PNHP

The Medicare Advantage Influence Machine

The Medicare Advantage Influence Machine

By Fred Schulte and Holly K. Hacker
KFF Health News, September 30, 2024

Federal officials resolved more than a decade ago to crack down on whopping government overpayments to private Medicare Advantage health insurance plans, which were siphoning off billions of tax dollars every year.

But Centers for Medicare & Medicaid Services officials have yet to demand any refunds — and over the years the private insurance plans have morphed into a politically potent juggernaut that has signed up more than 33 million seniors and is aggressively lobbying to stave off cuts.

Critics have watched with alarm as the industry has managed to deflate or deflect financial penalties and steadily gain clout in Washington through political contributions; television advertising, including a 2023 Super Bowl feature; and other activities, including mobilizing seniors. There’s also a revolving door, in which senior CMS personnel have cycled out of government to take jobs tied to the Medicare Advantage industry and then returned to the agency.

Sen. Chuck Grassley (R-Iowa) said Medicare Advantage fraud “is wasting taxpayer dollars to the tune of billions.”

“The question is, what’s CMS doing about it? The agency must tighten up its controls and work with the Justice Department to prosecute and recover improper payments,” Grassley said in a statement to KFF Health News. “Clearly that’s not happening, at least to the extent it should be.”

David Lipschutz, an attorney with the Center for Medicare Advocacy, a nonprofit public interest law firm, said policymakers have an unsettling history of yielding to industry pressure. “The health plans throw a temper tantrum and then CMS will back off,” he said.

Government spending on Medicare Advantage, which is dominated by big health insurance companies, is expected to hit $462 billion this year.

New details of the government’s failure to rein in Medicare Advantage overcharges are emerging from a Department of Justice civil fraud case filed in 2017 against UnitedHealth Group, the insurer with the most Medicare Advantage enrollees. The case is pending in Los Angeles. The DOJ has accused the giant insurer of cheating Medicare out of more than $2 billion by mining patient records to find additional diagnoses that added revenue while ignoring overcharges that might have reduced bills. The company denies the allegations and has filed a motion for summary judgment.

Records from the court case are surfacing as the Medicare Advantage industry ramps up spending on lobbying and public relations campaigns to counter mounting criticism.

While critics have argued for years that the health plans cost taxpayers too much, the industry also has come under fire more recently for allegedly scrimping on vital health care, even dumping hundreds of thousands of members whose health plans proved unprofitable.

“We recognize this is a critical moment for Medicare Advantage,” said Rebecca Buck, senior vice president of communications for the Better Medicare Alliance, which styles itself as “the leading voice for Medicare Advantage.”

Buck said initiatives aimed at slashing government payments may prompt health plans to cut vital services. “Seniors are saying loud and clear: They can’t afford policies that will make their health care more expensive,” she said. “We want to make sure Washington gets the message.”

AHIP, a trade group for health insurers, also has launched a “seven-figure” campaign to promote its view that Medicare Advantage provides “better care at a lower cost,” spokesperson Chris Bond said.

Revolving Door

CMS, the Baltimore-based agency that oversees Medicare, has long felt the sting of industry pressure to slow or otherwise stymie audits and other steps to reduce and recover overpayments. These issues often attract little public notice, even though they can put billions of tax dollars at risk.

In August, KFF Health News reported how CMS officials backed off a 2014 plan to discourage the health plans from overcharging amid an industry “uproar.” The rule would have required that insurers, when combing patients’ medical records to identify underpayments, also look for overcharges. Health plans have been paid billions of dollars through the data mining, known as “chart reviews,” according to the government.

The CMS press office declined to respond to written questions posed by KFF Health News. But in a statement, it called the agency a “good steward of taxpayer dollars” and said in part: “CMS will continue to ensure that the MA program offers robust and stable options for people with Medicare while strengthening payment accuracy so that taxpayer dollars are appropriately spent.”

Court records from the UnitedHealth case show that CMS efforts to tighten oversight stalled amid years of technical protests from the industry — such as arguing that audits to uncover overpayments were flawed and unfair.

In one case, Jeffrey Grant, a CMS official who had decamped for a job supporting Medicare Advantage plans, protested the audit formula to several of his former colleagues, according to a deposition he gave in 2018.

Grant has since returned to CMS and now is deputy director for operations at the agency’s Center for Consumer Information and Insurance Oversight. He declined to comment.

At least a dozen witnesses in the UnitedHealth case and a similar DOJ civil fraud case pending against Anthem are former ranking CMS officials who departed for jobs tied to the Medicare Advantage industry.

Marilyn Tavenner is one. She led the agency in 2014 when it backed off the overpayment regulation. She left in 2015 to head industry trade group AHIP, where she made more than $4.5 million during three years at the helm, according to Internal Revenue Service filings. Tavenner, who is a witness in the UnitedHealth case, had no comment.

And in October 2015, as CMS department chiefs were batting around ideas to crack down on billing abuses, including reinstating the 2014 regulation on data mining, the agency was led by Andy Slavitt, a former executive vice president of the Optum division of UnitedHealth Group. The DOJ fraud suit focuses on Optum’s data mining program.

In the legal proceedings, Slavitt is identified as a “key custodian regarding final decision making by CMS” on Medicare Advantage.

