PNHP

Failure of Nursing Home Safety Monitoring

Failure of Nursing Home Safety Monitoring

Summary: NY Times research found a huge gap between safety problems found in nursing homes and the public reporting of those problems. Quality star ratings are misleading. Consumers are not being protected.

How Nursing Homes’ Worst Offenses Are Hidden From the Public, New York Times, Dec. 9, 2021, by Robert Gebeloff, Katie Thomas, and Jessica Silver-Greenberg

A New York Times investigation found that at least 2,700 similarly dangerous incidents were also not factored into the rating system [Care Compare] run by the federal Centers for Medicare and Medicaid Services, or C.M.S., which is designed to give people reliable information to evaluate the safety and quality of thousands of nursing homes.

Oklahoma’s inspections agency referred to nursing homes as its ‘clients,’ according to a letter from the agency reviewed by The Times. Inspectors in Pennsylvania complained about being told to be ‘kinder and gentler’ with nursing homes, according to the 2013 survey. Last year, in the depths of the pandemic, the California department of health told inspectors to act as safety “consultants” to nursing homes and to not take on an enforcement role. (The policy was scrapped after inspectors objected.)

Jonathan Blum, the chief operating officer for C.M.S., said that citations are omitted during state-level appeals to be fair to nursing homes that are disputing inspectors’ findings. He acknowledged that even after appeals are exhausted, some citations still don’t appear on Care Compare. He said C.M.S. is ‘working to correct this issue.’

The Times asked public health agencies in all 50 states how often citations were upheld, reduced in severity or deleted entirely since 2016. Eighteen states provided figures. About 37 percent of the time, the nursing homes succeeded in getting citations removed or reduced in severity.

Studies have found that federal inspectors tend to find more serious problems than their state counterparts during these examinations. But the Medicare agency does not publish the reports of its own inspectors — even when they turn up dangerous or deadly conditions — or factor them into homes’ star ratings.

http://healthjusticemonitor.org…

Comment:

By Allison K. Hoffman, J.D.

The COVID-19 pandemic revealed the depths of problems in U.S. nursing homes, but it is also clear that nursing homes have had serious deficiencies leading up to the pandemic. Worse, even when these problems are uncovered, they are sometimes later buried. There are many reasons why nursing homes became an epicenter for the pandemic, but one has been well illuminated by recent New York Times reporting: the failure of regulatory monitoring and reporting systems, including Care Compare and star ratings, which were intended to reflect nursing home quality.

These types of ratings systems are part of a consumerist turn in health care, based on the idea that with all the right information, patients will be able to navigate the system to choose among care providers and balance things like quality and price. There are many flaws in these assumptions. The N.Y. Times reporting over the past year shows that one necessary piece of the consumerist model is completely lacking: the quality of information to inform decisionmaking. This article, in particular, illuminates the fact that even after major problems were uncovered in surveys and inspections, nursing homes had too many tools to keep those problems from coming to light and eventually making it into Care Compare. The problems don’t harm their star ratings – a scale from 1 to 5 that is supposed to—but often fails to— indicate nursing home quality.

The failure of these ratings to capture what is actually happening in settings where residents often cannot advocate for themselves is tragic. When the faults in such a system intersect with a pandemic, people who think they have chosen quality nursing homes for loved ones learning that they are tragically wrong.

Even the best nursing homes went through extremely trying times over the past two years. But some nursing homes began this period in a state of poor oversight, management, staffing, and operations that never should have been tolerated.

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.

There’s a Revolution Happening in Harm Reduction for Drug Users. Can Our Broken Health Care System Handle It?

In the face of unprecedented opioid overdose deaths, the people most at risk can’t reliably access care—including life-saving treatments like methadone and buprenorphine.

By Laura Weiss
The New Republic, December 17, 2021

After decades of efforts by advocates fighting in the trenches of America’s ongoing opioid crisis, harm reduction is finally having its day. Late last month, New York City opened the doors of its first supervised injection sites, or overdose prevention centers—the first such facilities in the nation. On day one, the staff saved two people’s lives.

It’s taken a long time for supervised injection sites to open, mainly because they operate in a legal gray area. But overdose deaths have reached record levels because fentanyl, a painkiller 50 times more potent than heroin, is increasingly being laced into heroin supplies and putting users at unprecedented risk of overdosing. The fallout of the Covid-19 pandemic hasn’t helped: In 2021, a record-breaking 100,0000 people have died from drug overdoses in the United States.

Overdose prevention centers give participants a safe place to use, under supervision of medical staff who have clean needles and naloxone on hand, as well as equipment to test drugs for fentanyl. These centers also provide resources for health and social services, including treatment for substance use disorders.

Harm reduction “used to be a totally taboo subject,” according to Maritza Perez, director of the Office of National Affairs at the Drug Policy Alliance. Now, she says, more people are recognizing that harm reduction “actually meets people where they are at and [does] work to save lives and ultimately hopefully connect people to health services.”

Joe Biden has become the first U.S. president to speak publicly in favor of harm reduction, after decades of failed enforcement policies that purport to police their way out of a public health issue. Last week, the Substance Abuse and Mental Health Services Administration announced the first round of federal grants for harm-reduction programs. There are efforts on the Hill to make it easier to access drug treatment, which the Biden administration has already made some effort to relax. However, the administration stopped short of explicitly endorsing the overdose prevention centers.

“It’s a promising time,” said Dr. Bruce Trigg, a longtime harm-reduction and addiction medicine doctor who works with the Bronx-based St. Ann’s Corner of Harm Reduction. “But the crisis is worse than it’s ever been.” Since Thanksgiving, two patients at his facility have overdosed.

The depth of the opioid epidemic—and the graveyard of overdose deaths it has produced—has forced the administration to admit that the status quo doesn’t work. Even tepid acknowledgments that there might be something to harm reduction is a huge step. But it’s only a small part of the effort to shift drug policy from the purview of the criminal justice system into the public health sphere.

In order to take a larger step toward solving the overdose crisis, we must face the failures of our health care system. People at higher risk of developing an opioid use disorder—including those with chronic physical and mental health conditions and trauma, uninsured people, and low-income communities of color—face barriers to life-saving comprehensive medical care. Legal restrictions add further barriers, subjecting those with opioid use disorder to a dizzying, fragmented maze of coverage plans and regulations. The opioid epidemic can’t be fully overcome without a new approach to our privatized insurance and health care system.

Our current system makes it extremely difficult to access effective treatment. While nearly two million people report having an opioid use disorder in the U.S., less than 10 percent of those who need treatment are receiving it. Although a 2008 law that sought to require most insurance plans to include substance use and mental health treatment was strengthened by the Affordable Care Act and Medicaid expansion, the definition and application of that treatment has varied widely in practice. Notwithstanding the millions of people without insurance, those with Medicaid or private insurance face a daunting patchwork of networks, authorizations, and requirements to access covered care.

The use of evidence-backed medications, particularly methadone and buprenorphine (brand name Suboxone), to treat opioid dependence is a vital tool in the fight. Most state insurance plans cover buprenorphine and naltrexone, but just over half cover methadone, according to a trove of data from the Prescription Drug Abuse Policy System. Less than two-thirds also include coverage for behavioral health services related to opioid use disorder. (The majority of private rehab centers don’t use medication.)

Those with private plans are by no means better off. Only eight states require commercial insurance to cover medication-based treatment for opioid use disorder. And about a fifth of adults with an opioid use disorder are uninsured, making them particularly vulnerable to overdose and death.

Moreover, private insurance coverage restrictions differ from state to state and plan to plan, forcing doctors and billing staff to dedicate massive amounts of time to determine who and what is in-network and who and what is out. Participants are limited by age, number of refills, quantity of pills, and cost caps and are usually subject to prior authorization requirements. Some insurance companies will only cover certain clinics or only portions of the costs. Trigg called the requirements “complete nonevidenced bullshit.”

