PNHP

House and Senate Dems want CMS to drop ACO REACH members due to fraud concerns

House and Senate Dems want CMS to drop ACO REACH members due to fraud concerns

By Robert King
Fierce Healthcare, December 12, 2022

Nearly two dozen House and Senate Democrats are pressing the Biden administration to remove 10 organizations with documented fraud and waste from the controversial ACO REACH payment model that starts next year.

The letter, released by a collection of 21 House and Senate lawmakers last week, is the latest scrutiny to befall the alternative payment model, which aims to give physician groups a pathway to take on high financial risk and get savings in exchange for meeting spending and quality targets.

“The ability of organizations with known histories of fraud and abuse to take part in the program increases the risks for Medicare beneficiaries and raises concerns that [Centers for Medicare & Medicaid Services (CMS)] screening procedures for participants are inadequate, putting taxpayer dollars at risk,” according to the letter sent to CMS on Dec. 8.

The lawmakers cite a review conducted by the Physicians for a National Health Program (PNHP), an organization that advocates for single-payer healthcare, that explored the 99 entities participating in the Direct Contracting Model, the predecessor to ACO REACH. The 10 organizations dinged by the analysis were also accepted into ACO REACH, which starts its first performance period Jan. 1 and will have more than 200 entrants.

The new voluntary model offers full or partially capitated payments to physicians if they agree to meet certain spending and quality metrics. The Center for Medicare and Medicaid Innovation (CMMI) transitioned Direct Contracting into ACO REACH after concerns from progressive lawmakers surrounding the role of private equity.

“We have long been concerned about ensuring this model does not give corporate profiteers yet another opportunity to take a chunk out of traditional Medicare,” the letter said.

The lawmakers, led by Sen. Elizabeth Warren, D-Massachusetts, and Rep. Pramila Jayapal, D-Washington, singled out 10 participants that have a history of fraud and abuse in the Medicare program. Warren and Jayapal (the head of the House Progressive Caucus) have previously raised concerns about Medicare Advantage (MA) plans that use tools such as upcoding to make patients appear sicker than they are to inflate risk scores and get higher payments.

One of the participants the PNHP singled out is a subsidiary of Sutter Health, which reached a $90 million federal settlement over allegations of mischarging MA and submitting unsupported diagnosis codes to get higher payments from Medicare.

Another organization singled out was Cigna for an ongoing lawsuit filed by the Justice Department over alleged MA overpayments.

Major insurers Centene and Humana have also been highlighted in the analysis surrounding allegations of duplicative Veterans Affairs claims. According to an audit by the Department of Health and Human Services inspector general in April 2021, a Humana Inc. health plan for seniors in Florida improperly collected nearly $200 million in 2015 by overstating how sick some patients were.

The lawmakers asked CMS a series of questions about the methods the agency is using to screen ACO REACH participants. It also wants to know what protections it will employ to clamp down on fraud and abuse.

CMS told Fierce Healthcare that it has received the letter from the lawmakers and will respond accordingly.

Advocates for ACO REACH have previously countered that the model is vital toward putting Medicare “on a more sustainable financial path and improve patient care,” according to a statement from the National Association of ACOs.

The group, which represents ACOs, added in a fact sheet that most participants in ACO REACH have a history of participating in value-based care programs and a “long track record of upholding solid, quality patient care.”

CMMI introduced the ACO REACH model earlier this year with some changes that appeared to address progressives’ initial concerns with Direct Contracting.

These include a requirement that an ACO REACH model must have 75% of its governing board be made up of providers compared with 25% under Direct Contracting.

Another key change is the requirement for participants to create and implement a health equity plan that would identify gaps in care and strategies to mitigate them.

But concerns among PNHP and progressive lawmakers have continued even after the overhaul.

“We think the model is misguided and it is designed in such a way that it is an invitation to fraud,” said Stephen Kemble, M.D., a PNHP board member, in an interview with Fierce Healthcare.

The progressives’ concerns come amid heightened scrutiny from Capitol Hill over MA. Sen. Ron Wyden, D-Oregon, has pressed plans over aggressive MA marketing tactics in response to an increase in complaints.

https://www.fiercehealthcare.com…

Doctors call for shutdown of hopelessly compromised Medicare REACH program

Congressional letter using PNHP research warns of bad behavior by several companies set to participate in the program

FOR IMMEDIATE RELEASE: January 9, 2022

Media Contact: Gaurav Kalwani, PNHP communications specialist, gaurav@pnhp.org

Physicians for a National Health Program (PNHP), an organization of over 26,000 physicians who support publicly financed Medicare for All, commends 21 members of Congress who sent a letter to CMS Administrator Chiquita Brooks-LaSure raising serious concerns about the ACO REACH program, based on initial research by PNHP.

ACO REACH, which is set to begin officially operating in January, is a redesigned version of the Trump administration’s Medicare Direct Contracting program that allows third-party entities (often private insurers) to administer traditional Medicare benefits. The Congressional letter, led by Senator Elizabeth Warren and Representative Pramila Jayapal, describes documented histories first collected by PNHP of bad behavior by numerous insurers set to participate in the program. These companies faced allegations of overcharging Medicare and Medicaid, inflating diagnoses, misleading seniors through dubious marketing, and more, often paying tens or even hundreds of millions of dollars to federal and state governments in settlements and fines.

The letter urges CMS to halt participation of any insurers that have previously settled allegations of health care fraud, and expel from the program the insurers who do not meet its new standards. It also seeks clarification from CMS as to the screening process for participants in the program, and what steps the agency is taking to protect Medicare beneficiaries and taxpayers from waste, fraud, and abuse.

“As Medicare advocates have been saying over the past year, ACO REACH is nothing more than a fresh coat of paint on Medicare privatization,” said Dr. Phil Verhoef, an adult and pediatric intensivist and president of Physicians for a National Health Program. “It further opens the door for private insurers to make money at the expense of our public health programs and those who benefit from them. We applaud these members of Congress for raising the alarm on the most egregious profiteers operating in the Medicare space, and continue to call for CMS to shut REACH down for good.”

For more information on the REACH program and the danger it presents to our public insurance programs, please visit protectmedicare.net. 

