By Ed Weisbart, M.D., C.P.E., F.A.A.F.P.
American Association for Physician Leadership, July 25, 2019

In the nearly ten years since I retired as chief medical officer for a large pharmacy benefit manager, it seems my perspective has shifted.

Before I left, I remember a discussion bemoaning the public’s increasingly critical view of managed care. We valiantly searched for a narrative to bolster our industry’s image.

The best example we found was about an insurer that helped a patient switch from the non-formulary drug her physician prescribed over to that insurer’s preference. We were all proud that the insurer had done extensive patient outreach and care coordination rather than just deny the pharmacy claim. While patting ourselves on our backs, we failed to recognize that the very existence of our fragmented insurance industry was the reason the patient needed to take something other than her physician’s first choice.

I was reminded of all of this when I read Erik Sherman’s “Sudden Medical Bills Surprising, But No Fun” in the May/June 2019 Physician Leadership Journal. Sherman has documented many of the symptoms of our fragmented system, and then recommended multiple solutions whose “effort, costs, and time commitment would be significant.” The entire strategy is based on making it easier for patients to understand their out-of-pocket costs, so that it would be “easier to collect,” in the words of financial advisor quoted in the article. This advice flies in the face of the fact that millions of Americans already declare bankruptcy from overwhelming medical bills despite having insurance when they get sick.

There’s nothing in Sherman’s article addressing our nation’s unsustainable cost trends, the fact that financial barriers keep so many Americans from healthcare, or the professional burnout created by needless administrative complexities. Instead, his proposal would add even more administrative complexity and waste. As any student of Deming and Juran can tell you, complexity is the enemy of quality.

Enough, I say, and most Americans agree.

Managed care is a model that’s had its day, if there ever really was one.

“Surprise medical bills” and “balance billing” are consequences of this fragmentation. They point to the need for us to build a single national health program, insuring every American with comprehensive first-dollar coverage. With this being the insurer for every American, virtually every physician and hospital would be “in network” and the surprises and unaddressed balances would fade into the dust heap of history.

The simplicity and success of this approach has been demonstrated around the world and resonates with patients and physicians alike. Indeed, ever since 2001 there has been a net migration of American physicians into Canada. Every year since 2004 there has been a net repatriation of expat Canadian physicians. Dr. Trina Larsen Soles, president of Doctors of British Columbia, describes practice in Canada as “It’s not a big hassle. I can focus on patient issues, not administrative issues.” Compare that to Dr. John Cullen, at the time president-elect of the American Academy of Family Physicians, who described American medical practice as “An incredible bureaucratic mess to get anything done for patients.”

It is time to move away from the convolutions and contortions that define this uniquely American industry, get rid of these intermediaries, and switch to the American system with the lowest overhead, consistently high levels of popularity, and extends our life expectancy.

Let us build our solution upon traditional Medicare (Parts A and B): eliminate the copays and deductibles; add in coverage for pharmacy, optometry, dentistry, and a few other critical elements; and fully fund our national health insurance through an equitable public funding mechanism rather compound overwhelming illnesses with overwhelming financial burdens.

With these improvements, there would be no market for supplements or Advantage plans. According to dozens of economic analyses, the savings from reduced administrative overhead and more consistent pricing would mean that the vast majority of Americans would spend less on healthcare. And be put back in control of their own healthcare decisions.

https://www.physicianleaders.org…

---

Comment:

By Don McCanne, M.D.

My father, my two brothers and I joined together in a traditional general practice (in the days before “family practice” was a discipline). In 1966, the implementation of Medicare and Medicaid (Medi-Cal) was a godsend. We were able to obtain more essential services, especially specialty care, for our patients, though the instability of individual insurance coverage and employer-sponsored plans remained a problem (60 million people leave their jobs each year!). Referrals of the uninsured and undocumented were often very difficult, though a few specialists did share our views on health care justice.