Methadone, which has been highly successful in helping people stop heroin, can only be dispensed at specialized clinics and often requires people under its treatment to spend hours every day for dosing and supervision, explained Trigg. That burden is such that two of Trigg’s patients dropped out of their methadone programs during Covid-19. “They had children and jobs, and couldn’t go every day,” he said. Both have since relapsed.

“The system used to look for excuses not to treat people. Now we should be bending over backward to get anyone into treatment who wants it,” said Trigg.

Buprenorphine, for its part, may be more promising in providing low-threshold treatment to patients. It’s safer than methadone because it’s nearly impossible to overdose on, and some patients prefer it because it’s less sedating and less disruptive to life. It can be prescribed in a primary care setting by any prescribing health professional with the appropriate waiver. Getting that waiver used to require doctors to attend an eight-hour training, but that requirement has been dropped in a bid to get more doctors to agree to treat people with opioid use disorders, explained Dr. Daniel Alford, a primary care physician and director of the Safe and Competent Opioid Prescribing Education, or SCOPE of Pain, program at the Boston University School of Medicine.

Still, just 7 percent of primary care providers have that waiver. Due to the stigma that people with addiction are untrustworthy, volatile patients, many doctors don’t want the responsibility. But for Alford, prescribing buprenorphine is one of his most rewarding experiences as a doctor. “People with opioid use disorder who you start on buprenorphine, oh my God,” he said. “They’re no longer in withdrawal, they’re able to focus on other things, I mean, it’s just remarkable.”

Unfortunately, access to buprenorphine is often segregated along racial lines. Studies have shown that Black and Latinx communities have more facilities that provide methadone per capita, while white communities have more access to buprenorphine, the newer and less disruptive medication treatment option. “The same disparities that you see in the health care system are prevalent when we’re talking about people with substance use disorder,” said Perez.

In addition to medication-assisted drug treatment, the widespread use of naloxone, the overdose-reversing drug, is key to ending opioid overdoses. But as demand for naloxone has skyrocketed, so has price gouging from pharmaceutical companies. While you used to be able to get a dose of Narcan for $2.50, it can now cost up to $75 or more. And while Purdue got a slap on the wrist for its role in starting the opioid crisis, its malfeasance has continued: Beyond price gouging naloxone, it also marketed fentanyl in the parts of the country hardest hit by the crisis.

“The pharmaceutical industry has total control,” said Trigg, who is also a board member with the Physicians for a National Health Program. “As a result, we either have to give out less naloxone, or health departments and public agencies that pay for it have to cut back on other things.”

The rampant profiteering and fragmentation of care isn’t limited to drug treatment. The lack of comprehensive, affordable, and quality mental and physical health services has also spurred addiction, especially among groups who are most at risk of developing an opioid use disorder—uninsured people, those with mental health conditions and/or past trauma, and people suffering from chronic pain.

Research has shown that mental health conditions and substance use disorders are often comorbid: Up to half of those who have a mental illness in their lives will also experience an addiction, according to the National Institute on Drug Abuse. Despite the law that mental health and drug treatment must be covered by insurance, networks are limited, and behavioral health specialists, especially those who are able to prescribe medication, are often not taking new patients.

A 2019 study by the National Alliance for Mental Health showed that behavioral health visits are five times more likely to be out of network than an appointment with a primary care provider. These inadequate networks “effectively discriminate” against people needing this care, concluded the report.

Trigg said that he’s had so much trouble finding a psychiatrist for his patients, even though they all have Medicare, that he’s resorted to prescribing them antidepressants himself, even though it’s outside his specialty. Many of his patients have also had bad experiences with mental health professionals who treat them with scorn and mistrust.

The role of trauma in fueling addiction is another reason why access to affordable behavioral health care is so important. As addiction researcher Gabor Maté put it in a recent article in Yes! magazine: “We have a social structure that induces trauma in a lot of people. Therefore, it induces escapist, addictive behaviors.” And when accessing health care adds to that trauma rather than addressing it, it makes people less likely to pursue it in the future.

The lack of coordination between mental and physical health care and the fragmentation of our system contribute to the cycle of self-medication. As Trigg posited: “How many people have a primary care provider who they can talk to, who asks about depression and substance use?”

Among those who do have a doctor, few feel comfortable talking about their drug use. Alford said that some doctors he’s worked with to train them on appropriate prescribing practices for opioids have gone so far as to “fire” their patients when they’ve tested positive for drugs. This, of course, is a time when those patients need care more than ever.

“Many people may not feel comfortable going to a medical provider because they might face criminal repercussions or discrimination, and we know that that typically happens to Black and brown people,” said Perez.

Alford led a 2016 study that found that a whopping 87 percent who tested positive for drugs or heavy alcohol use had chronic pain. And 81 percent of those who misused a prescription drug did so to self-medicate. The 2019 National Survey on Drug Use and Health reported that two-thirds of people who last abused a prescription were also trying to relieve pain. The majority got the drugs from a family member or friend—just 7 percent bought them off the street.

These figures “speak to the complexity of managing chronic pain and also the lengths that people will go to relieve that suffering,” said Alford.

For patients without a trusting relationship with a primary care doctor who helps coordinate their care, it can be much easier for a provider to prescribe painkillers than to look comprehensively at the root of preexisting health problems that cause pain. (It’s important to note that opioids do have legitimate medical uses. “There is no question that there are patients who are more functional because they’re able to get this one type of medication, and they’re taking it as prescribed, and they’re doing just fine,” says Alford.)

There are other treatments for pain, pharmacological and otherwise, that can help people manage their symptoms. Many of these—such as cognitive behavioral therapy, massage therapy, acupuncture, lidocaine injections, and nerve blocks—are often not covered by insurance. Moreover, new medications can be exorbitantly expensive; insurance companies often refuse to cover them.

It’s no surprise, then, that many have plunged into medical debt, which only exacerbates the impact of opioid use disorders among the same at-risk groups: low-income individuals, the uninsured, and people with chronic medical conditions, according to the Kaiser Family Foundation.

Doctors can’t help their patients when they’re spending a prodigious amount of time fighting with insurance providers. According to a 2018 doctors’ survey, nearly a third of doctors reported spending 20 hours or more a week on paperwork. It’s well documented that patients who spend more time with their doctors have better health outcomes, but our health care system incentivizes doctors to see as many patients as they can as quickly as possible and then turn to the giant stack of prior authorizations on their desks.

In short, there is no way to address the opioid crisis—both in terms of treating people with opioid use disorder as well as caring for people who could develop it—without massive reforms. A good first step would be the creation of a national formulary for pharmaceuticals, which would enshrine one set of rules that could apply to everyone, freeing doctors and staff from having to comprehend the intricacies of each individual plan’s coverage. Biden recently introduced a prescription drug–pricing framework as part of the Build Back Better bill, which, if passed, would help address big pharma’s profiteering of life-saving medications.

Harm reduction is an important step in the right direction of shifting our drug policy from a criminal justice to a public health lens. But acknowledging that drug users deserve not to die is really only the barest of minimums. We need to go further to meet the scale of the crisis, through a single-payer system that would take profit out of the health care system entirely. Given the scale of the crisis, any harm-reduction policy must prioritize making mental and physical health services, including treatment, accessible to all.

