By Diane Archer
Common Dreams, November 21, 2023

During this Medicare Open Enrollment period, ask yourself these seven questions. And, please know that you can always call the Medicare Rights Center at 1-800-333-4114 or your SHIP—State Health Insurance Assistance Program—for free, unbiased advice on any of your Medicare questions.

Q. What’s the biggest difference between traditional Medicare and a Medicare Advantage plan? To ensure you have good coverage for both current and unforeseeable health needs, you should enroll in traditional Medicare. In traditional Medicare, you and your doctor decide the care you need, with no prior approval. And, you have easy access to care from almost all doctors and hospitals in the United States with no incentive to stint on your care. In a Medicare Advantage plan, a corporate insurance company decides when you get care, often requiring you to get its approval first. Medicare Advantage plans also restrict access to physicians and too often second-guess your treating physicians, denying you needed care inappropriately. The less care the Medicare Advantage plan provides, the more the insurance company profits. You will pay more upfront in traditional Medicare if you don’t have Medicaid and need to buy supplemental coverage, but you are likely to spend a lot less out of pocket when you need costly care. Regardless of whether you stay in traditional Medicare or enroll in Medicare Advantage, you still need to pay your Part B premium.

Q. Should I trust an insurance agent’s advice about my Medicare options? No. Unfortunately, insurance agents are paid more to steer you away from traditional Medicare and into a Medicare Advantage plan, even if it does not meet your needs. While some insurance agents might be good, you can’t know whom to trust. Keep in mind that while Medicare Advantage plans tell you that they offer you extra benefits, you still need to pay your Part B premium, and extra benefits are often very limited and come with high out-of-pocket costs; be aware that many Medicare Advantage plans won’t cover as much necessary medical and hospital care as traditional Medicare. For free independent advice about your options, call the Medicare Rights Center at 1-800-333-4114 or a SHIP.

Q. Why can’t I rely on my friends or the government’s star-rating system to pick a good Medicare Advantage plan? Unlike traditional Medicare, which gives you easy access to the physicians and hospitals you use from everywhere in the U.S. and allows for continuity of care, you can’t count on a Medicare Advantage plan to cover your care from the healthcare providers listed in their network or to cover the medically necessary care that traditional Medicare covers. Even if your friends say they are happy with their Medicare Advantage plan right now, they are gambling with their healthcare. The government’s five-star rating system does not consider that some Medicare Advantage plans engage in widespread inappropriate delays and denials of care, and other Medicare Advantage plans engage in different bad acts that can endanger your health. So, while you should never sign up for a Medicare Advantage plan with a one, two, or three-star rating, Medicare Advantage plans with four and five-star ratings can have very high denial and delay rates.

Q. If I’m enrolled in a Medicare Advantage plan, can I count on seeing the physicians listed in the network and lower costs? Unfortunately, provider networks in Medicare Advantage plans can change at any time and your out-of-pocket costs can be as high as $8,300 this year for in-network care alone. You can study the MA plan literature, and you can know your total out-of-pocket costs for in-network care. But, you cannot know whether the MA plan will refuse to cover the care you need or delay needed care for an extended period. This year alone, dozens of health systems have canceled their Medicare Advantage contracts, further restricting access to care for their patients in MA, because MA plans make it hard for them to give people needed care.

Q. Doesn’t the government make sure that Medicare Advantage plans deliver the same benefits as traditional Medicare? No. The government cannot protect you from Medicare Advantage bad actors. The insurers offering Medicare Advantage plans can decide you don’t need care when you clearly do, and there’s no one stopping them; they are largely unaccountable for their bad acts. In the last few years there have been multiple government and independent reports on insurance company bad acts in Medicare Advantage plans.

Q. If I join a Medicare Advantage plan, can I disenroll and switch to traditional Medicare? You can switch to traditional Medicare each annual open enrollment period. However, depending upon your situation, where you live, your income, your age, and more, you might not be able to get supplemental coverage to pick up your out-of-pocket costs and protect you from high costs. What’s worse, you could incur thousands of dollars in out-of-pocket costs in Medicare Advantage.

Q. If I have traditional Medicare and Medicaid, what should I do? If you have both Medicare and Medicaid, traditional Medicare covers virtually all your out-of-pocket costs. You will get much easier access to physicians and inpatient services in traditional Medicare than in a Medicare Advantage plan if you need costly healthcare services or have a complex condition.

