PNHP

Private Equity vs. Health Care

Private Equity vs. Health Care

Private equity in health care is causing widespread problems. Regulation is not the solution. Comprehensive reform with a lead public role is.

Private Equity-Acquired Physician Practices and Market Penetration Increased Substantially. 2012-21, Health Affairs, March 2024, by Ola Abdelhadi, et al.

Private equity (PE) firms have consistently shown an upward trend and an increased interest in acquiring various medical specialties within physician practices. Our analysis revealed evidence of a recent increase in PE market penetration at the physician level across multiple specialties, particularly gastroenterology, dermatology, and urology. We found that specialties such as primary care, obstetrics-gynecology, radiology, orthopedics, and oncology also showed considerable increases from 2012 to 2021. Acquisition of these practices may be attractive to PE firms because of the fragmentation of the practices and increasing patient demands as the result of an aging population and rising private insurance coverage.

This upsurge in acquisitions, particularly after 2010, has raised concerns about their impact on PE market penetration. Previous studies showed an increase in PE acquisitions of physician practices between 2013 and 2016, resulting in expansion and higher prices without any impact on the quality of health care services. Our findings indicate that in specific local markets, PE firms hold market shares exceeding 30 percent and 50 percent, sometimes by a significant margin. This trend raises concerns about its potential impact on competition, patient care, and prices in those local markets.

PE firms tend to prioritize short-term profit maximization over long term investment in patient care and infrastructure, implement aggressive acquisition strategies that may curtail patient choice and competition, use complex financial structures and leverage to finance acquisitions, and possess limited experience in the health care industry – all of which may lead to difficulties in managing and enhancing patient care.

The findings raise concerns about competition and call for closer scrutiny by the Federal Trade Commission, state regulators, and policy makers.

Private Capital, Public Impact: An FTC Workshop on Private Equity in Health Care, Video here, March 5, 2024 

Opening Remarks:

  • Lina M. Khan, Chair, Federal Trade Commission
  • Jonathan Kanter, Asst. Attorney General of the Antitrust Division, Dept. of Justice
  • Christi A. Grimm, Inspector General, Dept. of Health and Human Services
  • Jonathan Blum, Principal Dep. Administrator & COO, Centers for Medicare & Medicaid Services

Comment:

By Patty Harvey

The March 5 webinar on private equity et al. in health care carefully enumerated the drawbacks and dangers of privatized health care in the U.S. All of this was duly documented and verified by the speakers as well as by personal anecdotes. We all have had brushes with the downsides of a health-care system that prioritizes profit and the experiences of Atty General of R.I., Peter Neronha, were especially revelatory as he described endless battles against phalanxes of high powered and richly funded attorneys protecting the private equity juggernaut. He observes, briefly in conclusion, that ‘all private equity should be kept a thousand miles from health care.’ When panelists were asked for real remedies for this worrisome privatization scourge, the band aids proposed were: “increase transparency, close loopholes and levy fines for malfeasance.” What is strange is that the obvious was never suggested even while it was implied by Mr. Neronha: that no matter what regulations, punishments or vigilance is brought to profiteering, those who stand to profit will never cease to find ways to accomplish their goal. Given this reality, why are we ignoring the obvious solution; namely, a healthcare system that is publicly provided by a single payer, especially a governmental agency, that takes no profit and streamlines in its singularity all administrative activity, that would, at the same time, obviate the need and role for these predatory profit seekers? We don’t allow a profit motive in many of our public institutions—police, fire, public education, libraries and many more operate for the common good. How much more crucial to universal human need is the need for life-saving medical support? Why do we allow profit-seeking middlemen to take over this job, when the result is universally lower quality and higher cost? We need to petition the CMS to adopt pilot programs that explore the implementation of a universal, guaranteed, single-payer, not-for-profit healthcare system instead of grinding us down with these bogus, dangerous and destructive privatization programs. The March 5 webinar exposed many important realities. The neglect was to ignore the most obvious solution.

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

The negative consequences of the role of private equity in our health system are finally receiving much-needed attention. We can now see why health care costs have been increasing without the improvement in quality and expanded coverage that we would expect for what we spend.

What is sad is that Arnold Relman warned us so long ago about the medical-industrial complex, and we did nothing. Then, more recently, individuals such as Laura Katz Olson in her book “Ethically Challenged” sounded the alarm about private equity (HJM post), and we still haven’t done what is needed to correct these deficiencies.

While we dither, afraid of a core public role in health care, the private equity market is exploding, lucrative for investors and deleterious for health care providers and, above all, patients.

The US government workshop convened on March 5th focused attention on this profound problem. Yet, as Patty Harvey’s comment so poignantly highlights, there was no mention of the real solutions — a “universal, guaranteed, single-payer, not-for-profit healthcare system.”

Although single payer financing would resolve many issues in ensuring access to affordable health care for all, the issue of provider ownership must also be addressed to avoid the adverse consequences caused by private equity. Wouldn’t it be better for doctors and hospitals to be publicly owned wherein they deliver health care to patients without profits for passive investors? Everyone can receive care from public-spirited providers, without accruing medical debt, fairly funded by progressive taxes.

The article authors and webinar presenters argue for transparency and regulation of the private owners. But with public ownership, transparency would be automatic since we would all be owners.

The authors correctly state that rising private insurance coverage has made private health care system purchases more attractive to private equity. Yet private insurance itself has been a major contributor to our health care inequities and dysfunctions – one more compelling reason to switch to single payer.

Suppose we listen to those people who say that we don’t want the government involved in ownership. Who would pay the outrageous purchase prices that private equity firms want when they sell entities that they have drained of value? Where in the private sector is the money going to come from? Inevitably it would still be some form of private equity, with or without health care providers … buying money opportunities, not health care.

Regulators alone are not going to save us from the billionaire private equity predators. The only way we are going to take health care back is for all of us to take public ownership together. No? Then read the full Health Affairs article and listen to the workshop to understand what to expect in the near future – venture capitalists have all the money and we have a seriously underperforming, dysfunctional mess of a health care system. Not that we aren’t already well on our way there.

https://healthjusticemonitor.org…

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

Medicare Advantage Worsens Coverage

A national survey of Medicare beneficiaries quantifies the coverage experience. Bottom line: Medicare Advantage (MA) underperforms traditional Medicare for most metrics. MA has more care delays and financial barriers, and similar care coordination burden, despite massive overpayment of MA plans.

What Do Medicare Beneficiaries Value About Their Coverage?, Findings from the Commonwealth Fund 2024 Value of Medicare Survey, February 22, 2024, by Gretchen Jacobson, et al.