But then managed care entered the picture. Awful! The plans were very successful in erecting barriers to care. It was so bad that we eventually welcomed EMTALA which enabled an enforced referral by sending our patients to the emergency department of the hospital. Talk about a terrible way to practice medicine, not to mention the damage it did to the previously collegial relationships between physicians. In Orange County, even Medi-Cal was split up into multiple managed care organizations. (An example of how that worked out: There was only one authorized psychiatrist on my list who happened to be an octogenarian who had practiced in the opposite end of the county far away from my patients, but who had his license suspended because of a morals offense committed in a city park restroom. So I didn’t have any psychiatrist to whom I could refer my patients. Yet Blue Cross had the gall to send an agent to my office to admonish me for sending patients out of network, when virtually none of the specialists in my region would accept my Medi-Cal [CalOptima] patients within the network. It was managed exclusion of care.)

And Medicare? There is now a march toward private Medicare Advantage plans. It may not be obvious to those who are enrolling in these plans, but they are designed to create barriers to care – the most important being limitation of care to contracted provider networks. Most patients do not know when preferred care is being bypassed or that it is not even offered at all because of these restrictions, or maybe because physicians are simply avoiding the hassle of obtaining prior authorizations.

And those who insist on the right to enroll in private plans as a condition for enacting a Medicare for All program? They truly do not seem to know what they are wishing for. They are making a plea for the perpetuation of the evils of managed care, though the insurers have been effective in making those evils less transparent.

Ed Weisbart has it right again: Managed care is a model that’s had its day. If only the public could understand that. We would then have the political support to move forward with single payer Medicare for All – affordable health care for everyone forever.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Jack Meyer
Health Affairs Blog, July 24, 2019

The debate over the future of the US health care system has entered a fact-free, extremist zone that will continue to impede progress toward the critically important goals of moving to universal health coverage, improving the quality of care and patient safety, and controlling the growth of total health spending. The polarization of the health care debate will leave us in gridlock and block any bipartisan approaches to universal coverage that can be enacted and implemented.

Sabotaging The ACA

On one side of this debate, the Trump administration has been repeatedly sabotaging the ACA, while offering no constructive alternative.

Living In A Dream World

On the other side of the debate, most Democratic presidential candidates are shouting “Medicare for All” without explaining how that would work or how we would get from here to there.

A Better Approach To Achieving Universal Health Coverage

There are constructive, feasible, and affordable pathways to universal coverage that build on our mixed, public/private system.

Linda Blumberg, John Holahan, and Stephen Zuckerman of the Urban Institute have developed a plan to move toward universal coverage that allows people to keep their employer plan if they are satisfied with it.

The US needs to stop the ideological battle over the ACA and develop a realistic, affordable plan to move to universal health coverage. Instead of repealing the ACA or forcing people out of private coverage, we can construct a mixed public/private approach using large building blocks to forge a solid structure. No sabotage, no mandates, no villains, no easy sound bites. Instead, a blend of pluralistic approaches to affordable coverage using expanded public subsidies, private insurance, and sensible regulations.

---

Health Affairs Comment:

By Don McCanne, M.D.

There is absolutely no question that a well designed single payer model of reform is vastly superior from a policy perspective. It automatically includes absolutely everyone; it reduces administrative waste by hundreds of billions of dollars each year (not each decade); it improves equitable distribution of our health care resources thus improving access; it is financed equitably so that no person is exposed to financial hardship, and it uses public policies to slow future health care spending to sustainable levels. Incremental measures, such as described here, only add more layers to our highly dysfunctional health care financing, thus perpetuating inequities, inefficiencies, ineffectiveness, and ever rising health care spending. The problem is not with single payer policy, but it’s with the political path to get there, as this article implies.

It is a terrible error to automatically compromise on policy in order to clear a pathway through the politics, yet that is how it is typically done. What we should be doing instead is change the politics so that we can enact and implement the optimal policies that work best for all of us.