Again, for free independent advice about your options, call the Medicare Rights Center at 1-800-333-4114 or a SHIP.

Diane Archer is president of Just Care USA, an independent digital hub covering health and financial issues facing boomers and their families and promoting policy solutions. Ms. Archer began her career in health advocacy in 1989 as founder and president of the Medicare Rights Center, a national organization dedicated to ensuring that older and disabled Americans get the health care they need.

https://www.commondreams.org…

By Rep. Pramila Jayapal (D-Wash.) and Dr. Diljeet Singh
The Hill, November 17, 2023

Physicians and policymakers are, in different ways, both responsible for the health and well-being of patients. While physicians care for patients to the best of their ability, policymakers ensure that the structures that make up the health care system are effective and equitable. Whenever and wherever there is a threat to these goals, both groups have a role to play in recognizing and combating it. That is why we are speaking out on the need to make fundamental changes to the Medicare Advantage (MA) program.

MA as it exists today is a threat to patient care, to health equity, and indeed to the integrity of our public health infrastructure. A new report from Physicians for a National Health Program, an organization of doctors working to reform the health care system, shows that for-profit, corporate MA insurers are overpaid anywhere from $88 to $140 billion a year. That’s money coming out of patients’ and taxpayers’ pockets.

MA is the privately-run version of the traditional government-administered Medicare program. Instead of paying directly for care, the government instead pays insurers to “manage” patients’ needs. Enrollment in this program has grown significantly over the past two decades, with over 50 percent of eligible beneficiaries opting for an MA plan in 2023. Unfortunately, growth in the program has not led to better care for beneficiaries or a better deal for taxpayers — just the opposite, in fact. Tens of billions of taxpayer dollars are being siphoned off as profit by insurance companies that don’t even provide necessary care. That money doesn’t just cost our government, it costs seniors. For example, premiums paid for Medicare Part B, which covers most medical services outside of hospitalization, totaled $131 billion in 2022. With the amount of extra money that corporate insurers get from the government, we could totally eliminate Part B premiums and still have money left over.

Where is all this money coming from? It’s complicated, the result of a tangled web of loopholes, policies, and practices that are difficult for an individual beneficiary or physician to see. Even so, scholars and regulators have identified a few major factors that lead to overpayments. For example, insurance companies in MA tend to enroll patients that are healthier and therefore cost less than average but still get paid as if their patients were much sicker. This is called favorable selection, and by some estimates, it could cost as much as $75 billion a year in extra payments.

Because Medicare gives additional money to MA insurers for patients with more severe or more numerous diagnoses, another source of overpayments are all the irrelevant or old conditions that insurers record on patient charts. This practice is known as upcoding; these conditions aren’t being actively treated, so they don’t cost the insurance company anything, but they do lead to as much as $20 billion in extra payments. These methods only scratch the surface of all the ways in which MA insurers take advantage of the system, but the bottom line is clear: these companies are pocketing billions of dollars that belong to Medicare beneficiaries.

Of course, it isn’t just about the money; it’s also about patient care. Medicare Advantage plans tout their low premiums and extra benefits, but often these are only worth it as long as you’re healthy. If you get sick and need complex or significant care, plans start to show their true colors. Difficult authorization processes and narrow networks can make getting treated under an MA plan a nightmare. In fact, high-need patients with chronic conditions and patients in their last year of life are substantially more likely to switch out of MA and back to traditional Medicare, tired of having to justify each and every needed procedure or medication to their insurance company.

In our roles as a member of Congress and a practicing physician, we see different but equally concerning manifestations of these problems. Constituents call in with stories of being lured into an MA plan, and then denied care or prevented from seeing their doctor. Cancer patients, for whom an early diagnosis and treatment plan is imperative to survival, face weeks of delay because of onerous pre-authorization requirements. In fact, some of these patients have ended up needing emergency surgery or aggressive radiation that could’ve been avoided if insurers hadn’t gotten in the way. MA doesn’t just take billions in taxpayer dollars; it makes it harder for doctors to do their jobs, and harder for patients to get well.

With the money that we spend on corporate giveaways, we could entirely fund Medicare’s prescription drug benefit, establish an out-of-pocket maximum in traditional Medicare, or even provide dental, hearing, and vision benefits to everyone on Medicare and everyone on Medicaid. This doesn’t need to be a partisan issue. We should all agree that programs paid for by the people should benefit the people. It’s time to crack down on overpayments in MA and use those resources to improve Medicare for all patients.