Survey Highlights:

  • Whether enrolled in Medicare Advantage or traditional Medicare, about two in three beneficiaries overall said their coverage has fully met their expectations. Those who said it fell short of expectations pointed to a lack of coverage for needed services, high costs, or uncertainty about what benefits are covered.
  • Larger shares of beneficiaries in MA plans than in traditional Medicare reported they experienced delays in getting care because of the need to obtain prior approval (22% vs. 13%) and couldn’t afford care because of copayments or deductibles (12% vs. 7%). By other metrics, access to needed health care was similar. For example, more than a third of beneficiaries in each type of Medicare coverage said they had to wait over a month to see a doctor.
  • Three in five beneficiaries in MA plans and one-quarter in traditional Medicare said they were asked to undergo a health assessment, which most frequently resulted in a discussion with their doctor. Few said it resulted in any changes to their care plan or in more services or benefits being offered.
  • Seven in 10 beneficiaries in MA said they used some of their plan’s supplemental benefits in the past year; three in 10 did not use any. Four in 10 reported using their dental or vision benefits or an allowance for over-the-counter medications.

Administrative Burdens: Getting medical bills paid by their Medicare plan is one of the often time-consuming administrative tasks that beneficiaries must handle themselves. A somewhat larger share of beneficiaries in MA plans compared to traditional Medicare reported a delay in getting health care in the past 12 months because of administrative paperwork (9% vs. 6%; data not shown) or difficulty obtaining approval from their Medicare coverage (15% vs. 9%; data not shown).

More dual-eligible beneficiaries in Medicare Advantage than in traditional Medicare said their coverage has fully met their expectations.

Comment:

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

Talking with Medicare beneficiaries is the best way to assess their coverage experience. What we learn is that two-thirds of enrollees are happy with coverage, but one third are dissatisfied due to coverage gaps, costs, and benefit uncertainty.

Importantly, Medicare Advantage (MA) beneficiaries are more likely to experience care delays due to prior approvals and can’t afford care due to out-of-pocket costs. That is, access to care is worse in MA than in traditional Medicare (TM), despite overpayments of about $100 billion per year.

MA enrollees do, however, get more health assessments – 60% vs 25% in TM. Why? Because that’s a tactic that MA plans use to add diagnostic codes to game risk adjusted payments (discussed in our most recent HJM). Typically without “changes to their care plan or more services or benefits”.

Supplemental benefits in MA are used by most, though any particular benefit is not used much.

Being in MA increasing the likelihood of care delay due to paperwork and approvals. Strikingly, despite the claim that MA plans integrate care, MA enrollees are just as likely as TM enrollees to coordinate their own care.

One finding favors MA: Among Medicaid-Medicare dual eligibles (typically with complex medical issues), those in MA are a bit happier with coverage than those in TM. Not sure what that’s about, and no explanation is offered.

Overall, negative coverage value for the huge added expense of MA. Time to switch to an (improved) traditional Medicare for All – single payer.

https://healthjusticemonitor.org…

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

Medicare Advantage: How Private Insurers Exploit Medicare

An excellent interview with the former head of CMS, which oversees Medicare, lays out how Medicare Advantage insurers manipulate costs and quality, grabbing massive profits from public funds with no clinical benefits for patients. He wants its growth stopped and its problems fixed.

Obama CMS Chief: Medicare Advantage Plans Game the System, MedPage Today, March 1, 2024, by Cheryl Clark

(HJM bolding)

Donald Berwick, M.D., M.P.P. was the administrator of the Centers for Medicare & Medicaid Services (CMS) during the Obama administration and is president emeritus and senior fellow at the Institute for Healthcare Improvement.

MedPage Today interviewed him about his concerns that too many Medicare beneficiaries are being misled into enrolling into private Medicare Advantage plans, which he said should be slowed or stopped because the plans have gamed the system to receive billions more than what is spent for traditional Medicare beneficiaries’ care.

Cheryl Clark: Medicare Advantage, or MA, plan enrollment has been growing so fast; 52% of beneficiaries are now enrolled, with 60%, 70% projected in a few years. … I hear a traditional Medicare patient can’t find a primary care provider in some parts of the country because all the doctors are locked in MA.

Will every eligible beneficiary have no choice but Medicare Advantage? … And is that a good idea, given your concern about how MA plans have gamed the system to get more money?

Berwick: I think MA growth should be slowed or stopped, at least until we end the extraordinarily high subsidies for MA plans, which are unfair to traditional Medicare and burdensome to the public treasury and many beneficiaries. Many beneficiaries can get better care for themselves and greater choice through traditional Medicare, and that option should remain robust and available. …

Clark: Let’s talk about … how MA plans are overpaid. They’ll receive $88 billion more this year than what is spent for the same patients in traditional Medicare. That is a huge concern. But I don’t think it’s clear to readers how the plans are paid, that it’s not necessarily for better care.

Berwick: It’s a really complicated process and, I must say, possibly intentionally so, because I think it serves the interests of the private plans to have payment rules that are so hard to understand.

What the benchmark begins with is a comparison to the traditional Medicare population: people like me, who are in fee-for-service, traditional Medicare. There’s a calculation of the cost of my expected care… based on demographics and county, because care is more expensive in some counties than others. …

Most importantly, the amount that an MA plan gets is adjusted for the number of codes for diagnoses that a beneficiary has, like atrial fibrillation or diabetes, and for each code the plan gets more money, supposedly reflecting the additional care the patient needs. And that’s where the gaming nonsense occurs. Many codes have no real implications at all for evidence-based clinical care, but they carry with them extra payment nonetheless. The coding system has created opportunities for these plans to upcode. They comb through patients’ histories and try to stuff in as many diagnoses as they possibly can, even if they have nothing to do with the care of the patient.

Clark: During a January 12 MedPAC meeting, one of the commissioners mentioned that the plans were paying doctors to go through each record and look for anything that could add to capitated payment.

Berwick: That’s right. That’s worth a bit of a dive. There are three ways health plans manipulate the coding processes. What they’re after is what you said, which is, comb through the patient’s record, send a nurse into the patient’s home to find additional diagnoses. Sometimes, in some of the MA systems, they actually pay the doctor to code using a software package the insurance plan gives to the doctor. …

And a third and now much more popular, certainly to insurers, is to simply employ the doctors. Once the doctor is an employee, then you can set up all sorts of ways to accelerate upcoding. You can train the doctors or give them incentives to upcode. And now, the largest employer of doctors is a health plan, an MA plan. In this third tactic, the MA plan gets the benefit of all the upcoding, and that’s part of the game they are playing.

Now rather than lower costs, MA has much higher costs — something to the tune of $80 billion a year. Other estimates are as high as $120 billion. For the most part, that money doesn’t represent the needs of the patient. In fact, we know that beneficiaries in MA are, on the whole, healthier than those in traditional Medicare, and ought to cost less, not more.

It’s just a transfer of money to the private sector. Most of that goes to profit for the plan, or for stock buybacks, high compensation for plan executives, …

And further, because of all the gaming of diagnoses, it gets really, really hard to compare quality of care and outcomes between Medicare Advantage and traditional Medicare patients.

Clark: You’ve said you think MA plans should be slowed or stopped. How do you think that should happen?

Berwick: … We need to stop these abuses as quickly as possible. And we need simultaneously to improve the attractiveness of traditional Medicare, which is what tens of millions of Americans still have. …

Clark: [The MedPAC director] said that for chronic conditions, there is evidence that MA plans deliver better care.

