PNHP

Docs Come to D.C. to Protest Medicare’s Direct Contracting Program

Docs Come to D.C. to Protest Medicare’s Direct Contracting Program

Would be the end of traditional Medicare, they say

By Joyce Frieden
MedPage Today, December 1, 2021

WASHINGTON — Medicare’s direct contracting program, if it is allowed to continue, will be the end of traditional Medicare, a physician group said here Tuesday.

Two dozen members of Physicians for a National Health Program (PNHP), which supports a single-payer healthcare system, and other healthcare groups attended a rally in front of the Department of Health and Human Services (HHS); they brought with them petitions to HHS Secretary Xavier Becerra asking him to stop the program.

“We all benefit when everyone has access to healthcare,” said Susan Rogers, MD, PNHP’s president and a retired internist from Chicago. “And the only way to do that is to have a system that does not include profit margins or shareholder dividends disguised as a middleman. We cannot allow the ongoing onslaught of privatization with these direct contract entities.”

The direct contracting program, which began under the Trump administration, “creates opportunities for a broad range of organizations to participate with the Centers for Medicare & Medicaid Services (CMS) in testing the next evolution of risk-sharing arrangements to produce value and high quality healthcare,” according to a CMS fact sheet. “The payment model options available under direct contracting also leverage innovative approaches from Medicare Advantage and private-sector risk-sharing arrangements.”

The program, which includes three different types of direct contracting models, will offer “both capitated and partially capitated population-based payments that move away from traditional fee-for-service” and seeks to broaden participation “by allowing model participation by organizations new to Medicare fee-for-service, such as physician managed organizations that currently operate exclusively in the Medicare Advantage program … and innovative, new organizations that seek to assume responsibility for Medicare fee-for-service beneficiaries in a geographic target region,” according to CMS.

This is bad news for the program on several fronts, PNHP members say. First, it allows insurers and other commercial entities to enter the Medicare fee-for-service market. “I personally used to think it was a great idea” to let for-profit entities get involved in healthcare, PNHP board member Ed Weisbart, MD, a retired family physician from St. Louis who attended the rally, said in a phone interview Monday.

“I went to medical school because I loved the idea of having financial interests aligned with making us healthier; I thought that was a great idea … And I worked inside the managed care industry for years and years because I really did think that. But what I actually learned was that that’s the opposite of the truth. In reality, when you have a for-profit entity in charge of your health, the best way to make money is to impede the care of people who are sick with high-end, expensive illnesses,” Weisbart said.

Another problem is the program’s “auto-enrollment” feature, he continued. “The way this is set up is for CMS to data-mine their claims and find — or think they find — your primary care physician. And if your primary care physician has signed a contract with a direct contracting entity, they will automatically capitate the direct contracting entity for your care, and you won’t be told that. Or you might be told that, but it will be a typical bureaucratic letter that will say at the very top, ‘You don’t need to take any action about this.’ So you might get a letter, but you certainly won’t be asked for your approval. If you actually learn about it and decide you don’t like the idea, there is no opt-out alternative. You can’t get yourself out of this.”

Melinda St. Louis, director of Public Citizen’s Medicare for All program, agreed. “This direct contracting experiment could lead CMS to auto-assign as many as 31 million people involuntarily to a Medicare Advantage-type health plan that they specifically opted not to join when they signed up for traditional Medicare,” she said at the rally.

“This is an unacceptable ‘bait and switch’ that presents real threats to people enrolled and to the Medicare program overall. With private insurers and the for-profit investors in the program, maximizing revenues, not quality of care, will become the central focus, and that is the problem with our current broken, expensive, and cruel healthcare system,” St. Louis said.

Currently, 53 direct contracting entities — including physician practices, health systems, and insurers, have signed up for the program, “but there are six [entities] that are really big ones,” with the vast majority of potential members, Weisbart said. “And those six are all insurance company-owned.”

The group brought petitions signed by 13,000 people, including 1,500 physicians, asking for the program to be stopped. However, they were not allowed to present their petitions to the HHS secretary, and no one at the building’s reception desk would accept them.

“Their department knew we were coming; we had made multiple phone contacts with them,” said Claire Cohen, MD, a child psychiatrist from Pittsburgh. “Despite that, when we got in, we were not able to deliver our petitions.”

CMS was unable to comment by presstime on the issues the group raised about the direct contracting program. HHS also did not respond to a question about why the group’s petitions were declined.

https://www.medpagetoday.com…

High Profit COVID Vaccines

Summary: A new article in the Journal of the Royal Society of Medicine describes how the price charged by US-based COVID-19 manufacturers exceeds production costs by 10-fold or more. That’s a stunning profit margin, for technology developed with huge government support and a guaranteed market. Comprehensive pharmaceutical price regulation is essential in any comprehensive health care financing reform.