Physicians for a National Health Program (pnhp.org) is a nonprofit research and education organization whose more than 25,000 members support single-payer Medicare for All reform.

Thomas Piketty’s Vision for Modern Socialism

Summary: Economist Thomas Piketty alerted us to accelerating economic inequality over the last 40 years. Now he proposes the solution: a revived socialism that embraces public-spirited investment in health and education for all, while adopting modern equity and ecological values.

Time for Socialism, Yale University Press, 2022, by Thomas Piketty

Born in 1971, I belong to a generation that did not have time to be tempted by communism, and which became adult when the absolute failure of sovietism was already obvious. I was more liberal than socialist in the 1990s. I could not stand those who obstinately refused to see that the market economy and private property were part of the solution.

But now, thirty years later, in 2020, hypercapitalism has gone much too far, and I am now convinced that we need to think about a new way of going beyond captalism, a new form of socialism, participative and decentralized, federal and democratic, ecological, multiracial, and feminist.

History will decide whether the word “socialism” is definitively dead and must be replaced. For my part, I think that it can be saved, and even that it remains the most appropriate term to describe the idea of an alternative economic system to capitalism. In any case, one cannot be just “against” capitalism or neoliberalism: one must also and above all be “for” something else, which requires precisely designating the ideal economic system that one wishes to set up, the just society that one has in mind, whatever name one finally decides to give it. 


Between 1930 and 1980, the (tax) rate applied on the highest incomes was on average 81% in the United States, and the rate applied to the highest inherited estates was 74%. Clearly, this did not destroy American capitalism, far from it. It made it more egalitarian and more productive, at a time when the voters in the United States had not forgotten that it was their level of educational advancement and their investment in training and skills that was the backbone of their prosperity, and not the religion of property and inequality.

Reagan, then Bush and Trump subsequently endeavored to destroy this heritage. They turned their backs on the egalitarian origins of the country, by counting on historical amnesia by fueling identity-based divisions. With the hindsight we have today, it is obvious that the outcome of this policy is disastrous. 


The challenge of global warming and the international awareness of the growing inequalities do act as leverage for change, but we are still far from that goal. The Organisation for Economic Co-operation and Development (OECD) projects for the taxation of the profits of multinationals only concerns a small fraction of the latter, and the scale of the contribution proposed is much more favorable to the rich countries than to the poor ones. “The Triumph of Injustice,” a book published in the United States by Emmanuel Saez and Gabriel Zucman, demonstrates that there are more ambitious solutions with the key element being financial transparency and the return to fiscal progressivity in order to finance health and education for all, and the ecological transition. The success of these ideas among the American Democrats (in particular, Warren and Sanders) does allow for optimism. 


Let it be said at once: The treatment received by Bernie Sanders in the leading media in the United States and in Europe is unjust and dangerous. Everywhere on the main networks and in the major daily papers we read that Sanders is an “extremist” and that only a “centrist”candidate like Biden could triumph over Trump. This biased and somewhat unscrupulous treatment is particularly regrettable when a closer examination of the facts actually suggests that only a full-scale reorientation of the type proposed by Sanders would eventually rid American democracy of the inegalitarian practices which undermine it and would deal with the electoral disaffection of the working classes.

To say emphatically, as Sanders does, that a public, universal health insurance would enable the American population to be cared for more efficiently and more cheaply than the present private and extremely unequal system is not an “extremist” statement. It is on the contrary a declaration perfectly well documented by many research studies and International comparisons. In these difficult times when everyone deplores the rise of “fake news,” it is right and proper for some candidates to rely on established facts and not resort to obscure language and complex tactics.

Similarly, Sanders is right when he proposes large-scale public investment in favor of education and public universities. Historically, the prosperity of the United States has relied in the twentieth century on the educational advance of the country over Europe and on a degree of equality in this field, and definitely not on the sacralization of inequality and the unlimited accumulation of fortunes which Reagan wished to impose as an alternative model in the 1980s. The failure of this Reagan-style rupture is evident today with the growth of national income per capita being halved and an unprecedented rise in inequality. Sanders simply proposed a return to the sources of the country’s model for development: a very wide diffusion of education. 


If the Democrats [DM: choose your own nonpartisan label] want to regain the socially disadvantaged vote, whatever its origin, then more needs to be done in terms of social justice and redistribution. The road ahead will be long and arduous. All the more reason to get started now.

Comment:

By Don McCanne, M.D.

Just think of what a great society we could have if we all joined together in support of a government designed to serve all of the people. In the excerpts from his book, Thomas Piketty describes accessible and affordable health care for all of us. He also describes large scale investment in education and public universities that have been shown to be the source of a prosperous society as opposed to policies that are merely designed to accumulate greater fortunes for the wealthy.

Yet at election time, what happens? Some of us seem to get hung up on
 what shall we say? Rhetoric? One term that seems to turn off many voters is “socialism,” when that term basically means that we are joining together to make this a better place for all of us. Yet when it comes time to vote, roughly half of us vote the Reaganesque or Trumpist ticket. What is their rhetoric? Freedom? What does that mean? Freedom to have the wealthy take even more of our assets and leave much of society in a compromised state without high performance health care or education systems that would be designed to serve all of us well?

Piketty tells us that we don’t have to use the term “socialism” but that we have to acknowledge an alternative economic system to capitalism and not merely be against capitalism or neoliberalism. Shall we name our system “utopia”? It would probably not take long for “utopia” to come to define the luxurious retreats for the wealthy that lock out the rest of us.

The other day I was looking at a photograph of participants in a panel discussion in San Francisco several years ago. I was standing next to Milton Friedman and I couldn’t help but notice how true it was that he was not a giant in economics – his small physical stature (5’0”) reminded me of his small intellectual perspective, fixated on markets as the antithesis to, not ally of, government.