Berwick: … There is some information that suggests that for some conditions, some MA plans do offer better chronic care but that’s a really hard statement to prove, and it certainly doesn’t apply across the board. And remember: MA plans are upcoding patients, so they make the patients look sicker, so when you try to assess outcomes, adjusted for severity, you’ve already fallen into the hole created by this game in which you’re no longer comparing apples to apples….

Clark: You spoke of the quality bonus program, which is a factor in MA capitated payments. How does it work?

Berwick: … the quality bonus system needs a big overhaul. It now has been pretty thoroughly gamed by MA plans. They focus on the scored variables, not overall better care – “teaching to the test,” as it were. Something like 80% of plans now are four-star or five-star on a five-star scale. I call that the “Lake Wobegon” effect, where everybody is above average. It’s a tricky system with unintended consequences. For example, when you’re treating a very distressed population with limited resources and there are barriers to treatment, you don’t want to take money away from the very organizations that need more money because their populations are harder to treat. But it has just become too easy to get a high score. …

Comment:

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

Don Berwick is a hero for many of us, for his decades of foundational work in quality of medical care and his forthright criticism of Medicare Advantage, the private insurance arm of Medicare.

In this interview, he reviews how insurers thoroughly game the MA systems for payment and quality rating, yielding tens of billions in excess payments with no evidence of clinical benefit. Indeed, there is evidence of impaired access to care for the sickest and poorest, and financial harm to providers who treat the most needy.

You should read the entire interview, it’s wide-ranging and informative, and only a little technical. We’ll be writing more on Medicare Advantage issues in coming days.

As Dr. Berwick points out, traditional Medicare – in which the government pays providers directly – works more efficiently to assure access to care. But it needs some coverage gaps closed. That is, we need an improved traditional Medicare. Then we could extend that to everyone. That’s an “improved Medicare for All”. Aka: single payer.

https://healthjusticemonitor.org…

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

The effect of health-care privatisation on the quality of care

By Benjamin Goodair, M.Sc. and Aaron Reeves, Ph.D.
The Lancet Public Health, March 2024

Summary: Over the past 40 years, many health-care systems that were once publicly owned or financed have moved towards privatising their services, primarily through outsourcing to the private sector. But what has the impact been of privatisation on the quality of care? A key aim of this transition is to improve quality of care through increased market competition along with the benefits of a more flexible and patient-centred private sector. However, concerns have been raised that these reforms could result in worse care, in part because it is easier to reduce costs than increase quality of health care. Many of these reforms took place decades ago and there have been numerous studies that have examined their effects on the quality of care received by patients. We reviewed this literature, focusing on the effects of outsourcing health-care services in high-income countries. We found that hospitals converting from public to private ownership status tended to make higher profits than public hospitals that do not convert, primarily through the selective intake of patients and reductions to staff numbers. We also found that aggregate increases in privatisation frequently corresponded with worse health outcomes for patients. Very few studies evaluated this important reform and there are many gaps in the literature. However, based on the evidence available, our Review provides evidence that challenges the justifications for health-care privatisation and concludes that the scientific support for further privatisation of health-care services is weak.

Effects on health outcomes: At an ecological level, high rates of privatisation and outsourcing almost always corresponded with worse health outcomes in the studies included in this Review. Two articles looked at regional levels of privatisation for an entire country and both found that increases in the percentage of outsourcing corresponded with higher avoidable mortality rates than before outsourcing took place. The only other article that assessed mortality rates did so in incarcerated populations, and also found increased avoidable mortality rates as the proportion of outsourced health care increased. Additionally, outsourced cleaning services corresponded with higher rates of inpatient infection than internal cleaning services. More nuanced results were found in Sweden when outcomes in avoidable hospitalisations improved across the country after a privatising reform to primary care; results from this study did not show dose-response variation—ie, areas that reformed first or had the highest increases in private providers did not show the biggest improvements in quality of care—and this factor therefore is not attributable to finding causality. No studies in this Review found that increased privatisation corresponded with better health outcomes for patients. None of the articles that assessed hospital conversions included health outcomes, an important gap in the literature identified in this Review.

Conclusion: There is only a small number of studies addressing the effect of privatisation on the quality of care offered by health-care providers, and yet within this small group of longitudinal studies, we find a fairly consistent picture. At the very least, health-care privatisation has almost never had a positive effect on the quality of care. But outsourcing is not benign either, as it can reduce costs, but seems to do so at the expense of quality of care. Overall, our Review provides evidence challenging the justifications for health-care privatisation and concludes that the scientific support for further privatisation of health-care services is weak.

full study:
https://www.thelancet.com…

Veterans Care Under Attack

An article in the American Prospect lays out how the Veterans Health Administration public approach to care – effective & efficient – is under siege, pushed at great cost to privatization. Not only by the proposed GOP/MAGA gutting, but by a complicit current administration.

Trump’s VA Plans Look Too Much Like Biden’s VA Reality, The American Prospect, Feb. 19, 2024, by Suzanne Gordon and Steve Early

While Project 2025 plots VA dismantling, its Biden-appointed leader tells workers to ‘stay out of politics.’

During a recent campaign speech in North Carolina, former President Donald Trump claimed that, when he first entered the White House seven years ago, there were “sadists” working at the VA who “would beat up old wonderful soldiers. Beat the hell out of them … and we weren’t allowed to fire them.” In a meeting with New Hampshire veterans, Trump urged them to support his re-election effort so, next year, he can fire “every corrupt VA bureaucrat who Joe Biden has outrageously refused to remove from the job or put back in the job.”

Such threats are not MAGA rally rhetoric. They constitute Trump’s plan of action for the Department of Veterans Affairs (VA), which has the second-largest workforce and third-largest budget of any federal agency.

As the Prospect and other media outlets have warned, Trump and his supporters will be much better prepared next January to seize the levers of power than they were in 2017. According to one former Trump official, their collective mission will be to act as a “wrecking ball” aimed at “the administrative state [from] Day One.”

Right-wing policy wonks, who are part of a Heritage Foundation–sponsored group called Project 2025, have developed a detailed agenda to slash federal spending and cut taxes, dismantle key agencies, strip 50,000 workers of civil service protections, renegotiate union contracts, and privatize even more government functions, like providing medical care to nine million patients of the VA-run Veterans Health Administration (VHA). …

[T]he current administration does not offer enough of an alternative to Trump’s own VA agenda, past and future. Biden’s VA leaders continue to ignore the elephant in the room: the already swinging wrecking ball of privatization. One sign of this is the rare Project 2025 praise of Biden appointees, for “adopt[ing] some of their predecessors’ governance processes” at the VA.

… Biden’s VA secretary Denis McDonough has dragged his feet on reversing Trump-era administrative rules determining veteran eligibility for private-sector care. The Veterans Community Care Program (VCCP), launched by his Republican predecessor and authorized by the MISSION Act, has been expanded to include 1.6 million outside medical care vendors. VCCP utilization is growing by 17 percent a year, 42 percent of VA patients are now channeled into the private sector, and the program is consuming over 30 percent of the VHA’s clinical care budget. That has, of course, weakened the VA’s direct-care capacity, strained its finances, and made working conditions worse for frontline caregivers.

