PNHP

Medicare is on the menu

Medicare is on the menu

By Robert S. Kiefner, M.D.
Concord (N.H.) Monitor, November 12, 2021

Since 1965, Medicare has been the foundation of medical care for millions of seniors and those with disabilities in this country. Now, however, it is on the dinner table, being served as an appetizer and main course to ravenous for-profit corporate entities as never before.

Once a relatively straightforward plan, publicly financed and privately delivered care with extremely low overhead, Medicare has become hopelessly complex and impossible to navigate, complements of health insurers, Big Pharma, enabling legislators, think tank “geniuses” and a great multitude of wealthy lobbyists.

For all of its shortcomings, traditional Medicare has provided reasonable security for those in need of patient-centered, comprehensive and affordable healthcare. Indeed, if we had simply followed the lead of other industrialized countries with a comprehensive not-for-profit model, we could have offered truly universal coverage (including all expenses related to inpatient and outpatient care, and complete benefits relating to drug costs, dental, vision, hearing, mental health and even paid family leave) at one half of the per capita costs which we now incur in this country. But a majority of legislators fed the rich and addictive diet of corporate contributions and, entertained by the seductive dance of lobbyists, will not let a publicly funded and not-for-profit program gain traction.

Medicare Advantage is, perhaps, the most blatant for-profit distortion of the traditional Medicare model. With the yearly Medicare enrollment window now being open, we are subject to the hyper-caffeinated cacophony of pitchmen like Joe Namath and J.J. Walker, who we perhaps thought were dead, only to return to after 30 years of irrelevance to grab a few bucks and to entice a clueless audience of Medicare-eligible folks with visions of free dental care, glasses, hearing aids, refund checks, free rides, groceries, the sun, moon and the stars.

Most of the major health insurance companies also hawk their own Medicare Advantage program with advertising dominated by entitled, perky and smart-appearing old people who annoyingly want you to know they’ve found a great deal. Here’s the real deal, though. The federal government seriously overcompensates private insurers offering this bounty of services, counting upon the astigmatism of seniors trying to read the fine print, the unchecked power of big business, and the inability of federal regulators to nail down the true cost of care.

Medicare Advantage plans have a simple business plan, which involves making bigger profits by actually paying for less care, jacking up co-pays, and restricting care to narrow networks of providers.

These plans tend to be very popular until you need them for an expensive illness.

And every fiscal conservative should be outraged by the unregulated flow of taxpayer dollars to private insurers who “control” costs by restricting care and channeling funds into their coffers.

A Wall Street Journal article on Sept. 23 by Anna Wilde Mathews highlighted the findings by the Office of the Inspector General, focusing upon the gaming of the system by the major insurers from 2016-2017.

This systematic deceit is costing taxpayers billions of dollars per year while undermining traditional Medicare.

In many cases, insurers clearly falsified the medical conditions of their clients or upcoded them relative to medical severity in order to gain higher payments to Medicare Advantage plans from the federal government. And because medical expenses may well be greater at the end of life, Medicare Advantage plans are finding ways to encourage the sickest patients to return to traditional Medicare, and thus weasel out of paying for expensive conditions. By exaggerating the severity of beneficiaries’ illnesses, Medicare Advantage plans have been able to surreptitiously increase their charges for the care of those patients, often to the tune of thousands of dollars per year per beneficiary.

According to former CMS Administrator Dr. Don Berwick, the Medicare Payment Advisory Committee (MedPAC) has documented $140 billion in overpayments to Medicare Advantage Plans over the past 12 years, and with risk adjustment overpayments on the rise, up to $355 billion will be overpaid to the plans in the next eight years. Simply put, Medicare Advantage has devised ways of signing up low-cost patients (cherry-picking) while dis-enrolling high-cost patients (lemon dropping) all while misrepresenting the severity of the illness to obtain higher payments. Recently, if you can believe it, we have become aware of an even more insidious threat to your traditional Medicare. In a scheme first floated by the Trump Administration, but still sanctioned by the Biden Administration and the Centers for Medicare Services (CMS), the creation of “Direct Contracting Entities” (DCEs) empowers middlemen (including venture capitalists) to actually manage the care of beneficiaries in traditional Medicare. DCEs will have many of the nasty features of Medicare Advantage Plans relative to the ability to inflate service codes and thereby deceitfully pad their revenues while operating with limited oversight.

Of the 53 DCEs now active in 43 states, 28 are investor-owned, six are insurer based and the rest are provider controlled (physician and hospital). Insurers control the majority of potential patients, some 57% of traditional Medicare fees for service patients.

Here’s the clincher — patients can be enrolled in a DCE without their knowledge or consent! Their doctors may end up participating in a DCE with a tempting 40% increase in provider Medicare reimbursement and a reduction in the need to comply with a set of core quality measures. Once doctors sign up with a DCE, their patients are automatically signed up. Patients may receive a letter, typically incomprehensible and quickly tossed in the trash.

While defending “Medicare for All” over many years, I was often met with the objection that “I don’t want government-controlled health care.” Well, now you will have health care decisions made by corporate types in the luxurious C-suites of health insurance companies or venture capitalists cruising the Bahamas in gigantic yachts who really want to sign you up on their plans, only to throw you overboard if you get too expensive.

