By H. Dixon Turner, M.D.
Portsmouth (N.H.) Herald, Letters, Nov. 6, 2024

To the Editor:

It’s that time of year again, namely the annual Medicare Enrollment period. At times it seems that every other commercial on TV is for another Medicare Advantage plan. I would urge people to be very cautious when considering enrolling for one of these plans as opposed to remaining in Traditional Medicare. A report by the organization, Physicians for a National Health Program, titled “Our Payments Their Profits” revealed that insurance companies offering Medicare Advantage plans can “earn” profits that are estimated at 88 to 140 Billion dollars every year!! That is money from the Medicare Trust Fund which is NOT going to direct medical care for seniors, but instead is lining the pockets of these companies.

Medicare Advantage (MA) companies reap these exorbitant profits through various means: First, MA companies charge overhead expenses averaging 15-20% whereas Traditional Medicare has an overhead of 2-3%. MA companies aim to enroll healthier patients than the average Medicare recipient and they function like an HMO, often with a very limited panel of providers. Prior approval is often required for procedures which result in delays or denials of necessary care–services which would normally be covered under Traditional Medicare. Upcoding of patient diagnoses frequently occurs by adding on non-existent diagnoses or by exaggerating the severity of existing diagnoses to increase payments. Finally, if a patient does develop a serious illness, such as cancer, those patients – either voluntarily or involuntarily – are often dropped from the MA program.

An additional problem which may occur when patients switch from a MA plan back to Traditional Medicare is that they may not be able to get a Medigap or supplemental insurance policy at all or only at a very high cost. Currently only 4 states (Connecticut, New York, Massachusetts and Maine) mandate that Medigap plans must be offered at community rates. Attempts to pass such a mandate in NH failed to pass in the legislature this year.

The ”Our Payments Their Profits” report estimates that Medicare and Medicaid could cover dental, hearing and vision benefits for ALL Medicare and Medicaid recipients for $80 billion per year, which is less than the lowest estimate of the profits which MA companies are projected to receive this year. These huge profits very likely will rapidly deplete and could bankrupt the Medicare Trust Fund.

Thus, I believe that Medicare Advantage plans are a huge rip off foisted on the American public and should be avoided. I encourage seniors to sign up for or to stick with Traditional Medicare. Also, please lobby our national representatives to terminate or restrict these MA plans and seek instead to increase the benefits currently available under Traditional Medicare.

https://seacoastonline.com…

Dr. H. Dixon Turner is a member of the Granite State (N.H.) chapter of Physicians for a National Health program.

By Thomas Lane and Lin Brown, M.D.
New Hampshire Bulletin, Oct. 25, 2024

This fall, countless New Hampshire seniors will be reexamining their Medicare coverage options for 2025 during the open enrollment period, which runs from Oct. 15 to Dec. 7. One of us, Thomas Lane, is far from Medicare eligibility age, but as a health economist, he is frequently asked by friends and family about what plan they should choose. After all, health insurance is complicated, and it’s very hard to find unbiased advice.

Usually, Thomas responds to the question with a question of his own: What kind of a plan are you considering?

Often, the response is some sort of a Medicare Advantage plan, and every time, he is shocked at how little folks know about the risks associated with signing up for that program instead of Original Medicare. Seniors should know that while Medicare Advantage may sound enticing in the advertising that blankets the airwaves each fall, it’s better known as “Medicare Disadvantage” because it can expose you and your family to big risks.

Dr. Lin Brown is both a physician and a Medicare beneficiary. As a physician, she considered herself knowledgeable and modestly intelligent, which she assumed would allow her to make a wise choice for her first Medicare plan. The initial allure of Medicare Advantage sucked even her in. The ads promised lower rates and more services! Who could resist? She is also healthy, minimizing the risk she would need complicated care. However, she soon realized she had made a mistake.

First of all, what is Medicare Advantage? Its formal name is Medicare Part C, and it serves as a single-package replacement for Medicare parts A (hospital care); B (physician services); and D (prescription drugs). However, it’s deceptively named because it isn’t real Medicare.