The first step should be to have a little more honesty in our national dialogue on reform. Instead of discussing how well selected policies work for the dysfunctional elements of the existing system, we should be discussing how well optimal policies (single payer) would benefit the patients, and then be sure that the public is educated on the differences. Difficult? Sure it is, but this multi-trillion dollar industry is being funded by us, the people, and for that level of spending we should be demanding optimal value – high quality health care for everyone.

https://www.healthaffairs.org…

---

Further Comment:

By Don McCanne, M.D.

Think about these two problems society faces:

1. We have the most expensive health care system in the world yet it is failing us in preventing much avoidable suffering, financial hardship and premature death.
2. We have a political system that serves as a barrier to problem #1.

So what have we been doing? We first approach problem #2. We decide that we have to agree to compromise and then we decide what health policies can survive the compromise process.

Through the decades, we have agreed on policies that sacrifice universality, access, affordability, efficiency, effectiveness, and especially equity. Yet we have defined this as success because we were able to negotiate the politics.

We still see that today. Forget the dream world of a high performing health care system that’s affordable and takes care of everyone. Let’s spin our wheels on the real challenge – achieving political compromise – but to do that, we have to dump the beneficial policies that actually would work for all of us. In other words, we must tackle the barrier to reform – problem #2 – by sacrificing real solutions for problem #1 – our health care.

As stated above, we need more honesty in our national discourse on reform. People need to understand what really would work best for them. By placing a priority on policy, you would hope that the politics would align.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Sarah Miller, Sean Altekruse, Norman Johnson, and Laura R. Wherry
National Bureau of Economic Research, July 2019

Abstract

We use large-scale federal survey data linked to administrative death records to investigate the relationship between Medicaid enrollment and mortality. Our analysis compares changes in mortality for near-elderly adults in states with and without Affordable Care Act Medicaid expansions. We identify adults most likely to benefit using survey information on socioeconomic and citizenship status, and public program participation. We find a 0.13 percentage point decline in annual mortality, a 9.3 percent reduction over the sample mean, associated with Medicaid expansion for this population. The effect is driven by a reduction in disease-related deaths and grows over time. We find no evidence of differential pre-treatment trends in outcomes and no effects among placebo groups.

Interpreting the Estimates

Our estimated change in mortality for our sample translates into sizeable gains in terms of the number of lives saved under Medicaid expansion. Since there are about 3.7 million individuals who meet our sample criteria living in expansion states, our results indicate that approximately 4,800 fewer deaths occurred per year among this population, or roughly 19,200 fewer deaths over the first four years alone. Or, put differently, as there are approximately 3 million individuals meeting this sample criteria in non-expansion states, failure to expand in these states likely resulted in 15,600 additional deaths over this four year period that could have been avoided if the states had opted to expand coverage.

Conclusion

There is robust evidence that Medicaid increases the use of health care, including types of care that are well-established as efficacious such as prescription drugs and screening and early detection of cancers that are responsive to treatment. Given this, it may seem obvious that Medicaid would improve objective measures of health. However, due to data constraints, this relationship has been difficult to demonstrate empirically, leading to widespread skepticism that Medicaid has any salutary effect on health whatsoever. Our paper overcomes documented data challenges by taking advantage of large- scare federal survey data that has been linked to administrative records on mortality. Using these data, we show that the Medicaid expansions substantially reduced mortality rates among those who stood to benefit the most.

https://www.nber.org…

---

Comment:

By Don McCanne, M.D.

Health policy can be a matter of life or death.

The Affordable Care Act offered states the opportunity to expand their Medicaid programs that provided care to low-income families, with 100 percent federal funding for the first three years. Several states declined the offer. This NBER report shows that this decision “likely resulted in 15,600 additional deaths” over the first four years of the program. For the states that expanded their Medicaid programs, there were “roughly 19,200 fewer deaths over the first four years.”

