PNHP

Universal healthcare as pandemic preparedness

Universal healthcare as pandemic preparedness

The lives and costs that could have been saved during the COVID-19 pandemic

By Alison P. Galvani, Abhishek Pandey, Pratha Sah, Kenneth Colón, Gerald Friedman, Travis Campbell, James G. Kahn, Burton H. Singer, and Meagan C. Fitzpatrick
PNAS (Proceedings of the National Academy of Sciences), June 13, 2022

Significance

The fragmented and inefficient healthcare system in the United States leads to many preventable deaths and unnecessary costs every year. Universal healthcare could have alleviated the mortality caused by a confluence of negative COVID-related factors. Incorporating the demography of the uninsured with age-specific COVID-19 and nonpandemic mortality, we estimated that a single-payer universal healthcare system would have saved 212,000 lives in 2020 alone. We also calculated that US$105.6 billion of medical expenses associated with COVID-19 hospitalization could have been averted by a Medicare for All system.

Abstract

The fragmented and inefficient healthcare system in the United States leads to many preventable deaths and unnecessary costs every year. During a pandemic, the lives saved and economic benefits of a single-payer universal healthcare system relative to the status quo would be even greater. For Americans who are uninsured and underinsured, financial barriers to COVID-19 care delayed diagnosis and exacerbated transmission. Concurrently, deaths beyond COVID-19 accrued from the background rate of uninsurance. Universal healthcare would alleviate the mortality caused by the confluence of these factors. To evaluate the repercussions of incomplete insurance coverage in 2020, we calculated the elevated mortality attributable to the loss of employer-sponsored insurance and to background rates of uninsurance, summing with the increased COVID-19 mortality due to low insurance coverage. Incorporating the demography of the uninsured with age-specific COVID-19 and nonpandemic mortality, we estimated that a single-payer universal healthcare system would have saved about 212,000 lives in 2020 alone. We also calculated that US$105.6 billion of medical expenses associated with COVID-19 hospitalization could have been averted by a single-payer universal healthcare system over the course of the pandemic. These economic benefits are in addition to US$438 billion expected to be saved by single-payer universal healthcare during a nonpandemic year.

full study:
https://www.pnas.org…

House of Representatives Public Hearings Done Right

Summary: This week the US Congress televised an extremely compelling hearing on the January 2021 Capitol riot and coup attempt. It may nudge our country toward re-asserting democracy. We need something similarly powerful for single payer.

January 6 hearings: Watch first public House committee hearing on Capitol attack, Streamed live on June 9, 2022, USA TODAY

Stephen’s LIVE MONOLOGUE After The January 6th Committee Primetime Hearing, The Late Show with Stephen Colbert, June 9, 2022

Comment:

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

We saw on Thursday how to effectively address a major political issue using public hearings in the US House of Representatives. The topic was, of course, the Jan 6, 2021 attack on the Capitol, engineered by the then President to try to reverse his November 2020 electoral defeat. The future of US democracy is at stake. The hearings combined new information, insider debunking of the election fraud narrative, forceful oratory and affecting video footage, and testimony (both live and recorded) to powerfully advance truth and the integrity of our governance system. You can watch the full two hours, or Stephen Colbert’s excellent 10-minute summary.

The House learned well from special counsel Robert Mueller’s halting and ineffective 2019 testimony about his team’s investigation into Russia’s interference in the 2016 elections. In pleasing contrast, this week’s event was properly and professionally handled as a critical opportunity to persuade the American people. Compelling revelations were delivered using equally compelling production values. It was a spectacle suited to the critically important issue.

How would a similar spectacle look for single payer?

Here are a few ideas. (Disclaimer: I’m definitely not a TV producer. I hereby invite a real TV producer to jump in and take over.)

  • Frame as a truly critical issue for our country. Shouldn’t be too hard: our health is suffering, with longevity falling, and our financial security is constantly at risk.
  • Persuasive orators. Bernie comes to mind. And Pramila Jayapal.
  • Whistleblowers, revealing the truth of the inside game. Wendell Potter would be a fine choice.
  • Startling revelations. Perhaps the 100,000 or so who die annually from being un- or under-insured. Not a new fact, but new to the public.
  • Compelling witnesses revealing the system’s harm. How about a few of the many thousands who went medically bankrupt?
  • A clear villain. Could be the health insurance CEOs making tens of millions of dollars by denying access to care.
  • Individuals from the political center or right who speak truths about our health care problems. Like business owners who struggle to insure their employees.
  • Exciting video. Perhaps an anguished family who recently lost a loved one due to financial barriers to care. Or the National Mall packed with hundreds of thousands of doctors in white coats, demanding health care justice.

Let’s elevate single payer to a prime-time national event and reveal the truth behind our inexcusable, deadly, and undemocratic health care system.

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.

Private Equity Targets Gastroenterology & Lots More in Medicine

Summary: Private equity inroads to clinical practices are both targeted (to especially lucrative activities) and far-reaching (with so many profitable deals to make). However, ethical standards for clinical care and private equity sharply diverge, and this poses serious moral dilemmas for American medicine. We need health care reform in two realms: financing and ownership.

Betting on ‘golden age’ of colonoscopies, investors buy up gastroenterology practices, Fortune, May 27, 2022, by Emily Pisacreta, Emmarie Huetteman, and Kaiser Health News

Private equity, known for making a profit on quick-turnaround investments in struggling businesses across many industries, has taken an increasingly active interest in health care in the past decade. It has invested in gastroenterology practices in recent years to tap into the revenue potential in meeting growing demand.

Tired of having to manage the increasingly complicated business of running a practice and, often, lured by the sweet deals investors offer, more and more doctors have partnered with or even sold their practices to private equity funds. So investment managers now control the financial decisions for many medical offices caring for patients with digestive ailments. With profit the primary driver, patients may find they pay much more for the same—or less—care.

Doctors think, “If I’m going to survive, then I will either have to sell myself to the hospital or, what is the alternative? The alternative is private equity.”

Your Money and Your Life: Private Equity Blasts Ethical Boundaries of American Medicine, Interview of Laura Katz Olson, author of “Ethically Challenged,” Institute for New Economic Thinking, May 18, 2022, by Lynn Parramore

Lynn Parramore: Does private equity belong in medicine at all? Should it be banned?

Laura Katz Olson: This is something I didn’t put in my book, but the conclusion I have come to is yes, we have to ban it. We really need to prohibit, I think, the corporate practice of medicine, period. If you look at the private equity playbook, its only goal is to make outsized profits – they can’t make ordinary profits. If they make ordinary, respectable profits, their investors will go somewhere else because of the risk.

Private equity doesn’t care whether the product is Roto-Rooter or hospice. That’s one of the major differences between PE and a regular company, which may care about the community, the reputation of the company, and the quality of the product. They want to keep their customers. They care about the future. But private equity doesn’t work like that. Because private equity often aims to sell a company after four or five months, they don’t care about the future. They don’t care about the product at all. Private equity is antithetical to our health care system.

So yes, we need to ban private equity from health care. But given that it’s not going to happen, I would say that we need to prohibit the corporate practice of medicine – anybody can make a case for that. You can eliminate their tax advantages. You can limit the debt imposed on companies, especially in the health sector. You could easily control consolidation and monopolies in the health sector. You could use specific anti-trust laws. I would definitely forbid investment by retail customers such as their 401(k)s.

Comment:

By Don McCanne, M.D.

Our very expensive health care system, which should be serving everyone well, is not. There are two particularly important reasons why not. One is our dysfunctional, fragmented health insurance system that leaves so many under-insured or completely uninsured. The other is the increasing shift of wealth to the top, especially enabled by private equity which increasingly is moving health care dollars away from health care and into the creation of personal wealth.

The financing of health care would easily be remedied by the establishment of a bona fide single payer system as described recently in HJM, if we could only negotiate the political barriers.

In an age when “billionaire” has become a commonplace term as deficient wages, homelessness, food insecurity, and other forms of poverty surround us, it is clear that we need to adopt new economic tools to make socioeconomic adjustments that are more equitable. In health care that means doing something about private equity that is moving funds away from health care for the masses and into the coffers of the wealthy.

What about the physician, say a gastroenterologist? When he has built a practice and is ready to retire, should he be able to accept a generous offer from private equity that essentially removes these funds from the health system and the benefit of patients? Or should he be limited to selling his practice to another physician or physician group? For that matter, should he be allowed to sell to a private equity firm and accept a limited partnership thereby drawing off profits that would otherwise go to patient care (if the general partner doesn’t skim off the funds first)? Or should he be able to choose the option of having the private equity firm take over the business management while enjoying the pleasure of practicing pure medicine as he was trained to do (an option that likely would be regretted since private equity managers have mastered how to convert such opportunities into much greater profits for themselves). (Public ownership is another option, but that is a discussion reserved for another day.)