“I don’t have any awareness of that conversation,” Slavitt told KFF Health News in an email. Slavitt, who now helps run a health care venture capital firm, said that during his CMS tenure he “was recused from all matters related to UHG.”

‘Improper’ Payments

CMS officials first laid plans to curb escalating overpayments to the insurers more than a decade ago, according to documents filed in August in the UnitedHealth case.

In a January 2012 presentation, CMS officials estimated they had made $12.4 billion worth of “improper payments” to Medicare Advantage groups in 2009, mostly because the plans failed to document that patients had the conditions the government paid them to treat, according to the court documents.

As a remedy, CMS came up with an audit program that selected 30 plans annually, taking a sample of 201 patients from each. Medical coders checked to make sure patient files properly documented health conditions for which the plans had billed.

The 2011 audits found that five major Medicare Advantage chains failed to document from 12.3% to 25.8% of diagnoses, most commonly strokes, lung conditions, and heart disease.

UnitedHealth Group, which had the lowest rate of unconfirmed diagnoses, is the only company named in the CMS documents in the case file. The identities of the four other chains are blacked out in the audit records, which are marked as “privileged and confidential.”

In a May 2016 private briefing, CMS indicated that the health plans owed from $98 million to $163 million for 2011 depending on how the overpayment estimate was extrapolated, court records show.

But CMS still hasn’t collected any money. In a surprise action in late January 2023, CMS announced that it would settle for a fraction of the estimated overpayments and not impose major financial penalties until 2018 audits, which have yet to get underway. Exactly how much plans will end up paying back is unclear.

Richard Kronick, a former federal health policy researcher and a professor at the University of California-San Diego, said CMS has largely failed to rein in billions of dollars in Medicare Advantage overpayments.

“It is reasonable to think that pressure from the industry is part of the reason that CMS has not acted more aggressively,” Kronick said.

CMS records show that officials considered strengthening the audits in 2015, including by limiting health plans from conducting “home visits” to patients to capture new diagnosis codes. That didn’t happen, for reasons that aren’t clear from the filings.

In any case, audits for 2011 through 2015 “are not yet final and are subject to change,” CMS official Steven Ferraina stated in a July court affidavit.

“It’s galling to me that they haven’t recovered more than they have,” said Edward Baker, a whistleblower attorney who has studied the issue.

“The government needs to be more aggressive in oversight and enforcement of the industry,” he said.

Senior CMS official Cheri Rice recommended in the October 2015 email thread with key staff that CMS could devote more resources to supporting whistleblowers who report overbilling and fraud.

“We think the whistleblower activity could be as effective – or even more effective – than CMS audits in getting plans to do more to prevent and identify risk adjustment overpayments,” Rice wrote.

But the handful of cases that DOJ could realistically bring against insurers cannot substitute for CMS fiscal oversight, Baker said.

“Unfortunately, that makes it appear that fraud pays,” he said.

Document: October 2015 email with Rice and other CMS officials

Spending Surge

In December, a bipartisan group of four U.S. senators, including Bill Cassidy (R-La.), wrote to CMS to voice their alarm about the overpayments and other problems. “It’s unclear why CMS hasn’t taken stronger action against overpayments, despite this being a longstanding issue,” Cassidy told KFF Health News by email.

In January, Sen. Elizabeth Warren (D-Mass.) and Rep. Pramila Jayapal (D-Wash.) called for CMS to crack down, including by restricting use of chart reviews and home visits, known as health risk assessments, to increase plan revenues.

Cassidy, a physician, said that “upcoding and abuses of chart review and health risk assessments are well-known problems CMS could address immediately.”

Advocates for Medicare Advantage plans, whose more than 33 million members comprise over half of people eligible for Medicare, worry that too much focus on payment issues could harm seniors. Their research shows most seniors are happy with the care they receive and that the plans typically cost them less out-of-pocket than traditional Medicare.

Buck, the spokesperson for the Better Medicare Alliance, said that as the annual open enrollment period starts in mid-October, seniors may see “fewer benefits and fewer plan choices.”

The group has ramped up total spending in recent years to keep that from happening, IRS filings show.

In 2022, the most recent year available, the Better Medicare Alliance reported expenses of $23.1 million, including more than $14 million on advertising and promotion, while in 2023, it paid for a Super Bowl ad featuring seniors in a bowling alley and left viewers with the message: Cutting Medicare Advantage was “nuts.”

Bruce Vladeck, who ran CMS’ predecessor agency from 1993 through 1997, said that when government officials first turned to Medicare managed care groups in the 1990s, they quickly saw health plans enlist members to help press their agenda.

“That is different from most other health care provider groups that lobby,” Vladeck said. “It’s a political weapon that Medicare Advantage plans have not been at all reluctant to use.”

The Better Medicare Alliance reported lobbying on 18 bills this year and last, according to OpenSecrets. Some are specific to Medicare Advantage, such as one requiring insurers to report more detailed data about treatments and services and another to expand the benefits they can offer, while others more broadly concern health care costs and services.

Proposed reforms aside, CMS appears to believe that getting rid of health plans that allegedly rip off Medicare could leave vulnerable seniors in the lurch.