“The pivot to harm reduction in both Congress and the administration is fantastic, but it’s not enough,” said Perez. “We need to use every tool at our disposal, and go big.”

https://newrepublic.com…

COVID Stumble: US Politics, Vaccine Hesitancy, & Mortality

Summary: On Monday we posted on how well Taiwan dealt with COVID; today, one way the US fell sadly short. NPR reports that COVID mortality is 3 times higher in heavily Trump than heavily Biden counties – due to lower vaccination rates, in turn due to misinformation and vaccine hesitancy. Thus political division and distortion of science are deadly.

Pro-Trump counties now have far higher COVID death rates. Misinformation is to blame, NPR Morning Edition, December 5, 2021, Daniel Wood and Geoff Brumfiel

Since May 2021, people living in counties that voted heavily for Donald Trump during the last presidential election have been nearly three times as likely to die from COVID-19 as those who live in areas that went for now-President Biden.

NPR looked at deaths per 100,000 people in roughly 3,000 counties across the U.S. from May 2021, the point at which vaccinations widely became available. People living in counties that went 60% or higher for Trump in November 2020 had 2.73 times the death rates of those that went for Biden.

In October, the reddest tenth of the country saw death rates that were six times higher than the bluest tenth…

The data also reveal a major contributing factor to the death rate difference: The higher the vote share for Trump, the lower the vaccination rate.

Recent polling shows that partisanship is now this single strongest identifying predictor of whether someone is vaccinated. Polling also shows that mistrust in official sources of information and exposure to misinformation, about both COVID-19 and the vaccines, run high among Republicans.

It was not always this way. Earlier in the pandemic, many different groups expressed hesitancy toward getting vaccinated. African Americans, younger Americans and rural Americans all had significant portions of their demographic that resisted vaccination. But over time, the vaccination rates in those demographics have risen, while the rate of Republican vaccination against COVID-19 has flatlined at just 59%, according to the latest numbers from Kaiser. By comparison, 91% of Democrats are vaccinated.

Being unvaccinated increases the risk of death from COVID-19 dramatically, according to the CDC. The vast majority of deaths since May, around 150,000, have occurred among the unvaccinated, says Peter Hotez, dean for the National School of Tropical Medicine at Baylor College of Medicine.

While vaccine hesitancy exists in many different groups, Hotez suspects that the deaths are “overwhelmingly” concentrated in more politically conservative communities. “How does this make sense at any level?” he asks. …

Republicans are far more likely to believe false statements about COVID-19 and vaccines. A full 94% of Republicans think one or more false statements about COVID-19 and vaccines might be true, and 46% believe four or more statements might be true. By contrast, only 14% of Democrats believe four or more false statements about the disease.

Comment:

By Gregg Gonsalves and Robert Heimer

This is an interesting look by NPR at vaccine hesitancy, COVID-19 conspiracy thinking and its impact on pandemic mortality by political affiliation. Similar trends have been noted in the New York Times, by the Kaiser Family Foundation and researchers.

However, many of these stories have put the onus on individuals, neglecting to mention or downplaying the notion that it is elected officials, at the state and local levels, who have downplayed and even legislated against epidemic control measures that promote or require masking, testing, or getting vaccinated. The focus on individuals completely neglects the structural determinants of health.

What would be more informative to see would be an analysis of the statements of local and state officials who, aligning with the anti-science attitudes of President Trump, instituted policies at these levels of jurisdiction, and how these policies led to increased COVID-19 mortality. We would assume—and let’s put it to the test—that these factors might have a stronger relationship with mortality than simply voting patterns in the last election.

However, such a simple analysis is likely to miss one of the key features of the cumulative mortality of the COVID pandemic. In the first months of the pandemic, as we were accumulating knowledge about SARS-CoV-2 transmissibility and severity, especially in specific populations, the first places where the virus spread were hit hardest. These include very blue regions of the country. What is disappointing is that the lessons learned there were dismissed in more red regions, perhaps in part because the lessons came from blue states.

http://healthjusticemonitor.org…

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

Medicare for All Explained Podcast: Episode 68

Interview with Scott Desnoyers

December 15, 2021

Single-payer activist Scott Desnoyers tells the story of his son Danny, whose loss of critical medication after a $20 missed premium payment led to his tragic death by suicide.

“I’m on a mission to make our politicians look me in the eye,” says Scott. “They must understand that when they support the for-profit system that we have now, they’re supporting murder.”

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

https://medicareforallexplained.podbean.com

School Approves Health Reform Club After Med Student Sues

By Donavyn Coffey
Medscape, December 14, 2021

A medical school has changed its tune about a controversial student club after being sued for initially rejecting the group. As of this fall, the Eastern Virginia Medical School (EVMS), in Norfolk, Virginia, will host one of the country’s newest chapters of Students for a National Health Program (SNaHP). The club was approved in August, 7 months after being denied by the student government and a day after a medical student sued the institution for viewpoint discrimination.

Just before Christmas break in 2020, Edward Si, a medical student at EVMS, applied to start a SNaHP chapter. He believed the application process was a formality. Registering through the student government would give the new SNaHP chapter access to school facilities, funding, and use of the university’s name. However, the application was denied.

According to the complaint filed in US District Court, the student government rejected the application, stating it did “not want to create clubs based on opinions, political or otherwise, and the mission and goals of [SNaHP] do not describe what we believe to be necessary or sustainable for a club.”

The club, which advocates for a single-payer healthcare system, had to fight for its newfound legitimacy on campus for 7 months before being approved.

EVMS did not respond to Medscape’s interview requests.

The EVMS roster of clubs raised questions about the university’s reason for denying his proposed group, according to Si. For example, Medical Students for Choice, LGBT-focused Alliance Group, and the Christian Medical and Dental Association, to name a few approved clubs, are all officially registered with the school, though they elevate specific viewpoints and take political stances on certain issues. To Si, it appeared the student government found some opinions more palatable than others.

Believing that his constitutional rights were being undermined, Si sought legal counsel and sued the school for viewpoint discrimination in August. The day after the suit was filed, EVMS approved the club.

Now, almost a year later, the club is actively advocating for a single-payer healthcare system on campus. But Si’s legal counsel says they’re continuing the suit until the school changes the policies that allowed for discrimination in the first place.

Organizers at SNaHP headquarters in Illinois say a student chapter has only been denied on one other occasion.

“This was really unusual for a university to deny a group of medical students the chance to develop an organization promoting health policy,” Clare Fauke, communications specialist for the organization, said.

First started in 2010, SNaHP now has more than 100 chapters across the country hosting educational activities, speakers, and seminars. They organize phone banks to call congressional leaders and lead street medic efforts, Fauke said. Many of these students go on to be members and leaders in SNaHP’s parent organization, Physicians for a National Health Program.

Long-time member and current president of Physicians for a National Health Program, Susan Rogers, MD, said, “I don’t know why they had to go to these lengths to get their org approved. I can only say that the political climate in this country has gotten so polarized that it would be remiss to think it didn’t trickle into universities.”

When he received the rejection letter from the student government in early January 2021, Si was initially disheartened. But then he read the email several times.

Si said he believed he might have been discriminated against or had his rights violated.

“That was more shocking than getting rejected in the first place,” he said.

EVMS doesn’t have a way to appeal a decision made by the student government, so Si texted a member of the student government about his concerns. They called Si to explain, but Si found their explanation insufficient. He would have to go above the student government to the administration. But before he could do that, he felt he needed protection and a legal expert who could explain the law.

Si reached out to FIRE, the Foundation for Individual Rights in Education. Attorneys at FIRE sent a letter to EVMS in February detailing their opinion on the student government’s alleged viewpoint discrimination.

“The first amendment protects the right to an opinion and the right to associate with others,” Jeff Zemen, one of the attorneys on Si’s case, explains in this video. “So EVMS can’t prevent the club because of its opinions.”