But then, whether or not we use the word “socialism,” Piketty reminds us that we do need to do more in terms of social justice and redistribution, and WE NEED TO GET STARTED NOW!

http://healthjusticemonitor.org…

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

Dr. Ed Weisbart on “MRCC Medicaid Minute”

PNHP national board member Dr. Ed Weisbart appeared on the Missouri Rural Crisis Center’s “Medicaid Minute: Medicare Edition” podcast on December 6, 2022. Dr. Weisbart warned seniors about the false promises of Medicare Advantage plans. He added that many of the insurers that are active in Medicare Advantage are lining up to administer Traditional Medicare benefits through the ACO REACH program.

“They make more money the less health care you get,” he said, referring to the financial incentives that are present in both Medicare Advantage and REACH. “That is a radical transformation of Traditional Medicare [and] it’s rolling forward unless we stop it.”

COVID Settling Provokes Harm from Insurance Gaps

Summary: As the COVID crisis subsides from pandemic to endemic, special funding to support its care is disappearing. This leaves many uninsured without access to COVID care, despite daily cases still exceeding 50,000. Once again, COVID exposes massive gaps in our health insurance.

For the Uninsured, Covid Care Has Entered a New Stage of Crisis, New York Times, December 6, 2022, by Noah Weiland and Sarah Kliff

When Mandy Alderman caught the coronavirus in June for a second time, she hoped her usual primary care physician could prescribe a monoclonal antibody treatment or Paxlovid, the antiviral pill that has been shown to reduce the severity of an infection. But without health insurance, she could not afford a visit.

Ms. Alderman, 44, a former medical assistant in Lawrenceville, Ga., found a doctor willing to prescribe a cocktail of other drugs, but not the proven Covid-19 medications she wanted. She took what she could get. She had to lean on her aunt for the $85 it cost to retrieve the drugs from a Publix grocery store pharmacy near her home.

“I felt like I was irrelevant,” Ms. Alderman said, recounting the ordeal. “I felt like I didn’t matter.”

Difficulty getting care for Covid-19 has become an increasingly common problem for poor, uninsured Americans. After paying about $25 billion to health care providers over the course of the pandemic to reimburse them for vaccinating, testing and treating people without insurance, the federal government is running low on funds for Covid care for the nearly 30 million Americans who are uninsured. 


Adding to the dilemma for the uninsured, the administration is planning to allow vaccines and treatments for Covid-19 to hit the commercial market by next summer — a move that could further hinder access for those without health coverage.

The result, public health experts say, is the end of the universal access that Americans have had to Covid care during the pandemic, a rare exception in the fragmented U.S. health care system. As federal funding dries up, people without insurance may be left footing the bill for tests and treatments, or they may be discouraged from seeking care altogether. 


The problem is especially acute in states that have yet to expand Medicaid under the Affordable Care Act. Those areas, where Republicans partly or entirely control state government, tend to have a larger share of residents without health insurance than the states that have adopted the expansion.

“Because of Covid, we’ve been able to temporarily create a bright spot for care,” said Kody H. Kinsley, the top health official in North Carolina, one of the states that has not expanded Medicaid. He added, “That island is slowly vanishing.”

Michele Johnson, the executive director of the Tennessee Justice Center, a legal aid group that helps poor residents in the state, which is one of those that has not adopted the expansion, warned that people without coverage were facing a new risk of Covid-induced medical debt.

“We’re back to the old ways,” Ms. Johnson said, adding, “People are going without vitally important services, and/or they’re going into debt for the rest of their lives.”

For much of the pandemic, the federal government covered the cost of vaccinating, testing and treating the uninsured through a fund run by the Department of Health and Human Services. But that program shut down in the spring because of a lack of funding, and in September, the government stopped providing free at-home tests through the Postal Service for the same reason.

Roughly 50,000 coronavirus cases — a figure that is almost certainly a significant undercount — are being reported in the United States each day, and people without insurance can face an array of costs. Bills for tests can be large and unpredictable; some people have faced charges of more than $3,000 for the routine nasal swab. For those who become seriously ill, a hospitalization can cost more than $1 million.

Comment:

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

As we’ve written before, the COVID pandemic has revealed the hazards of our grossly inadequate insurance system. Including hundreds of thousands of excess COVID deaths.

Epidemiologists now speak of COVID settling into an “endemic” state – more predictable and manageable. Indeed, President Biden declared the pandemic over. In a sense, this is fair: major accomplishments in vaccination and therapeutics – including the highly effective drug Paxlovid – have transformed an overwhelming public health crisis into merely a serious ongoing health issue.

With this much-appreciated pivot, federal funding for special COVID support is falling. Programs to subsidize COVID care for the uninsured and under-insured are sunsetting. (Not that these protections were ever perfect, as we’ve noted.)

As a consequence, individuals infected with COVID face serious financial barriers to care: untenable choices between medical risks and financial burdens. The NY Times article elegantly describes this heart-wrenching situation.

Why do we do this to ourselves?

Oh, yes, I remember. Because there are profits to be made in preserving the scarcity of insurance and care. Because maintaining the fiction that health care can work as a market commodity enriches those who exploit the convoluted structures and rules we establish to pursue this myth.

How many decades of increasing failures of our health insurance non-system are enough?

When are the moral precept “health care is a right” and the practical insight “universal insurance saves money” sufficient to motivate doing the right thing?

When?

http://healthjusticemonitor.org…

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

Is Medicare Advantage too good to be true?

By Brenda Gazzar
Code Wack Podcast, December 5, 2022

Medicare’s 2023 enrollment period is ending on December 7 and Code WACK! is on the case! What are the true risks of choosing Medicare Advantage instead of original Medicare with a Medigap supplement? Are you risking your pocketbook, or your health? 

Both, suggests expert Dr. Ed Weisbart, a retired family physician, former chief medical officer of Express Scripts and a national board member of Physicians for a National Health Program.

“Don’t get tricked” by Medicare Advantage, he warns, because there’s a lot at stake. Why don’t our lawmakers protect us by leveling the playing field between the two Medicare programs? To find out, listen to the episode!

Transcript

Dispatcher: 911, what’s your emergency?

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

(ambulance siren)

Welcome to Code WACK!, where we shine a light on America’s callous healthcare system, how it hurts us and what we can do about it. I’m your host, Brenda Gazzar. This time on Code WACK! How are Medicare Advantage plans riskier than traditional Medicare and how are such plans affecting the shrinking Medicare trust fund? To find out, we spoke to Dr. Ed Weisbart, a retired family physician, former chief medical officer of Express Scripts, and a national board member of Physicians for a National Health Program.