Medicare Advantage may actually work well for some seniors for a period of time, before serious illness occurs and before the amassed bills exhaust the Medicare Trust Fund and bring about the collapse of traditional Medicare.

Well-funded lobbying organizations such as the Partnership for America’s Healthcare Future and the Better Medicare Alliance are spending millions of dollars daily to convince those in Congress and their constituents that a bunch of upfront freebies is more important than being able to choose your healthcare provider and to guarantee affordable healthcare in the future.

Before you dial the number for a Medicare Advantage Plan at the urging of a celebrity du jour, start a conversation with your congressional reps, your doctors and your hospital to find out just how fragile your healthcare coverage might be going forward.

Dr. Robert S. Kiefner is a retired family physician. He lives in Concord.

https://concordmonitor-nh-app.newsmemory.com…

ACA Private Plans Financial Barriers Rising

Summary: The Affordable Care Act uses private plan Marketplaces and tax subsidies to try to make insurance affordable for middle class families. New research shows that from 2015-2019, low cost Bronze plans increased in net cost, with combined premiums and deductibles reaching 26.6% of median income. ACA financial protections, already weak, are eroding.

ACA Marketplaces Became Less Affordable Over Time For Many Middle-Class Families, Especially The Near-Elderly, Health Affairs, November 2021, by Paul D. Jacobs and Steven C. Hill

From Abstract: As a measure of affordability, we calculated potential [Affordable Care Act] Marketplace premiums as a percentage of family income among families with incomes of 401– 600 percent of poverty. In 2015 half of this middle-class population would have paid at least 7.7 percent of their income for the lowest-cost bronze plan; in 2019 they would have paid at least 11.3 percent of their income. By 2019 half of the near-elderly ages 55–64 would have paid at least 18.9 percent of their income for the lowest-cost bronze plan in their area. The American Rescue Plan Act temporarily expanded tax credit eligibility for 2021 and 2022, but our results suggest that families with incomes of 401–600 percent of poverty will again face substantial financial burdens after the temporary subsidies expire.

Comment:

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

A major element of the Affordable Care Act (ACA) was to establish “Marketplaces” or “Exchanges” to facilitate access to regulated private insurance plans for the middle class – those earning too much to qualify for Medicaid, lacking workplace insurance, and not wealthy enough to go it alone.

This strategy has a number of problems. It’s inefficient, just like (even more than) all private health insurance, with administrative and profit costs. It’s a government hand-out to private insurers – after all, the subsidy is really to the insurers, passing through the insured. And the plan designs are flawed, with inconsistent coverage rules and for low-cost plans (Bronze especially) consistently high deductibles.

This new research shows that initially (2015) for families at 400-600% of the Federal Poverty Level (currently $69,680–$104,520 for a family of two), the premium represented 7.7% of income for a Bronze plan, and this reached 18.3% when including the deductible – potentially a significant financial burden and barrier to care. By 2019, these costs rose to 11.3% and 26.6% of income, respectively. For those 55-64 years old, the premium alone is now 18.9% of income.

Sorry for the deluge of geeky percentages. They reflect real financial barriers to insurance and to medical care. The fact that the portion of income is substantial and increasing should add to evidence that the ACA is a flawed overlay patch to our fundamentally dysfunctional health insurance system.

It’s time to end the overlay patches, and adopt a simple, direct, understandable, efficient, and equitable system, one that has been demonstrated to work in dozens of countries around the world. Single payer.

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.

U.S. Ranks 36th Out of 37 Nations on COVID-19 Mortality

Summary: A new study quantifies the loss in life expectancy due to COVID-19 in nations around the world. The US is in the worst tier, with a drop of nearly two years. Blame lays at the feet of mishandling by Trump, but also long-term degradation of public health and primary care access. Both must be rebuilt.

Effects of covid-19 pandemic on life expectancy and premature mortality in 2020: time series analysis in 37 countries, BMJ, November 3, 2021, by Nazrul Islam et al.

From abstract: “Reduction in life expectancy was estimated as the difference between observed and expected life expectancy in 2020 using the Lee-Carter model. . . .

Results: Reduction in life expectancy in men and women was observed in all the countries studied except New Zealand, Taiwan, and Norway, where there was a gain in life expectancy in 2020. No evidence was found of a change in life expectancy in Denmark, Iceland, and South Korea. The highest reduction in life expectancy was observed in Russia (men: −2.33; women: −2.14), the United States (men: −2.27; women: −1.61), Bulgaria (men: −1.96; women: −1.37), Lithuania (men: −1.83; women: −1.25), Chile (men: −1.64; women: −0.88), and Spain (men: −1.35; women: −1.13)”

[Note: All figures are in years; confidence intervals deleted to enhance readability]

Comment and Graph:

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

These data provide further evidence of the criminal mishandling of the COVID-19 pandemic in the US.  By another measure – years of life lost per 100,000 population – the US was better only than Bulgaria, Russia and Lithuania. Donald Trump’s denialism and malfeasance bear much of the blame for the US’ sorry record on COVID-19. But the gutting of public health capacity, which occurred under both Democrats and Republicans, and our defective health care system, which obstructs access to care and discourages trusting relationships, were and remain major contributors.

6% of health spending should go for public health, double the current proportion. Further, we need to erase access barriers, and build a real and universal primary care infrastructure.

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.