Pramila Jayapal represents Washington’s 7th District. Dr. Diljeet K. Singh is a women’s health advocate and an integrative gynecologic oncologist in clinical practice since 1999. She currently serves as vice president for Physicians for a National Health Program.

https://thehill.com…

November 15, 2023

Healthcare for All Campaign Director Aija Nemer-Aanerud (of People’s Action) invites anybody who cares about the state of health care in the U.S. to join the Care Over Cost campaign.

This nationwide campaign, which is carried out by a large network of local affiliates, encourages people to share their personal struggles with care denial at the hands of U.S. health insurers.

“Your community will have your back,” they say. “Your fight with the insurance company is my fight with the insurance company.”

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

https://medicareforallexplained.podbean.com

By Brenda Gazzar
Code Wack Podcast, November 12, 2023

What can be done in light of Medicare Advantage overcharging taxpayers to the tune of around $140 billion a year? What’s the Medigap Trap and why should you worry about it?  Why should we work to improve traditional Medicare while pursuing Medicare for All?

To find out, we spoke to Dr. Ed Weisbart, the national board secretary for Physicians for a National Health Program and president of the Consumers Council of Missouri.

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Transcript

Dispatcher: 911, what’s your emergency?

Caller: America’s healthcare system is broken and people are dying!

Welcome to Code WACK!, where we shine a light on America’s callous healthcare system, how it hurts us and what we can do about it. I’m your host, Brenda Gazzar.

(music)

This time on Code WACK! What can be done in light of Medicare Advantage overcharging taxpayers to the tune of $140 billion a year? And what’s the Medigap Trap and why should you worry about it? Should we improve traditional Medicare or pursue Medicare for All as a solution? To find out, we spoke to Dr. Ed Weisbart, the national board secretary for Physicians for a National Health Program and president of the Consumers Council of Missouri.

Welcome back to Code WACK!, Dr. Weisbart.

Weisbart: Thanks Brenda.

Q: Last time we spoke about how Medicare Advantage companies are overcharging the government as much as $140 billion dollars through various ways, including upcoding or adding diagnoses so that people appear less healthy than they are. You also mentioned the No Upcode Act which would fight fraud and upcoding by restricting the use of old or unrelated medical conditions to determine the cost of care. I think that’s great and I hope the bill passes. What else can be done to fight these Medicare Advantage overcharges?

Weisbart: It’s tough. There aren’t any other legislative initiatives that I know of that would actually start to address this. So I think it’s incredibly important that as we expose problems with Medicare Advantage, we need to get people aware of this, but we need to simultaneously be fighting at least as hard to improve traditional Medicare. We need to eliminate or greatly reduce the out-of-pocket expense so that people can afford to go into traditional Medicare. We need to add those extra benefits so that you don’t have to give up your choice of doctors so that you can get a gym club membership. We need to level the playing field so that it’s fair. So we need to be working at the same time. If you just got rid of Medicare Advantage today, there’s a lot of people who wouldn’t have a place to land. I mean, because it is a lower premium. We need to do these two things in tandem.

Q: Yeah. So what do you think about single-payer Medicare for All and where does that fit into the differences between Medicare Advantage and Traditional Medicare?

Weisbart: What does single payer mean? It means one payer instead of a multitude of payers. So today we have a multi-payer model where we have all these dozens or I don’t know how many insurance companies and all these employers and all these, there’s a whole bunch of people that pay for insurance that’s called a multi-payer model and it fragments us and it makes it kind of crazy. It locks you into your job because you don’t want to give up your insurance because that means giving up your doctor.

It’s a crazy system having it the way it is today. So one payer instead of hundreds of payers would be great and we should all be in it. So what should that one payer be? And to me the most sensible one would be to build it on Medicare. You know, Medicare’s got decades of a track record showing that it rescues seniors from poverty, that it improves life expectancy, that it lowers death rates, you know, and that it gives you a peace of mind and gives you choice. You can pick almost any doctor in the country or any hospital. So if you live in Boise, Idaho, and you have your Medicare there, but you spend four months in the winter in Florida, if you have Medicare, regular Medicare, you can spend four months of the year in Florida and go to get any health care you need. If you have Medicare Advantage or any other insurance and you go to Florida, you wind up only being able to get emergency care paid for if you’re lucky.

