Summary: This JAMA commentary supports doubling down on “value-based care” despite a dismal record of failed demonstrations, and doing so in the context of our dysfunctional multi-payer system. Make no mistake – this is all about enriching corporations that increasingly control our health system. They’re winning, but single payer can still come from behind.

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The Center for Medicare and Medicaid Innovation — Toward Value-Based Care, JAMA, May 9, 2022, by John E. McDonough and Eli Y. Adashi

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Section 3021 of the ACA established the Center for Medicare and Medicaid Innovation (CMMI), replete with $10 billion in guaranteed federal appropriation for 2010 through 2019. Ensconced within the Centers for Medicare & Medicaid Services (CMS), the CMMI was to expand the scope and accelerate the pace of learning with an eye toward hastening the transition from fee-for-service payment models to value-based care.

Since its inception, the CMMI has launched more than 50 model tests involving 28 million patients and more than 528,000 health care practitioners. These efforts at transitioning to value-based care involved Medicare, Medicaid, the Children’s Health Insurance Program, and commercial payers. Of the greater than 50 models tested during CMMI’s first decade, only 6 generated significant savings for Medicare and thereby for taxpayers. Despite this limited record of success and continuing political disagreements regarding Medicaid expansion and other aspects of the ACA, the drive for value-based care remains widely endorsed by both political parties and across most segments of the health care sector.

The first strategic objective of the CMMI, to “drive accountable care,” continues and accelerates this core initiative. CMMI’s new strategy sets an ambitious goal according to which “[A]ll Medicare beneficiaries with Parts A and B will be in a care relationship with accountability for quality and total cost of care by 2030,” as will “the vast majority of Medicaid beneficiaries.”

The second strategic objective of the CMMI, to “advance health equity,” will assume a much higher profile in CMMI’s second decade than it did in its first. Specifically, the CMMI will “require participants to collect and report the demographic data of their beneficiaries.”

The third strategic objective of the CMMI, to “support care innovations,” elevates and operationalizes the incorporation of social determinants of health into the “daily DNA” of the work of the CMMI.

The fourth strategic objective of the CMMI, to “improve access by addressing affordability,” seeks to reduce by 2030 the percentage of beneficiaries who forgo necessary care because of cost.

The fifth and final strategic objective of the CMMI invites opportunities to “partner to achieve health system transformation” by aligning priorities and policies across CMS, and by engaging “payers, purchasers, providers, states, and beneficiaries to improve quality, achieve equitable outcomes, and to reduce health care costs.” Under this strategic objective, all new CMMI models are to make multipayer alignment achievable by 2030.

The value-based care transformation of the US health care system as launched by the ACA is now more than a decade old. Some components of the ACA were the subject of intense and lengthy political conflict. However, the value-based care movement enjoyed near-universal support from federal leaders and key physician, hospital, and other health system organizations despite heretofore mediocre outcomes on both cost and quality. The new CMMI review and planning initiative is a welcome opportunity to renew and reinvigorate this vital national project, especially with the heightened profile of health equity as a core goal.

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Comment:

By Don McCanne, M.D.

We now have a decade of “value-based care” experimentation through the Center for Medicare and Medicaid Innovation (CMMI) involving 28 million patients and over a half million health care practitioners. Eighty-eight percent of the VBC models clearly failed and the other twelve percent “successes” were dubious or minimal. Yet the contention is that “value-based care” is widely endorsed and thus the transition should be hastened. The strategic objectives planned over the next decade appear to be intensification of the same questionable policies.

Particularly ominous is the plan to have our entire health care system locked into multi-payer alignment of all new CMMI models by 2030, obviously precluding consideration of a single payer Medicare for All model. That should give the multibillionaires and their private equity enough time to acquire our entire health care delivery system. It will be interesting to see how they implement their value-based care as we pass our health care trillions to the billionaires.

Perhaps we, the people, in an effort to revitalize our movement, should consider adopting a virtual mascot, a pony named Single Payer. We could give it a trial run against a field of ponies representing private equity, corporations, billionaires, industry-supported politicians and deaf government bureaucrats. Since they all operate in secrecy, for this test run we could give our pony the lucky pseudonym Rich Strike (sound on, full screen) … from behind, Rick Strike (Single Payer) wins!