As a result of this and other management decisions, the VHA is now facing a $4 to $5 billion budget deficit and will have to curtail new hiring. …

VA headquarters has already informed local and regional medical center leaders that they must maintain “neutral FTE’s.” Dr. Shereef Elnahal, the VA’s current under secretary for health, has repeatedly acknowledged that the resulting workload increases will add to job stress and burnout. But he is already contributing to that with his drive to increase patient loads for clinicians via a much-disliked system of “bookable hours,” a productivity measurement of the sort favored by Project 2025.

Prospect interviews with VHA facility managers around the country reveal that they are warning VA headquarters that local program cuts and staff layoffs will be necessary soon, if outsourcing costs continue to drain local budgets. As one VA medical center chief of staff predicted, “If the Secretary does not revise the access standards to community care so we are actually able to meet them, in five years, we won’t be able to deliver care, we’ll be just another insurance company.”

… the Biden administration plans to spend $23.5 billion over the next decade on an “Integrated Critical Staffing Program” (ICSP), a gravy train for HR outsourcing firms that will fill VA jobs by hiring non-union temps. Another just-announced initiative allocates $14 billion to hire “commercial health care consultants” and other vendors who will advise the agency on modernization of its service provision. The VA will be adding many more contractors to its roster even though its own Office of Inspector General has just released a report documenting that the agency isn’t adequately vetting and monitoring those already on the payroll.

Both initiatives are very much in the spirit of Project 2025’s encouragement of private-sector partnerships “to improve the overall patient experience,” which most studies confirm is better inside, rather than outside, the VHA. …

In a New Year’s message, the VA secretary warned about “controversies and challenges … that will get accentuated during this presidential election year.” During this trying period, he wrote, “our noble mission, our singular purpose and our critical responsibility to always keep Veterans at the heart of everything we do … requires each of us to stay out of politics” (emphasis added).

…As one former AFGE official told us, “That message was threatening, dangerous, and factually wrong—something you’d expect of his Republican predecessor. The original intent of the Hatch Act was to protect federal workers from political pressure and patronage. It does not mean they should ‘stay out of politics.’”…

This year’s general-election contest will indeed be noisy, but 2024 is not a year for political inaction by federal workers, either organizationally or individually. At the VA, where a third of the health care workforce consists of former service members like Hayes himself, nobody is better positioned to counter Trump’s demonization of “VA bureaucrats” as “sadistic” and “corrupt” than its frontline caregivers.

Only they can put a human face on who actually delivers “high-quality care” and helps veterans gain “timely access” to other service-related benefits. And if they fail to do that in sufficient numbers, particularly in key battleground states, just 11 months from now the keys to VA headquarters will be handed over to conservative promise-keepers from the Heritage Foundation. Their agenda has already proved disastrous, for VHA patients and providers, during Trump’s first term and, unfortunately, in its Biden-era iteration as well.

Comment:

By Jim Kahn, M.D., M.P.H. and Don McCanne, M.D.

The Veterans Health Administration provides some of the most efficient and clinically effective care in the US, as revealed in various studies, many covered in HJM. It is living proof of the benefits of a mission focused on patient care and simplified (single payer!) financing.

Yet it is under attack by the MAGA GOP, as described in the Project 2025 plan. But also by the Biden administration with the current VA leadership pushing the ill-conceived privatization and incorrectly discouraging political involvement by employees in the pivotal upcoming election.

To be clear, a GOP/MAGA White House will destroy the VHA. A Democrat administration will permit us to fight for the integrity of the public VHA.

We, the people, must elect government legislators and administrators who do understand how well the public policies have been working for our veterans – officials who are dedicated to supporting them. Not only do we have to go to the polls to prevent the turnover of control to the Heritage extremists and their ilk, but we must communicate clearly to the current administration that we need to perpetuate the public VAH program that has served our veterans (and the taxpayers!) so successfully. We owe that to them!

https://healthjusticemonitor.org…

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

Failure to Address Homelessness Harms Health

Finland is effectively addressing issues of homelessness, says a new report. Being unhoused is associated with health problems and high medical costs. Yet homelessness is growing in the US, despite our massive resources. We must seriously address this problem.

Finland Sees Housing and Health as Inextricably Linked, The Commonwealth Fund, International Insights, Vol. 24, by Munira Z. Gunja

It’s hard to imagine that just four decades ago, there were some 20,000 people in Finland without a home. By last year, this number had fallen to less than 3,700, a roughly 82 percent decline that represents the most significant decrease in homelessness within the European Union.

It’s a completely different story in the United States, where the number of people experiencing homelessness is the highest it’s been in decades. About 20 of every 10,000 Americans lacked stable housing in 2023, a 12 percent increase over the previous year. Black people, Native Americans, and Pacific Islanders are unhoused at disproportionately high rates, while Asian Americans had the sharpest percentage increase in homelessness compared to all other races and ethnicities.

The health consequences of not addressing the U.S. housing crisis are clear:

  • People who experience homelessness have higher rates of illness and die an average of 12 years earlier than the general U.S. population.
  • Unhoused people are more likely to have behavioral health needs.
  • Low-income and unhoused people are the top 5 percent of hospital users and account for 50 percent of health care costs.
  • One-third of emergency department (ED) visits are made by people experiencing homelessness, with nearly 80 percent of those visits for concerns that could have been preempted with preventive care. ED visits are estimated to cost $18,500 annually for each unhoused person.

The evidence shows that stable, affordable housing improves mental and physical health outcomes.  Finland’s government recognizes this and has worked to ensure that thousands of its residents who would otherwise be forced to sleep on the streets have access to dignified housing.

(Finland’s) Housing First moves people into stable housing right away – with no conditions – and then provides additional social services as needed. People receive a rental unit as well as access to support staff to help them navigate their finances, find jobs, and address any other needs. To build community, tenants are invited to participate in group activities and undertake charity work. To foster financial independence, they pay a percentage of the overall rent with the help of financial subsidies, if needed.

How is the U.S. addressing homelessness?

The federal government encourages the use of Housing First practices, and several U.S. cities and states have adopted the model.

But success hinges on filling significant gaps in funding. Currently, communities across the U.S. lack the financing necessary to provide housing for everyone who needs it, a problem that will likely get worse. Nationally, the number of people losing housing each year is outpacing the number of people gaining it.

Half of U.S. primary care physicians report a lack of sufficient coordination with specialists and hospitals for their patients’ care. But fully addressing the needs of unhoused patients, such as through community-based care models that offer supportive housing, requires just that.

Comment:

By Don McCanne, M.D.

Whoa. Didn’t we end this article synopsis with the resolution of this crisis up in the air? If we go ahead and address the problem of homelessness, we can simultaneously address the problem of deficiencies in mental and physical health and also the increasing need for other social services as well.

This report states that many communities lack the financing necessary to provide adequate housing, but the nation as a whole certainly does not lack the potential resources. We now have large numbers of individuals and corporate entities with great wealth which would not be impacted at all negatively by relatively modest tax policies that would be required to ensure the presence of community-based care models that included assurances of adequate housing. They’ve done it in Finland; we can surely do it here in “the greatest nation on earth.” Or are those with mega wealth going to argue that this is no longer the greatest nation?

https://healthjusticemonitor.org…

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

Company Behind Joe Namath Medicare Advantage Ads Has Long Rap Sheet of Misconduct

The firm formerly known as Benefytt pocketed millions selling sham insurance to seniors and other consumers.