You can see that a significant potential problem is that physicians might be opposed to government control or elimination of private equity if that would remove business options for them while not being convinced, in spite of the overwhelming evidence, of the detrimental effect on their patients.

The HJM on private equity posted last week, based on Laura Katz Olson’s book, “Ethically Challenged,” really made it clear that private equity should have no place in medicine, as she clarifies in the Q & A above. If the private option is eliminated, and the physician is faced with only morally justified choices, what option does he have then?

So the solution to the two problems mentioned is clear: eliminate private equity and establish a bona fide single payer financing system. Though the solution is clear, politics are a challenge. Let’s work hard on meeting that challenge now, immediately, before any more damage is done.

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.

Trump wanted to privatize Medicare. Biden’s letting it happen.

The Trump administration initiated a program that critics say will pave the way for the total privatization of Medicare. Biden is quietly letting that program continue.

Interview with Branko Marcetic
The Real News Network, The Marc Steiner Show, June 9, 2022

Donald Trump claimed to be a supporter of Medicare, yet his administration took numerous steps to cut its budget and introduce schemes to privatize it, including the Direct Contracting Entity (DCE) program, also known as ACO REACH. Rather than overturn this program, President Biden and his administration have been quietly letting it continue. As Branko Marcetic recently wrote in Jacobin magazine, “ACO REACH’s continued existence is a serious looming threat to Medicare as we know it and to seniors themselves. And in a sadly typical trend, it’s a Democratic president who’s trying to get away with gutting Medicare, something a Republican could never hope to get away with.” In the latest installment of The Marc Steiner Show, Marc talks with Marcetic about his recent Jacobin piece, the corporate-serving “logic” behind the push to privatize Medicare, and about the grassroots effort to fight against it.

Transcript

Marc Steiner: Welcome to The Marc Steiner Show here on The Real News. I’m Marc Steiner, and it’s great to have you all with us. In the midst of the madness of mass murders in our schools and the war in Ukraine, a lot of stuff that could really affect our lives is sliding under the radar. To wit, the future of your, our, Medicare benefits could all morph into a privatized thing, what we know now is the past. Trump was working on privatizing Medicare when he slinked through the White House. Now President Biden is, at best, not doing anything to stop it. Look I’m on Medicare, and it doesn’t really cover much of anything sometimes. Not dental care, hearing aids, eye exams, eyeglasses, home healthcare. I mean, all the things that older people need. You can get some of them, but you have to buy private supplemental health insurance that could cost thousands of dollars a year.

Now, what Trump began, Biden is allowing to take hold. Giving more services over to so-called accountable care organizations, letting private companies decide what coverage you can use. Recently, Seattle City Council and even the conservative Arizona AMA, the American Medical Association, said, no, this is a disaster. Why is this happening? Where are the movements to stop it and fight for real Medicare? What could the future hold? We turn to writer and activist Branko Marcetic. Who is a Jacobin staff writer, author of Yesterday’s Man: The Case Against Joe Biden, lives in Chicago. And the article that came to our attention that was in Jacobin and Portside was “Biden’s Little Publicized Medicare Privatization Scheme is Starting to Raise Alarm Bells.” And Branko, welcome back. Good to have you with us.

Branko Marcetic: Thank you very much for having me.

Marc Steiner: So let’s talk a bit about what’s happening here. I mean, take a step backwards for just a moment. I mean, Medicare that was created in, I think if I have the date right, July 30, 1965 under Lyndon Baines Johnson, was really much heralded. It was going to take care of the healthcare needs of people over 65. And we hear all of the talk about how it’s insolvent; We can’t afford it; It has to go to private healthcare; It can’t do the job right. So let’s talk about that political dynamic, the economic dynamic, the power dynamic that is causing the crisis that we’re facing.

Branko Marcetic: Well, it’s a great and tragic irony, really, because Joe Biden was elected and swept into power on this kind of Rooseveltian vision. We heard all this talk about the second coming of the New Deal. Well at least, the Great Society, and of course, Medicare is one of the great legacies of the Great Society. And yet, not only is Biden’s agenda when it came to expanding Medicare and expanding the role of government in people’s lives to guarantee the economic security dead in the water now, but in fact, through this very little known program, what already exists, the Medicare system that is already very limited, is now quite under threat. And critics of this program, of this ACO REACH program, as it’s now known, warned that this is basically the first tip to ultimately privatizing the entire thing.

And I can tell you a little bit about why this particular program is so, I think, pernicious and underhanded, really. We all know about Medicare Advantage. It was set up in the ’80s as a way to give the private sector more of a role in the program. So basically chip away at the original vision of Medicare, which of course is meant to be a publicly-owned, publicly-controlled health insurance system. But the thing with Medicare Advantage at the very least is that you choose to be on it. You can choose whether you want traditional Medicare or whether you want to go for one of these private plans. With this ACO REACH model, which at the moment is a pilot project, but CMS, The Center for Medicare and Medicaid Services, has outright said they want everyone on Medicare to move to it by 2030. This ACO REACH model does not even give you that choice.

Seniors just go to their letterbox one day, they see a letter there, and it tells them, don’t panic, don’t worry. You’re being moved into this ACO REACH pilot program. Nothing’s going to change. In fact, if anything changes, it’s going to be for the better. You’re going to have better care. And you don’t have to do anything. And so what this is is it’s targeting people who have explicitly chosen not to go for Medicare Advantage. And it’s basically putting them in a Medicare Advantage style system where Medicare ends up paying a third party, a private equity-backed company or a health insurance-backed company, which then basically administers and decides what kind of care you’re going to get. And has incentives, obviously, to make money. And again, this is completely without their consent. And so you can see why people are saying this is one major step toward a goal of ultimately privatizing the entire thing.

Marc Steiner: So when I read your article and was reading other pieces on this and thinking about Medicare, the reality is if you don’t have Medicare Advantage, let’s say if you’re on Medicare and you don’t pay for that extra. There’s two extra things for it. Dental care, eye care, whatever else that you have. You have to pick a plan out of a plethora of plans that you pay anywhere from $100 to $300 a month for. But if you didn’t do that, Medicare would cover nothing that you really need in the long run. So it’s interesting to me that the battle around Medicare is no longer about expanding Medicare or expanding what coverage it is, it’s about how you turn it over to private insurance. There’s a dynamic here going on in terms of the power of insurance companies that are really kind of pushing this agenda.

Branko Marcetic: Well as some of the people I spoke to for these various pieces I’ve written on this topic have said, the idea is that of course the private sector wants its hooks into whatever it can to make money. Of course the federal government has essentially unlimited money in the United States. And you see this huge pot of money that, essentially, Medicare controls. And naturally, if you’re someone who is profit driven, you want a piece of that. Medicare Advantage is one thing, but the overall Medicare spending, that’s the real prize. And so this is the way that I guess both the private sector and those parts of the federal government that it’s managed to capture have figured out a way to try and insert themselves into what should be just a publicly administered program.

And the idea is this is meant to be a cost saving efficiency. That’s the argument, of course. We’ve heard that so many times, that businesses, the private sector, they’re always more efficient. They know what they’re doing. They’re going to be able to save you costs and all that. But that’s not the reality. Number one, usually when you try and make something more efficient, you don’t end up putting a middleman in. You end up cutting the middleman out.

Marc Steiner: Right.

Branko Marcetic: In this case, there’s a middleman being unnecessarily inserted between people’s Medicare coverage and themselves. Second of all, Medicare Advantage does not show that there’s any cost efficiency. I think there was a report some years back that showed that actually the amount of overpayment in Medicare Advantage plans was something like over $100 billion over –

Marc Steiner: Over payments to provide.

Branko Marcetic: Yeah. And it’s because, as any good businessman will tell you, and as anyone who is a lover of the free market will tell you, what is it that businesses exist to do? They exist to maximize their profits. To make as much money as possible. And so of course, as we’ve seen with Medicare Advantage, what these companies end up doing, these third party companies, is they do things like, it’s called upcoding. And so they make a patient seem sicker than they are, because that way they get overpaid by Medicare. And then when they don’t end up spending all that money, they pocket what hasn’t been spent as a profit for themselves. Or they deny people care. That if it’s too expensive, then they’re just not going to do it. Or they say, well, you’re going to have to shoulder more of this cost burden because this procedure is so expensive. And there’s a real risk that’s going to happen basically as all these seniors get dumped onto this ACO REACH program.

Marc Steiner: So I’m curious what you think about, what your analysis is of the political end of this. I mean, clearly there are people in Congress and around the country, the members of the progressive caucus. I think 50 people signed the petition to Biden to end this, to end this Trump plan. He refused to do it. He has, well, he’s not done it. And it’s going to run through the end of his term. And so, I mean this, what’s happening here could actually really open the door to erode Medicare and create a private system taking over. So what is your analysis of A, what’s the political dynamic that allowed this to happen? Who are the forces that were around Trump in the beginning and others now around Biden who are allowing this to happen? And what are the forces to stop it?