Whoah, talk about taking a risk.

Weisbart: Yeah. A one single payer based on Medicare, fix the things that are wrong with Medicare and give that to everybody in the country and we would save money, the country would spend less on health care. We would stop having to, you know, every year rethink, ‘well, do I want Blue Cross? Do I want Humana? Do I want Cigna?’ You know, we just, you know, stop that.

What’s their one job? Their one job? The one thing the insurance companies get is they’re tasked with telling us which doctors and hospitals we can’t use . Who would do that? Who would set up a system like this? It’s nuts. So yeah, I think single payer Medicare for All, improved Medicare in the ways we were talking about is really the right way to go.

Right, because under a Medicare for All system, we could all go where we want for care because everyone would have the same coverage.

Weisbart: So there’s a bill in the House (of Representatives) and a bill in the Senate that would accomplish that. Hooray – and they’re actually increasing in popularity. They have more co-sponsors than they’ve ever had when they were brand new. So it’s huge and they’re growing, but I know that they’re not going to pass next week. They’re not going to pass in probably in the next two years. So instead, you know, to get there, let’s work on the things that we know we need. We need to improve traditional Medicare. We need to eliminate those copays and deductibles, or at least greatly reduce them. We need to add the missing benefits, improve traditional Medicare and that and a few other ways, and at least expose what’s going on with Medicare Advantage.

So think about it. You brought up that they’re now in the majority, you brought up that most people in Medicare are in Medicare Advantage, which is terrifying to me. But it’s true. This year we crossed the Rubicon and now 51% of people in Medicare this year are in Medicare Advantage. So they’re on track to keep on growing….Let’s say they’re on track to get to 60% in three years. I don’t know that, but let’s say they’re on track to get to 60% in three years. Well, if we could do things to keep them at 50% instead of 60% three years from now, that would be huge. I mean, these are usually for profit, publicly traded companies. They want to see growth. If we can stop their growth…

Q: How could we do that?

Weisbart: Well, you can’t get them from 60% down to zero unless you get Medicare itself improved. But you can get them to stop growing or maybe even shrink a little bit. If the people that could afford Medigap learned this. They don’t realize what’s happening. They sign up for Medicare Advantage and they, most of them don’t realize that they’re giving up their choice of doctor.

Q: Yes, and that’s usually what people care most about.

Weisbart: They don’t realize they’re taking a gamble on their future health. They don’t realize that their hospital may no longer be in-network. ’cause Hospitals are leaving Medicare Advantage left and right nowadays. So they don’t know this. They don’t know if they sign off for Medicare Advantage that they may have to start traveling 30 miles to get to the nearest hospital instead of going to the one that’s 10 miles away if you’re rural. They don’t know this stuff and they don’t know that once you’re in Medicare Advantage, there’s a really good chance that you’re trapped there.

Q: Oh? How so?

Weisbart: Yes, you can always get out of Medicare Advantage and go back to traditional Medicare. Absolutely you can do that. But there’s no guarantee that you can still buy Medigap, so the first six months that you’re in Medicare, or the first 12 months that you’re in Medicare Advantage, if you apply for that Medigap policy, the Medigap insurers are legally required to say yes. They’re legally required to sell you a policy and they’re legally prevented from asking you if you have cancer or diabetes or any of that stuff. They can’t send you a survey about your health.

They can’t ask you that stuff. They can’t look at your medical claims history. So for the first 6-12 months that you’re in Medicare, if you want to buy Medigap, and almost everybody does, ’cause otherwise you’re risking bankruptcy the first 6-12 months that you’re in Medicare, yeah, you can buy Medigap. But after that, there’s no guarantee about that. There’s I think four states that do guarantee it, but you know, 46 states don’t. So pretty much you can’t count on that.

So you go into traditional Medicare for a year, for two years, for five years, and then you get one of the cancers that I was talking about a few minutes ago. You get something bad and you try to go to the cancer center, the National Cancer Institute approved Cancer center, and you didn’t think to look that up when you signed up for Medicare Advantage cause you know you didn’t have cancer. You can’t look up everything. You didn’t think to look that up. So you didn’t know you signed up for Medicare Advantage. You didn’t realize you were taking a gamble.