Okay, just a pretend virtual reality, but if they are going to tell us that we want value-based care for all in the form of privatized Direct Contracting/REACH and then force it upon us, can’t we, as the people, force single payer onto the billionaires, bureaucrats, and politicians – for the benefit of all of us? I’d like to ride that virtual pony!

http://healthjusticemonitor.org…

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Summary: A JAMA viewpoint published in December advocated Medicare Advantage for All, ignoring the sordid record of Medicare Advantage plans. Those plans extract tens of billions in profits, avoid and eject unprofitable patients, decrease funds available for medical care, have a worrisome quality record, and constrain patient choice of providers. Inserting private insurers into Medicare for All would fatally undermine such reform.

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Letter to the Editor, JAMA, April 26, 2022, by Drs. Adam Gaffney, David Himmelstein, and Steffie Woolhandler

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[A recent JAMA viewpoint by Zahner et al advocates] Medicare Advantage (MA) for all over single payer reform. Zahner acknowledges that Medicare Advantage plans raise Medicare’s costs but offers no estimate of the excess expense (and waste) entailed in subcontracting universal coverage to private insurers. The 2020 national health expenditure estimates, coincidentally released the day before this Viewpoint, offer insight into this waste.

In 2020, private insurers’ overhead totaled $301.4 billion, vs. $236.6 billion in 2019. Privately administered Medicare plans accounted for $63.4 billion of the total (up 41.2% from 2019); $55.5 billion (up 64.9%) went for overhead of privately administered Medicaid plans. Overhead consumed 15% of Medicare Advantage premiums in 2020, eight-fold higher than traditional-Medicare’s 1.9% overhead, implying that subcontracting to private plans raised Medicare’s overhead by $55 billion.

Medicare Advantage plans’ high overhead explains the paradox that they cost 4% more, yet pay-out less to doctors and hospitals than traditional Medicare. While profits per se account for some excess overhead, much reflects the bureaucracy erected to garner profits – e.g. network management, utilization review and referral restrictions – bureaucracy that cuts both high- and low-value services. Additional billions go for upcoding and other schemes that Medicare Advantage plans have used to outmaneuver CMS’ risk adjustment efforts for decades, belying Zahner’s prediction that tweaks to risk adjustment will eliminate overpayments.

Zahner asserts that Medicare Advantage plans offer better quality, citing an exploratory study encompassing mainly lower-cost services and patients, a profitable group that Medicare Advantage plans structure their benefits to attract. Yet MedPAC cautions that the lack of data precludes definitive quality comparisons. Moreover, the exodus from Medicare Advantage of patients needing high-cost services like dialysis, skilled-nursing or home care, offers “revealed-preference” evidence that Medicare Advantage poorly serves unprofitably-ill patients.

Patients want good coverage and unrestricted choice of doctors and hospitals, not – as Zahner suggests – choice of which insurance plan processes the bill. Traditional Medicare offers virtually unrestricted choice, but its coverage, which leaves many with large uncovered bills, needs improvement. The Congressional Budget Office estimates that an expanded and upgraded version of traditional Medicare could provide universal, first-dollar coverage, while achieving administrative savings that would reduce overall costs, even while expanding clinical spending and patients’ choices. In contrast, Medicare Advantage for all would perpetuate the upward spiral of healthcare spending, divert more medical resources to insurers and restrict choice.

Far from looking to Medicare Advantage as a model for reform, we should question whether it should play any role at all.

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Comment:

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

Private insurers now get the majority of their total premium revenues from Medicare Advantage (MA) and Medicaid managed care. And their overhead from those programs is enormous; in 2020, MA overhead averaged $2,256 per enrollee. Because that overhead is pushing the 15% limit mandated by the Affordable Care Act, MA insurers have been shifting profits to the provider groups and prescription management firms they own, whose profit/overhead is not capped; UnitedHealthcare, the biggest MA insurers, also controls more than 60,000 clinicians and paid $90 billion to its non-insurance subsidiaries in 2021. They are further boosting income and profits through diagnostic upcoding.

So expect to hear a rising chorus of calls (orchestrated by the private insurance industry) to expand Medicare Advantage and similar programs. CMS has is already implementing one such program, Direct Contracting Entities, although protests by patients and providers forced it to rebrand that program as “REACH”. REACH would auto-assign (without their knowledge or consent) most remaining traditional Medicare enrollees to managed care plans, many of them owned by the same firms that dominate MA. HJM has critiqued REACH, most recently here.

Health reform must eject the insurance middlemen who are draining resources from care.

http://healthjusticemonitor.org…

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Summary: Friends around the world watch in disbelief as the US is mired in democratic crisis, hoping we re-normalize soon. The frailties of our political system are on display, challenging its core strengths. This battle is paralleled in the health system, with similar dynamics and perhaps linked futures.