Branko Marcetic: Well with Trump, we all know that the administration was rampantly corrupt. And of course it was a feeding frenzy for the corporate sector. Trump appointed people who were the most rapacious, private profiteers into the exact government departments and agencies that would’ve been overseeing the sector they were working in. And of course in this case, the person he appointed that designed this program was very much… He designed the program with the company that he had been working for before he entered the administration in mind.

Marc Steiner: And who was that?

Branko Marcetic: And they actually contracted with a company, this was an Intercept report. They contracted with a company that was set to benefit from this program to actually staff, basically the agency that was making it. Since then, yeah, you would think the Democrats would want to protect one of the greatest legacies that their party had created. However, number one, unfortunately, the Democrats are just captured by the corporate sector, as the Republicans are. Maybe not quite as in your face and obviously, but Biden took a lot of money from pharmaceuticals, health insurers, health insurance executives over the course of his campaign.

Beyond that, he’s put in people. I mean, Liz Fowler, who is sort of overseeing this ACO REACH or direct contracting program, as it used to be called. She herself has a background in private health insurance and pharmaceuticals. In fact, the company she used to work for, Anthem, they’re one of the… They’re an ACO, they’re an accountable care organization, so.

Marc Steiner: Right.

Branko Marcetic: So that’s number one, that’s sort of number two. I mean the last thing is that no one knows about this. This is why it’s been allowed to go on. It’s just quietly happening, and it’s been a real struggle for the people who are on the front lines trying to prevent this and trying to raise the alarm about it. The biggest fight has just been to let people know it’s happening so that they can get sufficiently outraged and worried and get in touch with their elected representatives and tell them to stop it. And it’s been a real uphill battle. And unfortunately the Biden administration may face some pushback.

And what they did was they basically acted along the lines of exactly what the industry had requested in a letter. And they simply just rebranded the program and made a few cosmetic changes. But they rebranded basically to take the toxicity of that first name, the first label Direct Contracting. That became too unpopular, that became associated with something that people didn’t want. So you know what, we’ll just change it. Now it’s called ACO REACH, and that’s done and dusted. We can just keep going forward with it. So they’re trying to avoid the growing, I think, public and political opposition to this.

Marc Steiner: Well, what’s so insidious about this to me, in part, is that the guy, the person you were alluding to a moment ago, Adam Boehler, I think his name was. B-O-E-H-L-E-R, Adam Boehler, who was a best friend of Jared Kushner, the son-in-law, founded this thing called Landmark Health. And he’s the one who created this program for Trump. So it’s literally what you were saying. The private industry is coming in to create a program for his own benefit that screws us.

Branko Marcetic: Yeah, exactly. And I mean it’s, again, this will be a very simple thing to just end the pilot program.

Marc Steiner: Right. So the question becomes, politically, why isn’t he just ending it? Saying, no, we’re not going to do this. I mean, he knows where it comes from. Biden’s not a dummy. You know what I’m saying? He knows who founded this and who it’s benefiting. What do you think the dynamic is here?

Branko Marcetic: I mean again, I think part of it is the corporate capture that does reign in both parties. I think part of it is there is a large faction of the Democratic Party, the sort of party elite. The people that they tend to put in some of these roles, these government roles, who genuinely do seem to believe that the private sector is the answer to everything. But what was actually quite remarkable is one of the people I spoke to, one of the activists who was fighting against this, told me months ago, when they finally won a meeting with Liz Fowler to express their concerns, she said that Liz Fowler told them, look, we agree with you. If we were starting from scratch, we would go with a single payer system. But we’re not starting from scratch and so we’re not going to do that. [Marc laughs]

Which shows you – Yeah, pretty remarkable, right? I mean that suggests that they are aware that, obviously, a Medicare for all system, a government-run health insurance system that takes the provision of health out of for-profit hands, decommodifies it, and makes it a public good. They do understand some level that is the better way to go. But whether it’s corruption or whether it’s just some sort of ideological rigidity, I don’t know. They are just going along with this attempt to try and basically privatize this system.

Marc Steiner: Not to digress on this too much because of your time on the air, but I can’t help but think. I’ve been doing this series that we’re going to push even harder called The Rise of the Right, with Bill Fletcher Jr. And I keep thinking to myself, when I read your article and started doing research on some of things you’ve been writing, other people have been writing and what’s behind all this. It just strikes me that people actually campaigned and fought around this issue and told the truth through media, organizing, community groups, whatever. That this is a way to undercut the right wing. Because people are saying, what? You’re going to take away my Medicare? You’re going to do what? Do you know what I’m saying? I mean it’s just like it’s right there. I mean it’s clear cut that they’re allowing private industry to come rip us off.

Branko Marcetic: Yeah. I mean it’s completely mind boggling. And one of the other remarkable things is that in this meeting with Liz Fowler, she told these activists that you can’t opt out of this. Once you have been randomly selected to be in this pilot project, that’s it, you have to be. You can’t get out of it, except unless you change doctors. Because that’s how it works. The doctors get enrolled in the ACO REACH. So if you happen to have a doctor who has been enrolled there, you, by virtue of that, are also in. So you have to swap doctors to get out. Which, number one, if you’re in a rural area, is very difficult. Number two, when you have spent your entire life or years, decades, seeing the same doctor, particularly if you’re an elderly person, that’s not a small thing to just suddenly change doctors.

There’s a large degree of trust in that relationship. You rely on that person. It’s not that simple to just willy nilly swap and go with someone else. And we might think back to how outraged people were in 2009, 2010. What was the big attack against Obamacare? Which wasn’t really true, but this was the right-wing attack, was that Obamacare was going to make you lose your doctor. And people were very angry, quite understandably. And yet now the Biden administration is pursuing a policy that effectively tells people, hey, you either have to be enrolled in a semi-privatized system that you explicitly chose not to be, or you have to change doctors. And incredibly, I can’t think of something more politically unpopular and unpalatable to give to the voting public. And yet that is what they’re going for. So even on a political level, this does not make any sense to me.

Marc Steiner: So in your analyzing what’s going on and talking to people around the country and talking to advocates around the country in the pieces you’ve been writing, where do you see this opposition coming from? What kind of organized effort do you think is going to stand up and fight this? I mean when you’ve got… I think you wrote about the entire City Council of Seattle, and even the conservative AMA in Arizona. That’s what blew my mind, that they’re saying, no, this is a bad idea. And they don’t like single payer. So where do you see the opposition coming from, and how do you see this playing out?

Branko Marcetic: Well, number one, there is a huge collection of grassroots activists. They’re being led by the Physicians for National Healthcare Program, PNHP. They have really been fighting for this and fighting to not just raise awareness among people, but also to brief Congress people and to get Congress to state their opposition and to stand against this. They’ve got a, I think thousands of people, tens of thousands of healthcare professionals around the country who have signed petitions saying, we’re not for this. So there’s the activists who are trying to do that. The Seattle City Council and the Arizona Medical Association, those are key examples too because it shows that this issue is slowly filtering out into wider consciousness.

No one knew about this. I didn’t know about this until very late. Even though PNHP was working throughout all of 2021 to try and get people to oppose this. So it’s only slowly coming out and being made aware to people. And I think the fact that the Seattle City Council passed… And the person who introduced the resolution against it is fairly progressive but not some sort of radical or anything, you know? And I think it shows that there… Once people find out about what this actually is, it’s toxically unpopular. No one wants to semi privatize Medicare, or threaten seniors with having to change their doctors.

So I hope that those two votes are just the beginning. And I hope that there’s… As time goes on, we see more opposition and more awareness being raised. And I think anyone who’s listening to this broadcast, they should read the piece. They should read every piece they can about it. And they should tell people. They should try and tell people through word of mouth that this is happening. Because, ultimately, that’s part of how the opposition is going to spread. The people are only going to oppose this if they actually know that it’s happening. If they don’t know it’s happening, then there’s not going to be that groundswell opposition.

Marc Steiner: This is really, it was a really good article. And I’m glad you brought this up, and we’ll keep abreast of this with you and others and see where this goes, and see if we can’t get different activists talking about this. And I want to thank you again, Branko, for the article. It was a really good article. And for joining us here, it’s good to have you with us.

Branko Marcetic: Thank you. Thank you for raising the issue up.

Marc Steiner: It’s really important. I want to thank you all for joining us today, out there who are listening. This podcast, and you can find links and more about all of this here at The Steiner Show site on Real News. And please let me know what you think about what you heard today, what you’d like us to cover. Just write to me at mss@therealnews.com. I’ll get right back to you. I want to thank Adam Coley, Stephen Frank, and Kayla Rivara for making the show possible today, and our hardworking creative crew here at The Real News. And thank you again for joining us. I’m Marc Steiner. Stay involved, keep listening, take care, and don’t let them take advantage of us.

