., Jeanne Markey, J.D., and Ray Sarola, J.D., are members of the Whistleblower/False Claims Act practice group at Cohen Milstein Sellers & Toll.

https://www.medpagetoday.com…

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Comment:

By Don McCanne, M.D.

It is not clear that the multitude of our Quote of the Day messages on the problems with the private Medicare Advantage plans have been getting through. Today’s message gets right to the point. The attorney authors of this article say it like it is: This is fraud!

The Medicare Advantage plans are run by crooks. They use slick marketing to sell these plans to new arrivals in the Medicare program. They add nominal teaser benefits, plus they add the important benefit of providing catastrophic coverage. Although the purchasers of these plans may realize that they have limited networks, they are usually satisfied if their own primary care physician is on the list (not realizing that they may later develop problems that are best handled by physicians and facilities that are out of network). The more expensive patients soon learn that narrow networks and prior authorization requirements serve as significant barriers to the care that they need. The Medicare Advantage plans have developed a well earned reputation that the healthy go in and the sick come out. By outside appearances, the system does seem to work well enough for people that they have managed to entice into their programs, but those are individuals who have not discovered the problems lurking ahead.

This article reveals the heart of the matter. The nation’s largest insurers are using these private Medicare Advantage plans to post record profits on the stock exchange. These excess profits are obtained by cheating the taxpayers who are paying for the Medicare program. Congress and the various administrations have been complicit since each year they authorize financing gimmicks that game the system, while neglecting much needed revisions to the traditional Medicare program – revisions such as reducing out-of-pocket expenses and establishing a reasonable cap on catastrophic losses.

The wake-up call that we really need is for the public to realize what crooks these are and that it is time to get rid of them and to upgrade the traditional Medicare program so it works well for all of us – a single payer, improved Medicare for All. That won’t eliminate all abuses, but it would establish a financing framework that works much better for the patients and the taxpayers.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Where is the outcry among Democratic politicians to reverse completely the corporate takeover of Medicare?

By Ralph Nader

Do you remember the promises made by the Democratic Party’s presidential and Congressional candidates on universal health insurance? You can forget their pledges and somber convictions now that your votes put the Democrats in charge of the House and the Senate. The Democrats’ leaders are abandoning their promises and retreating into a cowardly corporatist future.

Here is the present scene. Leading Democrats, House Speaker Nancy Pelosi and Senate Majority Leader Chuck Schumer, have decided to spend tens of billions of taxpayer dollars to subsidize the giant health insurance companies like Aetna and United Healthcare to “cover recently laid-off workers and those who purchase their own coverage,” as The New York Times reported. There are no price restraints on the gouging insurance premiums or loophole-ridden policies. That is why giant corporate socialist insurers love the “American Rescue Plan,” which gives them socialist cash on the barrelhead. The law lets insurers decide how and whether they pay healthcare bills with co-pays, deductibles, or grant waivers. All these anti-consumer details are buried in the endless and inscrutable fine print.

Whatever happened to the Democrats’ (Bernie Sanders, Elizabeth Warren, Pramila Jayapal, etc.) demand for single-payer – everybody in, nobody out – with free choice of doctors and hospitals instead of the existing cruel, and profiteering industry for which enough is never enough? Senator Sanders often mentioned a Yale study, published on February 15, 2020, that found:

“Although health care expenditure per capita is higher in the USA than in any other country, more than 37 million Americans do not have health insurance, and 41 million more have inadequate access to care. Efforts are ongoing to repeal the Affordable Care Act which would exacerbate health-care inequities. By contrast, a universal system, such as that proposed in the Medicare for All Act, has the potential to transform the availability and efficiency of American health-care services. Taking into account both the costs of coverage expansion and the savings that would be achieved through the Medicare for All Act, we calculate that a single-payer, universal health-care system is likely to lead to a 13% savings in national health-care expenditure, equivalent to more than $450 billion annually….” (See the study: Improving the Prognosis of Health Care in the USA, February 15, 2020).