Original Medicare (Parts A and B) is operated by the federal government, while Part C is essentially just heavily subsidized private insurance that companies are allowed to label Medicare. Part D is operated by private companies. Insurers often try to make Medicare Advantage plans seem like a sweet deal through lower premiums and extra benefits like hearing and dental not covered under Original Medicare, but as the saying goes, putting lipstick on a pig doesn’t change the fact that it’s still a pig.

Under Original Medicare, there is little question about what care will be covered, a fact doctors like Dr. Brown appreciate because it means less paperwork for them and more time to provide actual care. But because Medicare Advantage isn’t real Medicare, private insurers can play all sorts of games to boost their profits by delaying or denying care. Often, this is through what is called a prior authorization, or extra paperwork for your doctor, forcing them to extensively justify why you need the care they seek to give you.

For Dr. Brown, this meant that in her practice, prior authorizations were the rule, not the exception. They wasted valuable physician practice time and delayed care. For you as a patient, this means that should a major issue or even an emergency arise, your insurer may turn around and surprise you by claiming the care your doctor says you need isn’t “medically necessary” and refuse to pay for it. Dr. Brown and her physician colleagues do not appreciate that there are two types of Medicare, especially given one of them works so well and the other does not.

Medicare Advantage denials are becoming increasingly common. Just between 2022 and 2023, denials skyrocketed by 55.7 percent. They also tend to be quite arbitrary; the reviewer, who has never met the patient, may not even read the patient’s records but deny care anyway. Increasingly, denials aren’t even done by real people, let alone clinicians, and are being taken over by poorly designed AI algorithms that are notoriously erroneous; 82 percent of denials that are appealed are overturned, showcasing the poor quality decision-making that goes into them. But just 11 percent of denials get appealed because many patients aren’t aware they can appeal or don’t want to undergo the burdensome process.

Delays and denials are more than just inconvenient. They can worsen illness and even kill. But, they are a great way for insurers to boost their profits. Obviously, we all hope to never have a health emergency, but should one occur, Medicare Advantage may well stand in the way of you getting the care you need.

Dr. Brown herself experienced a related issue when she was a Medicare Advantage beneficiary. She was disappointed when her plan really did not cover anything related to her hearing aids, since the care was “out of network.” And it covered nothing on a crown from her dentist, also “out of network.” In order to maximize their profits, Medicare Advantage plans tend to have limited and unclear provider networks that allow them to dodge responsibility for patient health needs. Original Medicare, in contrast, covers almost all providers.

Medicare Advantage is so heavily advertised because private insurers make lots of money on the program. Unfortunately, they often do so by gaming the system, siphoning off our tax dollars by exaggerating the health needs of covered patients to the tune of $88 billion to $140 billion annually. Dr. Brown experienced this too, with her Medicare Advantage plan insisting that she and her husband receive a nurse visit. This was likely so that her plan could add diagnoses to their health records, which enable them to receive higher government subsidies.

Most private health insurers in the program have been accused of fraud and are starting to face some accountability in the form of lawsuits and investigations to recoup overpayments, but there is little chance that all of the lost money will ever be recovered. Private insurers have been fighting accountability for years, exemplified by recently released court records that show how they pressured the Obama administration into killing proposed regulations in 2014 that sought to reduce overbilling. Unsurprisingly, these efforts continue to this day.

As a young person, this is what makes Thomas especially upset. He’s happy to pay his taxes and contribute to the care of all the incredible seniors in his life, but watching that money disappear into the Medicare Advantage money-incinerating bonfire for no good reason is depressing, to say the least. It also endangers Medicare’s solvency and decreases the chance that it will be there for him when he eventually becomes eligible.

To make matters worse, New Hampshire seniors on Medicare Advantage are facing even bigger difficulties than their peers nationwide. Insurers are so upset over even the limited scrutiny and declines in their profits that they have begun to face that some of them are now pulling back from a number of states, one of which is New Hampshire. Over a million seniors have been dumped by their Medicare Advantage plans as a result.