By Matthew Cunningham-Cook
The American Prospect, February 22, 2024

Former New York Jets superstar Joe Namath can be seen every year during Medicare open enrollment hocking plans that tell seniors how great their life would be if only they signed up for a Medicare Advantage plan. From October 15 to December 7 last year alone, Joe Namath ads ran 3,670 times, according to iSpot, which tracks TV advertising.

But the company behind those ads, now called Blue Lantern Health, and their products, HealthInsurance.com and the Medicare Coverage Helpline, have an expansive rap sheet of misconduct, including prosecutions by the Securities and Exchange Commission and the Federal Trade Commission, and a recent bankruptcy filing that critics say is designed to jettison the substantial legal liabilities the firm has incurred. In September 2023, the company became Blue Lantern; before that, it was called Benefytt; and before that, Health Insurance Innovations. Forty-three state attorneys general had settled with the company in 2018, with it paying a $3.4 million fine. A close associate of the company, Steven Dorfman, has also been prosecuted by the FTC, in addition to the Department of Justice.

Namath himself has a bit of a checkered past when it comes to his business associates—in the early 1970s, he co-owned a bar frequented by members of the Colombo and Lucchese crime families, according to reporting at the time cited in a 2004 biography. Due to the controversy surrounding the bar, Namath was forced by the NFL Commissioner to sell his interest in it. Last year, it was revealed that Namath had employed a prolific pedophile coach at his football camp, also in the 1970s, and the 80-year-old ex-quarterback is now being sued by one of the coach’s victims.

The Namath ads are the main illustration of the behemoth Medicare Advantage marketing industry, which is designed to herd seniors into Medicare Advantage plans that restrict the doctors and hospitals that seniors can go to and the procedures they can access through the onerous “prior authorization” process, and it costs the federal government as much as $140 billion annually compared to traditional Medicare. Over half of seniors—nearly 31 million people—are now in Medicare Advantage, and there is little understanding of the drawbacks of the program. Seniors are aware that they may receive modest gym or food benefits but typically do not realize that they may be giving up their doctors, their specialists, their outpatient clinics, and their hospitals in favor of an in-network alternative that may be lower quality and farther away.

How So Many Seniors Are Lured Into Medicare Advantage

Blue Lantern—with its powerful private equity owner Madison Dearborn—may be the key to understanding how so many people have been ushered into Medicare Advantage—and the pitfalls that private equity’s rapid entrance into health care can create for ordinary Americans. While Blue Lantern is just one company, it is a Rosetta Stone for everything that is wrong with American health care today—fraud, profiteering, lawbreaking, no regard for patient care—where only the public comes out the loser.

Blue Lantern uses TV ads and, at least until regulators began poking around, a widespread telemarketing operation, being one of the main firms charged with generating “leads” that are then sold to brokers and insurers, as Medicare Advantage plans are banned from cold-calling. Court filings reviewed by HEALTH CARE Un-Covered allege that after legal discovery, Blue Lantern (then known as Benefytt) at minimum dialed seniors over 17 million times, potentially in violation of federal law that requires telemarketers to properly identify themselves and who they are working for—ultimately, in this case, insurers that generate huge profits from Medicare Advantage.

The Namath ads have been running since 2018 when the company was named Health Insurance Innovations—the same year the FTC began prosecuting Simple Health Plans, along with its then-CEO Steven Dorfman. The Fort Lauderdale Sun-Sentinel identified Health Insurance Innovations as a “successor” to Simple Health Plans. After five years of likely exceptionally costly litigation, for which Dorfman is represented by jet-set law firm DLA Piper, on February 9, the FTC won a $195 million judgment against Simple Health Plans and Dorfman. The FTC alleged in 2019 that Dorfman had lied to the court when he said that he did not control any offshore accounts. The FTC found $20 million, but the real number is probably higher.

Friends in High Places

In February 2020, Trump’s Secretary of Health and Human Services, Alex Azar, said that the Namath ads might not “look or sound like the future of health care,” but that they represented “real savings, real options” for older Americans.

In March 2020, Health Insurance Innovations (HII) changed its name to Benefytt, and in August 2020, it was acquired by Madison Dearborn Partners. Madison Dearborn has close ties to the Illinois Democratic elite, pumping over $916,000 into U.S. Ambassador to Japan Rahm Emanuel’s campaigns for Congress and mayor of Chicago.

In September 2021, HII settled a $27.5 million class action lawsuit. The 230,000 victims received an average payout of just $80.

In July 2022, the SEC charged HII/Benefytt and its then-CEO Gavin Southwell with making fraudulent representations to investors about the quality of the health plans it was marketing. “HII and Southwell … told investors in earnings calls and investor presentations that HII’s consumer satisfaction was 99.99 percent and state insurance regulators received very few consumer complaints regarding HII. In reality, HII tracked tens of thousands of dissatisfied consumers who complained that HII’s distributors made misrepresentations to sell the health insurance products, charged consumers for products they did not authorize and failed to cancel plans upon consumers’ requests,” the SEC found, with HII/Benefytt and Southwell ultimately paying a $12 million settlement in November 2022.

By August 2022, Benefytt had paid $100 million to settle allegations that it had fraudulently directed people into “sham” health care plans. “Benefytt pocketed millions selling sham insurance to seniors and other consumers looking for health coverage,” the FTC’s Director of Consumer Protection, Samuel Levine, said at the time.

Bankruptcy and Another Name Change

In May 2023, Benefytt declared Chapter 11 bankruptcy—where the company seeks to continue to exist as a going concern, as opposed to Chapter 9, when the company is stripped apart for creditors—in the Southern District of Texas. The plan of bankruptcy was approved in August. The Southern Texas Bankruptcy Court has been mired in controversy in recent months as one of the two judges was revealed to be in a romantic relationship with a woman employed by a firm, Jackson Walker, that worked in concert with the major Chicago law firm Kirkland and Ellis to move bankruptcy cases to Southern Texas and monopolize them under a friendly court. While the other judge on the two-judge panel handled the Benefytt case, Jackson Walker and Kirkland and Ellis were retained by Benefytt, and the fees paid to Jackson Walker by Benefytt were delayed by the court as a result of the controversy.

In September 2023, Benefytt exited bankruptcy and became Blue Lantern.

The August approval of the bankruptcy plan was vocally opposed by a group of creditors who had sued Benefytt over violations of the Telephone Consumer Privacy Act (TCPA). The creditors asserted that Benefytt had substantial liabilities, with millions of calls made where Benefytt did not identify the ultimate seller—Medicare Advantage plans run by UnitedHealth, Humana, and other firms prohibited from directly contacting people they have no relationship with—and violations fined at $1,500 per willful violation.

Attorneys for those creditors stated in a filing reviewed by HEALTH CARE Un-Covered that Madison Dearborn always planned “to steer Benefytt into bankruptcy,” if they were unable to resolve the substantial liabilities they owed under the TCPA.