The costs of coronavirus vaccines and their pricing, Journal of the Royal Society of Medicine, November 2021, by Donald W Light and Joel Lexchin

COVID-19 vaccines need to be as globally affordable and accessible as possible as a public health good to help counter [the] threat to global public health.

[P]ublic funding to corporations has directly or indirectly financed all phases of vaccine research, development, testing and manufacturing, including the development of the innovations on which the RNA platform (mRNA) and other vaccines are based. Billions in funding from taxpayers, multiple branches of the United States (USA) government, from the European Union (EU) and countries such as Germany, has been so extensive that there is little investment or sunk costs for corporations to recover, except perhaps for those associated with manufacturing the vaccines themselves. In addition, company costs for liability are minimised, as are the large marketing costs typical of pharmaceutical products.

AstraZeneca [British-Swedish] has said it is selling its Oxford-based vaccine without profit during the global pandemic, but its inter-country price per dose varies – $2.15 in Europe, $3–4 in the USA and $5.25 in South Africa … Moderna and Pfizer [American] were charging more affluent nations and the EU for their mRNA vaccines with prices ranging from $14.70 to $23.50 a dose. Do their costs of developing and manufacturing vaccines, net of public subsidies, justify these prices, or are the companies just ‘making a killing’?

Adding these costs together, net manufacturing costs for 100 million doses ready for shipping appear to range from US$ 0.54 to US$ 0.98 a dose.

Comment:

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

This excellent synthesis of available cost information [imprecise, because cost detail is treated as proprietary] demonstrates that COVID-19 vaccine production costs are a very small fraction of charged prices. Especially for US-based manufacturers.

Of course we want companies to profit from drug development success – and the COVID-19 vaccines are a remarkable, indeed historic example of that. But the work was done with huge government financial support, the market is guaranteed by the government, and liability is restricted. So why do prices need to exceed costs by ten-fold or more?

They don’t. AstraZeneca – the only non-US company in this mix – charges about 85% less than Moderna and Pfizer.

Fair returns, based on full disclosure of production costs and reasonable adjustment for government support, is the proper basis for determining price.

The Build Back Better social infrastructure bill currently in Congress includes a few drug price control mechanisms, but far less scope than originally proposed – for limited numbers of drugs, and substantially gameable. More on that another day.

We need drug price controls as the default condition, not voluntary or sporadic.

http://healthjusticemonitor.org…

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Medicare Direct Contracting press conference

PNHP president Dr. Susan Rogers led a delegation of physician leaders to Washington, D.C. on November 30, 2021, where they demanded an immediate end to the stealth privatization of Medicare through the Trump-era Direct Contracting program.

Dr. Rogers was joined by PNHP past president Dr. Ana Malinow; national board members Drs. Judith Albert and Ed Weisbart; PNHP of Western PA leader Dr. Claire Cohen; and Students for a National Health Program (SNaHP) leader Edward Si. They spoke about the dangers of DCEs and highlighted a petition with more than 13,000 signatures collected by PNHP and Public Citizen.

To learn more about the dangerous and insidious Medicare Direct Contracting program, visit pnhp.org/StopDCEs.

Congress ‘Asleep at the Switch’ as Biden Continues Trump-Era Ploy to Privatize Medicare

More than 1,500 physicians warn that the experiment threatens "the future of Medicare as we know it."

By Jake Johnson
Common Dreams, November 30, 2021

A Trump-era pilot program that could result in the complete privatization of traditional Medicare in a matter of years is moving ahead under the Biden administration, a development that—despite its potentially massive implications for patients across the U.S.—has received scant attention from the national press or Congress.

On Tuesday, a group of physicians from around the nation will try to grab the notice of lawmakers, the Biden White House, and the public by traveling to Washington, D.C. and demanding that the Health and Human Services Department immediately stop the Medicare experiment, which is known as Direct Contracting (DC).

The doctors plan to present HHS with a petition signed by more than 1,500 physicians who believe the DC pilot threatens “the future of Medicare as we know it.”

Advocates have been publicly sounding the alarm about the DC program for months, warning that it could fully hand traditional Medicare over to Wall Street investors and other profit-seekers, resulting in higher costs for patients and lower-quality care.

“Everything we know about Direct Contracting should be cause to halt the pilot,” Diane Archer, the founder of Just Care USA and the senior adviser on Medicare at Social Security Works, told Common Dreams in an email. “Direct Contracting effectively eliminates the more cost-effective traditional Medicare program designed to ensure that people with complex health conditions get the care they need.”