Biden moves forward with Trump Medicare privatization plan

By Chris Tomlinson
Houston Chronicle, November 8, 2021

No one should be surprised the Trump administration hatched a plan to put private insurance companies in charge of Medicare. What’s shocking is how President Joe Biden is moving forward with it.

The 50-year-old, government-operated health program for the elderly will slowly and irrevocably end up managed by for-profit insurers under the Global and Professional Direct Contracting Model. The Center for Medicare Services says the program will increase “access to innovative, affordable care while maintaining all original Medicare benefits.”

Wall Street expects it will generate billions in new dividends for health care companies. Critics warn seniors will find it harder to obtain care, and taxpayers will end up paying more than ever.

This is not the first effort to hand over Medicare patients to private companies in the name of cost-saving. Recently, I explained how Medicare Advantage programs were failing to save taxpayer money and leaving many enrollees disappointed. But while seniors can opt out of Medicare Advantage, Direct Contracting will involuntarily put them in the same boat or a potentially leakier one.

Anyone who’s dealt with Medicare has experienced its mind-numbing complexity. Personal experiences vary based on plan choice and health conditions. But the fundamental question is why politicians think private insurance companies using Direct Contracting will deliver a better experience while making a profit when so far, they’ve never succeeded at doing better than government-run Medicare.

Lobbying and campaign donations are the answers. Private companies promise to solve the fundamental problem of Medicare paying doctors and hospitals a fee for each service they perform rather than paying providers to keep people healthy.

Primary care doctors are paid very little to prevent chronic problems, such as obesity, diabetes and heart disease, the biggest financial burdens on the system. But the surgeons and specialists who treat these problems when they become life-threatening make fortunes.

A few years ago, I praised the Accountable Care Organization/Medicare Advantage model because it encouraged providers to form teams of primary care providers and specialists. Instead of paying fee-for-service, Medicare paid an annual rate for each patient. If the team saved money by keeping the patient healthy, it kept some of the windfalls.

Medicare Advantage, though, drove up costs to taxpayers instead of reducing them. Depending on the program, patients also ended up paying more in deductibles and co-payments than they would have under traditional Medicare.

Despite this track record, the Biden administration paid private companies to take over 30 million traditional Medicare patients in 38 states on Jan. 1 this year. Millions more will be transferred to Direct Contracting in 2022.

Most Direct Contracting companies are investor-backed, for-profit corporations, according to government data. Most have experience with Medicaid Advantage, and Medicare officials expect them to impose similar cost-cutting steps. But can they cut enough to cover their profits and save taxpayers’ money?

The business opportunity looks vast. Medicare spending is expected to rise from $800 billion in 2019 to $1.6 trillion in 2028 as Baby Boomers live longer. Wall Street considers Direct Contracting firms eight times more valuable per patient than Medicare Advantage firms, even though they are supposed to save money.

Medicare is also offering sweetheart deals that reduce these companies’ financial risk. In just 18 months, investor-backed funds seeking big profits have put $50 billion of new investment into health care firms involved in Direct Contracting, according to Health Affairs, a non-partisan research journal.

“This business model is distorting health care delivery, creating excessive costs for taxpayers and Medicare beneficiaries, draining the Medicare Trust Fund, obstructing the badly needed value transformation of American health care, and diverting the money needed to fund other social services and goods,” the Health Affairs researchers concluded.

Corporations, non-profits and practitioners have proven very successful at gaming our for-profit health care system. A recent example is UnitedHealth’s $100 million lawsuit against emergency physician staffing firm TeamHealth for allegedly exaggerating their patients’ conditions to generate larger bills.

Biden’s decision to move forward with Direct Contracting reflects for-profit health companies and investors’ power over both political parties. He’s rejected a single-payer system like those found in Europe, and he parrots the demonstrably-untrue premise that private enterprise can do a better job than well-managed government employees.

Direct Contracting is also likely to kill any chance for progressive Democrats to make Medicare an option for any American who wants to enroll. If the government puts private companies in charge of all Medicare patients, it will eliminate any opportunity to overhaul our health care system truly.

Next year, millions more Americans will find themselves in privatized Medicare, and most will never know what happened.

https://www.houstonchronicle.com…

When will we transform our deadly insurance system?

Summary: New research with vital statistics data finds that since 1990 overall US mortality has increasingly worsened compared with other OECD countries, in poorer and richer geographic areas alike. The differences attenuate after age 65, when Medicare eligibility begins. The toll for Black Americans is worse, despite gains. These findings suggest that insurance shortfalls lead to hundreds of thousands of excess deaths per year.

Inequality In Mortality Between Black and White Americans By Age, Place, and Cause, and In Comparison To Europe, 1990-2018, NBER Working Paper No. 29203, September 2021, by Hannes Schwandt et al.

From Abstract:

Inequalities in life expectancy are starker in the U.S. than in Europe. In 1990 White Americans and Europeans in rich areas had similar overall life expectancy, while life expectancy for White Americans in poor areas was lower. But since then even rich White Americans have lost ground relative to Europeans.

Life expectancy for both Black and White Americans plateaued or slightly declined after 2012, but this stalling was most evident among Black Americans even prior to the COVID-19 pandemic.

From Results:

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.

Insurers Avoid Loss Ratio Limits by Shifting Profits to Provider Subsidiaries

Summary: Insurers don’t appreciate limits on their profits. So, to circumvent federal “medical loss ratio” rules, they buy up medical providers and send the excess revenues there. Voila, huge profits retained.