Testifying on behalf of CMS in a May 2023 deposition in the UnitedHealth Group suit, former agency official Anne Hornsby said some seniors might not “find new providers easily.” Noting UnitedHealth Group is the single biggest Medicare Advantage contractor, she said CMS “is interested in protecting the continuity of care.”

https://kffhealthnews.org...

Dr. Dan Doyle on WBOY 12 News

PNHP-WV chapter leader Dr. Dan Doyle was interviewed by WBOY News 12 for a segment on September 30, 2024. Dr. Doyle helped lead a rally outside the offices of Peak Health in Morgantown as part of a national day of action highlighting the dangers of so-called “Medicare Advantage” plans.

Corporate health insurers are “making huge profits” from privatized Medicare he said. “The way they do it is by denials of care, delays of care, nonpayment of care, and restricted networks.”

“Incestuous exploitation?” PBMs and corporate healthcare consolidation

By Brenda Gazzar
Code Wack Podcast, Sept. 30, 2024

We’re taking another look at Pharmacy Benefit Managers or PBMs. Why were PBMs started and how did they morph to become one of the most powerful entities in health care? Why have they caught the attention of the Federal Trade Commission? How are they a threat to consumers?

To find out, we spoke to Dr. Ed Weisbart, the national board secretary of Physicians for a National Health Program and former chief medical officer of one of the biggest PBMs in the country. This is the first episode in a two-part series.

Check out the Transcript and Show Notes for more!

https://heal-ca.org…

Medical Debt

By George Bohmfalk, M.D.
The Charlotte Observer, Letters, Sept. 29, 2024

Regarding “Inside North Carolina’s fight to make hospitals relieve billions of patient debt” (Sept. 23) and other reports:

So Atrium/Advocate finally decided to do the right thing after filing around 500 debt collection lawsuits per year. Most people who don’t pay their medical bills just don’t have the money. How much has Atrium spent on armies of lawyers to file these low-yield lawsuits?

We wonder why one-third of every healthcare dollar is wasted on administrative overhead. There is a better way. Under an Improved Medicare for All system, medical debt simply would not exist. No fire department ever sued a home or business owner after saving their building. Health care can work the same way.

https://charlotteobserver.com…

Wendell Potter on MoveOn

Former Cigna VP (and insurance industry whistleblower) Wendell Potter spoke with MoveOn for a social media segment that was posted on September 29, 2024. Mr. Potter discussed the under-reported threat that Project 2025 poses to Medicare—by making so-called “Advantage” plans the default option for enrollees.

Under the Heritage Foundation plan, people on Medicare “will not have access to the doctors they want to see, or the hospitals they want to be treated at, or even the medications that they [need],” he said, “because the insurance companies will be in control of all of that.”

Medicare Advantage plans are the junk bonds of health care

By James Fieseher, M.D.
New Hampshire Union Leader, Sept. 24, 2024

September starts the open enrollment period for seniors choosing a health care plan, either traditional Medicare (TM) or any one of a number of commercial “Medicare Advantage” plans. Picking the one plan that is right for you depends upon your overall health status, your financial situation, and your ability to predict your health in the future.

For the next three or four months, you’re going to be flooded with advertisements for various Medicare Advantage plans, pitched by older celebrities. You’ll hear them say the word “free” a lot, and if you think commercial health care is being offered for free, there’s a famous bridge in Brooklyn you might be interested in buying.

Congress established Medicare in 1965 to provide a highly transparent, cost-effective way to publicly fund the health care needs of seniors. It came with a set of clear guidelines for doctors and patients letting them know which services would be paid and which were not. Then, 98% of taxpayers’ dollars through Social Security went directly back to medical costs for seniors while roughly 2% went to administrative fees. Once the doctor and patient agreed on the medical services needed, those costs were promptly paid. That same formula is still in effect today, 59 years later, although the administrative costs are now closer to 3%.

By contrast, Medicare Advantage plans started in the 1970s and came into their own in 2004, when commercial insurers started aggressive advertising. They boasted “free” everything as well as dental and eye coverage — “depending upon your zip code.” Clearly, their health care isn’t free, they bill the Medicare Trust Fund directly, with a built-in 10% profit margin for administrative services.

Commercial health insurers found loopholes in the way Medicare Advantage (a.k.a. Medicare Part C) was structured enabling them to increase profit margins at least threefold. One of these was that medical insurers would self-regulate, so little chance that outright fraud would be detected. Last year alone, commercial insurers overcharged CMS (the Center for Medicare and Medicaid Services) an estimated $88 billion. But because of a lack of transparency, that number could be as high as $140 billion.

What does that mean to you when deciding on a plan?

One of the ways commercial Medicare Advantage insurers can extract more money from the Medicare Trust Fund is through a process known as “upcoding.” This is a way of taking a past or present medical condition and redefining it as a more serious problem than your medical practitioner originally listed. Suddenly elevated blood pressure is redefined as a serious blood pressure problem, or pre-diabetes becomes uncontrolled diabetes. This enables the private insurer to bill CMS at a higher rate.

Commercial insurers have the right to “manage” your health care having a say whether or not they will pay for a medication or procedure that you and your doctor have decided is necessary through “prior authorization.” Waiting for a for-profit insurer to approve treatment has caused serious delays or outright denials of urgently needed care, often resulting in patients paying the entire cost out of pocket, saving the insurer millions.