You like the health club, you like having this, you know, you pick your six favorite teeth and you got the dental care for those. I’m overstating that. But you know, you got that stuff but then five years in, you get cancer and you want to go to the National Cancer Institute approved Cancer center and they say you can’t. And the Medicare Advantage company says, ‘sure, go there, but we’re not going to pay a penny for it.’ And then you’re in trouble, then you’re in trouble and your gamble isn’t paying off anymore.

And you can go back to traditional Medicare, but you’ve got to pay $1,600 every time they put you in the hospital for that cancer. Or you got to pay 20% for every office visit to your oncologist – 20% for every, every, every chemotherapy infusion and you are gonna go bankrupt.

Q: Yeah. So let’s say I’m in Medicare Advantage and want to switch to traditional Medicare. Did you say that in the first six months to a year I can buy supplemental policy?

Weisbart: Yes. The first six months that you’re in Medicare Part B or the first 12 months that you’re in Medicare Advantage, the federal law requires every Medigap insurance company to sell you a policy at the same price they would sell it to anybody else in your community. They have to say yes. They can’t ask you why you want to buy the policy. They can’t exclude you for preexisting conditions. None of that stuff….But after that, that protection against preexisting conditions disappears. Disappears.

Q: So after 12 months, I won’t be able to get the Medigap policy, which protects people against medical bankruptcy?

Weisbart: You might be able to, but there’s no guarantee. And the sicker you are, the less likely they would sell it to you. It’s insurance that disappears when you need it. Well, that’s not insurance, that’s theft . I’m paying my premium and not getting what I’m paying for. That’s a really inferior way to set up a healthcare system. Which goes back to your question. Yeah. Single payer Medicare for All is absolutely the smart way to do this.

Q: Got it, And it sounds like it would solve the affordability problem that so many people in Medicare Advantage have because they won’t have to worry about paying premiums or deductibles under Medicare for All.

Weisbart: No, like I said, there’s a bill in the house and a bill in the Senate that, a state that is called the Medicare for All Act of 2023, each one. They’re not identical, but they’re very, very similar and both of them say exactly what you just said. The proposed bills eliminate copays, eliminate deductibles, eliminate co-insurance, don’t charge a premium at all. They’re publicly funded in the same way we publicly fund everything else that’s important for the whole country to have. They’re publicly funded through a progressive tax model the same way we do for clean drinking water and for the clean air and for the military and for most schools and the roads and sewage and the handful of things for which, you know, everybody left and right, you know, the most progressive to the most libertarian or the most conservative everybody thinks yeah sewage collection, you know, that should be tax funded. The military.

Yeah. We don’t want to each have our own military and maybe we don’t like everything the military does, count me into that camp, but we all think there needs to be a military. Not too many people don’t want that. So there is a handful of things that across the political spectrum, people agree, yeah, this is what progressive tax model should fund. And I submit to you that health care should be one of those things. It’s to my advantage to have you be healthy. I want you to have health insurance because if you’re here in this country, you know, I don’t want you coughing up an infectious disease on the bus, you’re not able to go to work ’cause your diabetes is out of control. You know, I want you healthy if you’re here. I think everybody that’s living in this country should have access to health care without financial barriers and then fund it the way we fund other things that are necessary for the public good, like a progressive income tax.

And it turns out that that increase in your tax is smaller than what we would save by not having to pay premiums or copays or co-insurance or any of that stuff. … So yeah, most of us would save a lot of money.

Q: That would be wonderful. Is there anything else you wanted to say, Dr. Weisbart?

Weisbart: Yeah, take action. Go to our website which we built called ProtectMedicare.net and there’s a bunch more resources. Our report is going to be up there by the time the podcast airs. There’s a petition there that you can sign to say that you don’t like this and you want to stop these overpayments, you want to fix this, you want to stop, you know, letting our Medicare program be so drained. We have a survey that we’d like you to fill out talking about your experience with Medicare or Medicare Advantage. And if you’re a physician, there’s a physician centric survey about what’s, what it’s like treating patients. So we’d like you to fill that. And there’s tools (at) ProtectMedicare.net that can help you write letters to the editor and help you be more articulate about this. … So go to ProtectMedicare.net for all this stuff and more.

Thank you Dr. Ed Weisbart of Physicians for a National Health Program.