Branko Marcetic is a Jacobin staff writer based in Toronto, Canada, and the author of Yesterday’s Man: The Case Against Joe Biden.

Tune in for new episodes of The Marc Steiner Show every Monday on TRNN, and subscribe to the TRNN YouTube channel for video versions of The Marc Steiner Show podcast.

Pre-Production/Studio: Adam Coley

Post-Production: Stephen Frank

https://therealnews.com…

Repeat: Medicare Advantage & Other Private Investment Hurt Medicare

Summary: A September 2021 Health Affairs blog revealed how Medicare Advantage insurers use aggressive and fraudulent diagnostic coding practices to artificially boost revenues, with similar risks looming from Direct Contracting Entities. That blog was criticized as inaccurate by two corporate leaders in healthcare. The original blog authors responded this week, buttressing their case against Medicare Advantage and DCEs (now known as ACO Reach).

The Emperor Still Has No Clothes: A Response To Halvorson And Crane, Health Affairs Forefront, June 6, 2022, by Richard Gilfillan and Donald M. Berwick

Following our September 2021 Health Affairs Forefront articles on the “Medicare Advantage Money Machine,” the most common reaction of which we are aware has been that this was an “Emperor Has No Clothes” moment. Many knew the Medicare Advantage (MA) game, but few had called it what it was. Two responses to our articles … have been published in Forefront that find fault with our analyses. … For the most part, their arguments fail.

We count more than a dozen assertions in these critiques, some matters of opinion and others matter of fact. These can be grouped into … six categories … [see HJM Comment]

[Many] have documented that MA costs more than fee-for-service [largely due to the gaming of risk scores]. Every extra dollar paid to MA plans is, indeed, a transfer of taxpayers’ money to MA plans, which then benefit in terms of growth and higher profits. Those profits represent direct transfers of wealth from taxpayers to plans.

The impact of MA on the delivery of care goes well beyond the Risk Score Game. Traditional Medicare presents a relatively straightforward, highly standardized approach to coverage and the financing of health care. MA creates a highly fragmented coverage and financing system that brings complexity and additional cost for all segments of the industry, particularly the providers. The result is an expensive MA administrative superstructure that we have layered on top of, and that now permeates and distorts, the actual delivery of care. Estimates of administrative costs and profits for all health system parties vary significantly but the broadest definitions are in the range of 25 percent. MA is a major driver of those costs. We must ask what we are getting for that if, after 35 years of privatized Medicare costing more than fee-for-service, we cannot demonstrate real clinical outcomes improvement. The answer is, “We are not getting much.” The opacity that comes from the privatization of public payment confounds objective, scientific analysis.

Comment:

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

Gilfillan and Berwick logically and effectively counter the two published criticisms of their September 2021 “Medicare Advantage Money Machine” blog (discussed in HJM). In so doing, they solidify an appropriately harsh assessment of Medicare Advantage and ACO Reach (rebranded DCEs). Below is a structured summary, incorporating quotations from the blog.

Bottom line: Massive insurer profits achieved via widespread diagnostic upcoding deplete Medicare funds without evidence of added value for beneficiaries.

1) The Medicare Advantage Business Model

Snapshot: Model = diagnostic upcoding to raise capitation rates

Coding efforts are not just to inform clinical practice, as the critic argues; they are to drive up payment rates. “MA risk scores have for decades risen continually … now almost 2 percent per year faster than those in traditional Medicare. That is not a mark of … increasing relative severity of actual illness in MA compared with the fee-for-service population; it is the Risk Coding Game …”

The industry is so focused on this, it refers to a “risk score headwind” when COVID prevented home visits used to add more diagnoses.

Overall, an estimated 14 percent risk score excess will result in overpayments to Medicare Advantage of $600 billion from 2023-2031.

2) The Profitability of MA Firms

Snapshot: Huge profits and valuations

The critic proposes “Most businesses in most industries would see their stock prices dropping with only 4.5 percent profits [as seen with insurers].”

Yet “[T]he increases in plans’ stock prices and valuations [are extraordinary].” Why? I argue in HJM that the nominal 4.5% for insurers obscures a real return rate of 30%, and thus explains why the investment is so attractive.

“Profits are the product of profit margin multiplied by revenue. Risk Score Gaming positions plans to increase profits from both.“

And here’s the maximum profit strategy: if insurers buy up providers, as they are doing, the “Medical Loss Ratio” restriction on profits is easily evaded, dropping the real MLR from 85% to 70% and thus more than doubling actual profit margins.

3) The Effects of MA On Care and Underinsurance for Low-Income MA Beneficiaries

Snapshot: Lower upfront costs, but poor financial protection when sick

“Plans use some of the subsidies [overpayments] from CMS to offer products with improved benefits and lower premiums for members. … Zero-premium products, with less-rich benefits and more out-of-pocket costs, are targeted at cost conscious buyers, particularly those with limited disposable income. Lower-income individuals have little choice but to trade a known zero premium cost for an unknown likelihood of greater out-of-pocket costs. But that tradeoff leaves many low-income beneficiaries underinsured and possibly experiencing significant negative impacts on their health.”

The Kaiser Family Foundation found that “enrollees in Medicare Advantage do not generally receive greater protection against cost-related problems than beneficiaries in traditional Medicare with supplemental coverage, particularly for some enrollees, such as Black beneficiaries in relatively poor health…”

4) Financial Savings for MA Beneficiaries

Snapshot: Impossible to tell, with distorted comparisons

The critics claim that “MA members actually spend much less money each year on care.”

Gilfillan and Berwick explain why: a) MA plans are subsidized due to over-payment by Medicare, and they share the subsidies with members, and b) the plans use risk selection to enroll a healthier population than traditional Medicare.

In other words, apparent savings are artifact, meaningless.

5) The Quality of Care In MA

Snapshot: Mixed and ambiguous picture, with flawed data

The critics claim higher quality of care in MA. We just can’t know, say Gilfillan and Berwick.

For example, “[R]ecent studies document that MA plans are actively ignoring system-improvement efforts as they use lower-quality skilled nursing facilities and home health providers more, and high-quality hospitals less, than traditional Medicare.”

Claims that integrated care systems like Kaiser improve care (itself dubious, IMO) don’t carry over to the non-integrated Medicare Advantage norm.

MA plans actually artificially boost quality scores – “manipulating contracts to ‘move about 550,000 enrollees from non-bonus contracts to bonus-level contracts, resulting in unwarranted bonus payments in the range of $200 million in 2019.’”

“Understanding the effects of MA on quality is extremely difficult in part because MA operates in an information environment in which it is all but impossible to demonstrate better clinical outcomes for patients.” Data are missing, biased, or manipulated. [Stunning eg’s in the blog.]

Gilfillan and Berwick’s positive view of ACOs diverges from my deep skepticism. But I agree with them, the greatest danger lies in the growth of investor-controlled entities.

6) The Direct Contracting Model/ACO Reach Model

Snapshot: Investor control portends problems such as in Medicare Advantage

[W]e remain concerned that [ACO Reach] brings MA investor and insurer-controlled firms directly into the fee-for-service alternative payment model (APM) world. The 52 of 100 Reach ACOs that are investor-controlled operate in 49 states (including the District of Columbia and Puerto Rico) containing 99 percent of the 35 million fee-for-service beneficiaries.

7) Resolution via Single Payer

Snapshot: They didn’t say this. They should have.

http://healthjusticemonitor.org…

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Don’t Hand Medicare to the Profiteers

Interview with Dr. Susan Rogers

By Patty Fahy, M.D.
Licensed to Lead Podcast, June 6, 2022

Listen to “042 – Dr. Susan Rogers Tells Senate: Don’t Hand Medicare to the Profiteers” on Spreaker.

Community, connection, purpose: these values are almost palpable even in a virtual conversation with Dr. Susan Rogers. Dr. Rogers is an internist, educator, and activist on behalf of those who suffer when profit motives bulldoze the institutions that are meant to serve the public. A neon example of a public good which has been targeted by profiteers is traditional Medicare. As president of Physicians for a National Health Program, Dr. Rogers is fighting back against the shape-shifting strategies launched by insurance companies and private equity firms to cash in on Medicare. She fills us in on the importance of preserving the choice of traditional Medicare, and talks about her work to inform the public and Congress about the “predatory DCEs” or Direct Contracting Entities.