Profits swell when insurers are also your doctors, Axios, July 16, 2021, by Bob Herman

The big picture: Federal law caps health insurance profits to 15-20% of collected premiums, depending on the type of market. But there are no limits to how much profit a provider can keep. So if an insurer can steer its members toward its own providers, the company is able to keep a lot more of those premium dollars.

The bottom line: Insurers keep more of the premiums they collect when they also own the medical providers that are paid those premium dollars. And no insurer has expanded as aggressively into care delivery over the years as UnitedHealth.

Comment and Graph:

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

UnitedHealth and other large health insurance firms have been buying up doctors’ practices and other health providers (e.g. Aetna’s merger with CVS). That lets insurers ship profits to their provider subsidiaries, skirting federal standards for medical loss ratios – the share of premiums they’re allowed to spend on administration and profit. In essence, allowing insurers to own providers is a loophole that makes loss ratio requirements meaningless.

As indicated in the graph below (based on the data Bob Herman reports), over the past decade – and especially since 2019 – UnitedHealth has greatly amped up its payments to itself.

For detail on the mechanics of how insurers’ double dipping is pushing up Medicare’s costs and accelerating its privatization see the September 30, 2021 HJM post on Medicare Advantage and DCEs.

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 66

Interview with Dr. Scott Goldberg

November 1, 2021

PNHP national board member Dr. Scott Goldberg describes the ways in which our public health programs have been privatized, and why we need to demand an improved version of Medicare as the basis for national health insurance.

“It’s important to say we want public Medicare for All.” he says. “We don’t want Medicare Advantage plans.”

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

https://medicareforallexplained.podbean.com

Setting our sights for real health care reform

Summary: Build Back Better is falling short even on modest health reforms. Let’s focus on building the popular movement needed for truly progressive transformation of our health care system.

Locked Out of the Sausage Factory: Will Medicare Expansion Survive the Budget Reconciliation Debates?, Common Dreams, October 27, 2021, by Michael Lighty & Mark Dudzic

The Build Back Better Bill started out as a great, sprawling piece of legislation comprising the most ambitious set of social programs since the Johnson Administration.

But the fact that the Bill appears to be floundering is a reminder of the persistence of the forms of neoliberalism that exercised near hegemonic control over the policies and practices of the Democratic Party from the 1990s through the Obama administration (coupled, of course, with a generous amount of shameless corporate hucksterism.)

A big reason that we are in this fix is because we have not yet built the kind of popular movement strong enough to back up the resolve of our Progressive Caucus stalwarts in the House.  All too often, advocates and organizers get infatuated with the inside game when their real job is to build the kind of mass movement that can hold politicians accountable to real principles and real people.

They say that legislation is like sausage-making. The healthcare profiteers and their army of lobbyists all have their hands in the process together with all of the other monied interests with a stake in the Bill. Meanwhile the people whose lives will be most affected by the legislation have been locked out. And, as any trade unionist will tell you, the only way to break a lockout is to maintain unity, bring in new allies and shine the light of day on those who would deprive people of their livelihoods in order to keep the profits flowing.

Comment:

By Don McCanne, M.D.

Our healthcare system is the most expensive in the world yet fails in achieving the performance goals we should expect. What are some of the goals that would create a system of which we could be proud?

  • Universal – Everyone should be included
  • Comprehensive – All reasonable health care should be provided
  • Affordable – For each individual, and collectively for society
  • Equitable – Distribution of healthcare resources should be fair regardless of factors such as age, sex, race or ethnicity
  • Patient-oriented – Designed to serve patients rather than private corporate interests
  • Publicly funded – Using economic tools such as modern monetary theory and progressive taxes only available to the people’s government
  • Publicly administered – to provide efficiencies in administration available only through our government and not through the fragmented private corporate sector

Deprivatizing healthcare financing will eliminate the high costs, inefficiencies, and inequities of private corporate greed.

With our current president and current Congress that are debating the Build Back Better Bill, how many of these goals can be attained? Absolutely none. Not even close.

According to Michael Lighty and Mark Dudzic, astute observers of the healthcare political scene, we have not yet built a strong enough popular movement that can hold politicians accountable to real principles and real people. We have been spinning our wheels in excitement over the prospects of passing the Build Back Better Bill, while we are sliding into disappointment over how inadequate the surviving elements of the legislation will be. We are forgetting that at the most optimistic peak of the process we would have gained none of the features of a healthcare system that we should be striving for.

Regardless of the outcome of the current negotiations, we should pull all stops in our efforts to achieve health care justice for all through a single payer, improved Medicare for All program. Anything less will sentence us to an expensive, mediocre system that is designed primarily to serve the interests of the privatizers rather than the interests of the public – the nation’s patients, all of them.

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.

U.S. Health Care — Down the Rabbit Hole

By Michael Flynn, M.D.
Louisville Medicine, Vol. 69, No. 6, pg. 35-36, November 2021

All of the other first world/industrial countries have health care systems whose function is to provide health care to all the citizens of each country. The purpose is simple in that the goal is to provide universal health care managed by the government. The method varies from government provided health insurance to a totally government-run health care system as in the United Kingdom. Funding also varies involving an assortment of taxation methods ranging from general taxation to multiple source funding, such as combinations of taxation (central and local), employer, employee and out-of-pocket sources. Some countries allow private health insurance, regulate fees, supervise and regulate drug costs. Health insurance is mandatory/compulsory in most and some countries do not allow for-profit health insurance.