Welcome back to Code WACK! Dr. Weisbart.

Weisbart: Oh, thank you Brenda. Nice to hear from you.

Q: So we’re continuing our recent discussion about the dangers of Medicare Advantage plans. How are Medicare Advantage plans riskier than traditional Medicare, both in terms of health and financial risk?

Weisbart: I like the way you asked that together because they are related. If you are given financial barriers to care, which you are under Medicare Advantage, you’re not going to get the same health outcomes. So we know that this is true for everybody in Medicare Advantage. We know that Medicare Advantage patients are significantly more likely to have cost related problems accessing care than are people in traditional Medicare who have purchased a Medicare supplement.

Overall, 19% of Medicare Advantage beneficiaries say they’ve had cost-related problems accessing care, whereas only 12% of people in traditional Medicare with a supplement say that. And that’s even more striking when you get sick. So people in poor or fair health have even more dramatic cost-related problems accessing health. It goes from 39% in people with Medicare Advantage who are in fair or poor health saying that they have cost related problems accessing healthcare to still 27% in people in traditional Medicare with a supplement. So traditional Medicare is not perfect by any means today, but in terms of personal risk financially and in terms of your health outcomes, it’s way better than Medicare Advantage is.

Q: Mmmm. Okay. If these Medicare Advantage plans are so risky, why is the government allowing them to be sold and even seeming to promote them at times?

Weisbart: The government is not just seeming to promote them <laugh>. Just last week I was watching TV and an ad came on saying, ‘hey, you know it’s open enrollment season again and there’s all sorts of new plans out there with all sorts of new benefits that you should be sure and check this stuff out’ and they didn’t mention any specific Medicare Advantage plan, but traditional Medicare hasn’t changed, but Medicare Advantage has so they were clearly talking about Medicare Advantage and I looked at the bottom of the ad I was watching on TV and it was paid for by the U.S. government – by the Health and Human Services, by Medicare, Medicare itself through our tax dollars is purchasing ad time on primetime television gently directing people from traditional Medicare into Medicare Advantage. I’ve personally never seen that before, but I saw that last week so that was eye opening.

And if you look at the Medicare book, you know everybody who is in Medicare gets one of these three-eighth inch thick books for Medicare every year talking about, you know, your options. It’s pretty hard to read through and not feel nudged towards Medicare Advantage so they’re doing that. More strategically or more importantly, I guess, the federal government is literally overpaying Medicare Advantage plans compared to what they pay for the same exact people were they in traditional Medicare. So the federal government pays Medicare Advantage plans roughly now I think it’s averaging about 4% more per year per person than that same person would’ve cost were they in traditional, original Medicare and the Medicare Advantage plans use that to promote themselves so they use that to claim that they give you eyeglasses or dentistry or some other gym club memberships. So that’s another way
 the federal government is promoting Medicare Advantage. I mean, who’s going to pick a Medicare Advantage plan because they wanted the gym club? Healthy people. You’re going to pick Medicare Advantage because of dentistry. Maybe. But the dental benefit is so limited that if you actually have a dental problem, dental insurance from Medicare Advantage isn’t worth very much and eyeglasses, they’re going to be the bottom end eyeglasses and may not really actually meet your visual needs. All of those things are designed to attract relatively healthy people, but the things that you need that are expensive, they’re not doing those very often.

Wow.

Weisbart: So why is the government encouraging that? Well, I think it comes back to the question of how troublesome democracy is these days. You know, they shouldn’t be doing that, but you know, our legislature uses the Medicare Advantage insurance company as one of their larger sources of funding for their campaigns so they’re loath to take it on.

Q: How are the government subsidies that benefit Medicare Advantage insurers plus their business practices affecting the Medicare Trust Fund?

Weisbart: It’s a terrible problem. Medicare Advantage plans are paid 4% more for the same person than traditional Medicare and so where does that money come from? You know, directly siphoning off the money from the Medicare Trust fund. So our unwillingness to address this is jeopardizing the Medicare program for all of us.

Q: Right, good point. It’s very puzzling that Medicare is a public health insurance program that by design requires people to get some kind of private health insurance to fill in gaps in coverage. Why isn’t there any public insurance coverage for these gaps? Or why doesn’t the government just eliminate them?

Weisbart: Yeah, the answer in one word, again is democracy, but you can, if you’re pretty low income and you’re on Medicare, a lot of those folks are also eligible to get Medicaid and so that’s called dual eligible. They’re eligible for both Medicare and Medicaid so depending on your state, you might be able to get public insurance to cover a lot of the problems that are in traditional Medicare. But when you retire, your employer might not be paying for a Medigap policy.

What we want Congress to do about this is to fix traditional Medicare. Given how inbred the Medicare advantage insurance companies are with Congress right now, it’s a pretty heavy lift asking them to, well I would, I would want to eliminate Medicare Advantage. It’s a pretty heavy lift for them to do that and I think there’s a lot of Americans who wouldn’t want today to see Medicare Advantage go away because they are getting a short-term better financial deal.

What should be done is just what you were talking about. Instead, they should fix traditional Medicare and that wouldn’t be that expensive, but they should eliminate the copays, they should eliminate the deductibles, they should expand the benefits in traditional Medicare to include eyeglasses and hearing aids and dentistry and all the other sort of bells and whistles that are good things to have
 If Congress just made a level playing field so that people in traditional Medicare or in Medicare Advantage had the same copays, the same deductibles, the same benefit design and had no copays and no deductibles and had the right benefit design, Medicare Advantage couldn’t begin to compete with that cuz all you’re left with then are the barriers to care. So yeah.

Q: Is anyone working on that?

Weisbart: One place to start would be to introduce an out-of-pocket maximum into traditional Medicare. So traditional Medicare has copays and deductibles, which if you’re not sick you don’t run into very much, but if you are sick, there’s literally no limit to that and that’s the key piece of protection that Medigap policies protect you with so that shouldn’t be the case. You know, there should be, you know, an affordable out-of-pocket pocket maximum as they’ve just passed with Medicare Part D in the next couple years or so, there’s going to be an out-of-pocket maximum for Part D so that if you have Medicare Part D, the drug benefit, your total exposure will be I think $2,000 per year and before they passed that a couple months ago, there was no limit <laugh>. So it’s a big deal that they’ve made that limit in Medicare Part D.