Do you have a personal story you’d like to share about our wack healthcare system? Contact us through our website at heal-ca.org.

Don’t forget to subscribe to Code WACK! wherever you find your podcasts. You can also find us on ProgressiveVoices.com and on Nurse Talk Media.

Code WACK! is powered by HEAL California, uplifting the voices of those fighting for healthcare reform around the country. I’m Brenda Gazzar.

https://heal-ca.org…

By Brenda Gazzar
Code Wack Podcast, November 6, 2023

Medicare Advantage is overcharging the federal government – and you won’t believe by how much! How’s this affecting taxpayers like you and me and what can be done about it?

To find out, we spoke to Dr. Ed Weisbart, the national board secretary for Physicians for a National Health Program and president of the Consumers Council of Missouri.

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Transcript

Dispatcher: 911, what’s your emergency?

Caller: America’s healthcare system is broken and people are dying!

Welcome to Code WACK!, where we shine a light on America’s callous healthcare system, how it hurts us and what we can do about it. I’m your host, Brenda Gazzar.

(music)

This time on Code WACK! Medicare Advantage is overcharging the federal government – and you won’t believe by how much! How’s this affecting taxpayers like you and me and what can be done about this? To find out, we spoke to Dr. Ed Weisbart, the national board secretary for Physicians for a National Health Program and president of the Consumers Council of Missouri.

Welcome back to Code WACK! Dr. Weisbart.

Weisbart: Thanks, Brenda. How nice to see you again.

Q: So it’s Medicare open enrollment where people age 65 and older, and those with certain disabilities, are deciding whether they want traditional Medicare or Medicare Advantage. Today over half of Medicare beneficiaries have Medicare Advantage. What are a couple of key differences between these two programs for consumers?

Weisbart: So Medicare is the program that, you know, we know and love started in 1965. It covers your hospital stuff, it covers your doctor stuff. If you buy Part B and it’s traditional. We’ve had it for forever, and it’s seamless. They never say no, they never get in your way. You can go to almost any doctor in the country and there’s nobody trying to make a profit off of it. They operate with like a 2% overhead. It’s a terrific program.

Medicare Advantage is really neither Medicare nor an advantage. So instead of having the Medicare program just pay for your doctors and hospitals for you, instead of that, now, Medicare prepays insurance companies, like the insurance companies that do most of the employer kind of health care. So they prepay the insurance companies for every person that’s in there.

Pre-paid? Lucky them.

Weisbart: And of course, you know, once the insurance companies are prepaid for you, they don’t want to let go of that money. It’s in their bank account. They want to, they want to keep it. … So they have all sorts of games to kind of get in the way. They keep you from going to certain doctors and hospitals. They delay paying for your care, even just stand in the way for a week or two of being able to get care. That’s money that’s still in their bank that they can make a profit off of.

So they don’t want you to go get care, and they don’t want you to get it quickly, and they want you to go to the places that they pick.

And so that’s different from Traditional Medicare…

Weisbart: Medicare Advantage is completely different from Medicare. The only real advantage to Medicare Advantage is if you’re the CEO, you know, or the shareholders, the investment companies. I mean, nobody looks at Medicare and says, ‘gee, you know, what we really need are more bankers involved’ and that’s what you get with Medicare Advantage.

Q: And yet, more and more seniors are getting Medicare Advantage. Why is that?

Weisbart: It’s not because it’s any better, so it’s cheaper on the front end. What people don’t really realize is that although it may be cheaper initially, it’s not a lot cheaper and then they have somebody saying, ‘no, you can’t get the health care you want.’

So people in Medicare Advantage actually have more trouble accessing health care than people in good old traditional Medicare. People in Medicare Advantage have longer delays. Actually a new study came out recently that shows people in Medicare Advantage don’t go to the better hospitals as often. They have a longer time getting diagnosed. They have a longer time getting treated once they’re diagnosed with cancer, and they actually have higher death rates postoperatively if they have cancer surgery.

So, you know, you’re kind of taking a gamble when you’re going into Medicare Advantage. You’re gambling that spending a bit less money up front on premiums isn’t going to kill you. And sadly there’s evidence that it just might so it’s not a good choice.

Q: I see. So the single-payer advocacy group Physicians for a National Health Program recently released a bombshell report about Medicare Advantage overcharging titled “Our Payments, Their Profits: Quantifying Overpayments in the Medicare Advantage Program.” What were the key findings of this report?