She was shaped by growing up in a uniquely integrated community in Chicago as well as by the activism of the 1960s. When she was in middle school, her mom took her to a march led by Martin Luther King, Jr. protesting the state of the public schools in Chicago. She trained at Cook County Hospital in Chicago and then went on to hold leadership and teaching positions there as an attending. While she did defect temporarily to work in other settings in Chicago, she missed the camaraderie and like-minded passion of her Cook County colleagues. She emphasizes the importance of community with colleagues and the significance of a physician’s long-term relationships with patients.

Dr. Rogers is exasperated at the privatization of healthcare by people who know nothing about the practice and profession of medicine. She describes the total disconnect when decisions are made by financially-driven business people: “There should be no role for them.”

“Resources aren’t placed where they’re needed—they’re placed where they can generate more money.”

She compares the inroads of private equity firms in healthcare to the debacle of private equity firms and charter schools siphoning funds away from public schools in poor communities. As in healthcare, the motives are not to provide the needed services to the public—but to amass profits for investors. Rural hospitals that are acquired and then closed by large healthcare systems are another example of decision-making by those seeking to maximize profit, not community benefit.

Dr. Rogers and other representatives from Physicians for a National Health Program had success on Capitol Hill when they petitioned Congress and HHS to reject DCEs. While PNHP’s efforts were influential regarding DCEs, she describes how it didn’t take long for a new acronym and strategy to emerge. “Same shirt, different color,” she says about ACO REACH (ACO Realizing Equity, Access, and Community Health). She emphasizes the remarkable lack of oversight by Congress for this program that can be hoisted on patients without patients realizing that their traditional Medicare decision has been overruled.

Also in this episode:

  • The powerful impact of a high school biology teacher
  • Activism in the time of role model Angela Davis
  • A Tuskegee airman who exemplified the bond between physician and patient
  • She was able to see patients as people: “They shared their lives with me”
  • “Are you going to open your own office?” a question rarely posed to medical students now that 70%+ physicians are employed
  • Burgeoning full-service hospitals arising in close proximity are as logical as putting a town’s four fire stations on facing corners.

Meet Susan Rogers, M.D.

Dr. Susan Rogers is president of Physicians for a National Health Program, a national organization with over 23,000 physician members, whose mission is to advocate for Single Payer/Medicare for All.

Dr. Rogers received her medical degree from the University of Illinois College of Medicine and completed her residency in Internal Medicine at Cook County Hospital in Chicago. She spent most of her career at Cook County Hospital (now Stroger Hospital of Cook County), where she practiced internal medicine in a neighborhood clinic before becoming a hospitalist and Director of Medical Student Programs for the Department of Medicine. She has also worked at the Lakeside VA hospital in Chicago affiliated with Northwestern and was a prior Medical Director at Near North Health Services, an FQHC in Chicago.

She retired in 2014 but remains a voluntary attending at Stroger Hospital and continues as active faculty at Rush University in Chicago as an Assistant Professor of Medicine.

Dr. Rogers is a Fellow of the American College of Physicians, and a member of the National Medical Association.

Resources:

https://spreaker.com…

Beat cancer? Your Medicare Advantage plan might still be billing for it.

Firms mined patient records for outdated, irrelevant conditions to increase profits, Justice Department contends

By Christopher Rowland
The Washington Post, June 5, 2022

Kathy Ormsby’s work auditing medical case files uncovered an alleged scheme to defraud the federal government: The California health system that employed her was scouring health histories of thousands of elderly Medicare patients, then pressuring doctors to add false diagnoses it found to their current medical records.

The point of larding the medical records with outdated and irrelevant diagnoses such as cancer and stroke — often without the knowledge of the patients themselves — was not providing better care, according to a lawsuit from the Justice Department, which investigated a whistleblower complaint Ormsby filed. It was to make patients appear sicker than they were.

The maneuver translated into millions of dollars in inflated bills to the federal Medicare Advantage insurance program, the government alleged in its false-claims lawsuit filed in U.S. District Court in California.

The case was part of a broader government crackdown on abusive billing practices in Medicare Advantage, the privatized insurance option that by next year is expected to cover more than half of all Medicare beneficiaries. The Justice Department is pursuing civil lawsuits against multiple companies that participate in the privatized system, from huge insurers to prestigious nonprofit hospital systems, alleging they have cheated the system for unfair profit.

Ormsby’s former employer, the Palo Alto Medical Foundation, which has 1,600 doctors, and its parent affiliate, Sutter Health, which runs 24 hospitals in Northern California, settled the case with the government in August 2021 for $90 million. It admitted no wrongdoing or liability.

The government said its investigation confirmed that Palo Alto Medical and Sutter systematically added false diagnoses to patient records. In a sample of hundreds of cases Ormsby audited, the government’s lawsuit said, she discovered 90 percent of diagnoses for cancer were invalid, as were 96 percent for stroke and 66 percent for fractures.

“As we continued to audit, I started to see more things,” Ormsby said in an interview with The Washington Post, the only time she has spoken publicly since reporting the alleged misconduct in 2015. “I couldn’t believe how bad it was.”

In response to questions from The Post, Sutter indicated it was ready to move on. “The agreement brought closure to a long-running dispute and enabled Sutter to avoid the uncertainty and expense of protracted litigation,” it said in an email statement.

Medicare Advantage, which is run by outside companies under contract with the government, was added to traditional Medicare in 2003 with the support of Republicans in an effort to improve care and lower costs through privatization. But it is costing taxpayers increasingly more money to run than traditional fee-for-service Medicare, according to MedPAC, a government watchdog panel. The higher cost, what MedPAC labels “excess payments,” reached $12 billion in 2020 out of total program costs of $350 billion and are projected to top $16 billion next year, MedPAC said in March.

The aggressive billing tactics stem from incentives built into Medicare Advantage. Under the program, companies are paid a flat fee per month to provide whatever care is required for a patient based on age, gender, geography and health risk factors. To compensate plans and providers for potential costs of care for individual patients with conditions such as diabetes, heart disease or cancer, Medicare boosts the monthly payment to Medicare Advantage plans under a “risk adjustment” for each additional condition. The system differs from the traditional “fee for service” payment, in which Medicare pays hospitals and doctors directly each time they provide a service.

If companies add more risk adjustment codes to a Medicare Advantage beneficiary’s medical record to receive higher payment — but don’t spend money on the additional care — they make more money.

Industry officials broadly rebut the charge that companies game diagnostic risk codes for financial gain. They say Medicare Advantage firms adhere to Medicare’s rules and follow the system’s guidance on regulations that are not always clear. Moreover, the industry says that listing all health issues on medical records is a crucial part of Medicare Advantage’s promise to anticipate health problems, proactively manage disease and reduce hospitalizations.

But the government considers it improper — potentially even fraudulent — for providers to add codes for medical conditions that have been resolved or have no bearing on a patient’s current health.

For-profit insurance companies have typically been the primary target of these probes. More recently, unsealed whistleblower cases such as Ormsby’s against Sutter Health, and a pending case against Kaiser Permanente, reveal how such investigations have spread to prestigious, nonprofit physician and hospital groups.

Doctors, or sometimes even non-physician medical coders, updated patients’ current records without providing treatment and often unbeknown to the patients themselves, the government’s investigations have found.

Heart attack, stroke, cancer, vascular disease, depression, obesity and malnutrition were among diagnoses most often cited by the government in its false-claims lawsuits. In an example cited in the Sutter case, thyroid cancer was added as a current condition in a patient record even after the thyroid gland had been removed five years earlier and the patient had been free of cancer for years. None of the allegations has been fully tested in court, because they were settled by the companies without an admission of liability or, in the case against Kaiser Permanente, remain pending.

Some critics contend that a byproduct of these practices is that patients’ medical records, padded with false diagnoses, are inaccurate. That could unnecessarily stigmatize patients who were improperly deemed obese, or malnourished, or mentally ill. It introduces potential phantom influences on treatment decisions, critics say.

In addition to her shock over thousands of alleged false billings, Ormsby “was not comfortable with what she perceived as the complete divorce from the reality of what was in patient records” at Sutter Health, said Sarah “Poppy” Alexander, a whistleblower lawyer at Constantine Cannon, which represented Ormsby.

“The accuracy of patient records is critical for anyone’s health-care treatment,” she said. “Think about all the decisions that are made based on what’s in your health-care record. If that health-care record is not accurate, it’s extremely dangerous.”

Several doctors interviewed by The Washington Post said it was common practice for insurance companies and medical systems to search or data-mine the histories of patients covered by Medicare Advantage. Health systems were known to advise doctors on the most lucrative billing strategies, cajole them to document the maximum number of illnesses, and grade and rank them among their peers based on how they coded patients, they said.

“The emphasis is on how to code for more. It’s not ethical coding, it’s how to code for more money. That pressure is there,” said David Terry, a recently retired psychiatrist who worked within large health organizations in Kansas that are not part of any of the lawsuits.