These kinds of First Amendment infringements are “often resolved before the need of a lawsuit,” Zemen later told Medscape. However, in response to FIRE’s letter, EVMS invited SNaPH to reapply, claiming they hadn’t submitted a constitution, a document establishing the club’s operating principles, the first go-round. Si and Zemen both say that was untrue, that Si did submit a constitution on December 20, 2020, and the initial rejection from student government didn’t mention any insufficiencies in SNaHP’s application.

Si emailed the vice president and general counsel on March 1, 2021, according to court documents, concerned that the administration had been misinformed to think SNaPH was denied based on an unfinished application. Si did reapply on March 8, 2021. The following week. FIRE sent a second letter notifying EVMS about the reapplication, but EVMS never responded, according to the complaint. In late March, the SGA vice president said SNaHP’s application wouldn’t be reviewed until the fall.

Born out of a grassroots movement and unattached to an undergraduate institution, EVMS has developed a reputation for going its own way. The school is known for eccentric traditions, like themed costumes for Match Day and the POETS (Piss On Everything, Tomorrow’s Saturday) student program, which hosts regular student-faculty Friday celebrations.

“They take pride in the fact that they are the most diverse school in Virginia,” Si said. “You must understand, I would have thought that a club like mine would have been accepted. In our curriculum, we talk about healthcare disparity. I would have imagined that we would have been encouraged.”

Rogers said, “I can only [imagine] that they think getting students together to advance single payer is threatening, but I don’t know why.”

According to Zemen and the complaint, the decision to block the SNaHP chapter came from the student government association ― a body of medical students who are supervised by EVMS Board of Visitors. As a result of their decision, Si and his cofounders “were unable to avail themselves of resources made available to other groups: funding, school facilities, use of school names,” Zemen said.

Despite Si’s attempts to counter the rejection, the decision held for months. Then, FIRE filed the lawsuit against the EVMS president and other officials on Tuesday, August 17. Si’s club was approved on Wednesday.

“It felt good finally being vindicated,” Si said. “I felt like it was over and I can continue what I want to do, what I feel is necessary…. That’s what I’ve been doing right now.” The club is scheduling meetings, inviting speakers, and hopefully organizing advocacy events soon.

It’s a victory, but there are still some institutional changes that need to be made, Zemen said. There are bylaws in place within EVMS’s student government that allow for this type of decision making, he said. Beyond Si’s chapter of SNaHP, FIRE “want[s] to make sure that measures are in place that no longer allows student government to deny students based on viewpoint discrimination.”

FIRE said it plans to continue the lawsuit until “unconstitutional policies” are overturned, and they have remedied the 258 days Si went “without his constitutional rights.”

https://www.medscape.com…

Medicare Privatization Scheme Faced Legal Questions About Profiteering

Government attorneys expressed concerns that the Medicare direct contracting model — begun by Trump, and continued under Biden — was geared to benefit specific companies.

By Ryan Grim and Austin Ahlman
The Intercept, December 14 2021

In the final stretch of the Trump administration, government attorneys expressed ethics concerns about a Medicare privatization scheme being set up by Adam Boehler, a former dorm-mate of Jared Kushner’s who was made director of the Center for Medicare and Medicaid Innovation, also known as CMMI or the Innovation Center.

In January 2019, ahead of the launch of a new direct contracting model, the Office of the General Counsel for the Health and Human Services Department warned, in comments on a draft of the proposal, that it appeared as if the new project was being set up to benefit specific companies.

“We are concerned based on [Centers for Medicare and Medicaid Services]’s regular references to organizations like Chen Med, Oak Street Health, and Verily in the comments and otherwise, that this model has been designed with specific private sector entities in mind. If accurate, this could create ethics concerns, as the creation of this model would give those entities a leg up in the market,” read the guidance, a copy of which was obtained by The Intercept.

The direct contracting model was announced publicly in April 2019 and began its implementation phase in October 2020. The project pays private companies a predetermined but individualized amount per year, per patient, regardless of what the company spends on care, and has persisted and grown under the Biden administration.

Boehler, prior to working in the Trump administration, ran a startup called Landmark Health, which was backed by venture capital money, including the firm Oxeon. Multiple Oxeon-funded health companies, such as Oak Street Health, were directly referenced in the documents setting up the new project, which drew scrutiny from the Office of the General Counsel. Under Boehler, CMMI contracted with Oxeon to recruit the noncareer staff for CMMI, who then went on to design the program. Once the project was set up, Landmark Health announced it would be contracting with CMMI to become a direct contracting entity — meaning Boehler’s model was shoveling money to the firm he had left. Boehler is now CEO of Rubicon Founders, a venture capital and private equity firm operating in the health care industry. (Before taking his position in the administration, he had divested from any Landmark, along with other healthcare-related investments.)

In May 2019, a calendar alert went out to staff reading “discussion with Landmark on the direct contracting model.” Career staff were appalled. “This shit is so fucking gross,” wrote one in a group text with other aides which was shared with The Intercept. “Ugh. What the fuck,” replied another, with a third sending a link to the Office of the Inspector General, suggesting it be reported. (It does not appear to have been reported.)

The payment model is designed to be lucrative for firms contracting with the government: The government pays a set amount of money annually per patient based on a risk score that is easily gamed by the health care company, and there is no requirement that a minimum percentage of the money be spent on care, a requirement known as a “medical loss ratio” that is typically used to constrain insurance firms or providers from eating the bulk of the funding.

Brad Smith, a recruit of Boehler’s who briefly served as director of CMMI after Boehler was appointed to an unrelated position by President Donald Trump, wrote an article for the New England Journal of Medicine in February of this year that was highly critical of similar payment models the organization was rolling out, noting with unusual frankness that “the vast majority of the Center’s models have not saved money, with several on pace to lose billions of dollars. Similarly, the majority of models do not show significant improvements in quality.” Smith identified “inflated benchmarks” — in which providers wildly overestimate what they expect a patient will cost — and providers’ ability to “game” the payment models as key drivers of losses for the government. Smith expressed hope for direct contracting as a fix, though the project’s critics note it has the same elements. 

Smith, able to spot a good business opportunity, launched a health care company, Russell Street Ventures, in June. That company is now directly contracting with Medicare. Smith did not respond to a request for comment. In October 2020, when the direct contracting program was in its early implementation phase, Smith indicated on a panel with Boehler and another former CMMI head, Patrick Conway, that in the program’s early stages the firms that had “come into that space that [were] running the program” were mostly “new and mid-stage companies” — like his firm and those founded by Boehler. Conway noted that he had recruited Boehler to the job, just as Boehler had recruited Smith. As Boehler added during the panel, the trend is bipartisan. Andy Slavitt, Obama’s head of CMS and an outspoken resistance Democrat, has now linked up with Oxeon – the same VC firm that was funding Boehler – for his own direct contracting enterprise.

The latest privatization scheme echoes the Medicare Advantage system, the private-insurer-run version of Medicare currently used by over 40 percent of enrollees.

Direct contracting uses a model that, in theory, pays firms for maintaining the overall health of a patient rather than billing Medicare for individual medical services. Critics argue that the latter model, which is currently used for standard Medicare enrollees, incentivizes unnecessary hospital visits and treatments. But the former model, which is referred to as value-based contracting, requires complex bureaucratic oversight to ensure that providers are not juking the system by unreasonably inflating the cost and difficulty of caring for a patient.

Medicare Advantage also currently uses a version of the value-based contracting model, but the design failures of the program have led to significantly higher costs than under the traditional Medicare fee-for-service model — with little evidence to support the claim that patients are receiving better care. This is because of the insurer payment formula for Medicare Advantage, which largely depends on the number of diagnoses each patient has received, or their “risk score.”