Weisbart: The bottom line is that we overpay or they’re allowed to be overpaid by at least $140 billion.

Q: $140 billion?

Weisbart: I think the analysis is fair to say $140 billion and that’s just looking at the legal things. That’s not looking at fraud and abuse. That’s just looking at what’s legal. So I said $140 billion a year. It’s so hard to figure out. Is that a big number? You know, everybody in Medicare – just about – has to pay a part B premium, right? We spend about $170 out of pocket a month on our Part B premium so that we can get the Part B benefits, you know, go to the doctor and stuff.

But it usually comes out of your Social Security check… If you add up those $170 a month across everybody in Medicare, it comes to $131 billion. So we’re spending $131 billion on our Part B premiums, but the Medicare Advantage companies are getting $140 billion in overpayments.

Wow. So it sounds like the overpayments to Medicare Advantage plans could more than cover Medicare’s Part B premiums for doctor visits, outpatient hospital services and other medical services.

Weisbart: When I realized that that’s how the numbers work out, that all of my premium dollars for Part B and more are being diverted into Medicare Advantage companies for no reason, for worse outcomes. So all of our money is going to them and that just makes me mad that that should be happening.

And that’s one comparison to Part B premiums. You know, one of the things that is really troublesome in Medicare is the out-of-pocket costs. We have to pay 20% of our outpatient care. We have to pay, you know, $1,600 for a hospitalization, and if you have to go to the doctor once a year, 20% of one visit is probably something most can afford.

But if you’re sick and that’s why you have insurance and you have to go to a doctor once a month or once a week or two or three times a week, 20% of that is bankruptcy town and there’s no limit on that or $1,600 for a hospital stay, that’s already stuff that you need to take a loan out for and if you have to be hospitalized two or three times a year… So because of that, it’s a problem that Medicare doesn’t have a limit on how much those out-of-pocket costs can go to and this is directly relevant to our study because we found an analysis from the Urban Institute that looked at what would it cost to change Medicare and limit it so that nobody has to spend more than $5,000 out of pocket – $5,000’s still a lot, but it’s way the heck better than 20% of everything, you know?

Q: Interesting. And how much would it cost Medicare to implement a $5,000 out-of-pocket maximum for people?

Weisbart: $39 billion dollars. … So if we weren’t squandering our money, if the Medicare Advantage companies weren’t allowed to pilfer our money, we could do that.

Or the last piece, and then I’ll, you know, stop my little tirade here is if you look at the things that people also really want, they want dental insurance, right? They want hearing, they want vision. If you add that up, it comes up to, for everybody in Medicare and Medicaid together, it comes up to about $80 billion a year, $80 billion.

So that’s less, way less than what we give away to the Medicare Advantage companies.

In other words, we could have really nice things here. We could afford to have really good health insurance through the Medicare program and make it available to everybody in the country, but we have to stop the bleeding. You know, we have to stop letting these Medicare Advantage companies drain our funds, take it directly out of us. That’s not right. We shouldn’t be doing that. They’re giving us worse health care and we’re not getting anything for it.

Q: So you’re saying Medicare could have a $5,000 annual out-of-pocket cap, plus cover dental, vision and hearing for about what we’re paying the Medicare Advantage companies?

Weisbart: Yeah, we could fix all the things that are wrong with Medicare if we would just stop letting the Medicare Advantage corporations rip us off like this.

Q: Wow. So what are some of the ways that Medicare Advantage is grossly overpaid for the care and services it provides to beneficiaries?

Weisbart: Yeah, it comes down to four main ways.

The first is the way that’s sort of gotten the most attention, which is called upcoding. Upcoding means that they’re paid for the average person and then they get actually paid more if you’re sick. So Medicare Advantage companies long ago came to Congress and said, ‘Hey, you know, we have these really sick patients, you know, we deserve to be paid more than the average.’

So yeah, Medicare put in a program that said if your people are sicker, then we will pay you more and so it seemed to make sense. You know, maybe that makes a lot of sense, I don’t know. But it created this opportunity for the Medicare Advantage companies to pretend you’re sicker so they’ll send a nurse out to your house once to pick up diagnoses that your doctor didn’t think was clinically important.