Well, House Speaker Pelosi is discouraging House Democrats from supporting Representative Pramila Jayapal’s H.R. 1384, Medicare for All Act of 2019, the gold standard for single-payer. News reports indicate that Representative Jayapal (D-WA) and Representative. Debbie Dingell (D-MI) will reintroduce their Medicare for All bill next week. Speaker Pelosi is telling Democrats in the House to focus instead on the modest expansion of Obamacare with its corporate welfare, utter complexity and seriously inadequate coverage. Almost eighty million Americans are presently uninsured or underinsured – a level that will not be significantly reduced for deprived workers by tweaking Obamacare during the Covid-19 pandemic.

A modified Obamacare, with no price ceilings, will hardly reduce the tens of thousands of American deaths every year because people cannot afford health insurance to get diagnosed and treated in time to prevent fatalities. The Yale study also found that: “ensuring health-care access for all Americans would save more than 68,000 lives and 1.73 million life-years every year compared with the status quo.” Tweaking Obamacare does little to stem the relentless surge in healthcare prices and profits in our country, which is unique for not placing billing ceilings on medical procedures and drugs. This “get whatever you can” behavior by the vendors is so uncontrolled that healthcare billing fraud and abuse is costing people one billion dollars A DAY! Malcolm Sparrow, who is an applied mathematician at Harvard, estimates medical billing fraud amounts to at least ten percent of all healthcare expenses each year.

Obamacare does nothing to limit the perverse incentives of a fee-for-service system that includes unnecessary operations, over-diagnosis, and over-prescribing all of which increase the risks of preventable casualties. A Johns Hopkins University School of Medicine peer-reviewed study in 2016 estimates that close to 5000 lives are lost weekly due to such “preventable problems” just in hospitals (see: Study Suggests Medical Errors Now Third Leading Cause of Death in the U.S., May 3, 2016).

It gets worse. Year after year, the corporate Democrats, along with the Republicans, are facilitating expanding corporate takeovers of Medicare and Medicaid. The giant and widening attack on Medicare is called “Medicare Advantage,” which more accurately should be called “Medicare [Dis]advantage.” Our corporatized government, under both Parties, has been allowing deceptive promotional seductions of elderly people to take Medicare [Dis]advantage – now fully 40% of all Medicare beneficiaries – which is just a corporate insurance plan with multiple undisclosed tripwires.

Former President Trump worsened what he inherited from the Democrats in outsourcing Medicare. He launched something called “direct contracting” that, “could fully turn Medicare over to private health insurers” declared Diane Archer, former chair of Consumer Reports, in her article on March 8, 2021. Medicare Advantage premiums can be pricey. According to Kay Tillow, Executive Director of the Nurses Professional Organization, “The Medicare Advantage Plans are smiling all the way to the bank. In 2019 each Medicare Advantage beneficiary cost taxpayers $11,822 while those in original Medicare cost $10,813 each – that’s over $1,000 more and over 9% more per person for the for-profit insurers!”

Where is the outcry among Democratic politicians to reverse completely the corporate takeover of Medicare? Last year, many Democratic candidates pontificated about the need for single-payer health insurance, but now in Congress, we are scarcely hearing a peep about this vital human right. Their campaign rhetoric is just distant memory. Tragically, it is now harder than ever for the elderly to get out of Medicare [Dis]advantage and go back to traditional Medicare.

Millions of elderly people are deceived by televised marketing lies and slick brochures.  The hapless Federal Trade Commission (FTC) should investigate and end the deceptions. Congressional investigations and hearings are long overdue. As the authoritative Dr. Fred Hyde says about the so-called Medicare Advantage: “It’s not what you pay, it’s what you get.” That is, the corporate health plan works until they get sick, until “they want their doctor and their hospital.” Dr. Hyde was referring to the narrow networks where these companies park their beneficiaries.

More astonishing in this story of the rapacious corporate takeover of Medicare is that AARP promotes these flawed plans to their members, takes paid ads by big insurers in AARP publications, and derives income from this collaboration.

Imagine, over 50,000 SEIU retirees are automatically placed by their unions in these Medicare [Dis]advantage traps without first being allowed to choose traditional Medicare.