Madison Dearborn “knew that Benefytt’s TCPA liabilities exceeded its value, but purchased Benefytt anyway, for the purpose of trying to quickly extract as much money and value as they could before those liabilities became due,” the August 25, 2023, filing stated on behalf of Wes Newman, Mary Bilek, George Moore, and Robert Hossfeld, all plaintiffs in proposed TCPA class action suits. The filing went on to say that the bankruptcy was inevitable “if—after siphoning off any benefit from the illegal telemarketing alleged herein—[Madison Dearborn] could not obtain favorable settlements or dismissals for the telemarketing-related lawsuits against Benefytt.”

Under the bankruptcy plan, Blue Lantern/Benefytt is released from the TCPA claims, but individuals harmed can affirmatively opt out of the release, which is why the bankruptcy court justified its approval. Over 7 million people—the total numbers in Benefytt’s database, according to the plaintiffs—opting out of the third-party release is an enormous administrative hurdle for plaintiffs’ lawyers to pass, massively limiting the likelihood of success of any class action litigation against Blue Lantern going forward.

Their attorney, Alex Burke, stated in court that “[t]his bankruptcy is an intentional and preplanned continuation of a fraud.” His statement was before 3,670 more Namath ads ran during 2023 open enrollment.

In response to requests for comment from HEALTH CARE un-covered, the Centers for Medicare and Medicaid Services did not answer questions about Benefytt and why the company was simply not barred from the Medicare Advantage market altogether.

Corporations have used the bankruptcy process in recent years to free themselves from criminal and civil liability, with opioid marketer Purdue Pharma being the most prominent recent example. The Supreme Court is reviewing the legality of Purdue’s third-party releases currently, with a decision expected in late spring.

The role that private equity plays in keeping Benefytt going cannot be overstated. Without Madison Dearborn or another private equity firm eager to take on such a risky business with such a long history of legal imbroglios, it is almost certain that Benefytt would no longer exist—and the Joe Namath ads would disappear from our televisions. Instead, Madison Dearborn keeps them going, suckering seniors into Medicare Advantage plans.

This is part and parcel of the ongoing colonization by private equity into America’s health care system. Private equity is making a major play into Medicare Advantage. It has pumped billions of dollars into purchasing hospitals. It has invested in hospice care. It is gobbling up doctors’ groups. It is acquiring ambulance companies. It is hoovering up nurse staffing firms. It is making huge investments into health tech. It is in nursing homes. And it is in health insurance. Nothing about America’s health care system is untouched by private equity. That’s a problem, experts say.

“I’ve been screaming at the TV every time Joe Namath gets on—it is not an official Medicare website,” said Laura Katz Olson, a professor of political science at Lehigh University who has written on private equity’s role in the health care system. “Private equity has so much money to deploy, which is far more than they have opportunities to buy. As such, they are desperately looking for opportunities to invest. There’s a lot of money in Medicare Advantage—it’s guaranteed money from the federal government, which makes it perfect for the private equity playbook.”

Eileen Appelbaum, the co-director at the Center for Economic and Policy Research, who has also studied private equity’s role in health care, concurred that private equity was a perfect fit for Medicare marketing organizations. “I think basically the whole privatized Medicare situation is ready for all kinds of exploitation and misrepresentations and denying people the coverage that they need,” she said. “My email is inundated with these totally misleading ads. Private equity took a look at this and said, “look at that, it’s possible to do something that’s misleading and make a lot of money.”

Madison Dearborn receives a large portion of its capital from public pension funds like the California Public Employees Retirement System (CalPERS) and the Washington State Investment Fund—people who are dependent on Medicare. Appelbaum said that the pension funds exercise little oversight over their investments in private equity. “Pension funds may have the name of the company that they are invested in, they’re told that it’s ‘part of our health care investment portfolio,’ but they don’t find out what they really do until there’s a scandal. It is amazing that pension funds give so much money to private equity with so little information about how their money is being spent.”

Madison Dearborn did not respond to a request for comment from HEALTH CARE un-covered.

This article is a co-publication with HEALTH CARE un-covered, a website about the health insurance industry. It is available at wendellpotter.substack.com.

https://prospect.org…

Not One of the Nineteen Doctors in Congress Support Single Payer

Single Payer Action, February 20, 2024

Polls show that the majority of Americans favor a single payer Medicare for All system, similar to the one adopted by most industrialized countries – everybody in, nobody out, no premiums, no deductibles, free choice of doctor and hospital.

The majority of doctors in most polls support single payer.

But historically, the main organization of physicians and medical students in the United States – the American Medical Association – has opposed it.

Back in the 1960s, when there was an early push to create Medicare for seniors, doctors hired Ronald Reagan to help defeat the idea.

“One of the traditional methods of imposing statism or socialism on a people, has been by way of medicine,” Reagan said at the time. “It’s very easy to disguise a medical program as a humanitarian project.”

In 2019, the student section of the AMA forced a vote on single payer. During the debate, Dr. Donald Palmisano, of Metaire, Louisiana, who served as AMA president in 2003-04, said – “I think we ought to put a stake in the heart of single payer. We’ve done it before and we ought to do it again.” The measure was defeated 53 percent to 47 percent.

But that’s still 47 percent of doctors in the most conservative doctors’ organization in the United States voting for it.

So then how do you explain this?

Of the nineteen physicians who serve United States Congress – fifteen members of the House and four Senators, sixteen Republicans and three Democrats – there is zero support single payer.

That’s according to a survey conducted by the Capitol Hill Citizen and reported in the February/March 2024 issue.

“The fact that none of the physicians in Congress support Medicare for All indicates just how out of step those legislators are with their constituents and with physicians,” Dr. Philip Verhoef, President of Physicians for a National Health Program, told Capitol Hill Citizen. “These physicians know full well that our system isn’t working for doctors or patients.” “Poll after poll indicates that both the majority of physicians and the public support single payer – it’s equitable, it saves money, it’s much easier to navigate, and it will remove the barriers to care currently faced by so many in this country.”

There are no Republicans in Congress – physician or not – who support single payer.

One hundred and twelve Democrats in the House have signed onto the single payer bill there (HR 3421).

Not on the list are the three Democratic physicians in the House.

Fourteen Senators – all Democrats – have signed onto the single payer bill in the Senate – (S. 1655).

