What’s New and What To Watch For in the Upcoming ACA Open Enrollment Period, KFF Health News, October 8, 2024, by Julie Appleby

It’s that time of the year again: In most states, the Affordable Care Act’s annual open enrollment season for health plans begins.

Current enrollees who do not update their information or select an alternative will be automatically reenrolled into their current plan or, if that plan is no longer available, into a plan with similar coverage.

While some health plans offer small-dollar gift cards or other incentives to encourage participation in wellness efforts, they would not offer cash cards worth thousands of dollars a month to help with groceries, gas, or rent. Even so, social media and online sites are rife with such promises. Such ads are among the avenues allegedly used by unscrupulous brokers who enroll or switch plans without the express permission of consumers. Also, be cautious about the websites you use to search for coverage. Type “Obamacare” or “cheap health insurance” into a search engine and often what pops up first are sponsored private sector websites unaffiliated with the official state or federal government marketplaces for ACA coverage. While they may try to look official, they are not.

Another concern: Regulators are seeing an increase in complaints from consumers about offers of health coverage requiring consumers to join a limited liability corporation. These are often non-ACA products, amounting to a hodgepodge of discount cards, for example, or limited-indemnity plans. Some of these self-funded plans only cover preventive services such as a yearly check-up or annual health screening.

Short-term plans, which are technically not ACA coverage and not subject to its benefit rules and preexisting benefit protections, can be issued for only four months of coverage. Consumers who relied on the longer periods need to check their plans’ details and consider enrolling in an ACA plan instead to avoid a situation in which their short-term plan expires early or midyear, potentially leaving them unable to get coverage elsewhere for the remainder of the year.

Sorting through the dozens of options on the marketplace is challenging, so most people do seek assistance. Another consideration when choosing a plan is to check whether its network includes the doctors and hospitals you typically see, as well as whether its formulary covers your prescription medications, and how much it charges for them.

One piece of advice remains constant: Whether you are enrolling for the first time or have an existing plan, it’s always worth it to shop around.

Comment:

By Don McCanne, M.D.

Just a reminder: Of the high income nations appearing in the Commonwealth Fund report, the United States has the most expensive but poorest performing health care system of all.

What is ironic is that each year we are forced to reevaluate our existing health plans since the insurers frequently change the benefits or functioning of the plans, with changes usually accruing to the benefit of the insurers, and, at that, we may lose the option of keeping the plan we have. So, not only do we have the lousiest system, we may lose the option of keeping the benefits we do have, even if mediocre, or perhaps not even being able to select options that would be more appropriate for any change that could occur in our health status.

Being granted mostly poor choices amongst a dysfunctional system is certainly a contributor to the high expense and poor quality of our health care system. But we could have a much better choice, and that would be to elect government stewards who would enact and implement a vastly superior health care system that would greatly improve the value of our health care spending by funding it with progressive taxes, based on ability to pay, making it affordable for all with no negative impact on the lifestyles of the wealthy. All essential health care services would be accessible to everyone. Of course, that system would be a carefully redesigned, single payer, Medicare for All.

So it’s time to choose, but not from an overpriced, dysfunctional health care system, but rather from political candidates who understand the health policies that would bring us high quality care for everyone that is affordable for all.

https://healthjusticemonitor.org…

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Health Insurer Financial Performance in 2023, KFF, July 2, 2024, by Jared Ortaliza, et al.

At the end of 2023, gross margins per enrollee ranged from $753 in the Medicaid managed care market to $1,982 in the Medicare Advantage market. Gross margins [amount by which premiums exceed claims costs] per enrollee in the group and individual markets were $910 and $1,048, respectively, roughly half the level observed among Medicare Advantage plans on average.

The Medicare Advantage Influence Machine, KFF News, September 30, 2024, by Fred Schulte and Holly K. Hacker

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

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

Critics have watched with alarm as the industry has managed to deflate or deflect financial penalties and steadily gain clout in Washington through political contributions; television advertising, including a 2023 Super Bowl feature; and other activities, including mobilizing seniors. …

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

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

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

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

Revolving Door

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

Marilyn Tavenner is one. She led the agency in 2014 when it backed off the overpayment regulation. She left in 2015 to head industry trade group AHIP, where she made more than $4.5 million during three years at the helm, according to Internal Revenue Service filings.

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

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

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

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

Insurers cut Medicare Advantage plans for 2025, Business Insurance, October 4, 2024

Major insurers, including Aetna and Humana, are cutting back on Medicare Advantage plans for 2025, potentially affecting policyholder costs and care arrangements for seniors, Axios reports. This reduction follows policy changes by the Biden administration, leading insurers to adjust offerings and exit some markets. While average premiums are set to decrease slightly, the number of available plans per county has dropped.

Comment:

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

Medicare Advantage is highly profitable, with gross margins of $2000 per patient, 2-3 times higher than other health insurance sectors. Year after year.