Let’s do the same thing in traditional Medicare, put in an out of pocket maximum to it. There is such a thing in Medicare Advantage and it’s many thousands of dollars, but there is a limit we should introduce, you know, at least the as good a limit, if not even a better limit as a starting point in traditional Medicare. And then of course, my point would be there shouldn’t be anything out of pocket. We know that paying out of pocket for health care dissuades you from getting important bits of health care. We know that. So we should stop doing that. We want people to be healthy and live longer.

Q: Thank you, Dr. Weisbart, what is your organization, Physicians for a National Health Program doing about these worrisome Medicare Advantage plans?

Weisbart: We’re doing everything we can. So yeah, go to PNHP.org or you know, go to Physicians for a National Health Program. We’re 25,000 I think physicians and medical students and nurses and pharmacists and some nonclinical people as well all around the country. I think we have a presence in every state and we produce a ton of the research that healthcare advocates around the country rely upon. So if you go to our website, you’ll find a wealth of information and we’ve over the last few years been turning more into an advocacy group. We’re advocating for exposing these problems and fixing it in the ways we were just talking about. So we would very much like to see a single-payer national health insurance program come in essentially by taking the problems with Medicare that exist today. We had a lot of discussion about Medigap and Medicare Advantage and part C and D and E and F and G and R.

You shouldn’t have to do any of that. You should just – you’re born, you get your Medicare card, go to the doctor, what do you want? And it stays with you, you know, till the end of your life and it should cover virtually every doctor and hospital. No copays, no deductibles. So that’s the model of one payer, single payer improved Medicare for all. And that’s the core thrust of our group Physicians for National Health Program or PNHP.org.

That’s the thrust of our group is to really educate and advocate around getting that for the United States and we see Medicare Advantage as a huge threat to accomplishing that because it takes this precious public good that the nation has built (in)1965. The country decided we don’t want people to have trouble getting to see their doctor go to the hospital and we constructed this thing called Medicare and over the last 20 years we’ve been turning it more and more over to Wall Street and venture capital and the investment community and for-profit people who are stealing the bricks and mortar from our beautiful public machinery so what we would want to see is really the country moving to a single-payer national health insurance, improving Medicare and giving that to everybody.

Q: Right. What else do you want us to know about Medicare Advantage plans?

Weisbart: Don’t be tricked <laugh>. That’s probably the most important thing is that, you know, there’s these very attractive ads on TV and, you know, countless pieces of direct mail that we’re all getting, and they don’t even necessarily say they’re Medicare Advantage, you know, they’ll just say, ‘look, you can get these extra things with Medicare. Look at the extra benefits. All you have to do is sign up here’ and you may not even know that what you’re looking at is what we’ve been talking about. You may not even know that.

So when somebody wants to give you something for nothing, they’re probably tricking you. They’re probably tricking you <laugh> and that’s the case with this. So the first thing is to, if you, if you get one of those brochures in the mail, or if you see, you know, one of the ads on TV promoting Medicare Advantage, know that you’re giving up the most precious, wonderful insurance in the entire country. You don’t want to give up traditional Medicare. It’s the only insurance I know of where you can go to almost every doctor and hospital anywhere in the country and if you buy a supplement with virtually no copays and co-insurance and no financial risk, you can just think about your health. So the one thing I would want people to really know is don’t be tricked. Don’t be deceived by Medicare Advantage plans.

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

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

Find more Code WACK! episodes on ProgressiveVoices.com and on Nurse Talk Media. You can also subscribe to Code WACK! wherever you find your podcasts.

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

https://heal-ca.org


Plenty of benefits of single-payer health care

By Winchell Dillenbeck
Times-Standard (Eureka, Calif.), December 2, 2022

My name is Winchell Dillenbeck and I am a member of Health Care for All and Physicians for a National Health Program, a nonprofit statewide organization. Our mission is dedicated to achieving universal health care through single-payer public financing. Our goal is for all California residents to have guaranteed, high-quality, comprehensive health care.

A single-payer financing system has succeeded in countries throughout the developed world. People in these countries have better health and enjoy a lifestyle free of anxiety and worry about how to pay for a health crisis. All of this is accomplished at a lower cost to the people and businesses. The cost of health care in America is twice that of Western developed nations.

Our dysfunctional health care system is damaging our economy, suffocating our business, discouraging physicians and negatively impacting on the nation’s health while remaining unaffordable for a large portion of our citizens.

The key features of a Single-Payer/Medicare for All system include:

  1. Universal coverage: Everyone, no matter their age and ethnicity, is covered for life, regardless of their employment status, income level, health condition, marital status, or immigration status.
  2. Single-payer: One public agency versus numerous insurance companies.
  3. Comprehensive care: All essential and necessary care is covered including outpatient visits, hospitalization, ER, surgery, dental, vision, hearing, prescription drugs, mental health, reproductive and home health services, substance abuse recovery, and long-term care.
  4. Choice of providers: Patients choose their doctors, health professionals, and hospitals. There are no restrictive networks.
  5. Affordability: Eliminates the profit-driven motive of insurance companies; eliminates the high cost of executives; ends the wasted spending due to administration costs that account for the first 30 cents on every dollar spent on insurance; eliminate deductibles and co-payments; and saves money by negotiating prices for services, drugs, and medical supplies. It eliminates the employer based health care system and it allows individuals to have health care coverage if they lose their job or want to change jobs. Individuals and businesses pay less for health care coverage.
  6. Seniors: Eliminates supplemental plans and out-of-pocket expenses and includes vision, dental, hearing aids, and long-term care services.

The local chapter is the backbone of the organization. We activate people at a grassroots level by helping them understand not only how single-payer will improve their lives, but also how they can help make it happen. Local chapters organize panel discussions, host single-payer movie nights, attend fairs, send speakers to groups, meet with local legislators, write letters to the editor as well as a variety of other activities.