The Justice Department said in February that Medicare Advantage investigations are an “important priority.” In federal whistleblower cases, the government investigates allegations brought by people with knowledge of alleged fraud against the government and then decides whether it will join the lawsuit, based on its findings. Whistleblowers are rewarded for stepping forward with a portion of any settlement or court awards. Justice Department whistleblower allegations and similar lawsuits also are playing out in federal courts against UnitedHealth Group, Cigna and Anthem. The government’s Office of Inspector General has audited Humana and found it overbilled the government. United Healthcare, which is under the umbrella of UnitedHealth Group, and Kaiser Permanente denied any improper conduct. Cigna, Anthem and Humana did not respond to requests for comment.

The health insurance industry’s trade group, AHIP, did not comment on allegations of false billings. MedPAC’s estimates of excess payments, when compared with traditional Medicare, are exaggerated, AHIP executives said, because its calculations do not factor in all differences between the two payment systems.

“The Medicare Advantage system is designed to promote accurate coding and support integrated care,” said Mark Hamelburg, AHIP senior vice president for federal programs. “Plans have to consider the entire patient, and know all their conditions, and how their conditions interact.”

Medicare Advantage plans cut costs using the tools of the private insurance industry. They control the use of MRIs and other costly tests, for instance, cutting down on waste. They restrict care to certain hospital and physician networks. Then they use a share of those savings to keep monthly premiums lower than traditional Medicare, while offering extra benefits traditional Medicare does not offer, such as dental and hearing and gym memberships.

“It is a vast, complicated system. It involves all these various components,” Hamelburg said. “Our view is that you shouldn’t just look at individual components, you need to look at the totality.”

An industry-backed study found that Medicare Advantage members pay $1,965 less in out-of-pocket costs, including premiums, than traditional Medicare beneficiaries. Beneficiary satisfaction is high. Membership in the plans grew by 10 percent last year; they are expected to cover more than 50 percent of all patients next year.

‘Something unseemly’

Ormsby, one of the Medicare Advantage whistleblowers whose case was investigated by the government, quit her job at Palo Alto Medical Foundation in 2015 after two years in her job as a risk adjustment project manager. An outside consultant had found 8,000 false codes for the years 2012 and 2013, the government alleged in the whistleblower lawsuit she initiated.

The government’s investigation of her complaint revealed how physicians received computerized “daily alerts” for their patients flagging “suspected” diagnoses unearthed via data-mining. When their risk-adjustment diagnosis numbers fell short, doctors were urged by higher-ranking colleagues to improve, the government lawsuit alleged. In some cases, the government said, coders would add diagnoses to patient records without participation of doctors.

Some doctors pushed back on the pressure to add diagnostic codes.

“With my patient on hospice, there is something that seems unseemly about pursuing a new diagnosis of PVD [pulmonary vascular disease] when she has weeks to live,” one physician, Joann Falkenburg, wrote to colleagues helping lead the pressure tactics. The email was obtained by Justice Department investigators. “I try to be pretty legitimate about how I diagnose, document and chart and want to avoid any possibility that it looks like I am working someone up just for the financial upside.”

The government’s lawsuit does not indicate how Palo Alto Medical responded to her email, and Falkenburg did not respond to a phone message requesting comment.

A Palo Alto Medical auditor reported in internal correspondence that another physician, Thomas Deetz, complained that “pre-populating diagnoses into his visit encounter is possibly fraud. … Does CMS know about what you all are doing?” Deetz also did not respond to a request for comment.

Ormsby maintains that her multiple warnings about the practices were ignored or rebuffed. She said she received a poor performance review in early 2015, but by then she had already sought out private lawyers, a step that led to her whistleblower suit.

“I was finding too many errors, and they didn’t want to send the money back,” Ormsby said in the interview. Under rules for federal whistleblower lawsuits, Ormsby, 56, will receive 15 to 30 percent of the $90 million Sutter Health settlement.

‘Coding parties’

The practices at Sutter were not isolated, according to the government. Kaiser Permanente, a nonprofit health-care organization that treats patients in California, Colorado and elsewhere, including Virginia and Maryland, is accused in a separate Justice Department lawsuit of similar tactics that allegedly brought in about $1 billion in improper billings from 2009 to 2018. The case, which is pending, was consolidated from six whistleblower complaints against the company.

“As each year drew to a close, some employees referred to Kaiser’s rush to capture as many diagnoses as possible as the ‘dash for cash,’ ” the government said in its lawsuit. It alleges that at Kaiser Permanente, doctors were invited to “coding parties,” where physicians would be gathered in a room after hours and be expected to add diagnosis codes found in data-mining operations to current patient records.

Kaiser Permanente said in response to the government’s allegations that it was following the rules.

“We are confident that Kaiser Permanente is compliant with Medicare Advantage program requirements and we intend to strongly defend against the lawsuits alleging otherwise,” the company said in a statement sent to The Washington Post. “Our medical record documentation and risk adjustment diagnosis data submitted to the Centers for Medicare and Medicaid Services comply with applicable laws and Medicare Advantage program requirements. Our policies and practices represent well-reasoned and good-faith interpretations of sometimes vague and incomplete guidance from CMS.”

Internally, some doctors questioned the company’s practices, the lawsuit contends. Among the diagnoses Kaiser Permanente physicians were frequently asked to add to patient medical records was aortic atherosclerosis, according to the government’s lawsuit.

The condition, a hardening of the aorta wall, could often be observed incidentally in a chest X-ray or scan for some other ailment. Radiologists were instructed to record the presence of the condition if they detected any calcium in the aorta, “regardless of significance,” according to the government’s complaint.

Physicians would then be pressured via computerized queries to amend the patient records retroactively to include aortic atherosclerosis, which Kaiser had identified as having a “high rate of reimbursement” in the Medicare Advantage risk adjustment formula, the government alleged.

Some Kaiser Permanente doctors objected, saying the disorder was typically not serious in their elderly patients.

According to the government’s lawsuit, one physician, Matthew James Sena, observed in internal correspondence that “Aortic atherosclerosis is nearly ubiquitous in patients this age. It is not a clinically relevant diagnosis and doesn’t require treatment. Isolated [chest X-ray] interpretations are not grounds for clinical diagnosis in this case. … [It’s] clinically inconsequential in almost all cases.”

A coding administrator for Kaiser Permanente is quoted in the complaint as saying “[n]o one believes it is a real diagnosis,” and since “it is non-compliant to tell people to code for money, we need to really sort out a way to package this.”

Medicare Advantage programs are touted by industry as a way of ensuring that chronic conditions are carefully monitored through disease-management programs. But Kaiser Permanente’s increased diagnoses of aortic atherosclerosis threatened to create so many new patients with the condition that its disease management program for cardiovascular disease threatened to buckle.

Kaiser Permanente managers in 2011 came upon a solution, the government said: stop automatically enrolling aortic atherosclerosis patients in the cardiovascular disease management program.

After the change, the lawsuit alleges, medical leaders continued to pressure doctors aggressively to code for the disorder, identifying it as worth an additional $40 million in annual billing opportunity at one physician practice.

“How do we rally the herd?” a physician executive director wrote to colleagues at Kaiser’s Northern California Medical Group, in an email quoted in the lawsuit. “Everybody join in the discussion. $40m is no chump change.”

‘Where’s follow-up care?’

Minnesota-based United Healthcare, the largest health-insurance company in the country, quotes a founding father on the homepage of HouseCalls, its program that dispatches clinicians to Medicare Advantage beneficiaries’ homes: “Benjamin Franklin said it best, ‘An ounce of prevention is worth a pound of cure.’ We agree.”

Under such initiatives, companies routinely send clinicians, often nurse practitioners, into patients’ homes to conduct “health risk assessments.” Companies say the assessments are intended to identify any risks to beneficiary health that their physicians may have overlooked or that have developed since their last doctor visit.

But government reports have questioned whether the practice is intended to improve or capture more lucrative diagnosis codes. The visits often result in new codes added to patient bills without any evidence of doctors’ having considered or treated the newfound diagnoses, the Office of Inspector General of the Department of Health and Human Services found in a report last year.

A Connecticut primary-care physician, Kenneth Dardick (whose spouse is the executive director of the Center for Medicare Advocacy, a nonprofit that advocates for patients), said he routinely receives copies of United Healthcare’s in-home risk assessments and never learns anything about his patients that he did not already know.

He does notice that new patient codes are added to the reports, documenting conditions he already knew about or were irrelevant, he said.

He shared a copy of one assessment, with identifying information of the patient removed, that was sent to him by HouseCalls in April. He was already treating the patient, a man in his 70s, for diabetes. But the health risk assessment, in a section called “new diagnosis,” had added a different code, diabetes with complications. The new diagnosis section also listed a personal history of a type of skin cancer. Dardick said a precancerous growth was removed from the patient’s skin nine years ago and is no longer being treated.