The profitability derives from overcharging, via inflated diagnostic coding and risk selection, among other tactics. The overcharge exceeds $100 billion per year.

Further, these numbers understate real profits, because insurers overpay their proliferating affiliated companies (such as PBMs) in a ballooning corporate structure. It’s a shell game, designed to keep within “medical loss ratio” limits. The process is well described by HEALTH CARE un-Covered.

The regulators – CMS (Center for Medicare and Medicaid Services) – understand these problems. But heavy lobbying and a revolving door between CMS and insurers suppresses regulatory action. In the example above, in 2023 a penalty for overcharges prior to 2011 was sharply reduced, because the plans insisted that the findings couldn’t be extrapolated to all beneficiaries. The next step was postponed pending completion of audits from 2018, 5 years earlier! Why so slow? I suspect insurer foot-dragging. The insurers will fight those findings too.

When CMS does manage to scale back overpayment, as they’ve done to small degree in setting premium growth rates for 2025, the insurer response is to assure investors that they can cut costs, and to exit expensive (money-losing) markets (above and here). Who suffers? Sicker than average Medicare enrollees, and traditional Medicare.

Paying for health care shouldn’t be about private insurer profits, overcharges, lobbying, and market maneuvering. It should be about efficiently meeting the health care needs of the population.

https://healthjusticemonitor.org…

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US Senate votes unanimously to hold hospital CEO in criminal contempt, The Guardian, Sept. 25, 2024, by Maya Yang

The Senate voted to hold Ralph de la Torre, the CEO of Massachusetts-based, for-profit Steward Health Care, which declared bankruptcy earlier this year, in contempt of Congress after he ignored a congressional subpoena and failed to appear at a hearing over the hospital chain’s alleged abuse of finances.

Bernie Sanders, Vermont senator and chair of the Senate’s health, education, labor and pensions (Help) committee, said: “The passage of this resolution by the full Senate will make clear that even though Dr. de la Torre may be worth hundreds of millions of dollars, even though he may be able to buy fancy yachts and private jets and luxurious accommodations throughout the world, even though he may be able to afford some of the most expensive lawyers in America, no, Dr. de la Torre is not above the law.”

De la Torre was paid at least $250m by Steward Health Care as the hospital chain’s administrators struggled with facility problems, staffing shortages and closures. More than a dozen Steward Health Care patients died in recent years after being unable to receive adequate treatment while Dr. de la Torre embarked on various jet travels and private yacht excursions.

Senator Ed Markey said, “Steward, led by its founder and CEO Dr. Ralph de la Torre and his corporate enablers, looted hospitals across the country for their own profit, and while they got rich, workers, patients and communities suffered, nurses paid out of pocket for cardboard bereavement boxes for the babies to help grieving parents who had just lost a newborn. Dr. de la Torre is revealing himself for what he truly is – a physician who places personal gain over his duty to do no harm.”

Comment:

By Don McCanne, M.D.

Health Justice Monitor recently presented a brief summary of the Commonwealth Fund’s annual report once again demonstrating that, of the wealthy nations studied, the United States has the most expensive yet poorest performing health care system.

Most Americans tend to think that we have the greatest nation on earth, so what would account for the fact that our health care system performs so poorly? One basic fact is well understood. Though other higher performing nations insist that public policies are designed to assure that everyone is included in their systems, we do not. If we demanded that our elected legislators establish such policies, it would get done, or we wouldn’t elect them. As long as we insist on universal coverage, we could also insist on other public policies such as ensuring adequate capacity in the system and controlling wasteful costs, especially superfluous administrative expenditures and excessive profits of private insurance intermediaries.

A particularly onerous feature of our system is that we we allow private investors, the medical industrial complex, to assume ownership of large slices of provider capacity, enabling our health care dollars to bypass patients as they are diverted to investors. Today’s example shows how private equity can move in and buy up control of health care delivery, even physicians themselves through purchase of medical groups, convert much of the system to cash equivalents, and then disburse that value to the private investors … leaving the delivery system without adequate cash reserves and subject to bankruptcy. Result? We have the most expensive system with the poorest performance among wealthy nations.

How could we fix this system? First we need to remove private equity and other profit-seeking non-clinical investors from controlling and diverting our health care dollars. Then we need to set up a public healthcare financing system that is designed to direct funds to where they are clinically needed to ensure that everyone has affordable access to the medical care that they need. This would best be done by creating a public single payer system in the form of a carefully refined version of our current public Medicare system that is expanded to include everyone and cover everything. We also need improved public oversight and support for our dedicated clinical professionals who care primarily about the fate of patients and would be satisfied with a reasonable level of compensation for their services; that is, placing patients above profits.

That is not to say that Dr. Ralph de la Torre has not provided us with an important service. He has shown us beyond any doubt why we need to dump our current grossly inadequate and inhumane health care system and replace it with a benevolent public system that will ensure high quality health care for everyone – single payer Medicare for All.

https://healthjusticemonitor.org…

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