You’re likely asking yourself: This sounds awful, so how do I avoid this? The safest route to reliable health insurance coverage that will keep you protected in the face of whatever life may throw at you is Original Medicare. However, because the Original Medicare coverage package was designed all the way back in the 1960s when medical care was much simpler, you will likely need to bolster it with additional coverage, such as a Part D plan and/or Medigap policy. Supplemental plans are private insurance plans just like Medicare Advantage, but they are regulated through different mechanisms and entail somewhat less risk for patients.

Why is Original Medicare the safest option for all seniors and not just those who have significant medical needs?

Because Medicare Advantage premiums are generally cheaper than the alternatives, some wonder why not start on Medicare Advantage and then switch to traditional Medicare later on when health risks are higher. Theoretically, this may be possible for some. However, switching back to Original Medicare after starting out on Medicare Advantage is quite risky because supplemental policy insurers can take into account preexisting conditions, leaving you with much higher premiums or even a refusal to insure.

Dr. Brown experienced this, too. Due to a hiccup with her pension plan, she needed to rethink her Medicare enrollment and reached out to a Medicare navigator for help. He guided her to Original Medicare, but switching back was not easy. A lengthy health evaluation was required to determine her premium. She was lucky that she remained healthy and was able to make the switch.

Starting on Original Medicare plus supplemental insurance tends to cost a bit more per month in premiums than Medicare Advantage, but it is the only way to ensure you will have quality and affordable coverage later on in life when the risk of a significant health need is unavoidably greater. In the long run, it may even be cheaper, too. Do yourself a favor and stay away from Medicare Disadvantage.

Thomas Lane is a health economics, policy, and management master’s student at the Karolinska Institute in Stockholm, Sweden. He recently graduated with a bachelor’s in economics and public policy from Dartmouth College in Hanover, New Hampshire. There, he was a member of the steering committee of Granite State Physicians for a National Health Program.

Lin Brown, MD, FACR, MACP is a retired rheumatologist from Dartmouth Health. Over the years she has practiced as a rheumatologist, a section chief, a fellowship program director for training rheumatologists at DH, and the coordinator of the rheumatology course at Dartmouth Geisel School of Medicine. A member of Granite State Physicians for a National Health Program, she is now almost fully retired.

https://newhampshirebulletin.com…

By Kenneth Dolkart, M.D.
Valley News (West Lebanon, N.H.), October 18, 2024

Vice President Kamala Harris recently announced important new proposals for vision, hearing and long-term home care benefits via traditional Medicare. Pundits wasted no time in telling us this was “unaffordable.” People are unaware that their tax money is already funding such programs but is landing in private pockets.

In 1965, health insurers didn’t offer coverage to seniors, as they couldn’t determine how to make a profit on older Americans who often incurred hospital costs. The federal government created Medicare, which has since provided affordable medical coverage for seniors at 2% administrative costs. Long-term care was not a part of original Medicare: back then, male life expectancy was 67 years. Subsequent treatment advances and lengthening life expectancy prompted our need for long-term care services.

In considering this, let’s remember how the smartest guys in corporate boardrooms promote profit-directed insurance “innovations” while industry and well-lobbied politicians instill dread of “government expansion” of traditional Medicare.

This era is dominated by the mission of the Heritage Foundation: to promote public policies “based on principles of free enterprise and limited government.” Governmental services formerly considered a “public good” are privatized toward profit or attacked as “communism.”

The Medicare Modernization Act of 2003 and Medicare Part D, is an example of such philosophy. Lobbyists for BigPharma designed Part D as an opaque, stand-alone program using for-profit pharmacy benefit managers (PBMs) to administer medication coverage for Medicare. Seniors are left to scramble for ever-changing drug plans, which use hidden industry rebates and charge Medicare inflated costs, while BigPharma and PBMs reap record profits. (The Inflation Reduction Act of 2022 repeals the prohibition against Medicare negotiating with drugmakers to bring down prices.)