The Scandinavian countries, the European Union, the United Kingdom, Canada, Australia, New Zealand, Japan, South Korea, Taiwan and some South American countries all have different forms of universal health care, functioning market economies and have not been bankrupted by providing this benefit to their citizens.

In the US, we have a health care industry, which functions in a magical arena, the competitive medical market place. While all those other first world countries consider health care an essential public service, in the US health care is a commodity to be exploited by an assortment of profit-seeking entities.

Most other first world countries have health care systems managed by the central government. In the US, we have a patchwork or more correctly a crazy quilt of different entities, some focused on providing health care and others focused on extracting profit from the health care industry. Medicare is government health insurance for older citizens and some with disabilities. Medicaid provides government health insurance as a federal/state collaboration for the poor and individuals with certain disabilities. Medicaid covers different things in different states. The US Public Health Service is trained to respond to national health crises and emergencies. The Army, Navy and Air Force all have health care systems within the Department of Defense providing health care to active-duty military and their families, retired military and dependents and politicians. Senators McCain and McConnell and Presidents Reagan and Trump were all treated at military facilities without cost. The VA health system, while not without challenges, generally does a good job caring for veterans.

And then we have the uniquely American approach to health care, over 1,000 for-profit health insurance companies whose primary goal is profit, not providing health care. Actually using the revenue from premiums charged to customers anticipating health insurance is considered a “Medical Loss Ratio”.1 The Medicare administrative costs are in the 2-3% range, for-profit health insurance companies are allowed to keep 20% as administrative cost as per the ACA and often find ways to keep higher amounts in certain plans.2 Each health insurance company may have 10-30 different plans with a range of premiums and coverage. The end result is an insanely complex and confusing health care environment inflicted on the American public.

How did we get into this mess? From the mid-1970s to the mid-2010s, the number of administrators/managers has increased by an astonishing amount: over 3,000%. There are now 10 managers/administrators for each physician.3 These people do not work in ICUs or ERs, they do not do COVID-19 tests or vaccinate. They may help, but they also interfere and are paid salaries that are often multiple times higher than the nurses, respiratory therapists and physicians who provide medical care.

The pharmaceutical industry functions without restraint, a very different situation compared to most other first world countries. Medicare is prevented by law from negotiating with the pharmaceutical companies, an astonishingly stupid economic policy.4 The for-profit health insurance companies extract hundreds of billions of dollars annually out of our health care as profit, outrageous administrative costs, advertising, political contributions and investor dividends.5 Over 60% of bankruptcies filed in the US are the result of citizens unable to pay medical bills, a situation that simply does not exist in most other first world countries.6

As disturbing as the current situation is, it is already getting worse. Private equity firms are purchasing nursing homes, hospitals, health systems, physician practices, outpatient surgery centers, laboratories, imaging facilities and whatever else they can get their hands on.7

The Wolves of Wall Street are about to devour US health care. The process involves buying the non-professional component of a practice, “improving efficiency” with the expectation of a return on investment of 15-30% annually and selling for a profit in three to five years.8 This is not meant to be a long, happy marriage. The investor invasion into health care creates the fundamental conflict of interest. “You can’t serve two masters. You can’t serve patients and investors.”7 About 70% of US nursing homes are investor owned.9 The resulting “improved efficiency” involves reduced staffing, increased use of medications and decreased quality of care.

The horror stories of patients left on toilets for hours, or lying in bed with unchanged loaded diapers abound. In one nursing home in Florida, a patient died from a feces-contaminated decubitus ulcer.10 When the family was understandably unhappy and hired a lawyer to determine accountability, they encountered a nightmare corporate structure. One company owned the building, another company obtained the license to run a nursing home, another company provided professional staff and another the custodial staff. The owners and managers had spread control among 15 companies and five layers of firms.

A large dermatology practice in California purchased by a private equity company produced a disturbing lesson in corporate governance.7 The practice’s “nonclinical” assets were bought by the private equity company, leaving the physicians in control of all medical decisions after agreeing to pay a management fee to handle administrative tasks such as billing and marketing. The new management team established daily and monthly financial goals, rewarding the offices meeting the goals with cash rewards. The performance of revenue enhancing procedures, Botox, laser treatments and Mohs surgery, for instance, was encouraged. Private equity groups buy existing labs and hire pathologists. The doctors are encouraged to send biopsy specimens to company owned labs and pathologists. Corporate approval was necessary to get office supplies, even toilet paper. Without consulting the medical staff, a manager changed to a cheaper brand of sutures and needles. The quality was so poor that needles would break off during injection and physicians had to dig them out of the skin and repeat the injection.

These are just a few examples of the litany of conflicts of interest between the goal of providing good patient care and the goal of feeding the investors’ profit demands. Sadly, we are left with the unanswered fundamental question of whether health care in the US is a commodity, to be exploited by for-profit companies and private equity investors, or is it an essential public service and a government responsibility. The rest of the first world knows the right answer.