The ubiquitous media reports over the years suggest that these decisions to reject Medicaid expansion were based on political ideology, largely without much mention made of the concerns for the health outcomes of the affected populations, except, of course, by the advocates of health care justice. The opponents of public policies for reforming health care object to the use of the term “cruel” to describe these decisions, but that does not seem to be an inappropriate term to describe politicians who use a signature on a document to commit acts of voluntary manslaughter. (Whether this use of “voluntary manslaughter” fits the legal definition seems to have little import when considering that thousands actually died unnecessarily.)

Obviously the importance of health policy decisions extend far beyond the Medicaid program. We know what policies would improve the functioning of our health care system for the benefit of all of us. Optimal policies begin with the financing infrastructure inherent in the design of the single payer model of Medicare for All. The dispute is not over optimal policy. Tragically, the dispute is over politics. Leaving the current financing system in place while merely adding a public option trades away crucial beneficial policies for mere political considerations. On the other side, repealing the Affordable Care Act while promising only a nebulous “something great” as a replacement doesn’t even make an attempt to initiate rational policy discussions.

It is about policy. We can get that right. So what do we do about the politics that is perpetuating this cruelty? If we fail in our politics we will have to put up with more suffering, hardship, and even death. Now that’s cruel.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Adam Gaffney, M.D., M.P.H.; Danny McCormick, M.D.; David H. Bor, M.D.; Anna Goldman, M.D.; Steffie Woolhandler, M.D., M.P.H.; David U. Himmelstein, M.D.
Annals of Internal Medicine, July 23, 2019

Abstract

Background: Persons with comprehensive health insurance use more hospital care than those who are uninsured or have high-deductible plans. Consequently, analysts generally assume that expanding coverage will increase society-wide use of inpatient services. However, a limited supply of beds might constrain this growth.

Objective: To determine how the implementations of Medicare and Medicaid (1966) and the Patient Protection and Affordable Care Act (ACA) (2014) affected hospital use.

Design: Repeated cross-sectional study.

Setting: Nationally representative surveys.

Participants: Respondents to the National Health Interview Survey (1962 to 1970) and Medical Expenditure Panel Survey (2008 to 2015).

Measurements: Mean hospital discharges and days were measured, both society-wide and among subgroups defined by income, age, and health status. Changes between preexpansion and postexpansion periods were analyzed using multivariable negative binomial regression.

Results: Overall hospital discharges averaged 12.8 per 100 persons in the 3 years before implementation of Medicare and Medicaid and 12.7 per 100 persons in the 4 years after (adjusted difference, 0.2 discharges [95% CI, −0.1 to 0.4 discharges] per 100 persons; P = 0.26). Hospital days did not change in the first 2 years after implementation but increased later. Effects differed by subpopulation: Adjusted discharges increased by 2.4 (CI, 1.7 to 3.1) per 100 persons among elderly compared with nonelderly persons (P < 0.001) and also increased among those with low incomes compared with high-income populations. For younger and higher-income persons, use decreased. Similarly, after the ACA’s implementation, overall hospital use did not change: Society-wide rates of discharge were 9.4 per 100 persons before the ACA and 9.0 per 100 persons after the ACA (adjusted difference, −0.6 discharges [CI, −1.3 to 0.2 discharges] per 100 persons; P = 0.133), and hospital days were also stable. Trends differed for some subgroups, and rates decreased significantly in unadjusted (but not adjusted) analyses among persons reporting good or better health status and increased nonsignificantly among those in worse health.

Limitation: Data sources relied on participant recall, surveys excluded institutionalized persons, and follow-up after the ACA was limited.

Conclusion: Past coverage expansions were associated with little or no change in society-wide hospital use; increases in groups who gained coverage were offset by reductions among others, suggesting that bed supply limited increases in use. Reducing coverage may merely shift care toward wealthier and healthier persons. Conversely, universal coverage is unlikely to cause a surge in hospital use if growth in hospital capacity is carefully constrained.