This whole sordid sabotage of the nineteen sixties Democrats’ dream, under President Lyndon Johnson, of taking the first step toward universal healthcare coverage for everyone, begs for more exposes. It begs for more clamor by the progressive Democrats in Congress who are strangely passive so far. I’m speaking of Representatives Jayapal, Raskin, Ocasio-Cortez (AOC), and the receding “Squad,” as well as Senators Warren and Sanders. If we can’t expect these stalwarts to start the counterattack that will save lives, save trillions of dollars over the years, focus on prevention not just treatment, and diminish the anxiety, dread, and fear, that the citizens of Canada and other western nations do not experience because they are insured from birth on, who is left to defend the American people against the arrogant health insurance corporate barons?

I’m sending this column to these self-styled progressive Democrats along with a two-page specific critique of corporate Medicare from the Physicians for a National Health Program (PNHP) website. PNHP’s membership counts over 15,000 pro-single-payer physicians. In a comment on the PNHP site, Don McCanne, M.D., says, “Remember, the mission of private, for-profit Medicare Advantage insurers is to make money, whereas the mission of our traditional Medicare program is to provide health care. We are supporting a program that deferentially caters to the private insurers and their interests when we should be supporting a program that is designed to take care of patients. Those being deceived by the private Medicare Advantage marketing materials really do not realize the bad deal they may be getting until they face the private insurer barriers to needed care. Silver Sneakers won’t take care of that.” (See: https://pnhp.org/news/russell-mokhiber-explains-why-private-medicare-advantage-plans-are-a-bad-deal/)

If you care about this issue, tell your Members of Congress it is time to pass Medicare for All represented by H.R. 1384.

Ralph Nader is a consumer advocate and the author of “The Seventeen Solutions: Bold Ideas for Our American Future” (2012). His new book is, “Wrecking America: How Trump’s Lies and Lawbreaking Betray All” (2020, co-authored with Mark Green).

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Comment:

By Don McCanne, M.D.

Ralph Nader certainly seems to have a clear understanding of the issues regarding the corporate takeover of Medicare. Even those people over at PNHP and many others get the point as well. Just wish our president did.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

We need a system that is truly universal—everybody in, nobody out. Biden’s proposal will add more participants to the current program, but still leave millions out.

By F. Douglas Stephenson
Common Dreams, March 11, 2021

President Biden, the Democratic Party and America’s neoliberal vision of world order is rooted in an economic philosophy of privatization and financialization. Administrative costs (and immense profiteering) are greater in the private health care insurance system, and even Medicare itself is weakened by having to work through the private system.

Biden and many Democrats have spent their careers defending the financial sector, including big insurance and big pharma, whose leading policy is also to maintain and further privatize basic health care financing and infrastructure. As such, he represents the banking and credit-card industry. He sponsored the regressive bankruptcy “reform” written and put into his hands by the credit-card companies. As a budget hawk, he’s rejected “Medicare for all” as if it is too expensive for the government to afford.

Although health insurance affordability for the majority of US citizens remains a very large problem, Pres. Biden’s latest health insurance plan wants to shift many more dollars into private, Wall Street insurance industry hands. The takeover of health insurance by private Wall Street entities continues apace as Democrats/Biden propose to increase taxes and give it to the private profit insurance industry—the source of our profound administrative waste, along with the costly administrative burdens they place on the delivery system. Profiteering continues unabated as private insurance sells us services we don’t need/want, such as deductibles and other cost sharing, maintenance of narrow networks, requiring prior authorization with increased administrative costs, excessive ongoing paperwork/documentation requirements, all while avoiding paying for surprise bills and other denied benefits.

The private insurance industry is very happy that with ACA, Americans are forced to purchase the product of their private industry plus give huge tax-financed subsidies to their industry in the amount of a half-trillion dollars per decade.

When compared to an improved, single payer Medicare for All (M4A) insurance plan, Biden’s plan is disappointing and at best a bandaid approach. We need a system that is truly universal—everybody in, nobody out. Biden’s proposal will add more participants to the current program, but still leave millions out. M4A is truly universal:

1. Patients should have free choice of their professionals and health care institutions. Biden would continue health plans with restrictive networks that take away free choice. M4A allows choices within the entire health care system.
2. The privatization of public programs such as Medicare through Medicare Advantage and Medicaid through private managed care programs have proven to provide poor value for the taxpayer (obscured by cherry picking and lemon dropping) and should be eliminated. Biden would continue these programs, whereas M4A would eliminate them.
3. Fragmentation results in dysfunctional financing of health care. Biden would perpetuate fragmentation whereas M4A would bring an end to it.
4. Biden’s proposals would add more administrative burden along with the costs they entail. M4A is specifically designed to greatly reduce this burden and its associated costs.
5. Medicaid carries the stigma of being a welfare program which results in legislative underfunding and neglect. Biden would attempt to expand Medicaid in those states that have underutilized it. M4A would terminate the program and move everyone into a universal, comprehensive and equitable program.
6. We need a program that is affordable for each individual and for society as a whole. Biden’s plan will add significantly more spending to the program while leaving it still unaffordable for too many individuals. M4A would achieve all goals of financing reform without significantly increasing spending.
7. Health care coverage should be stable and permanent throughout life. Biden’s proposed fixes would be temporary, many expiring in two years. It is likely that legislators would develop reform fatigue in this session and fail to follow up with more permanent measures. M4A would be a single program—permanent throughout life.
8. Employer-sponsored insurance can create problems such as job lock, which many conservatives and progressives believe should be terminated. Biden would perpetuate it since it involves less government involvement—predominantly private spending with a tax benefit. M4A would end employer-sponsored insurance, and, for many, M4A would be better.

The highly respected British medical journal, “The Lancet,” recently summarized the health insurance situation in the USA:

“Although health care expenditure per capita is higher in the USA than in any other country, more than 37 million Americans do not have health insurance, and 41 million more have inadequate access to care. Efforts are ongoing to repeal/revise the Affordable Care Act which would exacerbate health-care inequities. By contrast, a universal system, such as that proposed in the Medicare for All Act, has the potential to transform the availability and efficiency of American health-care services. Taking into account both the costs of coverage expansion and the savings that would be achieved through the Medicare for All Act, we calculate that a single-payer, universal health-care system is likely to lead to a 13% savings in national health-care expenditure, equivalent to more than US $450 billion annually (based on the value of the US$ in 2017). The entire system could be funded with less financial outlay than is incurred by employers and households paying for health-care premiums combined with existing government allocations. This shift to single-payer health care would provide the greatest relief to lower-income households. Furthermore, we estimate that ensuring health-care access for all Americans would save more than 68,000 lives and 1·73 million life-years every year compared with the status quo.”

https://www.commondreams.org…

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Providers Blast Medicare Spending Cuts in COVID Relief Package: The American Rescue Plan triggers automatic cuts as a deficit control measure that will result in $36 billion in Medicare spending cuts in fiscal year 2022.

By Jacqueline LaPointe
RevCycleIntelligence, March 11, 2021

Leading healthcare industry groups are praising the package’s many healthcare provisions, particularly policies that support healthcare coverage for more Americans and widespread vaccination. But these benefits will come at a cost to healthcare providers, the groups are saying.

Implementation of the American Rescue Plan will trigger automatic spending cuts as a deficit control measure, resulting in $36 billion in Medicare spending cuts in fiscal year 2020 alone, AMGA (American Medical Group Association) states.

“Cutting billions from the Medicare program now would undermine healthcare providers who have heroically rallied all year to care for their patients and communities,” Jerry Penso, MD, MBA, president and CEO of AMGA, said in the statement yesterday.

https://revcycleintelligence.com…

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Comment:

By Don McCanne, M.D.

The American Rescue Plan Act of 2021 – a much needed $1.9 trillion economic stimulus bill – was signed into law by President Joe Biden this week. But as the celebration dies down, we should address what some may say are the “intended” consequences of this bill. It’s a godsend to the private insurance industry, and, further, it doesn’t just move the concept of a single payer Medicare for All program to the bottom of the policy heap, it actually dumps the heap into a shredder as the private insurance industry capitalizes on control of health care financing in America.

For providers who are celebrating, they should remind themselves of the pending automatic spending cuts in Medicare. Nice penalty for a job well done.

We really can fix this so everyone – the patients and their partners in the health care delivery system – can fare well. We merely need to enact and implement a single payer, improved Medicare for All program. Do you think we can get it done before the sunset of the two year provisions in the economic stimulus plan? It will be an uphill struggle when the Biden administration keeps dismissing us with the claim, “We’ve already fixed health care!” Yes, for the private insurers, but we can do much better by targeting the patients instead.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Ken Terry, David Muhlestein
Health Affairs Blog, March 11, 2021

Recently, a number of health policy experts have suggested that the best route to universal coverage might be to expand Medicare Advantage (MA) rather than enact Medicare for All—in other words, a private-sector instead of a government solution.