“My sense is they are doing that just to game the system,” Dardick said, citing the “new” diagnosis codes as “irrelevant.”

United Healthcare stood out among Medicare Advantage companies for its aggressive use of risk assessments without evidence new risk codes were related to ongoing medical care, according to the Office of Inspector General report last year. (OIG did not identify the company in its report, but it did confirm its identity after a records request from the Minneapolis Star-Tribune.)

United Healthcare has the largest share of Medicare Advantage patients in the country, with 7.2 million beneficiaries, or 27 percent of the total.

United Healthcare did not respond directly to the OIG report’s findings. In response to questions from The Post, spokesman Matt Wiggin emailed a brief statement. “Simply stated, compared to fee-for-service Medicare, Medicare Advantage costs less (for beneficiaries), is more equitable, has better quality, access, and outcomes with greater coverage and benefits and nearly 100% consumer satisfaction,” he said.

Jacqualine Reid, a government research analyst who led the review, said the findings about United Healthcare raised red flags. Of the $9.2 billion in risk adjustment payments in 2016 based on health risk assessments with no other records to support the diagnosis, United received $1.38 billion, Reid and her team found in their review.

The three top diagnoses generating those payments were peripheral vascular disease, major recurrent depressive disorder and Type 2 diabetes with peripheral angiopathy.

“These are serious medical conditions. If they are getting payments for in-home visits, but we do not see any other evidence of services being provided to them, it raises concern,” Reid said. “If they are appropriate, where’s the follow-up care that in most cases you would expect to see?”

https://www.washingtonpost.com…

What is Single Payer?

Summary: Today we take a step back to review a fundamental issue – the definition of single payer. Also its typical features and options. Why? Because sometimes we get lost in technical details, and forget the big picture. And too often experts get confused, and thus confuse others.

Comment:

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

It drives me to distraction when health policy researchers, journalists, medical journals, and critics misrepresent single payer. This has come up several times in recent months. I guess it’s understandable, with all the misinformation that’s floating around. But I’m eager to settle on a single, correct definition. Here’s my attempt…

DEFINITION:

  • One entity (a public agency) pays for health care. This agency receives all funding and disburses all payments for standard comprehensive coverage. Private insurers are prohibited from this role.
  • All patients and providers deal with just one payer for the standard coverage. This is especially important for providers, offering the simplicity of a single payment source.

TYPICAL FEATURES:

These elements are typical in single payer, if not in the definition, in order to achieve overall goals of universal, equitable, efficient, and affordable access to care.

  • Everyone is covered. Universal, lifelong – meeting a fundamental human need, and part of single payer’s efficiency.
  • Everyone has identical comprehensive coverage / benefits. This is hugely different from our current system, with myriad and varied restrictions on benefits according to health plan.
  • Payment rates are the same for everyone. Again, this is vastly different from today, with up to 10-fold differences in payment levels for the same services, creating strong economic forces for unequal access.
  • Cost-sharing is minimal. No deductibles, and co-pays either not used or small with low-income exemptions. This avoids financial barriers to care.
  • Capital spending (investment) decisions are made by the payer, not by providers. This assures that capacity is increased where most needed.
  • Negotiated drug & medical equipment prices. A single payer negotiates a single set of prices, directly with manufacturers. Currently prices vary widely across insurers and plans, and intermediary PBMs distort the market and extract profits.
  • Long-term care. In most single payer plans, long-term care (both institutional and community-based) is included as an essential care need.
  • A single electronic health record, focused on clinical care rather than billing. With much simpler billing, a universal EHR would reduce the burden on providers and facilitate exchange of medical information and enable effective public health tracking and intervention.

DO WE HAVE SINGLE PAYER NOW? NOT MUCH

  • Veterans Affairs (the VA) has a single payer (the federal government). With full-time staff, the VA resembles a national health service. Access to and quality of care is better than average. Some patients have private insurance as well, and recently more VA funds have been used for community providers, but still, a single payer.
  • Medicare is not a single payer, even though it’s the predominant payer for seniors. This is a common misunderstanding. Medicare is not a single payer because from the perspective of providers, it’s just one of many payers, losing the efficiencies and equity enhancements of single payer. The large role of private insurers in Medicare Advantage further distances Medicare from single payer.

CHOICES UNDER SINGLE PAYER:

  • Provider payment mechanisms. Fee-for-service is the most common proposed approach for individual providers, but they can also be paid with salaries. Hospitals and other institutions may be paid via global budgets. Indeed, capitated provider groups (without intermediaries, and not-for-profit) may be possible, though controversial and require very strong rules to prevent undertreatment and gaming.
  • Supplemental or complementary insurance. Many nations permit focused (small scope) additional insurance, e.g. to speed access to specialty care. These are fraught, potentially undermining standard coverage, but satisfying demand for service enhancements. In other countries, they take many forms and work acceptably (not materially reducing access for the broad population) … but can they in the US?
  • Parallel single payer systems. A single payer approach may permit having a second system in tandem, such as the VA. Two independent systems, each meeting the definition of single payer from the perspective of participating providers and patients.
  • Opting out. Providers can practice outside of the single payer system, accepting direct payments for services. But they are not permitted to both participate in single payer and accept payment for the same services. That is: either fully in or fully out.

So, now that we’ve clarified, let’s get back to winning the long-running battle for an efficient and equitable system to pay for health care – single payer (you know what I mean!).

http://healthjusticemonitor.org…

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Medicare for All Explained Podcast: Episode 78

Interview with Dr. Anthony Spadaro

June 1, 2022

Former Students for a National Health Program leader Dr. Anthony Spadaro talks about the importance of public health and celebrates the recent American Public Health Association endorsement of Medicare for All.

“Having groups like APHA support single payer helps build momentum,” he says. “We have to build our support and our political power to make this a reality.”

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

https://medicareforallexplained.podbean.com

Private Equity Takes Aim at Primary Care

Summary: If private equity firms have their way, traditional primary care will disappear, replaced by corporate skeletons stripped of financial assets and the most skilled practitioners, with investors sitting on billions in extracted profits. That’s the private equity model, now targeting front-line providers. We must stop them before they destroy our health system.

Ethically Challenged: Private Equity Storms US Health Care, by Laura Katz Olson, Johns Hopkins University Press, 2022

The advent of the neoliberal order and its restructuring of the US political economy coincided with the emergence of private equity in its shadow. Financialization took root and surged during the 1980s, and PE has been riding on that wave ever since. Buttressed through eased regulations and preferential tax treatment, the financiers have steadily advanced their tentacles into ever more market sectors, from manufacturing and retail to business and monetary products, energy, and information technology. Eventually, they gravitated toward human services, such as health care, where in some cases they created markets that had not previously existed.

Private equity’s business model can be characterized as a later stage of neoliberalism, one that takes its rationale to greater extremes; it is neoliberalism on steroids. Supersized earnings for PE and its shareholders are front and center, with no pretense otherwise. Nothing else matters. The profit motive guides everything in both word and deed. At a PE conference I (Laura Olson) attended in 2019 hosted by the Wharton School, the entrepreneurs discussed their buyout priorities, value-enhancing strategies, return on investment, and other metrics; not once did anyone mention the impact of their playbook on individuals or society, at least not at the sessions I joined.

The PE industry – capitalism in overdrive – weighs down its health companies with enormous debt while pushing for extra large earnings. Faceless PE shops take an oversized bite into US health dollars, transferring substantial public and private money for medical needs into the pockets of financiers who do not provide any health services per se.

PE firms are on a roll, pushing full steam ahead in the physician practice, urgent care, and medical staffing domains. What will be the next niche? It seems that the indispensable but long-neglected primary care doctors are on their radar, as are other relatively unclaimed health care spaces. If the trend continues – and I’m sure that it will – medical decisions will be less and less between you and your doctor.

Other Resources: Brief article about / summary of the book | Interview with Laura Katz Olson

Comment:

By Don McCanne, M.D.; David Himmelstein, M.D.; Steffie Woolhandler, M.D., M.P.H.; Jim Kahn, M.D., M.P.H.

We have been worried about the injustices of our current health care financing using a fragmented, inequitable system of health insurance, but, behind the scenes, private equity has been taking over the health care system, using various economic tools to divert massive amounts of health care dollars to its own industry. In her book, “Ethically Challenged,” Laura Katz Olson explains the surprising degree to which this has already occurred and how we are losing control of our health care system as a result.

Examples of some of the tools used by private equity include leveraged buyout using other people’s funds, dismissing expensive personnel and using less qualified individuals, establishing creative management fees and newly structured real estate payments for nominally owned facilities, “improving productivity” by slashing benefits for labor, raising prices and reducing product quality, extracting all funds available from the captured entities, pre-planned use of Chapter 11 to dismiss negotiated debts, early selloff of captured enterprises drained of assets in order to achieve maximum return on investment, etc., etc.