Primary Funding Source: None.

https://annals.org…

---

Medicare for All unlikely to cause surge in hospital use: Harvard study

Physicians for a National Health Program, July 22, 2019

Analysis finds no increase in hospitalizations after previous large coverage expansions; increased care for newly insured was counterbalanced by small decreases for the healthy and wealthy

As political leaders debate the merits of a future Medicare for All system in the U.S., some analysts predict that implementing universal coverage could cause a sharp, unaffordable increase in hospital use and costs, overwhelming the system. But new research by a team at Harvard Medical School and The City University of New York at Hunter College, published today in the Annals of Internal Medicine, contradicts that assumption, finding that past insurance expansions did not result in a net increase in hospital use. Instead, researchers found a redistribution of care, with increases in hospital care among those newly insured that was offset by small decreases among healthier and wealthier Americans.

The study examined changes in hospital use among those who gained coverage — as well as those whose coverage remained unchanged — after the implementation of Medicare and Medicaid in 1966 and the Affordable Care Act (ACA) in 2014. Each of those programs provided new coverage to about 10% of the U.S. population, about the same share expected to gain coverage under a Medicare for All program. The researchers analyzed large national surveys from both the Medicare/Medicaid and ACA eras, and examined hospital use before and after the coverage expansions. Hospital admissions averaged 12.8 for every 100 persons in the three years before Medicare, and 12.7 per 100 in the four years after Medicare’s implementation. Similarly, the hospital admission rate was statistically unchanged in the wake of the ACA, averaging 9.4 admissions per 100 in the six years before the ACA coverage expansion and 9.0 per 100 in the two years’ afterward.

While the study found no overall change in hospital use, the coverage expansions redistributed care. Medicare increased hospital admissions by 3.7 per 100 among the elderly, and by 0.7 per 100 among the poorest one-third of the population, i.e., the groups that gained new coverage. In contrast, hospitalizations fell slightly (about 0.5 per 100) for younger and wealthier individuals. After the ACA, admissions rose by 1.5 per 100 among sicker Americans, but fell by 0.6 per 100 among those in good health. The researchers also found a slight shift of hospital care toward the poor after the ACA.

Dr. Steffie Woolhandler, a study author and distinguished professor of public health at CUNY’s Hunter College who is also on the faculty at Harvard Medical School commented: “The good news is that even big coverage expansions didn’t increase hospitalizations overall, indicating that universal coverage won’t cause a surge in care, and that Medicare for All is affordable. On the other hand, it implies that overturning the ACA would deprive millions of needed care without saving any money.”

The researchers hypothesized that the limited supply of hospital beds constrained the overall use of hospitals when coverage was expanded. They noted that many previous studies, such as the Rand and Oregon Health Insurance Experiments, only examined the effects of greater coverage for the newly insured, not changes among those whose coverage was unchanged, nor the societal effects of expanded coverage.

“We’ve long known that when people get new or better coverage, they use more health care,” said senior author Dr. David Himmelstein, a distinguished professor of public health at CUNY’s Hunter College and lecturer in medicine at Harvard Medical School. “What we didn’t know is what happens to those who were already well-insured, and how this plays out society-wide given the limited number of hospital beds, doctors and nurses,” he stated. “Our data shows that if you sensibly control hospital growth, you can cover everybody without breaking the bank.”

Lead author Dr. Adam Gaffney, instructor in medicine at Harvard Medical School and a pulmonary and critical care physician at Cambridge Health Alliance, suggested that the small reductions in hospitalizations among healthier and wealthier individuals are unlikely to be harmful. “We know that the well-insured often receive unnecessary hospitalizations,” said Dr. Gaffney. “While defibrillator implants and coronary artery stents can be lifesaving, thousands of patients each year get these and other procedures even when they offer no benefit,” he added, pointing to an Institute of Medicine study that found that nearly one-third of medical spending is wasted. “The fact that coverage expansions shift hospital care to those who need it, and reduce care for groups currently getting excessive and possibly harmful interventions, means that universal coverage could help everyone,” he stated.