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Comment:

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

A European colleague texted me, in response to the news about Roe v. Wade and the divisive implosion of our politics: “I so don’t get your country. Nor do I understand my constant curiosity about it. It’s like watching a video of a car crash – you can’t look away but you cringe throughout!”

I think I know why: the US embodies the best and worst of political systems. This fraught duality is echoed in our health system. Indeed, health reform has the potential to mitigate our political ills.

Here’s my theory:

The best: The US is a beacon of modern democracy – the first (late 18th century), and the global defender (most notably World War II, and most recently in Ukraine). The US has no other fundamental societal identity – it is comprised almost entirely of immigrants to a land of freedom and opportunity. Meantime global democratic forces are weakening (India, China, Russia, Turkey, Hungary, Brazil, Myanmar, Nicaragua, etc), so the US as the last large democracy takes on special meaning. Observers from around the globe root for the continued success of our inspiring democratic example.

Yet: The US is guilty of horrendous systematic oppression of people of color through centuries of enslavement, marginalization, and in recent decades mass incarceration. Women have been subjugated and objectified, by law and culture. Despite formal separation, religious values influence state rhetoric and laws. Beyond our borders, the US has an inexcusable history of abusing its vast global reach. Many of us are deeply embarrassed by these flaws; reversing them is an ongoing struggle.

US history is a cycling battle between two fundamental values: Liberty (free of government control, especially national) vs. Community (government protecting the vulnerable). Since “Community” typically entails spending for the middle and lower classes, “Liberty” is often motivated by protection of wealth. Post-Great Depression and -WWII, “Community” triumphed, with FDR’s New Deal and LBJ’s Great Society, known as the “post-war liberal consensus”. But in 1980 Reagan started decades of deconstruction of social programs and lowering of taxes. Now “Liberty” is ascendent, as in the 1920s and 1850s. Enabling this, our “democracy” is procedurally flawed via the over-representation of small states, such that a minority can wield control. Historic wealth inequality reinforces the “Liberty” trend.

The looming reversal of Roe v. Wade reflects this ascendancy. As previously discussed in HJM, the current conservative Supreme Court reflects how aggressively, undemocratically, and even fraudulently the controlling minority succeeded in creating a court to do its bidding. The vast majority of US adults support retaining a 50-year-old decision protecting the right for women to choose abortion. It doesn’t matter: the packed court represents the minority in power.

Likewise, the dysfunction of our health system – with extravagant costs and excess deaths – represents this ascendancy of a minority. It reflects how aggressively, undemocratically, and even fraudulently the controlling minority – corporate health insurers, providers, and drug manufacturers – succeeded in creating federal legislators and bureaucracy to do its bidding. The vast majority of US adults support having the federal government pay for health care (as long as new taxes are offset by savings in premiums and out-of-pocket costs). It doesn’t matter: the packed federal decision-makers represent the corporate shareholders.

See the parallel?

The US sticks out like a sore thumb on health care. All other wealthy nations and many developing ones implement the principles of solidarity and human rights in health. A universal right to health has been uncontroversial. American exceptionalism in this context is especially mystifying and embarrassing.

There are more similarities: Just like our democracy has core strengths and appalling weaknesses, so does our health system. We excel on research and specialty medical care, but fall far short on financing methods, access, and primary care. We don’t vacillate between competing financing models, instead we combine them in an unwieldy mix that shifts over time.

An appealing link is in the solution: Reforming health care would lay the groundwork for a much-needed political calming and normalization. Single payer is the perfect cross-political policy. The progressives get the “community” they want – caring & equity. The conservatives get the “liberty” they want – shed the morass of divergent public and private insurer requirements we currently endure in favor of a simpler and less burdensome payment system. Estimated daily savings in electronic health record time for doctors: 1-2 hours. Free choice of providers. Straight up competition for patients, based on quality of service. I recognize that selling single payer to conservatives is a heavy lift, because the dreaded government will pay. But dozens of countries demonstrate that for providers and patients, it is loved and taken for granted, even with conservative governments.

Will real health reform treat our democratic malaise? Sharing the joys of universal health care access, with a renewed focus on clinical care instead of financial issues, while controlling costs through stripping away of administrative hassles and corporate profits – that’s bound to lower our democratic hypertension.

It won’t be easy. It’s the change struggle to end our democratic struggle.