An entire cottage industry has popped up to help insurers and providers increase a patient’s risk score by scouring for potential diagnoses before patients enroll in Medicare Advantage plans. By finding more diagnoses, whether treatable or not, the annual reimbursement rate under the value-based contracting model increases. Experts have estimated that the resulting overpayments will lead to hundreds of billions of dollars in cost overruns over the next several years. While technocratic fixes to the formula could fix many of the problems plaguing the Medicare Advantage program, Congress and executive branch appointees have so far been unwilling to stomach the political risks posed by large-scale interruptions to the care of Medicare enrollees that would be necessary to combat the wasteful spending generated by privatization.

In a paper published in September, Richard Gilfillan, the head of CMMI from 2010 to 2013, and Donald Berwick, a former head of Centers for Medicare and Medicaid Services, or CMS, during the Obama administration, warned that many of the waste-generating elements of Medicare Advantage programs would carry over to direct contracting. While the direct contracting pilot adjusts the formula for payments to blunt the impact of risk-score gaming, it is unclear whether these adjustments are sufficient to end the practice. Adjusting each firm’s scoring downward by an equal amount punishes firms behaving honestly, they argued, and rewards the firms who hire consultants to game the coding exercise. That puts the government’s thumb on the scale of the most aggressive coders.

“In Direct Contracting, CMS established a stated aim of bringing ‘organizations that currently operate exclusively in Medicare Advantage’ into traditional Medicare, targeting the very MA insurers and investor-controlled provider firms that are driving the MA overpayments,” Gilfillan and Berwick noted, specifically mentioning Oak Street Health and Landmark Health, which Boehler previously ran, as examples of investor-controlled provider firms. (Gilfillan himself is CEO of Trinity Health, a major player in the healthcare industry.)

Diane Archer, founder of Just Care and a health policy expert, described a similar scenario in an email to The Intercept. “The way they make money is by spending as little as possible on patient care, while ensuring as best they can that they have all diagnoses possible for their enrollees in order to maximize government payments. The more diagnoses, the higher the government payments. Government payments are set upfront and unrelated to the cost or number of services people receive.”

“And, yes, the incentive is to deny as much care as possible,” she continued, “it’s also to delay as much care as possible and to create administrative and financial barriers that make it hard for enrollees to get care, even if the DCE does not delay or deny care,” she said, referring to direct contracting entities approved to participate in the program.

Aside from the looting of public funds and the depreciation of care, the shift toward privatization has profound implications for the political economy of health care. Every new private equity or venture capital-backed firm that grabs a bigger piece of the health care market becomes an incumbent corporate stakeholder and a well-funded obstacle to public-minded reform efforts.

Throughout the medical industry, physician practices, hospitals, and groups of specialists are being bought up by investors and consolidated. In the direct contracting space, much of the funding is coming from venture capitalists, but private equity has gotten involved as well.

CanoHealth, a private-equity backed firm, told investors in a presentation that as of April 2021 it had added direct contracting to its existing Medicare Advantage business model. More than half of Medicare recipients have declined to opt in to the privatized Medicare Advantage model, and CanoHealth noted that becoming a direct contracting entity massively expands the company’s potential pool of customers, saying it “triples the addressable market opportunity.” (More recent estimates put the number of Medicare Advantage enrollees higher, at 42 percent.)

The entrance of big private money can be damaging to patient health. A recent study of private equity influence in nursing homes found that residents under the care of a private equity-owned facility were a startling 10 percent more likely to die.

At the center of this privatization project now that Joe Biden is in the White House is Liz Fowler, who was previously the lead health care staffer for former Sen. Max Baucus, D-Mont., who drafted massive chunks of the Affordable Care Act. Fowler was in the trenches battling progressives over the shape and construction of Obamacare, and before that, she had been a top lobbyist for the insurance company WellPoint. After that, she went on to work for Johnson & Johnson. Now she’s back in government, as the deputy administrator and director of CMMI, the innovation agency created by the law she helped write, and people involved in the fight over this project say she’s a strong backer of direct contracting. Fowler did not respond to a request for comment.

In May, four Democrats in Congress — Reps. Bill Pascrell, Mark Pocan, Katie Porter, and Lloyd Doggett — sent a letter to CMMI and to Health and Human Services Secretary Xavier Becerra, who is himself a supporter of Medicare for All, asking for the program to be frozen due to concerns that “funneling people into Medicare Advantage-like plans not only eliminates beneficiary choice, but also erects more barriers and provides fewer consumer protections for beneficiaries.”

In a sign of how big direct contracting has gotten, it has its own lobby now. The Direct Contracting Coalition, which operates as part of America’s Physician Groups, sent a letter in response, arguing that the critics don’t understand how much it can help beneficiaries and cut costs for the government.

The Biden administration paused implementation of two of the three models for direct contracting earlier this year, but there is no indication the administration intends to halt the program altogether. Archer, the health policy expert, said that the path toward a full privatization of Medicare is now apparent if the Biden administration doesn’t change course. “The private equity takeover is short term,” she predicted. “PE will sell their DCEs to insurers. We’ll get fully privatized Medicare, unaccountable and far less cost-effective. Traditional Medicare will wither on the vine.”

https://theintercept.com…

Experts concerned that Texas’ near-total abortion ban will cause an increase in maternal mortality

Researchers estimate that maternal mortality could could increase as much as 15%, and up to 33% for people of color

FOR IMMEDIATE RELEASE: Sept. 7, 2021

Contact: Clare Fauke, Physicians for a National Health Program communications specialist: clare@pnhp.org

Last week, the U.S. Supreme Court upheld SB8, a Texas law that prohibits abortions after about six weeks of pregnancy, resulting in a near-total ban on abortions in the state. Reproductive health experts estimate that the law could cause a spike in maternal mortality of up to 15% overall, and up to 33% for people of color.

“Recent research shows a strong correlation between abortion restrictions and increased maternal mortality,” said David Eisenberg, M.D., M.P.H., associate professor in obstetrics and gynecology at the Washington University in St. Louis School of Medicine. “With a near-total abortion ban in effect now, we can expect to see an increase in Texas’ overal maternal mortality rate in 2022.”

Two studies published in the last year show a link between abortion restrictions and increased maternal mortality. A study published in the American Journal of Preventive Medicine found states that enacted abortion restrictions based on gestational age saw an increase in their maternal mortality rate by 38%, and those that reduced the proportion of Planned Parenthood clinics by 20% increased their maternal mortality rate by 8%.

A second study, published in the journal Contraception and co-authored by Dr. Eisenberg, found that between 1995 and 2017, the maternal mortality rate increased significantly in states that enacted the most restrictive abortion laws; by 2017 the most restrcitve states’ maternal mortality rates were nearly double (28.5 maternal deaths per 100,000 live births) the rates in states that protected abortion access (15.7 maternal deaths/100,000).

Dr. Eisenberg notes that  many abortion clinics that will be forced to close due to SB8. He cites Texas’ experience after the passage of House Bill 2 in 2013, when more than half of the state’s abortion clinics shut down, causing “collateral damage” to sexual and reproductive health care services previously provided by those clinics. “While it is difficult to account for all the variables involved, it is not unreasonable to anticipate a 15% increase in Texas’s maternal mortality rate in 2022 to over 21 per 100,000 live births. Based on the number of births in prior years, we could see over 10 additional deaths per year,” he noted.

Dr. Eisenberg added that it’s especially important to look at the law’s impact on people of color, who received about 70% percent of abortions in Texas in 2019. “Our analyses of trends in maternal mortality rates broken down by race/ethnicity showed that a disproportionate amount of the increase in maternal death was due to the increase in deaths among Black and Native American women. Since the rate of maternal mortality for Black women is about 2.5 times higher than the national average, it is not unreasonable to expect the maternal mortality rate among Black Texans to be about 11% to 33% higher starting in 2022, with maternal mortality rate for Indigenous Texans to be about 8% to 25% higher.”