Dr. Michael B. Flynn is a retired surgical oncologist.

https://viewer.joomag.com…

References

  1. https://www.healthinsurance.org…
  2. https://healthcare.gov…
  3. New York Times, Business Section, June 9, 2019
  4. https://cnn.com…
  5. New York Times, Sunday Review, November 17, 2019
  6. Am J Med, 2009, 122:741-6
  7. https://www.bloomberg.com…
  8. https://pe-insights.com…
  9. New York Times, September 6, 2020
  10. https://www.nytimes.com…

Physician Burnout: Fix the Doctor or Fix the System?

By Nancy C. Greep, M.D.; Steffie Woolhandler, M.D., M.P.H.; and David Himmelstein, M.D.
The American Journal of Medicine, Commentary, November 1, 2021

Burnout—emotional exhaustion and depersonalization (ie, treating patients like objects)—affects almost half of American physicians, even before the coronavirus disease 2019 (COVID-19) pandemic.1 Burnout diminishes the quality of physician’s lives2 and undermines patient care by leading to more medical errors and physicians leaving practice.3

Physicians report that administrative burdens (eg, filling out forms, dealing with multiple formularies, prior authorization and network restrictions, and documenting quality metrics) are important contributors to burnout. Other factors include cumbersome electronic health records (EHRs), productivity pressures, long work hours, poor work-life balance, and loss of autonomy.4

Two types of remedies for burnout have been suggested: personal interventions to decrease stress and improving the work environment. The former category includes everything from resilience training, mindfulness, yoga, battle buddies and psychotherapy to doctors’ dining rooms. However, these approaches, many of which put the onus of fixing burnout on already overburdened and time-pressured physicians, have mostly had little or no enduring effect.4

Suggestions for improving the work environment have included improving patient flow, using scribes, enlarging workspaces, having a social worker readily available, flexible scheduling, more vacations, and an executive wellness officer.5 Although many such changes have merit, they generally require protected time for the physician, additional personnel or space, and expense. Moreover, they would not address the underlying cause of burnout.

As with most maladies, finding a cure requires understanding the cause. In the case of burnout, the main cause is not nonresilient physicians or suboptimal work environments. Rather it is our failed health care system, a system characterized by impaired access to care, high and uncontrolled costs, and suboptimal quality care for many. These shortcomings stem from a dysfunctional insurance system and the invasion of the profit motive into what should be a public service.

The insurance system’s dysfunction is attributable to the multiplicity of health insurers, their pursuit of profit, and the tethering of private insurance to employment. A multipayer system leads to billing nightmares. The profit motive means insurers seek to decrease costs by restricting care through prior authorizations and narrow networks. Because private insurance is tied to employment, patients lose their coverage, and often their doctors, when they lose their jobs, or their employer switches insurers. As a result, physicians are deprived of the gratification derived from long-term relationships with their patients.

For-profit enterprises have procured many hospitals, physician practices, dialysis units, nursing homes, home health agencies, and other health care entities.6 They prioritize their bottom line, a priority that often conflicts with physicians’ obligation to prioritize optimal care.7 The drive for profit, which has infected even many nonprofit health care organizations, has reduced physicians’ clinical autonomy and changed their role from leaders to expendable, albeit it, highly paid workers.8

To address burnout, we advocate moving to a single-payer, nonprofit insurance system, eliminating patients’ out-of-pocket costs, and removing the profit motive from patient care. We are not alone: A single-payer system has been endorsed by the American College of Physicians and the Society of General Internal Medicine. How might such reform mitigate physician burnout?

Access: Because everyone would be equally and well insured, there would be no need to check whether a patient had insurance, a drug was on their insurer’s formulary, or a specialist to whom one wants to refer a patient was in the patient’s network. No time would be wasted searching for charity care or workarounds for uninsured or underinsured patients. Prior authorization requirements would be largely eliminated, as they have in many nations. Billing would be streamlined, and billing personnel redeployed to facilitate better care. Coding would be simplified and documentation for quality metrics decreased. EHRs could be redesigned for patient care rather than billing, and current commercially driven impediments to interoperability reduced. With administrative tasks decreased, and EHRs made more user friendly, physicians could spend more time facing patients and less time interacting with a computer—both during and after visits.

Cost: Physicians’ offices would not have to collect copays or determine if a patient had met their annual deductible. Physicians could prescribe medications, imaging studies, and ancillary tests without worrying whether a patient could afford them.

Quality: Freeing clinicians from administrative and EHR burdens would allow them to devote more time to their patients and to thinking and learning. Eliminating insurance-mandated changes in providers would facilitate long-term doctor-patient relationships, a better understanding of patients’ priorities and concerns, and the avoidance of redundant workups that often result from breaks in continuity. Patients would no longer have to skip medications because of cost. The pressure to meet productivity targets would be reduced, decreasing one source of errors. Care would be directed by clinicians and not by bureaucrats and businessmen.

Converting to a nonprofit single-payer system will not be easy. For-profit medical enterprises will need to convert to nonprofit status and our multipayer system of insurance replaced by a single insurer, the federal government. Although a majority of the public and of physicians already support such reform,9 congresspeople, many of whom receive large donations from the corporate medical industrial complex, will need to vote for it.

It is unrealistic to expect that burnout would completely disappear with single payer reform. Care of sick patients will remain emotionally and physically taxing in any health care system. Stress from maintenance of certification would continue. Although a single-payer system would help alleviate health disparities, caring for disadvantaged patients who face challenges the physician cannot fix, like homelessness, would continue to cause provider distress.