For further information, contact Health Care for All / Physicians for a National Health Program at healthcareforallhumboldt@gmail.com.

Winchell Dillenbeck is a member of Health Care for All and Physicians for a National Health Program.

Online version: https://www.times-standard.com…

Print version: https://edition.pagesuite.com…

Voters to Politicians: We Demand Health Reform

Summary: An important story mostly overlooked in the 2022 midterms is strong voter support for health reforms in the face of politician inaction. Ballot measures that passed included regulating medical debt collection, expanding Medicaid, and demanding universal publicly administered health insurance.

Arizona’s debt collection reform–a small step towards health justice, BMJ, November 23, 2022, by Christopher Robertson, Steffie Woolhandler, and David Himmelstein

Americans are swimming in medical debt—or, more aptly, drowning in it. And, if the results of elections in Arizona on 8 November are any indication, they’re angry about it. Proposition 209, a ballot initiative on whether Arizona should place limits on debt collection for medical bills, garnered support from nearly three quarters of voters. That lopsided margin is particularly striking in a state whose government has long been controlled by Republicans and where the 2022 midterm election votes were almost evenly split between Republican and Democratic candidates.

The Arizona initiative continues the US trend of voters passing progressive health reform policies for an individual state that their Republican controlled legislatures had resisted. In the November election, for example, South Dakota became the latest jurisdiction to use a popular vote to expand Medicaid coverage for people on low incomes—following states such as Idaho, Missouri, Nebraska, and Utah. Like Arizona’s proposition 209, these votes suggest a mismatch between US politicians and many of their constituents. 


For Arizonans, proposition 209 does nothing to reduce the amount of medical debt they acquire, but it softens the consequences. The proposition’s most notable provision caps the interest rate on medical debts at 3% (or a percentage indexed to the yield on US Treasury bonds). Nonetheless, federal law allows national banks to export higher interest rates from the states where they are chartered. Consequently, if Arizonans put medical expenses on a credit card, or take on medical debt with another national lender, that debt will be unaffected by the 3% cap.

Proposition 209 includes several debt collection reforms, and these apply generally, not just to medical debt. 
 [it] protects a portion of debtors’ assets and incomes, making them “exempt” from debt collection. 


These sorts of exemptions from asset seizure and wage garnishment won’t resolve the medical debt and all its attendant problems. Even if uncollectible, the debt stays on a person’s record and thereby can continue to impinge on their health and access to credit for subsequent medical care or other needed expenses, such as housing or transportation. 


Proposition 209 does, however, make it somewhat less lucrative for healthcare providers to pursue patients for unpaid bills. 


Although proposition 209 is an important effort, these sorts of changes can’t substitute for the US implementing a simpler, more humane system of universal and robust health insurance coverage. One can imagine a world where consumer medical debt doesn’t exist—but Americans aren’t living in it.

Comment:

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

In the dozen years since the passage of the Affordable Care Act (ACA), policy wonks have applauded the shift to so-called “value based” payment. But this shift has had dire consequences: giant provider systems taking over local hospitals and physician practices, health insurer profits skyrocketing (mostly garnered from taxpayer-funded programs), and private equity marauders capturing a growing share of health care resources. Meanwhile, the number of Americans unable to afford care has surpassed pre-ACA levels.

In response, politicians have done … virtually nothing. The best that can be said is that they stopped Medicaid programs from expelling enrollees during the height of the COVID-19 pandemic, and tinkered with ACA premiums and Medicare drug costs.

When American voters have been asked whether that’s enough, they’ve answered, resoundingly, “NO” — in Red states as well as Blue. This year, Massachusetts voters in 20 districts were asked “Shall the Representative from this District be instructed to vote for legislation to create a single payer system of universal health care that provides all Massachusetts residents with comprehensive health care coverage including the freedom to choose doctors and other health care professionals, facilities, and services, and eliminates the role of insurance companies in health care by creating an insurance trust fund that is publicly administered?” Voter support was overwhelming: In Republican-dominated areas (yes, there are some in Massachusetts) as few as 55% voted to endorse that statement; in Democratic-dominated ones, as many as 87% did. Other communities across the US passed similar measures.

Now, more than ever, Americans need and want fundamental health care reforms that will assure universal, first-dollar coverage, and drive the money grubbers from the temple of medicine.

http://healthjusticemonitor.org…

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US Hospital Money Machine

Summary: US hospitals use aggressive business models (mergers, high prices, & marketing of lucrative services) to drive up revenues. For-profit hospitals benefit investors, but even not-for-profits act similarly, with huge financial rewards for participants. Single payer’s hospital global budgeting would remove these perverse incentives.

Hospital Billing Is a Crime Against American Patients, The American Prospect, November 22, 2022, by Robert Kuttner

Most hospitals in the U.S. are either for-profits, or nominal nonprofits like large teaching hospitals that behave just like for-profits. Their goal is to maximize market share, particularly for the most lucrative specialized procedures. That means they spend a great deal of capital, not just on acquisitions but on construction of new facilities (that may be redundant in many cities) and on new costly equipment.

U.S. hospitals have triple the capital costs of Europe’s hospitals. Meanwhile, every major European nation not only spends far less on health care but has much better outcomes in terms of every major health indicator.

Medicare could save taxpayers a lot of money. Why are they so timid? Because hospitals in many areas are the largest and most politically powerful local employers, even more so when they are teaching hospitals connected to universities.

One of the many regulatory failures of antitrust in the U.S. is the nearly complete failure to challenge hospital mergers and acquisitions, which have created monopoly power and degraded services in city after city. Even worse, many of these merger binges are by hospital systems that are nominal nonprofits.

There is no direct price regulation in the U.S., so hospitals are free to charge what they think the market will bear.

Hospitals also overuse specialists, who can bill at higher rates.

Executive pay is also exorbitant.

A variety of market-friendly techniques were devised to contain costs. Hospitals proved expert at gaming all of them.

Until recently, advocates of single-payer health care have focused on comprehensive coverage but less so on the abuses of profit-maximizing medicine. If we went to Medicare for All but did not reform these billing practices and did not end the system of profit-maximizing medicine entirely, these excess costs would simply be piled onto taxpayers.