What We Know About Medicare Advantage

We know that MA enrollment is growing much faster than that of traditional Medicare. By the end of 2020, more than 40 percent of Medicare beneficiaries were enrolled in MA plans, and the Congressional Budget Office has forecast that 47 percent of beneficiaries will be enrolled in these plans by 2029. In short, we’re witnessing the rapid privatization of Medicare.

Why is this happening? Simply put, MA plans offer beneficiaries a better deal than traditional Medicare. Instead of having to buy a Medigap plan (at an average cost of $172 per month) to cover costs that traditional Medicare doesn’t cover, as well as a Part D prescription drug plan ($46), MA enrollees pay only a small monthly premium ($40 on average in 2019), and 56 percent of enrollees pay no premium on top of their Medicare Part B premium. In many plans, they get some level of dental, vision, and hearing coverage, which is missing in traditional Medicare. here’s also a statutory annual limit on out-of-pocket costs, which is not part of traditional Medicare.

On the other hand, MA networks are restricted, and some are very limited. MA enrollees who become seriously ill may have to pay hefty fees to out-of-network providers.

Enrollment in MA plans tends to increase by the age of beneficiary up through the late 70s and then decreases beyond that point.

We know that Medicare pays MA plans slightly more per enrollee than it pays for comparable traditional Medicare enrollees, after accounting for quality bonuses and diagnostic coding intensity. This intensity represents the additional diagnoses that many physicians document for MA members but not for traditional Medicare beneficiaries. MA plans have a financial incentive to ensure that their providers record all possible diagnoses, since higher enrollee risk scores result in higher payments to the plan.

The close correlation of MA payments to traditional Medicare spending is built into the program. “Currently, all savings to the [Medicare] program that come from MA must be generated through FFS [fee for service] spending reductions,” noted MedPAC.

MedPAC further commented that MA plans are expected to be more efficient than traditional, or fee-for-service, Medicare, because they actively manage care and have an incentive to keep costs down.

We know that per-enrollee costs for MA are rising much faster than per-enrollee costs in traditional Medicare. In 2019, per-enrollee MA costs grew 6.3 percent, compared to 2.4 percent for traditional Medicare. This was the fourth year in a row that MA cost growth per member exceeded that in the traditional program.

We know that MA is dominated by a few large companies, and that it is a profitable line of business. At the end of 2020, the four largest MA companies accounted for more than 60 percent of total enrollment, and the 15 largest accounted for more than 80 percent. MA has also been very lucrative for many private health insurers. Researchers from the Commonwealth Fund found that between 2016 and 2018, annual gross margins in the MA market averaged $1,608 per covered person, roughly double the insurers’ margins in the individual and group commercial markets.

What We Don’t Know About Medicare Advantage

We don’t know how to explain the faster per-enrollee cost growth in MA compared to traditional Medicare. But if overall cost growth were to blame, why didn’t per-beneficiary spending rise just as fast under traditional Medicare?

We don’t know whether or not MA offers better quality of care for beneficiaries than traditional Medicare. A number of studies suggest that it does. Overall, however, a “definitive finding [that MA offers superior quality] is not possible with currently available data,” MedPAC stated in 2019.

Another marker of quality is whether Medicare beneficiaries remain in MA plans when their health deteriorates. On this basis, there is reason to question whether MA plans offer higher quality. One paper found that MA members who had been hospitalized at least once had a higher rate of switching back to traditional Medicare than did other MA enrollees. The same was true for users of home care and long-term nursing home care.

While MA plans save money for beneficiaries, we don’t know whether they create savings for Medicare. As noted, the plans are paid, on average, slightly more than traditional Medicare spends on similar beneficiaries in the same region.

According to health insurers, MA plans spend 20 percent to 40 percent less on care than traditional Medicare does. The question is, if these plans are being paid at above Medicare rates, where does the rest of the money go? Some of it is being invested in extra benefits and reduced or zero plan premiums. All of that comes out of the 50–70 percent of the difference between a plan’s bid and its CMS-determined benchmark that CMS rebates to the plan. For many plans, a meaningful share of the savings consists of profits; there are also administrative and other overhead expenses, but it is unclear what factors explain the whole gap between rebates and plan savings.