We recognize that our view is somewhat speculative as little hard data is available on the effects of single payer on burnout. However, a recent Canadian Medical Association survey offers optimism. More than 80% of Canadian physicians said that their emotional and psychologic well-being was high, and only 30% met criteria for burnout.10 To verify whether the level of burnout is lower in a nonprofit single-payer system such as Canada, a study using the same questionnaire in both countries at the same time would be informative.

https://www.amjmed.com…

References

  1. Shanafelt T, Hasan O, Dyrbye L. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
    Mayo Clin Proc. 2015; 90: 1600-1613. https://doi.org/10.1016/j.mayocp.2015.08.023
  2. Dyrbye LN, Varkey P, Boone SL, Satele DV, Sloan JA, Shanafelt TD. Physician satisfaction and burnout at different career stages. Mayo Clin Proc. 2013; 88: 1358-1367. https://doi.org/10.1016/j.mayocp.2013.07.016
  3. Tawfik DS, Profit J, Morgenthaler TI, et al. Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. Mayo Clin Proc. 2018; 93: 1571-1580. https://doi.org/10.1016/j.mayocp.2018.05.014
  4. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med. 2018; 283: 516-529. https://doi.org/10.1111/joim.12752
  5. Gergen Barnett KA. In Pursuit of the Fourth Aim in Health Care. Med Clin North Am. 2017; 101: 1031-1040. https://doi.org/10.1016/j.mcna.2017.04.014
  6. Physicians for a National Health Program. The case against privatization. Available at: https://pnhp.org/2018/12/03/the-case-against-privatization-of-u-s-health-care/. Accessed September 13, 2021.
  7. Relman AS. The problem of commercialism in medicine. Camb Q Healthc Ethics. 2007; 16: 375. https://doi.org/10.1017/S0963180107070466
  8. Relman AS. The new medical-industrial complex. N Engl J Med. 1980; 303: 963-970. https://doi.org/10.1056/nejm198010233031703
  9. Pew Research Center. More Americans now favor single payer health coverage than in 2019. Available at: https://www.pewresearch.org/fact-tank/2020/09/29/increasing-share-of-americans-favor-a-single-government-program-to-provide-health-care-coverage/. Accessed September 20, 2021.
  10. Canadian Medical Association. National Physician Health Survey 2018. Available at: https://www.cma.ca/physician-wellness-hub/resources/measurements-outcomes/2018-national-physician-health-survey/. Accessed June 17, 2021.

A successful Medicare should never be privatized

By Elizabeth R. Rosenthal, M.D.
The Riverdale Press, Bronx, N.Y., October 31, 2021

As a physician for 54 years, my career is just about the same age as Medicare.

When I was in practice, I appreciated that it always paid me promptly, in contrast to corporate insurance companies, which tried very hard not to pay me what was promised. Now retired, I worry about the ongoing attempts to further privatize this popular and effective public program.

We all know privatizing Social Security would harm us. Privatizing Medicare is worse — and insidious. As a volunteer Medicare advisor, I’ve seen patients lured into Medicare Advantage plans and then feel betrayed when illness strikes: What they need isn’t covered.

Original public Medicare treats health care as a social need, not as a profit-making commodity. We trust Medicare because it provides affordable, comprehensive health care equitably. Decades of research shows that Medicare improves the health of senior citizens. Medicare actually increases our life expectancy — dramatically. Hence its popularity.

But now accelerated privatization threatens Medicare. We must urgently oppose this. Privatizing began in 1997 and has been called Medicare Advantage since 2003, interposing profit-seeking middlemen — corporate health insurance companies — between physician and patient. It harms our health care and increases its costs — paid by taxpayers.

Medicare Advantage plans shift incentives away from the delivery of health care to profit-taking. For a health insurance company, the more health care it delivers, the smaller its profit. This perverse incentive leads to denials and delays of care — the reasons for prior authorizations. Never mind that in more than 75 percent of appeals against denials, patients win: Most patients are too sick and stressed to appeal, letting insurers win.

Presently, 40 percent of Medicare recipients are in Medicare Advantage plans, the most profitable of all for-profit plans. For-profit insurers want even more of this golden goose.

The corporate middlemen — the insurer — pockets 15 to 20 cents of every dollar paid by the government for Medicare Advantage recipients, contrasted to original Medicare’s 3 cents per dollar. Paying for bloated administrative costs — the wages of those who deny care — tens of millions annually for each chief executive, hundreds of millions in advertising, and out-sized profits for shareholders, all means less money for patient care — 80 to 85 cents, not Medicare’s 97 cents.

Unfortunately, because Medicare was designed with coverage gaps to protect corporate insurance, it can be expensive for seniors. It requires a monthly premium, out-of-pocket costs, and 20 percent of the doctor bill as well as deductibles for hospital stays. To be fully covered, seniors must purchase costly — too often, unaffordable — private insurance: a supplemental, or “Medigap,” plan, and a private plan for prescription drugs.

These gaps allow Medicare Advantage to lure patients with added benefits such as gym memberships and limited coverage for eye care, dental, hearing and prescription drugs. They require the same monthly Part B premium as original Medicare, but tout having no other upfront costs.