Rep. Pramila Jayapal’s current Medicare for All bill does best at addressing these abuses, and Bernie Sanders’s latest version is more attuned to them than his earlier bills.

Under Jayapal’s bill, co-sponsored by about half of the House Democratic caucus, the system would keep some elements of fee-for-service medicine and diagnosis-related coding, but hospitals would operate under “global” budgets. That is, they would receive an annual flat sum from the government that would be adjusted regularly to reflect caseloads. Medical education—one of the ways that teaching hospitals pad bills—would be its own separate budget item. Capital outlays and staffing ratios would be regulated. Incentive compensation aimed at gaming the system would be prohibited. There would be much greater emphasis on primary care.

This legislation, which merely reflects common practices in most European nations, is at the outer fringe of what is even debated in the U.S. It is a reminder of how inefficient as well as unjust is market-led medicine, and how incremental reforms can never repair our broken health system.

Comment:

By Don McCanne, M.D.

Although we have the most expensive health care system in the world, it performs very poorly by international standards. We have far too many who are uninsured or underinsured and thus suffer financial hardship, and our system has too many features designed to direct health care dollars to the wealthy rather than to the patients where the need is so great. This article by Robert Kuttner demonstrates that another defect is in one of the most basic elements of our health care system: our hospitals!

Hospitals have not escaped much of the fragmented and dysfunctional design defects that characterize our health care system. As a glaring example, our nominally nonprofit hospitals, which should be dedicated to providing health care to the most needy, frequently engage in activities that make the rich (e.g., prodigiously paid CEOs and procedural specialists) richer as unmet community care needs should make us cry out for universal insurance.

Yet where are our reform activities directed? Our current government, which is supposedly more progressive than the alternative, has been busy converting our public Medicare program into private insurance plans, via heavily marketed but optional Medicare Advantage and now involuntary Direct Contracting through the REACH program. Meantime, ownership of the actual health delivery system is passing to private investors through private equity and other innovative business constructs designed to siphon off the massive pool of health care dollars that we have but are not using in the high performance system that our nation deserves.

What is wrong with us? For decades we have known that a well-designed single payer system, using an improved version of Medicare, would serve all of us well. As we have stalled and deferred, allowing inadequate, dysfunctional, incremental measures to substitute for reform, we have allowed our health care system to feed the injustice of wealth inequities such that we now have a much greater legislative problem than merely establishing a universal public health insurance program.

That makes it all the more urgent to act now. The shift of wealth to the top is a rapidly accelerating process. We are not talking about some vague population in the future. We are talking about our grandchildren and even our children. Look around at the medical needs that our aging friends face. How can we be so callous as to not ensure that those needs will be met for all of us in the future. Now is when we have to act! Dammit, now!

http://healthjusticemonitor.org…

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Corporations Are Thankful for US Health Care

Summary: UnitedHealth proposes a $13 billion acquisition of other insurers’ billing data, which they swear they won’t use for business purposes. Hospitals farm out unpaid patient bills to high interest lenders owned by private equity firms and banks. Once again, untrammeled profit-seeking hurts patients.

What Will UnitedHealth’s New Trove of Claims Data Mean for Consumers?, ProPublica, November 16, 2022, by Cezary Podkul

Data from Change [a medical claims processing company] could yield “improved medical policy and benefit design” for UnitedHealthcare, the UnitedHealth deal team wrote in a memo. The data could also help UnitedHealthcare track the pricing of medical procedures and expand insurance underwriting. There was just one problem: Using Change’s data in some of these ways could raise “antitrust concerns,” according to an internal UnitedHealth document. 


UnitedHealth announced plans in January 2021 to buy Change for $13 billion. 


[At antitrust trial, the judge accepted] UnitedHealth’s claims that the company would never do such a thing. 


“it’s clear that they are finding ways to use data to make money,” Prof. Fuse Brown said. That applies to the Change Healthcare deal, she said: “You have to wonder: What is the value proposition? Why is United spending so much money to buy this company?”


Wall Street seems to have viewed UnitedHealth’s recent ambitions through that prism. Since the merger was first announced on Jan. 6, 2021, UnitedHealth’s stock has far outpaced the broader stock market, rising 46% vs. 17% for the health care sector and 7% for the S&P 500. JPMorgan Chase analysts predicted in a research note that insights from Change’s data will benefit UnitedHealth’s insurance arm as well as Optum’s other customers. Analysts at Deutsche Bank 
 called UnitedHealth’s courtroom victory a “positive leading indicator” for more consolidation in the health care sector.

How Banks and Private Equity Cash In When Patients Can’t Pay Their Medical Bills, KHN, November 17, 2022, by Noam N. Levey and Aneri Pattani

Patients at North Carolina-based Atrium Health get what looks like an enticing pitch when they go to the nonprofit hospital system’s website: a payment plan from lender AccessOne. The plans offer “easy ways to make monthly payments” on medical bills, the website says. You don’t need good credit to get a loan. Everyone is approved. Nothing is reported to credit agencies
.

As Americans are overwhelmed with medical bills, patient financing is now a multibillion-dollar business, with private equity and big banks lined up to cash in when patients and their families can’t pay for care. By one estimate from research firm IBISWorld, profit margins top 29% in the patient financing industry, seven times what is considered a solid hospital margin. 


Patients enrolled in a CareCredit card from Synchrony, the nation’s leading medical lender, face a nearly 27% interest rate if they fail to pay off their loan during a zero-interest promotional period. The high rate hits about 1 in 5 borrowers, according to the company
.

In February 2020, records show, just 9% of UNC patients in an AccessOne plan were in a loan with the highest interest rate of 13%. Two years later, 46% were in such a plan. Overall, at any given time more than 100,000 UNC Health patients finance through AccessOne.

Comment:

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

As I sit at my son’s house in Colorado, sated by a delicious Thanksgiving feast, I’m extremely thankful for a loving and healthy family, and the recent improvement in US political prospects.

The health news that caught my attention elicited a more ambivalent thought: US healthcare is a playground for corporations, rife with opportunities to exercise business prowess – often at the expense of beneficiaries.