Because of upcoding, Medicare Advantage patients appear to have more serious health problems than patients on traditional Medicare, while at the same time those same patients receive fewer medications and procedures due to prior authorization denials. Advantage plans may save money in the up-front costs and added benefits such as hearing and dental, but you’ll lose your shirt and a lot more if you develop more than a minor medical condition.

In many ways, Medicare plans resemble the bond market. Traditional Medicare, managed by the U.S. government is like treasury notes, they’re AAA rated, a guaranteed safe investment. Medicare Part C “Advantage” plans are like C rated bonds (a.k.a. “junk bonds”), they entice with higher yield offerings, but the pay-off is risky.

If you’re on a Medicare Advantage plan and want to switch back to traditional Medicare, you might not be able to, or it might cost you a higher rate depending upon your health and the number of years you’ve been on an Advantage plan. There are commercial plans that cover “gaps” in traditional Medicare, such as hearing, dental, and eye care. These can be covered at fairly low cost through supplemental plans known as “Medigap” plans. But if you have a pre-existing condition, especially if it’s serious, you might be ineligible or have to pay a much higher rate for any of the Medigap coverage plans. Plus, switching is intentionally difficult, even if you don’t have a pre-existing condition.

If you think you’ll never need any serious hospitalization or surgery for the rest of your life, an Advantage plan might be right for you. For the rest of us, I would suggest sticking to the tried-and-true; traditional Medicare will save you lots of money in the long run and will avoid the frustrating delays in care.

Dr. James Fieseher is a retired physician and member of Granite State Physicians for a National Health Program.

https://www.unionleader.com…

Twenty Years of Failing Health System Report Cards

Since 2004, the Commonwealth Fund has done annual comparisons of health system performance among wealthy nations. The US consistently underperforms the others, and 2024 extends the streak: we are the worst, by a wide margin. Replacing our massively dysfunctional insurance morass is long overdue.

Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System; Comparing Performance in 10 Nations, Commonwealth Fund, September 19, 2024, by David Blumenthal, et al.

Conclusion: The U.S. continues to be in a class by itself in the underperformance of its health care sector. While the other nine countries differ in the details of their systems and in their performance on domains, unlike the U.S., they all have found a way to meet their residents’ most basic health care needs, including universal coverage.

Comment:

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

My comment today is brief, because this is “just” another annual iteration of findings from the venerable Commonwealth wealthy nations health system comparison. As always: the US lags far behind other nations. If I’m permitted a little tongue-in-cheek for a dire situation: The US is a consistent global leader if the goal is to rank last on health system performance metrics of central importance to patients.

We’re last on access, equity, and outcomes. The only result that baffled me is administrative efficiency, with Switzerland reported as worse than the US. Turns out, that’s because the metric doesn’t include the hundreds of billions diverted to insurers for profits, which Swiss insurers don’t get on the primary insurance plan. So, really, we’re last in that category too. We do well on care processes – we offer amongst the best care in the world, if you can afford it.

Why are other nations doing so much better? Because “have found a way to meet their residents’ most basic health care needs, including universal coverage.” Sounds like single payer to me (or, in some nations, identical broad benefits managed by not-for-profit insurers).

Check out the full report. It’s elegantly conceived and written. We can only hope that in the next 20 years, the findings will evolve to place the US among other wealthy nations in health system performance.

https://healthjusticemonitor.org…

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

UK National Health Service Resuscitation Implications for the US

In the United Kingdom, the first Labor government in 14 years must deal with Conservative fiscal and policy neglect of the National Health Service. This serves as a tough reminder of the US need for a durable social consensus on a public solution to our health care crisis.

Prime Minister Keir Starter sets out NHS plans following Darzi report, YouTube, Sept. 12, 2024

Lord Darzi today has published his independent report on the state of our NHS.

As everyone in the country knows, the last government broke the NHS.

Let me be clear from the outset, what reform does not mean. First, it does not mean abandoning those founding ideals of a public service, publicly funded, free at the point of use – the basic principle of dignity. “When you fall ill, you should never have to worry about the bill.” Second, reform does not mean just putting more money in. Now, of course, even in difficult financial circumstances, a Labor government will always make the investment in our NHS if it is needed. But we have to fix the plumbing before turning on the tap. So, hear me when I say this, no more money without reform.

The last Labor government reformed the NHS to deliver better outcomes for patients and better value for taxpayers. The Conservative government then undid that good work, which only goes to prove, once again, that only a Labor government can reform the NHS.

If we get this right, people can look up and say, “this was the generation that took the NHS from the worst crisis in its history, got it back on its feet, and made it fit for the future.”

Independent Investigation of the National Health Service in England, September 2024, by The Rt. Hon. Professor the Lord Ara Darzi of Denham

The National Health Service is in serious trouble.

This report sets out where the NHS stands now, how we arrived at this point, and some of the key remedies.

The NHS budget is not being spent where it should be – too great a share is being spent in hospitals, too little in the community, and productivity is too low.

Conclusions:

The NHS is in critical condition.

Some have suggested that this is primarily a failure of NHS management. They are wrong.

Despite the challenges, the NHS’s vital signs remain strong.

Nothing that I have found draws into question the principles of a health service that is taxpayer funded, free at the point of use, and based on need, not ability to pay.