Out-of-network physicians also must accept traditional Medicare rates. A study of payments to physicians for mid-level office visits and electrocardiograms found little difference between MA and traditional Medicare rates. What’s unclear is how much MA plans pay in-network doctors in quality bonuses and shared savings—not to mention risk contracts. Considering that MA network doctors have incentives to manage care and to code every potential health issue, they likely are receiving something beyond a flat traditional Medicare payment. Anecdotal evidence indicates that these bonuses can be quite substantial in some cases.

MA plans include health maintenance organizations and preferred provider organizations, both of which use standard managed care techniques to varying extents. Whether tools such as prior authorization and utilization review result in skimping on necessary care is unclear. While there is evidence of lower use of services in MA plans, compared to traditional Medicare, that doesn’t mean that the omitted services are necessarily of high value.

In conclusion, it is not clear that Medicare Advantage for All would help bend society’s cost curve more than Medicare for All or other policy proposals. In fact, the current evidence suggests that MA plans have not saved Medicare any money relative to traditional Medicare. To the extent that they lower costs, the lion’s share of those savings seems to be flowing to insurance companies, partly in the form of profits. Policy makers should consider whether this is the direction in which they want health care financing to go.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

For those who might be considering that private Medicare Advantage for All is a better way to go than single payer Medicare for All, you need only to read the concluding excerpt above: “In fact, the current evidence suggests that MA plans have not saved Medicare any money relative to traditional Medicare. To the extent that they lower costs, the lion’s share of those savings seems to be flowing to insurance companies, partly in the form of profits.”

Why would we want to keep the private insurers in the loop? Shouldn’t our funds all be spent on patient care instead?

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Bad news for one unlucky patient is also a stark example of how dysfunctional U.S. health coverage can be.

By Sarah Kliff
The New York Times, March 10, 2021

John Druschitz spent five days in a Texas hospital last April with fever and shortness of breath. It was still the early days of the pandemic, and doctors puzzled over a diagnosis.

They initially suspected coronavirus and hung signs outside his door warning those entering to wear protective equipment. Mr. Druschitz had already spent two weeks at home with worsening symptoms. He recalls one doctor telling him, “This is what it does to a person.”

Ensuing lab work, however, was ambiguous: Multiple molecular tests for coronavirus came back negative, but an antibody test was positive.

Doctors found that Mr. Druschitz had an irregular heartbeat and blood clots in both his lungs. They sent him home on oxygen, and ultimately did not give a coronavirus diagnosis because of the negative tests. He didn’t think much about the decision until this fall, when he received a $22,367.81 bill that the hospital has since threatened to send to collections.

Working with a patient advocate, he discovered that his debt stemmed in no small part from his diagnosis. Not having a coronavirus diagnosis disqualified his hospital from tapping into a federal fund to cover bills for people who do.

Mr. Druschitz ultimately fell slightly short of qualifying for multiple federal health programs that would have paid for his care if the details had been slightly different. Health policy experts see his experience as a case study in how easily patients can fall through the cracks of America’s fragmented health insurance system.

“It shows the insanity of having a health care system where literally the clinical diagnosis determines whether someone is going to get bankrupted,” said Dr. Ashish Jha, dean of the public health school at Brown University.

Mr. Druschitz was briefly among those uninsured millions. On the day the hospital admitted him, he was 64 years old, 23 days away from qualifying for Medicare. He had mistakenly terminated his private health plan, which he had purchased on the Obamacare marketplaces, one month early.

“It’s more likely than not that he did not have Covid, but it’s certainly not a zero chance,” Dr. Jha said. “The fact that it will end up making a big difference in the bill is really problematic.”

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

Suppose we had one single national health program – a single payer Medicare for All – that covers you from conception to death. None of this would have been a problem for Mr. Druschitz. In fact, none of the other millions who have problems with their coverage or lack thereof would have such problems in the future.

There are now innumerable studies that show that everyone can have comprehensive health care without having to face financial barriers, and we are already spending enough to pay for such a system once we recover administrative waste and correct the other deficiencies in our financing system.

How many lessons do we need?

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