Any increase in maternal mortality is especially concerning given the growing maternal mortality crisis in the U.S. After decades of improvement, maternal mortality rates started going up around the same time that many states began restricting access to abortion. The rate of pregnancy-related deaths in the U.S. has nearly tripled in the past 30 years, from 7.2 deaths per 100,000 live births in 1987, to 20.1 deaths per 100,000 in 2019; the rate jumped 15% just between 2018 and 2019. The only other nations with increasing maternal mortality rates are Afghanistan and Sudan.

“America’s rising maternal mortality rate should be considered a public health emergency,” said Dr. Eisenberg. “Restricting access to safe and legal abortion — which disproportionately affects those with low incomes and people of color — will only add to the death count. If state and national leaders are serious about protecting health, we need universal access and coverage for the full spectrum of reproductive health care, including primary care, contraceptive care, and abortion care.”

Physicians for a National Health Program (pnhp.org) is a nonprofit research and education organization whose more than 24,000 members support single-payer Medicare-for-All reform.

Trump had a scheme to privatize Medicare. The Biden administration isn’t stopping it.

By Helaine Olen
Washington Post, December 13, 2021

Donald Trump claimed to be a staunch supporter of Medicare. Yet he repeatedly attempted to slash the program’s budget while promoting an increased role in Medicare for insurers and other private businesses. But President Biden isn’t turning out to be the champion of Medicare activists had hoped.

At issue is a Trump administration-initiated program that many health-care reformers argue is essentially a backdoor attempt to further privatize Medicare. Almost no one realizes it’s going on — except, that is, corporate interests and private equity investors, who are lined up like pigs at the trough to get their hands on taxpayer dollars.

Medicare is administered in one of two ways: traditional fee-for-service Medicare and Medicare Advantage — private insurance offered in place of and through the Medicare system. The dispute is over something called the Direct Contracting pilot program, designed by the Center for Medicare and Medicaid Innovation as a new way of managing benefits in the fee-for-service program. Supporters say it will reduce the amount of money the government spends on traditional Medicare fee for service while improving the quality of patient care.

But many left-leaning health-care advocates say it’s a slippery slope version of Medicare Advantage. That program, as Just Care USA President Diane Archer points out, costs taxpayers more per patient than traditional Medicare, in part because of aggressive upcoding of risk assessments that determine how much money the insurer receives for covering the patient. And a 2018 report by the Department of Health and Human Services inspector general found “widespread and persistent” problems with Medicare Advantage programs inappropriately denying care. Opponents of the Direct Contracting program predict it will run up the government’s tab, add corporate bureaucracy, increase the financial strain on the Medicare trust fund and do nothing to improve patient outcomes.

Already, Direct Contracting is increasing the hold of Wall Street and the world of private equity on Medicare. The Centers for Medicare and Medicaid Services say 53 companies have signed up and have been approved to administer the program, which began earlier this year. They are, for the most part, a mix of publicly traded health-care companies and insurers, and private equity backed start-ups.

The lure of Direct Contracting for these companies is potential profits. The limits on the amount of money a Direct Contracting entity can keep that’s not used for a patient’s medical needs is significantly more generous than those imposed by Medicare Advantage.

And while patients choose to sign up for Medicare Advantage themselves, with Direct Contracting, the primary care doctor, not the patient, enrolls in the program. And why would a doctor sign on? Well, one participant, Clover Health Partners, says doctors can earn upward of 40 percent more on primary care visits through the program. (When I asked about that, a spokesperson for Clover told me the higher pay did not affect how much Clover earned from Medicare.)

Once their doctor is enrolled, patients receive a letter from the Direct Contracting company informing them of their participation. They are assured they are still in Medicare’s fee-for-service program and can still see any doctor they wish in the Medicare program. “Your doctor asked Clover Health Partners to see that you get the right care at the right time,” reads the missive sent out by that company. “We will coordinate your care according to your individual medical needs and treatment choices.” The program will, it adds, “work to reduce duplicate tests and duplicate paperwork that cost you time and money.”

The technical term is to say a patient’s care is being “aligned” by the Direct Contracting entity. Heath-care activists use another phrase. “It’s Medicare Advantage by another name but suddenly it’s not voluntary,” Archer says. She argues that doctors in the program can also be incentivized to refer within a particular network or recommend a particular regimen of care. And unlike in Medicare Advantage, the patient won’t necessarily understand that there is a corporate monitor.

The Biden administration did put at least a temporary stop this year to an even more egregious version of this program, which would have auto-enrolled almost all those in Medicare fee for service in a particular preselected geographic area. But CMS, HHS and, ultimately, the White House are continuing to press ahead with Direct Contracting, even though they could end it if they chose.

So how could something like this fly so under the radar? Well, the details are very technical, so, many people receiving notice of the change likely didn’t comprehend it. The program itself has not received much attention from the media. And information about it isn’t all that easy to come by. We don’t even know for sure how many people are experiencing “aligned” care; CMS says that data won’t be available till next year.

But here’s what we can say: An undetermined number of people enrolled in traditional fee-for-service Medicare are now taking part in an experimental program designed during the Trump administration to increase the role of big business in their medical care. And the Biden administration, which could easily stop this, is instead continuing to enable Trump’s scheme. That’s a big mistake — one that it could easily fix.

https://www.washingtonpost.com…

Dr. Ana Malinow on “Thom Hartmann Program”

PNHP past president Dr. Ana Malinow appeared on the “Thom Hartmann Program” on December 13, 2021. Dr. Malinow discussed the dangers of Medicare Direct Contracting, a Trump-era pilot program that will automatically “align” seniors who have chosen Traditional Medicare with a (often corporate) Direct Contracting Entity that has a financial incentive to skimp on care.

She placed Direct Contracting within the larger context of Medicare privatization, which Wall Street has been pushing for decades. For more information, visit pnhp.org/StopDCEs.

Navigating the COVID pandemic: Taiwan’s Example

Summary: As the US approaches 800,000 COVID deaths, this week we review how pandemic control fared in two countries. Today: Taiwan, where broad public cooperation coupled with technical finesse to minimize health and economic harm. On Wednesday: the US, where pandemic response was hobbled by tense interactions between political partisanship and public health.

How has Taiwan navigated the pandemic?, Economics Observatory, December 1, 2021, by Tsung-Mei Cheng

Taiwan has fared better than many other countries during the Covid-19 crisis. Political leadership, early action, a national plan, strong information and communications technology infrastructure and a cooperative public have all contributed.

As of October 2021, Taiwan ranked lowest in total number of Covid-19 cases and second lowest in deaths per 100,000 population among comparable OECD countries.

Of 20 nations, the United States ranked second with 13,825 cases per 100,000 population and Taiwan ranked twentieth with 69 per 100,000. … the United States ranked first with 224 deaths per 100,000 population and Taiwan ranked nineteenth with 4 per 100,000.

At the same time, Taiwan’s economy grew in both 2020 and 2021. This continued, and even outpaced, the growth seen in preceding years. In contrast, the world’s real GDP declined by 3.4% in 2020, with the G20 countries, members of the euro area and comparable OECD countries had negative growth ranging from -1% to -11%.

The situation has remained stable since the government lowered the emergency alert from level 3 to level 2 on 27 July 2021. Since September, new cases of domestic transmission have been at either zero or in the low single digits. Deaths have also remained very low. For nine successive days between 29 September and 8 October, Taiwan reported no deaths. This was at a time when the average daily deaths in the United States stood at 1,867, with most days exceeding 2,000 deaths per day.