It has taken more than a decade for the NHS to fall into disrepair so improving it will take time.

There are some important themes that have emerged for how to repair the NHS, which will need to be considered alongside strategies to improve the nation’s health and reforms to social care:

  • Re-engage staff and re-empower patients.
  • Lock in the shift of care closer to home by hardwiring financial flows.
  • Simplify and innovate care delivery for a neighborhood NHS.
  • Drive productivity in hospitals.
  • Tilt towards technology.
  • Contribute to the nation’s prosperity.
  • Reform to make the structure deliver.

The NHS is now an open book. The issues are laid bare for all to see. And from this shared starting point, I look forward to our collective endeavor to turn it around for the people of this country, and to secure its future for generations to come.

Comment:

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

For decades, progressives in the US have been striving to enact and implement an affordable, high-performance system which would provide health care access for everyone. We favored government control over the payment mechanism since private insurers have demonstrated an enduring desire and ever-increasing ability to divert our funds to their private wealth. This diversion would end with publicly funded and administered insurance.

In recent years, progressives have expressed renewed interest in public ownership of health care delivery itself, since entrepreneurial groups (e.g., private equity) entering the provider side have diverted payments for care to their own financial gain. In effect, progressive interest has expanded from universal public insurance as in Canada, to public ownership of the delivery system through a national health service such as the British NHS, valued since post-WWII.

Yet now both Canadians and the British are having problems with their public programs. A critical factor in both nations is ongoing political conflict over the proper role of government versus private sector in health systems. Patients who have great medical needs may find a public system to serve their interests very well by assuring that health care is always affordable. However, individuals with health care costs that are not personally burdensome may prefer to pay less in the taxes that make health care accessible and affordable for everyone.

In all nations and to varying degrees, voters align as either conservatives or progressives. When one of the political interests gains control, as with UK Conservative rule 2010-2024, the NHS suffered budget stasis and privatization. This conflicted with the core NHS goal of ensuring health care for all, regardless of personal financial means. This period of NHS austerity markedly damaged it, as noted in the YouTube and report above.

The lesson for US progressives is that when we propose either single payer or a national health service, it is imperative to create policies and controls that will ensure the maintenance of public programs regardless of the political control of the moment. The ordeal that the British are suffering to recover and repair their health care system demonstrates the consequences of failing this protection. The Conservatives took an electoral drubbing in part due to NHS problems, but the price to patients has been very high.

Recently we discussed a poll commissioned by Bernie Sanders demonstrating that views on public coverage of health care are more consonant across political divides than people realize. Wouldn’t it be amazing if individuals of all political persuasions could join and agree on a system that assures that we all have the health care that we need?

Realistically, we face challenges.

Major party politics in the US have shifted from a conservative-progressive spectrum to a narrower conservative-neoliberal spectrum. This reflects a Democratic understanding that more moderate political positions would be more appealing to voters. An example is the current US presidential election wherein one candidate remains conservative while the other has shifted from a progressive to a neoliberal political position, certainly on health care. We must empower progressive positions, as happened substantially (but insufficiently) under President Biden.

The progressive tax policies needed to power a government-run health care system appear to conflict with the wealth-enabling tax policies of conservatives and neoliberals. Yet, compared with the extremely progressive tax rates following WWII, the progressivity required for single payer is modest. Perhaps there’s a middle ground, whereby the already financially well-situated can continue to grow their wealth, albeit more slowly, while growing health and social cohesion via public insurance.

We should set limits on wealth accumulation, when it is at the expense of social welfare. Do we really need rockets that carry rich people to outer space? Real estate tycoons making fortunes while leaving people living in the streets? Trillionaires? Government and courts controlled by the wealthy?

What is a reasonable social contract? We believe that the wealthy have ample opportunity in this free market world to maintain and build their wealth. It’s time for a robust social contract that ensures that we meet health care and other social needs. Humanity and wealth can co-exist.

From a political perspective, can we mend divisions and work together on policies that serve our collective well-being? We need to be nimble as we pursued the very lofty goal of achieving health care justice for all, as a social consensus, robust across political fluctuations.

https://healthjusticemonitor.org…

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

Medicare for All Explained Podcast: Episode 115

The Advantages and Disadvantages of Electronic Health Records

September 15, 2024

Podcast host Joe Sparks discusses the pros and cons of electronic health records (or EHRs) within the context of our profit-driven health care system.

“Instead of focusing on patient care,” he says, “the EHRs are focused on billing.”

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

https://medicareforallexplained.podbean.com

Health Policy Issues in the Presidential Race

Donald Trump would replace the ACA, he says, but with what? His past proposals suggest ACA and Medicaid tightening. Kamala Harris would strengthen the ACA, she says, and limit out-of-pocket drug costs in Medicare and beyond. Neither supports single payer.

The “Concept of a Plan” President Trump Proposed to Replace the ACA, KFF QUICKTAKES, September 11, 2024, by Larry Levitt

When asked in the debate whether he had a replacement plan for the Affordable Care Act, former President Donald Trump said he had the “concepts of a plan.”

If you look at Trump’s record as president, there is truth in that statement. He did, in fact, propose the concept of an ACA replacement plan in his 2020 budget, though it has never gotten much attention.