The nineteen doctors who don’t support single payer are:

  • Senator John Barrasso (R-Wyoming) Medical speciality: Orthopedic surgery
  • Congressman Ami Bera (D-California) Medical speciality: Internal medicine
  • Congressman Larry Bucshon (R-Indiana) Medical speciality: Thoracic surgery
  • Congressman Michael Burgess (R-Texas) Medical specialty: Obstetrics and gynecology
  • Congresswoman Yadira Caraveo (D-Colorado) Medical speciality: Pediatrics
  • Senator Bill Cassidy (R-Louisiana) Medical speciality: Gastroenterology
  • Congressman Scott DesJarlais (R-Tennessee) Medical speciality: Family medicine
  • Congressman Neal Dunn (R-Florida) Medical speciality: Urology
  • Congressman Mark Green (R-Tennessee) Medical speciality: Emergency medicine
  • Congressman Andy Harris (R-Maryland) Medical speciality: Anesthesiology
  • Congressman Ronny Jackson (R-Texas) Medical specialty: Emergency medicine
  • Congressman John Joyce (R-Pennsylvania) Medical speciality: Dermatology
  • Senator Roger Marshall (R-Kansas) Medical speciality: Obstetrics and gynecology
  • Congressman Rich McCormick (R-Georgia) Medical speciality: Emergency medicine
  • Congresswoman Mariannette Miller- Meeks(R-Iowa) Medical specialty: Ophthalmology
  • Congressman Greg Murphy (R-North Carolina) Medical specialty: Urology
  • Senator Rand Paul (R-Kentucky) Medical specialty: Ophthalmology
  • Congressman Raul Ruiz (D-California) Medical specialty: Emergency medicine
  • Congresswoman Kim Schrier (D-Washington) Medical speciality: Pediatrics

https://singlepayeraction.org…

Presidential Leadership in US Health Reform

President’s Day is an opportune moment to reflect on the great moral potential of the presidency. Lincoln’s fine example, told by a historian, looms large. The role of presidents in health care reform, summarized by ChatGPT, is impressive but piecemeal, shy of the ultimate moral and practical victory of universal comprehensive insurance.

Letters from An American, February 18, 2024, by Heather Cox Richardson

That the American people in the twenty-first century celebrate Abraham Lincoln as a great president would likely have surprised Lincoln in summer 1864, when every sign suggested he would not be reelected and would go down in history as the man who had permitted a rebellion to dismember the United States.

The news from the battlefields in 1864 was grim. …  As the casualties mounted, so did criticism of Lincoln. …

[Lincoln wrote:] “… it seems exceedingly probable that this Administration will not be re-elected. …”

But then his fortunes turned.

… the Democrats chose as a presidential candidate General George McClellan … [and] rejected the new, popular measures the national government had undertaken since 1861—the establishment of state colleges, the transcontinental railroad, the new national money, and the Homestead Act—insisting on “State rights.”

Americans who had poured their lives and fortunes into the war and liked the new government were not willing to abandon both to return to the conditions of three years before.

Lincoln won about 55% of the popular vote compared to McClellan’s 45%, and 212 electoral votes to McClellan’s 12.

ChatGPT-4, February 19, 2024, Query by JGK: What is the role of presidents in health reform?

The role of presidents in health insurance reform in the United States has been significant, as they often serve as the primary advocates for major policy changes and help set legislative agendas. Here’s an overview of how U.S. presidents have influenced health insurance reform:

Vision and Agenda Setting: Presidents often use their platform to highlight the need for health insurance reform, setting the vision and goals for what they hope to achieve. This can include expanding coverage, reducing costs, improving the quality of care, or a combination of these objectives.

Legislative Leadership: Presidents work closely with Congress to draft and promote health insurance reform legislation. They may propose specific bills or outline key principles that they want the legislation to address. Through negotiations and collaborations with lawmakers, presidents can guide the legislative process.

Public Advocacy: Presidents engage in public advocacy to garner support for health insurance reform. This can involve speeches, press conferences, and public appearances. Effective communication can help rally public support, which in turn can influence legislators.

Political Capital: Presidents often expend significant political capital to push through health insurance reforms. This can be risky, as unsuccessful reform efforts or unpopular policies can impact a president’s approval ratings and influence over other policy areas.

Executive Actions: When legislative efforts stall, presidents may use executive actions to implement certain health insurance reforms. While these actions are generally more limited in scope compared to comprehensive legislation, they can still have a significant impact on the health insurance landscape.

Collaboration with Stakeholders: Presidents and their administrations engage with various stakeholders, including insurance companies, healthcare providers, patient advocacy groups, and the business community, to build consensus and address concerns related to proposed reforms.

Historical Examples:

  • Harry S. Truman: Failed in attempt to enact national health insurance.
  • Lyndon B. Johnson: Enacted Social Security Amendments of 1965, creating Medicare and Medicaid, for elderly, long-term disabled, and low-income individuals.
  • Bill Clinton: After failed comprehensive reform, implemented the State Children’s Health Insurance Program.
  • George W. Bush: Expanded Medicare to include prescription drugs.
  • Barack Obama: Enacted the Affordable Care Act (ACA).
  • Donald Trump: Failed to repeal the ACA; implemented rules to undermine parts of it.
  • Joe Biden: Temporarily increased ACA premium supports and extended Medicaid enrollment, as part of COVID response. Enacted Medicare drug beneficiary spending caps and some price negotiations.

Comment:

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

Lincoln’s moral vision and practical political skills saved the union and freed the slaves. Toward the end of his first term, the war was going poorly, and he faced dismal re-election prospects. Then, his opponent’s rejection of fundamental reforms intended to strengthen the nation and give a hand up to the less fortunate – along with key military victories – turned the tide to resounding victory at the polls. He was soon assassinated, undermining his legacy, and the nation suffered decades of disruption as the South resisted equality for the freed slaves. Yet his shining moral example and accomplishments reverberate more than 150 years later.

Each major health reform is properly associated with the president under whom it occurred — reflecting their vision of the needed and possible. Of course, presidential affiliation with a particular reform doesn’t tell the full story – of the perceived needs for change, a sense of the possible, advocacy by interest groups, and Congressional deal-making.

All the presidents have fallen short of the ultimate solution – universal comprehensive benefits through a greatly simplified financing system. Some tried (e.g., Truman and in a different form, Nixon); some aimed low (e.g., GW Bush); and some combined ambitiousness with perpetuation of the current flawed structure (e.g., Clinton and Obama).

In my view, there is only one reasonable way forward: the globally tried and true uniform insurance for all. In the US, that’s single payer. If we want to start with a few states to test and refine, that’s ok.

Many will say, it’s not politically possible. To which I respond that in Lincoln’s time many didn’t think it was possible to preserve the union and free the slaves, and in Washington’s time most assumed he would retain power indefinitely – but he stepped down.

The most morally visionary presidents take the US in great directions. A president who brings us universal comprehensive health insurance will become as hallowed as the two leaders we most celebrate today.

https://healthjusticemonitor.org…

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Dr. Paul Song on “Nuances”

PNHP Board Adviser Dr. Paul Song appeared on the “Nuances” podcast on February 18, 2024. Dr. Song discussed how U.S. health care is set up to benefit big insurance corporations, and why single-payer Medicare for All would provide much better experiences for both patients and physicians.

“People are led to believe we have the best health care system—full of freedom and individual rights—of any place in the world,” said Dr. Song. “The reality is, if you get sick, you soon realize you don’t have freedom.”

“Do No harm” – How Medicare Advantage policies are harming cancer patients

By James P. Waters and Young K. Hong
The American Journal of Surgery, February 16, 2024

Medicare Advantage began in 2003 as a rebranding of the then-named Medicare Part C. It has since expanded to include most Medicare-eligible patients and is projected to capture 60% of these patients by 2028. Its programs promote great benefits and high-value care at low premiums across the board, but recently, numerous organizations have scrutinized these claims. …

Despite claims that Medicare Advantage patients receive high-quality care, more Medicare Advantage patients, especially those from minority backgrounds or with low income, experience cost-related problems accessing care.