To my colleague, I say: “It does look like a car crash, but maybe we’ll regain control just in time.”

http://healthjusticemonitor.org…

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Summary: Medicare’s funder is defending its plan to yield control of the traditional fully public side of Medicare to private investors. The evidence they present is flawed, and the story they tell is misleading. This is abetting a corporate Medicare money grab.

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Expanding Accountable Care’s Reach among Medicare Beneficiaries, by Douglas Jacobs, Purva Rawal, Liz Fowler, and Meena Seshamani, New England Journal of Medicine, April 27, 2022

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The CMS Medicare ACO [Accountable Care Organization] portfolio consists of the Center for Medicare’s Shared Savings Program and the Center for Medicare and Medicaid Innovation’s ACO models. The Shared Savings Program, now 10 years old, includes 483 ACOs serving more than 11 million Medicare beneficiaries and more than 525,000 participating clinicians. Such ACOs have been found to perform better on certain patient-experience and performance measures than physician groups participating in the Merit-Based Incentive Payment System (see table). The Innovation Center has tested several ACO models, of which the Pioneer ACO and ACO Investment Models have achieved net savings; others, including the Advance Payment ACO Model and the Next Generation ACO Model, have not. …

The Innovation Center is currently testing the Global and Professional Direct Contracting Model, which has been redesigned as the ACO Realizing Equity, Access, and Community Health (ACO REACH) Model. This model will examine the effects of new risk-sharing arrangements in traditional Medicare, additional flexibility for beneficiaries (such as the ability to receive in-home care management), provisions for advancing health equity, and reduced administrative burdens for providers on quality of care and Medicare’s costs.

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Comment:

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

This is a defense by CMS (the Medicare funder) of the new ACO REACH program, the relabeled “Direct Contracting Entities”. Dr. Fowler runs CMMI, the part of CMS that oversees these programs. HJM has already critiqued REACH. And this new defense is unconvincing. Scrutinize the key assertions:

Assertion 1: ACO programs saved $6 billion for CMS over five years

Sounds like a lot of money, but it’s only 0.3% of relevant Medicare spending in that period.

And, it’s imaginary, for three reasons:

(a) It’s based on a strain-credulity extrapolation from data pre-2016 to after 2018. That is, it’s a structured guess.

(b) The estimated small savings pre-2016 come from ACOs that remained in the Pioneer program, yet the ACOs that dropped out – and thus were omitted from calculations – had near zero savings (see here, page 74). In medical research, that’s called biased attrition, and violates “intention to treat” analysis standards. It exaggerates the effect, even creates an effect where there isn’t one.

(c) To make matters worse, we have very good evidence that ACOs upcode diagnoses. This is another way to create apparent savings when there aren’t any.

Assertion 2: ACOs improved quality

The table lists some quality improvements. However, note the small (and mostly statistically non-significant) differences between ACOs and the comparison group. More importantly, note that only 10 measures are listed out of at least 40 — cherry-picking the favorable findings.

Assertion 3: REACH builds on this ACO success

Even if ACOs did work (unlikely, see above!), to equate DCEs and ACOs is ridiculous.

ACOs were predominantly medical provider organizations. In contrast DCEs are predominantly investors – private equity. They are flocking to this business opportunity because they see big dollar signs. They can upcode diagnoses to raise payments from Medicare, reduce care, and keep all of the net savings up to 25% (and more after that).

REACH, though packaged more cleverly than DCEs, is also designed for and dominated by investors. REACH highlights equity, but the fundamental profit-taking structure is intact.

CMS is slanting the playing field toward corporate investors, enabling private companies to steal hundreds of billions from Medicare right in front of our eyes.

When will we say, “Medicare is for patients, not profits?” When will we say, “Medical care is for patients, not profits?” When will we say, “Time for single payer?”

http://healthjusticemonitor.org…

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Summary: We hear lots, including from former President Obama, about the serious problem of disinformation stoked by social media algorithms, polarizing our society. What we hear less about is disinformation regarding private health insurance that comes from both Dems and the GOP and that compromises our ability to get care. We must address both.

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‘Regulation has to be part of the answer’ to combating online disinformation, Barack Obama said at Stanford event, Stanford News, April 21, 2022, by Melissa De Witte, et al.

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Former U.S. President Barack Obama delivered a keynote address about how information is created and consumed, and the threat that disinformation poses to democracy.