Taiwan was prepared and acted at the first signs of the virus in early 2020. Policy makers had learned lessons from the 2003 SARS crisis and made plans to prepare for future pandemics.

To that end, the government strengthened Taiwan’s CDC and healthcare delivery system, and taught the public the importance of face masks, hand hygiene and temperature checks. In addition, a 2011 constitutional ruling granted the government power to do all that is necessary in national public health emergencies, including ‘temporarily removing personal freedom of movement’. This made mandatory quarantine possible during the Covid-19 crisis.

Difficulties frequently encountered in many Western countries with vaccine hesitancy, contact tracing, quarantine and facemask resistance have not generally been problems in Taiwan. The public regards cooperating with the government in national emergencies as a civic responsibility and shares the recognition that everyone is in this together. The importance of these two attributes cannot be overstated in Taiwan’s highly successful Covid-19 outcomes to date.

Comment:

By Don McCanne, M.D. (with all due credit to Tsung-Mei Cheng and Uwe Reinhardt)

There has been considerable disagreement within the United States about the nature of the Covid-19 epidemic, a disagreement not shared in Taiwan where the people worked together to try to bring it under control.

It is interesting that the author, Tsung-Mei Cheng, and her late husband, Uwe Reinhardt, worked with Taiwan to help establish their single payer health care financing system — a system that proved to be very helpful during this epidemic, along with their other public policies. Their ethical principles helped make the Taiwanese government much more effective in combating the scourge of Covid-19 than we were in the United States, in spite of our wealth.

In a Princeton Policy Podcast, Tsung-Mei Cheng said, “Uwe writes in the book (‘Priced Out’), and I’ll paraphrase him, health reform as in Europe, Canada, or say Taiwan, which operates a government-run single payer health care system; they usually begin their debate on health reform making explicit the ethical principles that should govern or constrain their health policy. They explicitly state what these ethical values are. For example, in Germany, the word is solidarity. Everybody respects that, and there is agreement on that. Say… yes, we want solidarity therefore everyone shall have health care, the same health care. Well, Canada, in the Canada Health Act, it says that all shall have health care based on health care needs and not on ability to pay. Now, in this country, Uwe’s experience has been that, you know, by merely bringing up the topic of distributive ethics for health care it can easily raise the ire of an audience because it is viewed as too personal, too political, or too divisive. So, instead, we discuss health reform mainly in technical terms, usually in economic terms and let social ethics fall where they may, and people certainly have different social ethics. Now the second biggest takeaway from the book for me is about what Uwe said about the uninsured in America. He said, and this is a direct quote from him, ‘The issue of universal coverage is not a matter of economics; little more than one percent of GDP assigned to health care could cover all. It is a matter of soul.’”

Well, this is embarrassing. We, as a people, have it within our power to address these problems effectively – not just Covid, but health care for the entire nation, forever. What do we do? Well, for Covid, we’ll soon be approaching a million deaths. And all of our other health problems? For shame, America. For shame!

http://healthjusticemonitor.org…

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

Advocates Sound Alarm About Pilot Program They Say Could Privatize All of Medicare

Elder Law Answers, December 10, 2021

The Biden administration is moving forward with a Trump-era pilot program that would hand over the care of millions of Medicare beneficiaries to private, mostly for-profit, groups.

Health care advocates warn that that the little-known plan will limit patients’ choice of providers and effectively privatize Medicare for beneficiaries who specifically chose traditional, public Medicare because they wanted to be able to select their own doctors. The program was created without congressional oversight and can expand without Congress’s approval.

“It could potentially complete the privatization of our public precious good called Medicare,” says Ed Weisbart, MD, who chairs the Missouri chapter of Physicians for a National Health Program (PNHP). “It violates the spirit of a public health program, which Medicare is, by driving larger corporate profits as a priority over improving our health, which Medicare is remarkably successful at.”

Already, some 42 percent of Medicare beneficiaries are in private Medicare Advantage plans, to which the federal government gives a fixed monthly fee for each Medicare beneficiary under the plan’s care. The less money the plans spend on patient care, the more money they and their investors make.

The new pilot program, called Direct Contracting, would extend key aspects of this model to other Medicare beneficiaries in 38 states, Washington, D.C., and Puerto Rico, potentially covering 30 million of the 36 million beneficiaries in traditional Medicare.  Fifty-three Direct Contracting Entities (DCEs), most of which are investor-owned with ties to Medicare Advantage commercial insurers, have already signed contracts to be fiscal intermediaries between patients and their providers.

Beneficiaries Automatically Enrolled

Under the program, these DCEs will form their own networks of providers, which beneficiaries will be strongly encouraged, although not required, to use.  Traditional Medicare beneficiaries will be enrolled in these networks, often without their knowledge or consent.  The DCEs will be paid a set amount per patient, called a capitation payment, which will vary depending on a patient’s “risk score.”  If the patient care costs less than the per-patient amount, the DCE keeps some or all of the difference.  If it costs more, the DCE loses money.

Beneficiaries will not be able to opt out of being “aligned” with a DCE.  Medicare will assist the DCEs by searching the claims history of beneficiaries – again without patients’ knowledge or consent — to see if they have visited a participating DCE provider with which they could be aligned.

All this will likely be confusing for Medicare beneficiaries, many of whom will have three different entities processing their claims: the DCE, Medicare, and the beneficiary’s Medicare supplemental insurance (Medigap) plan.

“Rather than allowing patients to go to providers directly under traditional Medicare, DCEs invite insurers and investors to step in and interfere with the care that Americans get,” said Rep. Katie Porter (D-CA) at a recent PHNP webinar on Direct Contracting. The DCEs, Porter charged, will “drive up costs for patients in order to maximize profits . . . Wall Street wins, patients and taxpayers lose.”

Lowering Costs Is the Stated Aim . . .

The idea behind the pilot is that these care networks will lower costs and spur innovation by managing care.  The model, according to the federal Centers for Medicare and Medicaid Services (CMS), “is expected to increase beneficiaries’ access to innovative, affordable care while maintaining all original Medicare benefits.”

Not all medical providers oppose Direct Contracting, particularly those already affiliated with provider groups.

“Models of care that are focused on systems of reimbursement such as capitation and holding physicians accountable for cost, coordination, and quality are integral to moving away from the fee-for-service model and toward more transformative models of care that reward value,” said Don Crane, president and CEO, of America’s Physician Groups said in December 2020.

. . . But Financial Incentives Worry Critics

Critics of the program have raised a number of concerns.  They note that many beneficiaries will be unaware that they can opt out of a DCE’s provider network, and say that DCEs will seek to contain costs by discouraging or denying needed care. (It is unclear how CMS will monitor beneficiaries’ access to care.)

Advocates also note that, as with Medicare Advantage, DCEs will have a strong financial incentive to “upcode” patients – that is, to tell the government that patients in their care are sicker than they really are so the DCE can receive a higher reimbursement.  Finally, critics are convinced that DCEs affiliated with Medicare Advantage plans will use the opportunity to steer beneficiaries away from traditional Medicare and into these highly lucrative plans.

No one knows whether the DCEs will actually be profitable, but Wall Street is betting that they will be.

“Wall Street considers Direct Contracting Entities to be eight times more valuable per patient than Medicare Advantage firms,” wrote Chris Tomlinson, a business columnist for the Houston Chronicle.

Even if DCEs don’t make money initially, patient advocates say that many investors are betting on selling the DCE for a profit down the road, a favored model of private equity investment.  “The real strategy is to make rapid growth and then leave and go on to the next investment,” said PNHP’s Weisbart.