Trump’s conceptual ACA replacement plan would have repealed the ACA’s premium subsidies and Medicaid expansion, replacing them with a block grant to states. It also would have capped federal Medicaid spending. All told, Trump’s plan would have reduced federal spending on the ACA and Medicaid by over $1 trillion over a decade.

Trump also proposed providing “relief” from the ACA’s “insurance rules and pricing restrictions.”

Trump has long talked about making the ACA less expensive, but the question is less expensive for whom. Trump’s past proposals would certainly have made the ACA less expensive for the federal government, but with the trade-off of higher out-of-pocket premiums for people, more uninsured, and higher spending and greater risk for states.

Polling: Harris v. Trump on Key Health Care Issues, KFF, September 10, 2024, by Ashley Kirzinger, et al.

How Voters Are Prioritizing Health Care Issues in 2024: The economy and inflation continue to dominate the list of issues that voters are focusing on during this year’s presidential election with four in ten voters (38%) saying it is the most important issue determining their vote in the 2024 presidential race. Following the economy is threats to democracy (22%), immigration and border security (12%), then several individual health care issues including: abortion (7%), Medicare and Social Security (7%), and health care costs including prescription drugs (5%). Altogether, health care issues are seen as the most important issue by about one in five voters (19%). Gun policy (3%) and the war between Israel and Hamas in Gaza (2%) rank the lowest among the issues included in the list provided to voters.

Voters Want to Hear Candidates Talk About Lowering Health Care Costs: An indication of how the economy and health care consistently overlap for voters, economic concerns also rear up when voters are asked what health care issue they most want to hear the candidates talk about. Across partisans, the recurring theme is costs. Responses related to health care costs are offered by four in ten (42%) Democratic and Democratic-leaning independent voters when asked to say in their own words what is the one health care issue they would most like Vice President Harris to talk about. This includes voters who mentioned general health care costs (20%), prescription drug costs (15%), and the cost of insurance or reducing their monthly premiums (6%). About one in seven offered abortion as the one health care issue they want Harris to talk about and 13% mentioned universal health care – an issue that was largely debated during the 2020 Democratic primaries.

Comment:

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

Health issues are fairly high profile In this presidential campaign – collectively, the most important issue for one in five voters. Abortion is seen as the leading election issue for 7% of voters. Medicare & social security (combined, oddly in my view) are also at 7%, and health care costs are at 5%.

Trump proposes to replace the ACA with something TBD cheaper and better. His actual approach, per his 2020 federal budget request, seems to be repealing ACA premium subsidies and Medicaid expansion, placing these programs into state block grants. Which would cut federal costs by >$1 trillion over 10 years. Also, end the ACA’s “insurance rules and pricing restrictions.” This is all consistent with Project 2025, as summarized in HJM. He waffles on abortion, but is largely seen as a threat to abortion rights.

Harris aims to strengthen the status quo. She proposes to strengthen the ACA: to make permanent COVID subsidy increases and fix a “family glitch”. For drug prices she favors accelerating Medicare drug price negotiations, and extending two caps in Medicare ($35 insulin copay and drug out-of-pocket total) to the entire population. She wants to end drug companies blocking competition and abusive practices of drug intermediaries. She avidly supports abortion rights.

See a side-by-side comparison here.

Drew Altman notes that the “do not mention” program is Medicaid, since Medicare and the ACA are considered higher priority for voters. Yet the consequences for Medicaid are substantial, per above.

Of course, Medicare for All / single payer gets no favorable mention – despite its ability to sharply reduce health care costs for families, a leading concern of voters. Instead, it is used by Trump to attack Harris since pre-2020 she endorsed Bernie Sanders M4A bill. Don’t expect Harris to return to single payer. But if state reform efforts, such as currently in Oregon and California, are to garner federal regulatory cooperation (“waivers”), a Harris administration may be more flexible.

https://healthjusticemonitor.org…

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

Incredible (Terrible) Shrinking Physician Supply

Waiting times for physician appointments are growing. The immediate cause is contraction of the physician workforce. The root cause is clinician burnout, in large part due to fragmented insurance and resulting make-work inefficiencies. Single payer will help.

Health shrinkflation: Patients wait more for less, Axios, September 3, 2024, by Tina Reed

The U.S. spends more on health care than almost anywhere else. But increasingly patients are getting less in return, and enduring long waits to get not as much face-time with their clinician.

Why it matters: Shrinkflation is hitting a sector that accounts for almost one-fifth of the economy, eroding the doctor-patient relationship and leaving many turning to urgent care clinics or telehealth services.

  • Some who can afford it are gravitating to concierge practices that offer fewer hoop jumps and more add-on services with office visits.

The latest: The trend is being felt especially in primary care, but also in many specialties.

  • An Axios-Ipsos survey last month found that nearly one in five respondents said they had to wait more than two months to see a primary care physician or specialist, with waits trending longest in the Midwest.
  • NYC Health + Hospitals recently told primary care doctors to cut appointment times in half to 20 minutes, in order to squeeze in more patients, Gothamist reported.
  • A spokesperson told Axios that the public health system is grappling with 50,000 more primary care patients who’ve been added since 2021. The average number of days to the third next available appointment jumped from 12 days to 22 days.