Obama told a packed audience of more than 600 people in CEMEX auditorium – as well as more than 250,000 viewers tuning in online – that everyone is part of the solution to make democracy stronger in the digital age and that all of us – from technology companies and their employees to students and ordinary citizens – must work together to adapt old institutions and values to a new era of information. “If we do nothing, I’m convinced the trends that we’re seeing will get worse,” he said.

During the 1960s and 1970s, the American public tuned in to one of three major networks… “When it came to the news, at least, citizens across the political spectrum tended to operate using a shared set of facts – what they saw or what they heard from Walter Cronkite or David Brinkley.”

Fast forward to today, where everyone has access to individualized news feeds that are fed by algorithms that reward the loudest and angriest voices (and which technology companies profit from). “You have the sheer proliferation of content, and the splintering of information and audiences,” Obama observed.

Facts are competing with opinions, conspiracy theories, and fiction.

“Solving the disinformation problem won’t cure all that ails our democracies or tears at the fabric of our world, but it can help tamp down divisions and let us rebuild the trust and solidarity needed to make our democracy stronger,” Obama said.

The responsibility also lies with ordinary citizens, the former president said. “We have to take it upon ourselves to become better consumers of news – looking at sources, thinking before we share, and teaching our kids to become critical thinkers who know how to evaluate sources and separate opinion from fact.”

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Republicans Have Stopped Trying to Kill Obamacare. Here’s What They’re Planning Instead, Politico, April 26, 2022, by John E. McDonough

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So it doesn’t take a lot of effort to observe an active health policy ecosystem on the right that is busy recycling and developing ideas that would influence the direction of health policy in a future Republican-dominated federal government. Most of their attention focuses on the employer and individual commercial health insurance markets and the federal-state “marketplaces/exchanges” — the ACA-created entities where individuals and small employers can buy health insurance, ironically a model adapted by Democrats from a Heritage Foundation idea pioneered in the 1990s and early 2000s.

The result would be a system with more options and fewer guarantees. Giving employees less money to cover slimmed-down health insurance will lead many workers to forego coverage entirely. Are conservative politicians prepared to look the other way when they develop serious diseases and have no way to pay for care?

The two behemoths of federal health policy, Medicare for senior citizens and many disabled, and Medicaid for low-income households of every variety, are far less the reform target of Republicans and conservatives than they used to be. An essential reason for this is that both programs, with little controversy, have become increasingly privatized.

Indeed, a small and growing chorus of voices now suggest that Medicare Advantage could be the foundation for a unitary and reformed national health system, not Sanders’ “Medicare for All” which would eliminate Part C, but “Medicare Advantage for All” that would eliminate Medicare A and B, and make Part C universal.

In sum, conservative and Republican health policy voices, in spite of a full retreat on ACA repeal, are active and ambitious to reengage if and when Republicans retake the Senate and/or the House. This is especially true regarding private commercial health insurance, inside or outside of the ACA’s health marketplace/exchanges. They are ready to confront any and all threats to the growing hegemony of Medicare Advantage and to find new opportunities to expand it. They stand on the sidelines regarding fast-growing interest in health care equity and social determinants of health. They are down for the current moment and will be back with ideas and plans when the political climate changes. If prior history matters, so will their emerging ideas.

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Comment:

By Don McCanne, M.D.

Much of the noise around disinformation today stems from the misuse of online social media technology such as Twitter and Facebook. The massive threat that this disinformation poses led Barack Obama to speak on the issue in a conference at Stanford University. Although the hype has been about the technology, we should also be concerned about the transmission and misapplication of disinformation regardless of dissemination paths.

Look at our health care system. Is it suffering from disinformation propagated by social media, or is its failure due to disinformation spawned by political ideology and transmitted via all sorts of communication channels?

Obamacare is a system established by the Democrats built on a foundation of a Republican concept of federal-state marketplaces/exchanges. The public Medicare program established by Democrats is now well on its way to becoming private Medicare Advantage plans, and Medicaid is also largely taken over by private insurers. These are Republican concepts being implemented by Democrats. It is difficult to see how disinformation has not played a major role – not the disinformation that Obama addresses in this speech, but his administration’s disinformation about health policy. It brought us today’s flawed health care financing.

Obama is right when he says that all of us must work together to adapt old institutions and values to a new era of information. That means out with the old disinformation, and in with valid health policy science. An essential feature of valid health policy science is truth. Out with fiction; in with facts. Those of us at HJM and Physicians for a National Health Program stand ready to help you sort out and discard the rampant disinformation that has permeated our health care system so that we can implement a system of health care justice for all.

http://healthjusticemonitor.org…

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