This disparity in access to care is present in both Traditional Medicare and Medicare Advantage but is exacerbated under Advantage plans. Even worse, the disparate access to care under Advantage plans is leading to increased mortality rates for cancer patients.

A recent report in the Journal of Clinical Oncology shows that even though cancer patients have lower estimated hospital costs in Medicare Advantage, they deal with longer delays from diagnosis to treatment.

Further, cancer patients in Medicare Advantage are much less likely to use a National Cancer Institute (NCI) designated center of excellence for cancer surgery. These delays to treatment and redirection to less experienced hospitals are resulting in increased mortality rates in patients on Medicare Advantage plans.

full article:
https://www.americanjournalofsurgery.com…

No Surprises Act has Unpleasant Surprises for Providers & Patients

The No Surprises Act is a bipartisan law to protect patients from high medical charges for unavoidable out-of-network care, while providing providers with fair payments. Its implementation suffers from insurer-tilted rules, another example of “regulatory capture.”

Is the No Surprises Act backfiring on patients? And why is HHS Secretary Becerra letting it happen?, Health Care Un-Covered, February 14, 2024, by Wendell Potter

[O]ne area of real compromise, and policy achievement, in recent years came in December 2020 with the passage of the No Surprises Act (NSA).

For a decade, patients had seen an increase in “surprise bills” that were generated after an emergency room visit or some hospital-based procedures. In many cases, after a doctor provided emergency or specialist care at a hospital to a patient whose insurance was not “in-network” with that doctor, the patient received a bill for the balance left unpaid by their insurer. Sometimes those bills were into the tens and hundreds of thousands of dollars, driving a surge in medical debt.

The NSA took two years of intense deliberation by Congress and resulted in a significant bipartisan achievement for patients. It credibly addressed the problem in a way that was a compromise for insurers and doctors. It created a mechanism to set a reasonable, market-based rate for out-of-network medical procedures. As enacted by Congress, it seemed to be a fair means of resolving payment disputes between doctors and insurers, without patients in the middle. Consumers stopped receiving surprise bills and–even I believed–this was the rare problem in our health system that had been resolved fairly.

I was wrong. And to my surprise, the fault lies squarely at the feet of the Biden administration’s Department of Health and Human Services (HHS). The way the administration wrote the regulations, undoubtedly with “help” from my former colleagues, insurers scored a major advantage. In doing so a law that was meant to be a shield for patients has turned into a sword for insurers.

Since the act’s implementation in 2022, HEALTH CARE Un-covered has learned, in talking with doctors around the country, that insurers have abused their authority under the law. This gets technical, so bear with me.

The law created a new way to set the average cost of specific care in specific markets – called Qualified Payment Amounts (QPAs) – that is supposed to be the basis of patient cost-sharing. It’s also one of the factors in an arbitration process set up in the law when payers and providers can’t agree on out-of-network payment.

The problem is that the Biden Administration’s regulations empowered insurers to set the QPA amount and then made it a “rebuttable presumption” of payment in the arbitration–meaning the QPA as determined by the insurer is just assumed to be appropriate and fair–ignoring all other factors. … insurers have become the foxes guarding the hen house. …

Insurers are using the law to slash payments to doctors to boost profits.

[O]ver the past two years, the law has empowered insurers to terminate contracts and offer far lower payment rates in return. Here’s how it works: an insurer tells a group of emergency room doctors they will no longer pay $100 for a procedure. Instead, the insurer says it will pay $40. Outraged, the doctors decline, which triggers the arbitration rules set out under the NSA.

[Then, the QPA specified by insurers strongly tilts the arbitration their way.] …

There is a mechanism in the law to ensure this doesn’t happen, and insurers have to provide a reasonable QPA to the arbiter, and the QPA is supposed to only be one of several factors considered as to what rate is reasonable. And that, unfortunately, is where the failure of HHS Secretary Xavier Becerra is laid bare. Despite multiple federal court rulings against insurers and in favor of hospital-based doctors, Becerra’s agency has refused to enforce the act to ensure fair payment rates to both sides.

Now, you might be thinking, why should I care? …

[T]here has been a worsening shortage of doctors in rural and underserved areas. Emergency room wait times are increasing, and specialists are becoming more difficult to schedule. The NSA, as written by Congress, would have stopped surprise billing by bad actors while stabilizing the health care system by creating an equal playing field for resolving out-of-network disputes between insurers and providers. …

Why did CMS feel the need to give insurers a pass on this critical piece of legislation?  Well, in its recent guidance, CMS was concerned that insurers would have “significant challenges associated with the recalculations” of the QPA and that it would “require significant resources and take many months if not longer.”  This comment has been met with utter disbelief from hospitals and doctors who are struggling with significant challenges …

As insurers are using HHS’ approach to enforcement to squeeze providers to drive higher profits, the casualty is ultimately the patient. Becerra has been hounded by Republicans and Democrats alike on this issue, and he should take notice. Not enforcing a bipartisan law as Congress intended to the benefit of insurers is policy–and political–malpractice. And it affects a core constituency of President Biden’s: working Americans with employer-based insurance who deeply value the benefits they believe they have.

Comment:

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

The terrific post by Wendell Potter discusses a perfect example of “regulatory capture.” That is, the entities being regulated (the insurers) influence regulation rules and processes to their considerable advantage. What looks like a benign term or phrase yields out-sized benefits. Huge impact cloaked in technical minutia.

Wendell attributes this situation to Secretary Becerra* and the likely influence of insurance lobbyists. I don’t disagree. However, the “revolving door” of employment in DHHS and its insurance regulator CMS (Center for Medicare and Medicaid Services) means that regulation writers may have a mindset and incentive to lean toward insurers. On many issues (if not this one), Congress exerts a pro-insurer influence.

Other recent examples of regulatory capture covered in HJM include:

  1. Multiple technical tweaks that generate Medicare Advantage over-payments of >$100 billion per year.
  2. A delay in / lowering of proposed corrections to risk adjustment gaming, worth $10 billion to insurers for 2024.
  3. A requirement in ACO REACH to pay participating physicians lower than regular Medicare rates … saving the corporate intermediaries money and co-opting physicians into being co-conspirators for suppressing care utilization by patients.

So, the Biden administration is complicit with health insurers. This is not news, indeed the Affordable Care Act (Biden’s “big f-ing deal”) is a massive gift to insurers.

But make no mistake, the situation would be massively worse under a second Trump administration. We saw in his first (we hope only) term that ACA rules assuring fair insurance policies were completely circumvented by changing the definition of “temporary policy” to anything 364 days or less.

Let’s hold the HHS/CMS regulatory feet to the fire. But also, let’s give the Biden administration, despite blemishes in the health care arena, a chance to burnish its record.

By the way … as you know … under single payer, “out-of-network” charges is a non-issue.

* In his prior California role, Becerra was a single payer supporter.

https://healthjusticemonitor.org…

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