Traditional Medicare provides 100% of hospital costs but only 80% of outpatient services, with the remaining 20% of outpatient care covered by purchasing private supplementary “Medigap” insurance. The 2003 legislation required enrollment in private Part D plans to avoid later penalties, so both Medigap and Part D plans need be selected, and Centers for Medicare and Medicaid (CMS) rebranded Medicare Part C as “Medicare Advantage.” (MA)

Managed care insurers then designed lucrative government contracts to administer Medicare dollars, and integrated with PBMs to market combined Medigap and Part D plans. These MA contracts start with “benchmark” payments based on average costs of traditional Medicare services within a region. If the MA plan bids below the benchmark, it keeps a percentage of the difference, which may lower the premium, add profit or allow added bells and whistles. MA payments are boosted with benchmark “adjustments,” “risk adjustment” rebates when enrollees are supposedly sicker than average, and “quality” bonuses.

Accordingly, Medicare Advantage designed plans to attract and retain healthy people. They discouraged enrollment of sick, costly beneficiaries via drug formularies that limit treatments for expensive disorders and via narrow clinician networks. Although enrollees on MA plans are healthier, the average “risk scores” by which payments are calculated are inappropriately coded 20% higher than traditional Medicare. “Favorable selection” and risk score manipulation gives MA plans 6% more per enrollee than the cost incurred by traditional Medicare, although MA spends up to 25% less on care per enrollee.

MA insurers routinely “upcode” an illness’ severity to pad risk scores. What’s more, studies demonstrate that MA just makes things up. Investigative reporting from the Wall Street Journal found that MA plans fraudulently pocketed $50 billion for entirely invented diseases between 2018 and 2021. As far back as 2014, CMS efforts to claw back fraudulent overpayments were scuttled by “industry pressure.” Alas, CMS is a “captured agency” in which insurance executives shuttle through revolving doors between stints in CMS and the MA insurance plans that handsomely reward them. MA plans have accrued overpayments of $550 billion the past 15 years.

MedPAC, the agency that supervises Medicare, reports that MA plans were overpaid $88 billion in 2023 above what traditional Medicare would have expended for equal care for identical patients. Including fraudulent billing boosts overpayment estimates to as much as $140 billion per year. MA yields gross profit margins far exceeding that from other types of medical insurance, so insurers flocked to MA to reap public dollars. Profits by MA plans skyrocketed on our tax-fueled dollars, with UnitedHealthGroup quadrupling profit from $7.86 billion in 2013 to $32.4 billion in 2023. As Advantage ads fill your screens during open enrollment, realize that CMS allows MA insurers to spend billions of our taxes dollars on deceptive advertising campaigns that intentionally omit some vital facts.

Sure, healthy seniors are happy with low or absent MA insurance premiums. However, once seniors need care, recent studies demonstrate that denials, co-pays and co-insurances for skilled nursing, durable medical goods, chemotherapy, home visits and out-of-network treatment result in higher out-of-pocket costs than traditional Medicare. This is despite so-called MA “caps” on such costs. Care is hindered by denial or delay of Medicare-approved services and restrictions to narrow networks. Seniors with serious illness end up paying more, for less care, and, at that point, are trapped in MA plans due to absence of guaranteed issue of alternative, affordable Medigap plans. For clinicians and medical practices, the millions of wasted hours spent performing needless prior authorizations result in added moral and economic burden.

As to new benefits for Americans, the Congressional Budget Office estimates that it would cost $84 billion to cover dental, hearing and vision benefits to both traditional Medicare and Medicaid. Existing yearly overpayments to MA far exceed that, and can be better allocated to long-term home care and other services in traditional Medicare. Those dollars would actually go to needed medical care.

The stewardship of Medicare must be reclaimed from the financial interests of private equity and insurance conglomerates. Government can resume its essential role in updating and improving how Medicare serves the needs of Americans. CMS must eliminate “favorable selection” practices and redesign the benchmarks, risk adjustments and bonuses that are manipulated by MA plans. Improve and pass the bills in Congress that address denial and delays in care, and close the revolving door at CMS that serves industry rather than citizens. The Federal Trade Commission must be empowered to tackle insurance industry abuses and recoup huge losses from fraudulent billing.

If there is not the will to create efficient, universal health insurance, at least our Congressional leaders can allocate recovered savings to “level the playing field” and expand services in traditional Medicare, while securing the long-term stability of the Medicare Trust Fund.

Dr. Kenneth Dolkart is a geriatrician and an assistant professor at Dartmouth’s Geisel School of Medicine.

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