The fine print is hidden: Small physician networks, particularly specialists — many do not take these plans as they pay less and require more trouble to actually receive payment. If one becomes seriously ill, out-of-network specialists and hospitalization can make Medicare Advantage plans ruinous.

I like to call them “Medicare Disadvantage.”

Even worse is a new privatizing gimmick called “direct contracting entities,” or DCEs. Patients who chose original Medicare can be assigned to a Medicare Advantage plan without recourse. Some of these entities are Wall Street firms, entirely focused on profits. Green-lighting today’s pilot program will put all Medicare recipients at risk.

There is a better path forward. An expanded and improved Medicare for All would fix these problems. A federal bill, H.R. 1976, would bring everyone affordable, comprehensive medical care without the corrupting effects of profit-making entities. It would save patients, taxpayers and our government hundreds of billions per year. During the coronavirus pandemic, the vaccine rollout — an example of federal health care — was popular.

We New Yorkers don’t have to wait for Congress to enact a federal bill. We have a state bill: the New York Health Act. It would bring affordable, comprehensive health care for all residents of New York with progressive taxation replacing premiums and out-of-pocket costs. Only the wealthiest would spend more on health care than they do now.

It has a majority of co-sponsors in each chamber in Albany.

Let us all make sure our elected representatives know we oppose privatizing Medicare, and that we want Medicare for All. Call your state and federal representatives.

It’s only health justice if we protect everyone.

https://riverdalepress.com…

Let the Games End!

Summary: Two unrelated news stories highlight ways that powerful actors in our healthcare system manipulate complex reimbursement rules and procedures, approaching and crossing legal boundaries. Detecting and stopping abuse in our complex profit-focused system is impossible. We need to end this gaming, with a simple fair payment system.

5 things about DOJ’s upcoding allegations against Kaiser, Modern Healthcare, October 26, 2021, by Alex Kacik

Kaiser Permanente allegedly coerced employees to upcode claims for Medicare Advantage beneficiaries, resulting in an estimated 75% error rate, according to a new complaint from the U.S. Justice Department.

The federal government intervened in six related lawsuits in July and filed a complaint Monday, outlining how Kaiser physicians allegedly changed medical records often months after care was provided to boost the Oakland, California-based integrated health system’s Medicare Advantage reimbursement. More than half of Kaiser physicians said they were forced to add diagnoses they did not consider, evaluate or treat, according to one of the whistleblowers and former Kaiser medical coder, Randi Osinek. …

5. Some of the diagnoses that Kaiser allegedly added via the chart reviews did not even exist; many allegedly did not require or affect patient care or treatment. These chart reviews were often added months or even a year or more after the visit so that Kaiser could get risk adjusted payments for the newly added diagnoses, according to the complaint.

Wall Street Is Pressing ER Docs To Fleece Patients, Daily Poster, October 27, 2021, by Maureen Tkacik

Robert McNamara, a Temple University medical school professor who has been working for decades to galvanize ER doctors in opposition to the “corporate practice of medicine,” had proposed a resolution that would essentially force all ER staffing companies seeking to do business with ACEP [American College of Emergency Physicians] to periodically furnish their physicians with data on the services and procedures the company had billed for under their license numbers.

… Unsurprisingly, the ACEP Board expressed extreme reluctance to adopting the proposal, noting that four separate attorneys it had consulted believed there was “substantial risk” …

“ACEP engaged outside counsel to advise on whether securing regular reporting of billing in a physician’s name could inadvertently subject that physician to potential liability under the False Claims Act [emphasis added], since provision of this information could now leave them considered to be ‘knowing,’” they wrote.

In other words: emergency room doctors are better off not knowing what their private equity overlords are billing under their license numbers, because they are less likely to go to jail for Medicare fraud if they didn’t actually know they were committing it.

Comment:

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

Our health system’s arcane payment rules + big-profit corporate mentality = the perfect medium for intensive gaming, both legal and illegal. These two stories illustrate different manifestations of the problem — albeit just the tip of the iceberg quantitatively, a faint hint of the true scale of abuse.

Kaiser Permanente is considered by many an admirable actor in the HMO world, with a history of innovative care models. Yet, in this article in Modern Healthcare, we learn that the US Department of Justice is taking KP to court for orchestrated efforts to increase physician disease severity coding – even to add false diagnoses – to bump Medicare Advantage revenues by tens of millions of dollars. HJM has covered “risk adjustment” exploitation before. The money at stake with exaggerated coding is astronomical, eliciting the worst behaviors among corporate actors in health.

Organizations like ACEP were founded to represent the interests of doctors, which should include fair and transparent billing. But the Daily Poster describes that ACEP has increasingly focused on preserving ER profit, including for private equity investments. It abets a corporate model that hides potentially fraudulent billing. HJM recently addressed the hazards of private equity. The new article describes deep ties that two former heads of ACEP have to PE. One even dismissed the problem of surprise billing – rampant in ERs staffed by private equity-funded companies which seek to profit from out-of-network charges. The doctors are coerced into being complicit, with plausible deniability.

How can we end this gaming, abuse, and extraction of resources from the health system? Single payer would use simple, fair rules. For example: annual global budgets for hospitals and their ERs. Ambulatory care doctors would typically be paid fee-for-service, with no need for exploitable risk adjustment data. If capitation is permitted (a discussion), it would rely on a standard clinically-focused electronic health record containing legitimate, consistent diagnostic information.

Let the billing games end!

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