Two nationally known physicians who once led CMS are warning against the pilot program. Writing in the blog of the journal Health Affairs, Dr. Donald M. Berwick, a former CMS Administrator, and Dr. Richard Gilfillan, a former director of CMS’s Center for Medicare and Medicaid Innovation, call Direct Contracting a new addition to the “Medicare Money Machine” and characterize its name as “Orwellian.”  “‘Indirect Contracting’ would have been a far more accurate name,” they write, “since the cornerstone of the program was CMS’s opening the door to non-provider-controlled [DCEs] to become the fiscal intermediaries between patients and providers.”

Blanket Authority to Experiment

Experimental health delivery models like Direct Contracting were made possible by the Affordable Care Act.  The landmark 2008 law established the Center for Medicare and Medicaid Innovation and gave it almost blanket authority to test ways to improve health care quality and reduce costs without congressional approval or oversight.  The Trump administration seized on this authority to craft the Direct Contracting model.

Its most extreme version is called Geographic Direct Contracting, which would auto-assign every traditional Medicare beneficiary living in a number of large geographic regions into a Medicare Advantage-like “Geo DCE” without the right to opt out. Advocates persuaded the Biden administration to pause this program in March, although it is still “under review” and could resurface.

But the Biden administration has continued the rollout of a less extreme version, the Global and Professional Direct Contracting (GPDC), which CMS calls a “voluntary risk-sharing payment model.”

Rep. Porter is among lawmakers who are calling on the administration to immediately freeze this version as well, contending that while it is intended to make Medicare more efficient, it actually will do the opposite, noting that between 2008 and 2020 the federal government has overpaid Medicare Advantage plans — which were designed to contain costs in similar ways – by $143 billion.

In late November a group of physicians from around the nation traveled to Washington, D.C., to educate lawmakers about the Direct Contracting threat, call for a congressional hearing and present U.S. Department of Health and Human Services (HHS) Secretary Xavier Becerra a petition signed by more than 13,000 people, including 1,500 physicians.  The petition warns that moving the DCE program forward threatens “the future of Medicare as we know it.”

“[Direct Contracting] is very complex and it is extremely hard to explain,” said PNHP board member Dr. Judy Albert at the HHS press event.  “There has been very little coverage in the mainstream media, allowing the program to fly under the radar. . . . Together, we will continue to raise the alarm until we stop this threat to Medicare.”

https://www.elderlawanswers.com…

Health Insurance Headlines of the Single Payer Future

Summary: And now for something completely different: We take cost headlines recently reported in KHN (Kaiser Health News) and imagine how they would look under single payer, or how they just wouldn’t make sense. Enjoy the vision. Let’s make it happen.

KHN Health Costs, December 2, 2021

BILL OF THE MONTH: The ER Charged Him $6,500 for Six Stitches
No Wonder His Critically Ill Wife Avoided the ER.
Single Payer: You’re all set. No charge.

Stranded by the Pandemic, He Had Only Travel Insurance. It Left Him With a $38,000 Bill.
Although it’s possible to buy travel insurance that provides some health coverage, the devil is in the fine print. Obama-era laws that prevent refusal of payment for preexisting conditions don’t apply to travel insurance.
Single Payer: Stranded by the pandemic, man received the care he needed, free.

Your Out-of-Pocket Health Care Costs Need Not Be a Mystery
A new California law requires health insurance companies to notify consumers how much remains on their deductibles and how close they are to their annual out-of-pocket spending limits.
Single Payer: You don’t have any out-of-pocket costs.

Patients Get Stranded Out of Network as Insurer-Hospital Contract Talks Fall Apart
As hospital systems and insurers adjust to the pandemic, their contract negotiations grow increasingly fraught. Contracts for in-network care are ending without a new deal, leaving patients suddenly with out-of-network bills or scrambling to find new in-network providers.
Single Payer: Networks?

Congressional Doctors Lead Bipartisan Revolt Over Policy on Surprise Medical Bills
Congress last year shielded consumers from unexpected out-of-network charges, but hospitals and doctors have decried the arbitration plan put forward by the Biden administration for negotiating these bills as favoring insurers. More than 150 members of the House agree.
Single Payer: What’s a medical bill? Sure would be surprised to receive one of those.

New Health Plans Offer Twists on Existing Options, With a Dose of ‘Buyer Beware’
Fueled by consumer frustration with high premiums and deductibles, two new insurance offerings promise a means for consumers to take control of health care costs. But experts say they pose risks.
Single Payer: What’s a health plan?

Why You Can’t Find Cheap At-Home Covid Tests
You probably won’t be testing everyone at your Thanksgiving table for covid because the tests are expensive and hard to find. Why? The federal government is partly to blame.
Single Payer: Covid tests – all medical tests – provided free.

As Big Pharma and Hospitals Battle Over Drug Discounts, Patients Miss Out on Millions in Benefits
The number of pharmacies dispensing 340B discounted drugs soared to more than 31,000 this year. Drugmakers struck back by halting some discounts. Hospitals say they are losing millions of dollars — and cutting back services to patients — as a result.
Single Payer: Latest update of drug prices released by government.

Medicare’s Open Enrollment Is Open Season for Scammers
Medicare officials say complaints are rising from seniors lured into private plans with misleading information or enrolled without their consent. In response, officials have threatened to penalize the private companies selling Medicare Advantage and drug plans if they or agents working on their behalf mislead consumers.
Single Payer: Everyone covered, cradle to grave. No transitions between coverage, ever.

Medicare Enrollment Blitz Doesn’t Include Options to Move Into Medigap
TV ads and mailings targeting seniors tout Medicare Advantage plans this time of year, but millions choosing traditional Medicare make a costly and difficult decision about Medigap coverage, which gets much less attention.
Single Payer: See above. Not a thing.

Researcher: Medicare Advantage Plans Costing Billions More Than They Should
Some insurers pocketed ‘eye-popping’ overpayments, billing records show.
Single Payer: Doctors and single payer commissioner agree on payment rates for next year.

Uninsured in South Would Win Big in Democrats’ Plan, but Hospitals Fear Funding Loss
The latest iteration of President Joe Biden’s social-spending package would close the health insurance gap for at least 2.2 million people, making a huge difference especially in the South, where political opposition has blocked Medicaid expansion.
Single Payer: Hospitals get new annual global budget amounts. (What’s “uninsured”?)

Missouri’s Thin Dental Safety Net Stretched Amid Medicaid Expansion
An estimated 275,000 Missouri adults can get dental insurance now as the state has expanded who is eligible for Medicaid. But with so few dentists participating in the program, the state’s already-backlogged dental clinics are facing a glut of new clients.
Single Payer: Dentists settle on payment rates for next year.

How Rural Communities Are Losing Their Pharmacies
More than 1,000 independent rural pharmacies have closed since 2003, leaving 630 communities with no retail drugstore. As 41 million people stuck in pharmacy deserts make do, the remaining drugstores struggle to survive.
Single Payer: Rural pharmacies receive subsidies to stay open.

California Law Aims to Strengthen Access to Mental Health Services
The law doesn’t take effect until July, but its passage should force insurers to expand their rosters of therapists. Here’s how you can challenge your health plan’s mental health services until then.
Single Payer: 90% of mental health providers in single payer system.

KHN’s ‘What the Health?’: Why Health Care Is So Expensive, Chapter $22K
A new survey finds the average cost of an employer-provided family plan has risen to more than $22,000.
Single Payer: Who remembers work-based health insurance?

‘An Arm and a Leg’: Need Surgery to Save Your Life? Tips for Getting Insurance to Pay
Laurie Todd calls herself the “Insurance Warrior” and is sharing her strategies for getting health insurance companies to bend to her will.
Single Payer: Surgery included in coverage!

Comment:

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

This isn’t fantasy in any wealthy country except the US. Embrace this future.

http://healthjusticemonitor.org…

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