By the numbers: 17% of patients had to wait one to three months for their latest doctor’s appointment, per electronic health records company Tebra.

  • The most frequently cited specialties with long wait times included neurology (26%), ear, nose, and throat (26%), psychiatry (20%), and OB/GYN (17%). Primary care stood at 19%.
  • 43% of patients reported experiencing longer wait times for appointments since the pandemic, per the Tebra survey.
  • The surge in demand for in-person care since the crisis has been well-documented. AMN/Merritt Hawkins found that the average wait time for a physician appointment in 15 large metro markets surveyed in 2022 was 26 days, up from roughly 24 days in 2017, and about 21 days in 2004.

The big picture: This is what shrinkflation in healthcare looks like as the industry struggles with supply and demand issues, Robert Pearl, a Stanford University professor and former CEO of The Permanente Medical Group, told Axios.

  • There’s been across-the-board growth in patient volumes largely from pent-up demand for services many put off during the pandemic.
  • At the same time, tens of thousands of doctors have left the field due to burnout and other factors, and surveys indicate even more plan to retire early.
  • Red tape around insurance and rising out-of-pocket costs are leaving patients frustrated and confused, and in some cases burdened by more medical debt.

“You’re paying actually more for your health coverage, but you’re not getting more. You’re actually getting less,” Pearl said.

Comment:

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

The physician supply is steadily contracting, especially in primary care. This lengthens waits for clinical visits, not to mention the challenge of finding a new provider. Each year we pay more in premiums and cost-sharing, yet we suffer increasing challenges getting the care we need.

What’s going on? This tightening of physician supply reflects some simple math: more individuals leave clinical medicine than new trainees enter. Increasing the number of mid-level providers, like nurse practitioners, is a viable and valuable option. However, the physician flow dynamics remain critical. And recent trends are not encouraging:

This is ongoing: 7% of physicians left the workforce in 2021 and 2022. Nearly 1 in 4 physicians stated an intention to leave practice within two years. Long-term projections for physician supply are dire.

Why are so many doctors leaving? The short answer is growing burnout:

And why the burnout?

  • Too many bureaucratic tasks (eg, charting, paperwork): 62%
  • Too many hours at work: 41%
  • Lack of respect from administrators / employers, colleagues, staff: 40%
  • Insufficient compensation: 38%
  • Lack of control / autonomy: 32%
  • Full list here

All of these causes reflect, in substantial degree, our fragmented insurance system and the central role of for-profit insurers and provider groups. Here’s how single payer would help with each:

  • Reduce bureaucracy: eliminate an hour/day of billing & insurance-related tasks done by physicians.
  • Reduce hours at work: less time on bureaucracy; more providers especially in primary care.
  • Build respect: bolster the clinical role of physicians, and foster clinician-run practices.
  • Correct compensation inequities: Increase payment rates for primary care.
  • Build autonomy: make clinician-run practices more financially and administratively viable.

Single payer isn’t a magic potion for physician emotional well-being. But it is a viable framework to build clinical focus and autonomy, and to foster equity among specialties (and of course among populations groups). It is the only way to break out of our burnout quagmire.

https://healthjusticemonitor.org…

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

“Shocking”: Experts warn “irresponsible” Project 2025 Medicare proposal would harm seniors

"We've invited for-profit corporations to drain the Medicare Trust Fund … and we overpay them to kill people"

By Cara Michelle Smith
Salon, September 3, 2024

Something still haunts Ed Weisbart, MD, from his days in the health insurance business.

It was 1999, and Weisbart was the medical director of a Chicago medical group that managed care for more than 140,000 people. The enterprise was running like a well-oiled machine — until one day, a man presented with a rare blood clotting disorder that would cost the company $1 million a year to treat. At that sum, one of its regional offices would likely go out of business.

Weisbart caught himself entertaining dark thoughts. What if the company just gave this guy the cold shoulder? Could they simply not answer his calls? These were “paper records days,” he said — in theory, the company could lose his medical records. If he showed up at the office to meet with anybody, maybe they could make him wait an hour or two.

“And then, what? He would complain to us, and say this used to be a good office, and it’s not anymore – I’m going to go somewhere else,” Weisbart said. “And I would be thinking, I won.”

Weisbart never acted on any of these impulses, he said, nor did he tell anybody about those thoughts until years later. The office didn’t go out of business, either, and the man received his treatments. But the temptation toward corruption left a deep impact.

“It’s haunted me ever since,” Weisbart said. “I consider myself a generally ethical patient advocate, and yet, I was so corrupted by the finances of the system that I was actually developing schemes to make a very sick person not want to get health care with us. And isn’t the point of a health care system that you should want to get health care?”

Today, Weisbart is the national secretary for Physicians for a National Health Plan (PNHP), an advocacy group representing more than 25,000 physicians who support a national health insurance plan and oppose a profit-driven health insurance system in which companies can choose profits over patients. That system’s interests are at the heart of a stunning Medicare proposal in Project 2025, the Heritage Foundation’s 900-page right-wing agenda for a second Trump administration that experts say would harm patients while enabling insurance companies to funnel billions of dollars in desperately needed funds from the Medicare program.