Physicians for a National Health Program is a nonprofit research and education organization whose more than 23,000 members support single-payer national health insurance. PNHP had no role in funding or otherwise supporting the study described above.

https://www.eurekalert.org…

---

Comment:

By Don McCanne, M.D.

It is often assumed that expanding health care coverage to the uninsured and underinsured will unleash pent-up demand for inpatient hospital services. This important study shows that two periods in our history that expanded coverage by an amount that would be comparable to implementation of a single payer Medicare for All program – Medicare and Medicaid in 1966 and the Affordable Care Act in 2014 – actually may have improved allocation of our hospital resources. There was no surge in occupation of hospital beds, but use increased for older and lower-income populations (groups noted for often having greater health care needs) while decreasing for younger and higher-income persons (generally healthier populations).

System capacity is important. Excess capacity can result in over-provision of services of little value whereas deficient capacity can impair access to essential services. Two features of the single payer model can address these problems: 1) Regional planning and separate budgeting of capital improvements can establish optimal levels of capacity, taking surge capacity into consideration, and 2) Global budgeting of hospitals, much as fire departments are budgeted, can provide assurance that adequate funds are available to meet the needs, with contingency funds for crises, while not wasting funds on excess administrative services or on unnecessary profits.

We can dismiss alarmist comments such as that of Rep. John Delaney who said that, under Medicare rates, “Every single hospital administrator said they would close.” That’s ridiculous. Under single payer Medicare for All, the money will be there; it will be collected equitably and distributed equitably, and all of us will have the health care that we need. Bringing everyone under the umbrella will not place undue stress on the system providing we choose stewards for the system who know how to size the umbrella properly.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Marshall Allen
ProPublica, July 19, 2019

Health insurers are regarded as fierce defenders of health care dollars. But the case of David Williams shows one reason America’s health care costs continue to rise. The personal trainer spent years posing as a doctor and billing the nation’s top insurers, making off with millions.

There are a host of reasons health care costs are out-of-control and routinely top American’s list of financial worries, from unnecessary treatment and high prices to waste and fraud. Most people assume their insurance companies are tightly controlling their health care dollars. Insurers themselves boast of this on their websites.

In 2017, private insurance spending hit $1.2 trillion, according to the federal government, yet no one tracks how much is lost to fraud. Some investigators and health care experts estimate that fraud eats up 10% of all health care spending, and they know schemes abound.

Williams’ case highlights an unsettling reality about the nation’s health insurance system: It is surprisingly easy for fraudsters to gain entry, and it is shockingly difficult to convince insurance companies to stop them.

Williams’ spree also lays bare the financial incentives that drive the system: Rising health care costs boost insurers’ profits. Policing criminals eats away at them. Ultimately, losses are passed on to their clients through higher premiums and out-of-pocket fees or reduced coverage.

Insurance companies “are more focused on their bottom line than ferreting out bad actors,” said Michael Elliott, former lead attorney for the Medicare Fraud Strike Force in North Texas.

(This article provides details on the extensive acts of insurance fraud committed by David Williams for which he was eventually convicted, but. more importantly, it shows the lack of diligent responsiveness on the part of insurers in spite of repeated notifications of the extent of his fraud. – DMc)

Many health care experts and fraud investigators said they weren’t surprised to hear that insurers were slow to stop even such an outlandish case of fraud.

“It’s just not worth it to them,” said Dr. Eric Bricker, an internist who spent years running a company that advised employers who self-funded their insurance.

For insurance behemoths pulling in billions, or hundreds of billions, in revenue, fraud that sucks away mere millions is not even a rounding error, he said.

And perhaps counterintuitively, insurance companies are loath to offend physicians and hospitals in their all-important networks — even those accused of wrongdoing, many experts have said. They attract new clients by providing access to their networks.