What should a health care system do? IMO: offer easy access to high quality care, with no financial barriers or burdens. Profits must not displace care. We are, of course, falling far short of this ideal. The news provides two clear examples.

UnitedHealth – the largest private insurer, with 15% of the national market – is trying to purchase the company that handles billing (claims processing) for many insurers. Why would they spend $13 billion for this? Company analysts told the CEO that they could use the claims data to track provider prices and strengthen underwriting (predicting medical “losses”). This raised anti-trust concerns and led to a trial, in which UH promised not to do the very actions used to justify the acquisition. They won; the government is appealing.

What’s lost in these deliberations is that the aim of anti-trust regulation – helping consumers – is futile when the very fact of a for-profit insurance industry results in severe harm to patients.

The other story is about hospital tactics to offload management of patient debt onto credit companies owned by private equity firms. One large company structures interest rates to offer 0% for debtors paying the highest amounts most consistently, and 13% for those who can’t accomplish that. Which means that the least financially able pay extra by one-third, $2,500 in interest on top of a $7,000 original debt. Some lenders charge more than 25% if payments are missed. This loansharking (that’s what it is) exacerbates the underlying problem of pervasive medical debt. And the care credit business generates 29% profits.

I’ll reserve my deepest thanks for the day that the US follows the example of dozens of other countries which provide universal comprehensive care with no profit-taking, saving money and lives.

http://healthjusticemonitor.org…

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Healthcare and Labor advocates demand Cigna put Care Over Cost and cover critical treatment

Health care and Labor advocates deliver more than 3,000 petition signatures demanding Cigna live up to its promise

By Tim Rowden
St. Louis / Southern Illinois Labor Tribune, November 21, 2022

Dozens of health care and Labor advocates – including representative from Painters District Council 58 and Operating Engineers Local 148 – jammed the sidewalk surrounding Bemiston Tower in Clayton, Mo., Nov. 11 to launch of Missouri Jobs with Justice’s Care Over Cost initiative connecting health care policy holders stiffed by their insurance companies to demand private insurers provide the coverage they promised.

Bemiston Tower allegedly houses Cigna insurance’s St. Louis office. It’s hard to say for certain, however, as aggrieved policyholders and advocates were prevented from entering the building to deliver more than 3,000 petition signatures demanding they cover Springfield, Mo. resident Mark Hall’s ulcerative colitis medication.

Cigna is not alone among private insurance companies prioritizing profit over coverage for necessary health care expenses.

St. Louis

Andre Smith, a St. Louis resident and student at Rockhurst University, shared his story of facing crippling debt after receiving a surprise $15,000 bill from Blue Cross Blue Shield (BCBS) of Kansas City.

“Health insurance companies rake in billions of dollars of profits off our premiums and then turn around and deny services and medication to their customers” said Smith. “I know as an individual, I am powerless to stop them – BCBS has shown me that by ignoring my pleas.

“When I enrolled at Rockhurst in the fall of 2021, I got access to health insurance with Blue Cross Blue Shield, something I was very thankful for, but also a requirement to attend the institution. I assumed with insurance I could get access to the care that I needed. Isn’t that the entire point? But sadly, at 19 years old, I learned that that is not what health insurance companies do. Instead of helping me when I became sick, I was stuck with an over $15,000 surprise bill I cannot afford just for trying to use the insurance. Fifteen-thousand-dollars for a 19-year-old college student is a life-crippling amount of debt.”

Smith learned about the Care Over Cost campaign of Missouri Jobs with Justice and was on hand Nov. 11 for its launch.

The Jobs with Justice Care Over Cost initiative seeks to connect people like Smith and Hall and build a movement that demands insurance companies prioritize care over profits.

After months of trying to reach BCBS, Smith spoke last month as part of a national Care Over Cost event.

“Right after I spoke, they reached out to me and I am hopeful they will finally agree to cover the services I was provided while I was insured with them.”

Springfield

In Springfield, advocates stood in solidarity with Mark Hall and his wife Callie Gibson as the couple shared just a bit of their healthcare story – and the ongoing struggle of fighting Cigna to simply cover the care Mark needs to manage his chronic illness.

“I was diagnosed with ulcerative colitis when I was 20. Essentially my digestive tract gets inflamed, which causes sores and bleeding from top to bottom,” said Hall. “After months and months of working with my care team, I found a treatment that worked – and worked well for more than a decade – my last colonoscopy indicated I was in remission.

“Last summer, my employer-provided health insurance communicated that my medication was no longer the preferred drug and that I’d be switched. My doctor appealed this decision, but was denied. We began the new drug regimen, and my symptoms returned within four weeks.”

“Mark has been paying into Cigna for more than three years and is being denied the medication that we know works,” said Mark’s wife, Callie Gibson. “We spend MULTIPLE hours on the phone with the hospital and the insurance company EVERY WEEK – which we shouldn’t have to do.

“We’re sharing our story now because this is not how healthcare should work – and not how people should be treated. Cigna made BILLIONS of dollars last year – and this year – in part by making sure people don’t know what their options are, denying care, countering doctors’ orders, all the while we all get sicker, and the bills pile up.”

‘Good health insurance’

“Many of us think we are protected by ‘good health insurance.’ We only learn how companies win and patients lose once we become ill,” said Dr. Judith Dasovich, MD, FACP.

“As Mark Hall’s situation illustrates, private insurance companies are not prioritizing care. What are they prioritizing? Profit. In 2021, Cigna made $5.4 billion in profit. In the first nine months of 2022, they made $5.5 billion, more than all of 2021.”

‘Mad as hell’

“Most doctors I know are like me,” said Dr. Ed Weisbart, a family physician, chair of the Missouri chapter of Physicians for a National Health Program and former Chief Medical Officer for Express Scripts before it was purchased by Cigna. “We love helping our patients, but we are mad as hell that they have to go through this again and again and again.

“Think about it – Mark and his employer are paying Cigna to not give him the medication he needs to be healthy. That may be a great deal for Cigna and its investors, but it’s morally reprehensible, infuriating, and often deadly.”

https://labortribune.com…