They won’t send you out for home care, you know, you’re less likely to get home care, but they will send somebody to your house to get extra codes. They will very seriously pressure physicians to add diagnoses that are not of any real medical purpose so they can submit their claims to Medicare and say, ‘ see how sick people are here? And it’s really just not true. That’s called upcoding. And that one piece is pretty significant. That one piece is worth $20 billion. They’re overpaid by 5% just for that one piece and that’s actually the smallest of the ways.

A second way that they get overpaid is what’s called favorable selection, which is, as I said, they’re paid on the average with that little quirk of upcoding, but they’re paid on the average, but they don’t want you if you’re actually sick. So they have these ways of attracting healthier people, and it’s called favorable selection by attracting healthier people in all the ways I started to hint at. That gets them another $44 (billion) to $56 billion extra.

So that’s two key ways.

Q: So we’ve got upcoding and favorable selection. What are the other two ways?

Weisbart: And then the third way is a whole series of weird sort of benchmarks and bonuses that they have. And there’s a lot of those. But one in particular, I’ll just point out, ’cause it just really kind of is outrageous. They’re paid more, if they hit these quality targets, right? If it’s a better Medicare Advantage company, they’ll get paid more. That makes sense, except that the measurements of getting paid more don’t have anything to do with death rates and mortality rates and, and denials and delays in care. They’re kind of goofy things that aren’t that important.

And most interestingly, when a new Medicare Advantage company enters, they’re paid assuming that they’re going to be high quality, and even without any data at all, they’re given a three and half percent bonus for high quality when they haven’t done that yet.

So anyway, if you add all these crazy extra bonuses and benchmarks, that’s another $24 (billion) to $28 billion. So $20 billion on the upcoding, $44 (billion) to $56 (billion) on the favorable selection, $24 (billion) to $28 billion on the quality benchmarks and the quality bonuses and stuff that I’m talking about, if you add just those three factors together, you get to $88 (billion) to $104 billion that they’re overpaid.

And then there’s a fourth way, which is a little bit trickier. So we pay the Medicare Advantage companies as if they eliminate the financial barriers to care and as if therefore people could use health care more. But that’s not the case. They are not, they do not eliminate that.

In fact, we know the people in Medicare Advantage have more financial barriers to care than do people in traditional Medicare, but they’re paid as if they’ve eliminated them. That’s called induced utilization.

And that’s another 9%, and that’s $36 billion more. So if you add up the $44 billion to $56 billion from the favorable selection and the $20 billion from upcoding and the $24 to $28 billion from these benchmarks, and the $36 billion from induced utilization, that’s $124 to $140 billion.

And I think that’s very conservative and then, like I said, that doesn’t even begin to count the fraud and abuse and the illegal things that they do. So it’s a lot of money and it’s a lot of games. They’ve created an industry around maximizing how much they get out of each one of these games.

Q: What is the impact of these insurance company overcharges on taxpayers and Medicare beneficiaries, and why should we all be concerned about this?

Weisbart: And so here we are wasting, as I say, probably around $140 billion a year of our taxes … going to healthcare companies that actually make health care worse, not better.

So it’s a terrible impact on the taxes which we could fix. It’s interesting to note that Senators (Jeff) Cassidy and (Bill) Merkley, I believe, have submitted a bill called the No Upcoding Act, which would actually not deal with the $140 billion. It would deal with just the one that I was mentioning, the upcoding piece, which was about $20 billion.

If that bill that’s in the Senate got traction it would at least deal with that one piece. And that is actually like I told you four factors, and that was the smallest of the four factors. But if that bill got passed and became part of law, it would start the trend of reversing the tide of these overpayments. So I think, you know, the bill’s imperfect. It’s not anywhere near as strong as I would like it to be, but it’s still pretty darn good and it’s interesting to note that it’s sponsored by Senator (Jeff) Merkley, who is a Democrat and Senator (Bill) Cassidy, who’s a Republican.

So it’s literally got bipartisan appeal, and it’s not by an accident. The reason for that is because, frankly, you know, our fractured political landscape agrees in general that we don’t like wasting money, you know. This upcoding is a game that should not be allowed to steal our Medicare funds. So I think there’s hope for it.

Thank you, Dr. Ed Weisbart of Physicians for a National Health Program. Stay tuned for next time when we continue our discussion with Dr. Weisbart about Medicare Advantage overcharges and what can be done about them.

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