This ambivalence toward fraud, Bricker and others said, is no secret. Scammers like Williams are “emblematic of gazillions of people doing variants of the same thing,” Bricker said. Insurers embolden them by using a catch-and-release approach to fraud, in which the insurers identify criminals, then let them go.

Joe Christensen has pursued fraud for both government and commercial insurers, serving as a director in Aetna’s Special Investigations Unit, a team of more than 100 people ferreting out fraud, from 2013 to 2018 and as the director of Utah’s insurance fraud division for 13 years. Fraud in government programs, like Medicare and Medicaid, gets more publicity, he said, and has dedicated arms of agencies pursuing fraudsters. But the losses may be even greater in the commercial market because the dollar levels are higher, he said.

Some commercial insurers take a passive approach, Christensen said, in part because it’s expensive to press a fraud case. At Aetna, he said, investigators would identify cases of apparent fraud, but it was up to the executives and legal team to decide how to handle them. Taking fraudsters to civil or criminal court requires resources, so the company often settled for trying to get repaid through settlements or blocking a suspect provider from billing, he said.

Christensen said while he was at Aetna, investigators almost never sought to partner with law enforcement agencies to pursue criminal cases.

ProPublica asked Aetna how many criminal cases it had pursued in 2017 and 2018. A company official said the question could not be answered because it does not track such cases.

Williams’ trial began in the United States District Court for the Northern District of Texas. Without irony, the prosecutor, P.J. Meitl, argued that Williams had preyed on a health insurance system that relies “on trust, relies on honesty” when it pays claims.

He called fraud investigators from Aetna, Cigna and United, who testified that their companies auto-pay millions of claims a year. It’s not cost effective to check them, they said. “Aetna relies on the honesty of the person submitting the claim verifying that it’s true,” testified Kathy Richer, a supervisor in Aetna’s Special Investigations Unit.

Insurers promote themselves as guardians of health care dollars. United says on its website it wants to “help employers manage” medical expenses, resulting in “lower costs.” Aetna promises employers “affordability.” Cigna promises “increased savings.”

But private health insurers allow so much fraud that prosecutors use an idiom to describe the rare person who gets caught: “Pigs get fat, hogs get slaughtered.”

“Pigs” can steal millions, if they bill just enough to avoid notice. But if they get greedy and bill too many millions, they “become a data outlier,” said Elliott, the former fraud task force prosecutor. “You get slaughtered.”

Williams took years to reach hog status.

Part of the problem, experts say, is that health care fraud is often misunderstood as shafting greedy insurers — not the folks paying for health insurance. Ultimately, insurers don’t bear the cost. For their self-funded clients, like Southwest, they merely process the claims. For their traditionally insured clients, they can recover any losses by increasing deductibles and premiums and decreasing coverage.

https://www.propublica.org…

---

Comment:

By Don McCanne, M.D.

One of the arguments frequently made against single payer Medicare for All is that fraud and abuse are rampant in Medicare and that alone would make expanded Medicare unaffordable. It is known that Medicare fraud does occur, especially since we keep reading about it, and it is reported in the media because our public stewards are more diligent at ferreting it out and rectifying it. What this article contributes is an understanding that fraud is rampant in the plans administered by the private insurers, but that there is a deliberate effort to turn a blind eye to the problem.

Fraud in taxpayer-funded government programs quite appropriately creates public outrage and is not tolerated. Fraud in private insurance programs is just a cost of doing business. It does not harm the insurers since the costs are born by the purchasers of the plans in the form of higher premiums. Rarely is any publicity given to it since the insurers would not want their clients to think that they might not be adequately diligent in the oversight of their own trillion dollar industry, and they especially don’t want us to know that we might be bearing the costs of fraud.

Thus the existence of fraud and abuse is actually an argument in favor of enacting and implementing single payer Medicare for All since our public stewards would be much more effective in ferreting it out than would be the private insurers who merely want to keep it out of our sight as they pay off the crooks. Suppressing public knowledge of fraud might be a cool business move on the part of the insurers. but it’s our money that they are giving away.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.