Many health care niches have already been occupied by behind-the-scenes private equity entities, and much damage has been done, as Laura Olson explains. If you don’t already know how this is happening, you should read her book or a similar source to understand. Then the reason for the following statement will be clear.

URGENT WARNING: Primary care, the basic infrastructure of health care in America, is about to be taken over by private equity. Although the appearance of having your own health care professionals will continue, your health care will actually be under the control of invisible (to the public) private equity entities whose sole interest in you is to generate more wealth for themselves with absolutely no regard for your personal health, except to avoid blemishes to the market value of your primary care facility.

Again, read “Ethically Challenged” to learn how trillions of dollars are going to be milked out of our compromised health care system, and we will be unable to do much about it once the changes are in place. Single payer Medicare for All won’t be able to help us then. We urgently need to educate ourselves on what is transpiring, and then we urgently need to elect a Congress that understands and will take the appropriate measures.

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.

Honor Those Who Died for Our Country by Honoring Truth on Civilian Guns

Summary: On Memorial Day we mourn and thank the legions who fell in battle for the US. This Memorial Day we also mourn civilians who fell in recent mass killings, perpetrated with military-style assault rifles obtained by mentally unstable individuals. Sensible gun sale regulation would slow this bloodshed, say studies. Yet opponents once again are distorting the evidence. We offer resources to pursue honest debate.

Fact-Checking Trump and Cruz at the N.R.A. Convention, New York Times, May 27, 2022, by Linda Qiu

“Gun bans do not work. Look at Chicago. If they worked, Chicago wouldn’t be the murder hellhole that it has been for far too long.” — Senator Ted Cruz, Republican of Texas

This is misleading. …

There were more gun murders in Chicago than in any other U.S. city in 2020, fueling the perception that it is the gun violence capital of the country. But Chicago is also the third-largest city in the country. Adjusted by population, the gun homicide rate was 25.2 per 100,000, the 26th highest in the country in 2020 …

The three cities with the highest gun homicide rates — Jackson, Miss.; Gary, Ind.; and St. Louis — had rates double that of Chicago’s or more. All are in states with more permissive gun laws than Illinois.

Chicago’s reputation for having the strictest gun control measures in the country is outdated. Mr. Cruz cited the city’s handgun ban — without noting that the Supreme Court nullified the ban in 2010. An appeals court also struck down a ban on carrying concealed weapons in Illinois in 2012, and the state began allowing possession of concealed guns in 2013 as part of the court decision. …

Gun control proponents have also argued that the patchwork nature of gun laws in the country makes it difficult for a state like Illinois with tough restrictions on the books to enforce them in practice. A 2017 study commissioned by the city of Chicago found, for example, that 60 percent of guns used in crimes and recovered in Chicago came from out of state, with neighboring Indiana as the primary source.

How To Arm Yourself (With Facts) To Win the Gun Debate, Podcast (9 min), May 28, 2022, by Ben Glieb

[Practical suggestions on how to effectively counter fact twisting.]

Is It Time To Bring Back The Assault Weapons Ban?, Statista, Feb. 16, 2018, by Niall McCarthy

According to [Louis Klarevas], gun massacres fell 37 percent during the ban period and in the ten years after it lapsed in 2004, they went up an alarming 183 percent. Klarevas points out that the ban on high-capacity magazines holding more than 10 rounds made a huge difference. He says that if that is regulated, there will be a considerable drop in massacres and fatalities.

Presence of Armed School Officials and Fatal and Nonfatal Gunshot Injuries During Mass School Shootings, United States, 1980-2019, JAMA Network Open, Feb. 16, 2021, by Jillian Peterson et al.

Controlling for … location and school characteristics, the rate of deaths was 2.83 times greater in schools with an armed guard present.

The well-documented weapons effect explains that the presence of a weapon increases aggression. Whenever firearms are present, there is room for error, and even highly trained officers get split-second decisions wrong. Prior research suggests that many school shooters are actively suicidal, intending to die in the act, so an armed officer may be an incentive rather than a deterrent.

Comment:

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

We designate holidays to honor those who fought and who died in US wars. Although I am highly critical of many US wars, I am not a categorical pacifist. I believe that some of our wars were for necessary and admirable causes. Regardless, we should not blame the soldiers for terrible choices made by our leaders. I honor our veterans, especially my father, who served in a World War II German-Jewish immigrant military intelligence program.

But military weapons in the hands of civilians who are too young and/or mentally unstable and/or criminal is a horrendous mistake. In my view, it is an insult to those who wielded such weapons in service to their country. I recognize that the current interpretation of the Constitution’s 2nd Amendment means private ownership of guns cannot be banned. (Until 1959, the “well-regulated militia” clause was interpreted to mean that private ownership was not protected.) But even today, guns can be regulated. For example, universal background checks could be implemented, and high capacity bullet cartridges could be banned. More than 75% of Americans would like such reasonable regulation. It would reduce deaths. Yet the gun industry stymies action.

The GOP-proposed solutions have not been shown to work. Indeed the study cited above finds that having an armed school official worsens the problem.

Whenever a massacre occurs, Democrats and a few moderate Republicans push for regulation. Reliably, the GOP blocks legislation, and cites “data” in their defense. The data are distortions. The excerpts and links above give you a starter kit for arguing back. Here’s another – the reductions in gun killings in Australia after its 1996 gun buyback.

Please use these resources. Let’s implement the will of the vast majority. Let’s honor military service with honest debate about civilian guns.

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.

During COVID Insurers Collected Full Premiums But Paid Less for Care, Forcing Government to Bail Out Providers

Summary: In 2020, private insurer profits – largely from Medicare Advantage and Medicaid managed care – jumped 20-30% because they collected full premiums even as claims from health care providers fell due to decreases in elective care. Meanwhile, the government also compensated providers for revenue shortfalls. So taxpayers paid two-fold for the care dip.

Taxpayers Paid Twice for Healthcare: Private insurers are profiting more than ever during the pandemic, MedPageToday, May 25, 2022, by Steffie Woolhandler, M.D., M.P.H. and David U. Himmelstein, M.D.

While 2020 may have been a bad year for Americans, it was a great one for America’s health insurance firms. Profits at UnitedHealthcare, the nation’s largest private insurer, shot up 20%, reaching more than $12 billion. The second biggest, Anthem, collected $16.1 billion more in premiums than it paid out in benefits, a 30% jump over 2019, and CVS/Aetna’s take from its insurance business rose 29%.

It turns out that taxpayers footed the bill for this explosion in profits by, in effect, paying twice for healthcare.

. . . what could justify the nearly $65 billion increase in private insurers’ overhead? And how is it that two thirds of that increase came from private insurers’ subcontracts with Medicare and Medicaid?

. . . In setting 2020 payment rates to Medicare Advantage plans, federal officials boosted payments by nearly $49 billion, anticipating the usual annual increases in medical care use and costs. But with many doctor visits and non-urgent surgeries during the pandemic cancelled, Medicare Advantage plans pocketed most of that increase. Their overhead rose to $2,256 per enrollee. Meanwhile, the overhead of private Medicaid managed care plans also surged.

The flip side of insurers’ windfalls were financial shortfalls faced by many hospitals and doctors. Even hospitals full of COVID-19 patients hemorrhaged money, because the reimbursement for a case of COVID-19 was far lower than they would have gotten for the knee or hip replacements that were cancelled.

Private insurers’ payments to hospitals actually fell in 2020, even as hospitals faced sharp increases in costs for the staff and equipment needed for the tsunami of COVID-19 patients. The financial distress of hospitals and health professionals triggered congressional bailouts — the Provider Relief Fund and Paycheck Protection Program — that totaled about $165 billion in 2020.

In essence, government paid twice for care: once through premiums paid to private insurers for Medicare Advantage and Medicaid managed care, and a second time to fill the hole in hospitals’ and doctors’ budgets caused by falling reimbursements from private insurers.

Comment:

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

This article traces the spectacular increase in insurance overhead in 2020, which was attributable mostly to their Medicare Advantage and Medicaid managed care businesses.

While insurers’ profiteering from taxpayers in 2020 was extreme, Medicare Advantage plans have been fleecing the taxpayers for years, and look set to continue doing so. Indeed, the Biden Administration recently granted them a huge payment increase for 2023.

MedPAC estimates that between 2008 and 2019, Medicare Advantage plans’ upcoding raised Medicare’s costs by $132 billion, costs borne both by taxpayers and by Medicare enrollees’ as higher Part B premiums. And Medicare Advantage overcharges are projected to add as much as $355 billion to Medicare’s costs by 2030.

Medical spending should pay for care, not to line the pockets of insurance executives and shareholders.

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.