“It’s kind of shocking, when it comes to how irresponsible it is,” Andrea Ducas, vice president of health policy at the Center for American Progress, told Salon of Project’s 2025 proposed change to Medicare. “It’s emblematic of a desire to, essentially, increase corporate power.”

Project 2025 proposes making Medicare Advantage, as opposed to traditional Medicare, the default plan for all enrollees. Medicare Advantage has been around for decades; it was signed into law in 1997 as part of a bipartisan reform bill to balance the federal budget. Under Medicare Advantage, insurance companies offer plans that cover Medicare benefits. In turn, Medicare pays the insurance companies based on an estimate of an individual’s annual health care costs.

In theory, the Medicare Advantage program was supposed to help the government benefit from the private sector’s efficiencies. In practice, many insurers overcharge the federal government hundreds of billions of dollars in inflated estimates, often by adding diagnosis codes that make individuals appear sicker on paper than they are in reality. MedPac, a nonpartisan Congressional advisory committee, estimates that in 2024, inflated estimates will translate to $50 billion in overpayments. An analysis from PNHP, published in 2023, estimates that Medicare overpays insurers by as much as $140 billion per year.

In one analysis of Medicare Advantage data, The Wall Street Journal found that between 2019 and 2021, individuals enrolled in Medicare Advantage through UnitedHealth were roughly 15 times as likely to be diagnosed with diabetic cataracts than traditional Medicare beneficiaries. Payments to insurers for diabetic cataracts totaled $700 million in that period; most diagnoses were added by the insurers.

“The plans will get more for people who are more sick, so there’s significant incentive for the plans to make their enrollee population appear as sick as possible,” David Lipschutz, co-director of the Center for Medicare Advocacy, told Salon.

According to an analysis from Lever, an investigative newsroom, the private insurance giant Humana — one of the largest providers of Medicare Advantage plans — recorded $2.8 billion in profits in 2022. Without federal government overpayments into Medicare Advantage plans, though, Humana may have lost nearly $900 million that year.

“We overpay them to kill people”

Outside those abuses, Medicare Advantage doesn’t offer a better patient experience. In many instances, it can be worse.

Medicare Advantage beneficiaries are often limited to a smaller provider network, deal with more prior authorizations and are more often “inappropriately denied approval for necessary health care,” according to PNHP. In 2022, KFF found that those enrolled in Original Medicare were more often treated in higher-rated specialty healthcare facilities than those in Medicare Advantage.

Those consequences don’t exist in a vacuum: Medicare Advantage patients undergoing surgeries for certain liver, pancreas and stomach cancers had higher mortality rates than similar patients on Original Medicare, according to PNHP.

“We’ve created a system where we’ve invited for-profit corporations to drain the Medicare Trust Fund . . . and we overpay them to kill people,” Weisbart said.

A broader implication for the conservative movement

That Medicare Advantage’s patient harms are so well-documented, and that Project 2025 recommended that the plan replace Original Medicare, may belie a core truth of the modern American conservative movement, Kim Phillips-Fein, a historian and professor at Columbia University, told Salon.

“A lot of the less-visible parts of the project are going to wind up reinforcing economic inequality,” Phillips-Fein said of Project 2025. “They talk one way, but are very likely to govern another.”

Much of today’s modern conservative movement is rooted in the business community’s antagonism against the New Deal, Phillips-Fein said, which ushered in what corporate stakeholders saw as a large labor movement that threatened business interests. But by promoting a health care plan proven to harm individuals, Project 2025’s Medicare Advantage proposal — as well as the broader Project 2025 agenda — suggests that corporate interests aren’t just a component of the American conservative movement. Rather, it suggests that those interests are at the core of the movement — even at the known harm of the American worker.

“It’s just telling that you’ve got an authoritarian playbook that sort of, at every pass, seems to be more focused on driving up corporate profits at the expense of the American people,” Ducas said.

Reinvesting “the giant bag of cash” in traditional Medicare

Medicare Advantage was pitched as a private market solution to traditional Medicare. It exists because of the flaws of traditional Medicare. But experts say Medicare Advantage’s own shortcomings present a timely opportunity for the program to reign in fraudulent spending and reinvest funds into the original program.

“We can take these significant and wasteful overpayments, reinvest them into the Medicare program . . . and that rising tide would help all Medicare beneficiaries, because that would then become a new baseline,” Lipschutz said.

One badly needed reform? Adding an out-of-pocket cap to traditional Medicare plans. With no limit on out-of-pocket spending, beneficiaries can spend more than $5,000 per year on premiums. In 2018, those enrolled in traditional Medicare spent an average of $6,168 per year on premiums and services.

Another area ripe for reform: covering vision, dental and hearing under traditional Medicare, Ducas said. Under the current program, Medicare enrollees have to purchase a supplementary plan that covers the above health care as well as an extra plan known as Medigap, which reduces out-of-pocket costs associated with Medicare and the supplemental coverage.  On average, Medigap monthly premiums can range from $50 to more than $300.

Without reform to Medicare Advantage, the broader Medicare program is projected to overpay insurers by more than $7 trillion over the next ten years, according to the Department of Health and Human Services.

“As it would happen, there is a giant bag of cash we are, right now, throwing every year at Medicare Advantage plans,” Ducas said. “If we took that waste out . . . you could get to that reform future. That’s what excites me.”

https://salon.com…