“The Direct Contracting experiment is likely to be both a healthcare policy and a political nightmare,” Archer argued. “We already know from the Medicare Advantage experiment that Direct Contracting won’t save money, nor will it be able to show improved quality.”

But healthcare campaigners’ concerns have fallen largely on deaf ears in Congress and the Biden administration, which has allowed much of the pilot program to proceed as planned.

In a phone interview with Common Dreams ahead of Tuesday’s demonstration at HHS headquarters, Dr. Ed Weisbart—chair of the Missouri chapter of Physicians for a National Health Program (PNHP)—said that Congress is largely “asleep at the switch” as Wall Street-backed startups and private insurance giants close in on traditional Medicare, a 56-year-old program that covers tens of millions of U.S. seniors.

“People don’t know that it’s happening,” Weisbart, one of the physicians traveling to the nation’s capital, said of the DC experiment. “Most people in Congress don’t know that it’s happening. We’ve started having some of these conversations with congressional staff, and we’re hoping to have many more of them next week when we’re there, but it’s not on their radar either.”

“That’s the disturbing part,” he added. “How radical the transformation of Medicare is becoming under this new model, how widespread it will be—it’ll be the entire book of business—and yet that’s occurring with neither the awareness nor consent of Congress.”

The DC program was established by the Center for Medicare and Medicaid Innovation (CMMI) during the waning months of the Trump administration, which included former pharmaceutical industry executives, Wall Street bankers, and right-wing policy consultants notorious for gashing public health programs.

Under the DC model, so-called Direct Contracting Entities (DCEs) are paid monthly by the Centers for Medicare and Medicaid Services (CMS) to cover a specified portion of a patient’s medical care—a significant shift from traditional Medicare’s direct reimbursement of providers.

DCEs are allowed to pocket the funding they don’t spend on care, an arrangement that critics believe will incentivize the private middlemen to skimp on Medicare patients—many of whom could be auto-enrolled into DCEs without their knowledge or permission.

According to a policy brief released by PNHP, “Virtually any company can apply to be a DCE, including investor-backed startups that include primary care physicians, [Medicare Advantage] plans and other commercial insurers, accountable care organizations (ACOs) or ACO-like organizations, and for-profit hospital systems.”

“Applicants are approved by CMS without input from Congress or other elected officials,” the group notes.

At present, the pilot includes 53 DCEs in 38 states, Washington, D.C., and Puerto Rico. Drs. Richard Gilfillan and Donald Berwick pointed out in a September article for Health Affairs that 28 of the current DCEs are controlled by investors, not healthcare providers. A second tranche of DCEs is expected to debut in January 2022.

Dr. Ana Malinow, a physician from San Francisco who is taking part in Tuesday’s petition delivery, said in a statement that “Medicare Advantage—the first wave of Medicare privatization—showed us that inserting a profit-seeking middleman into public coverage does not save money for taxpayers, but rather costs more money while also taking away care choices from seniors.”

“If left unchecked, the Direct Contracting program will hand traditional Medicare off to Wall Street investors, without input from seniors, doctors, or even members of Congress,” said Malinow. “Health and Human Services Secretary Xavier Becerra has the power to stop this Trump-era program in its tracks, and must do so now.”

The DC experiment was launched by the Trump administration but actually has its roots in the Affordable Care Act (ACA), which established CMMI with the stated goal of identifying “ways to improve healthcare quality and reduce costs in the Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) programs.”

The ACA granted CMMI, also known as the Innovation Center, the authority to test alternative payment and service delivery models on a national scale without congressional approval—latitude that, in the hands of the Trump administration, ultimately spawned the DC pilot program.

CMMI is currently headed by Elizabeth Fowler, who previously served as vice president of public policy and external affairs for WellPoint, Inc.—a health insurance giant that later became Anthem. Fowler also worked as chief health counsel to former Senate Finance Committee Chair Max Baucus, a right-wing Democrat who infamously had single-payer proponents arrested in 2009 and helped ensure that the ACA did not include a public option.

Weisbart told Common Dreams that while the creation of CMMI may have been well-intentioned, the body’s ability to “so fundamentally and radically transform a public health program that so many Americans rely on” without congressional approval or oversight is a real danger that lawmakers must take seriously.

“Someplace there needs to be congressional oversight,” Weisbart said. “When the public does finally find out that [lawmakers] were asleep at the switch, they’re not going to be happy. This is your chance to do what democracy is intended to do.”

The Biden administration paused the most extreme form of Direct Contracting—known as the Geographic (GEO) model—in March, but it is allowing the Global and Professional Direct Contracting (GPDC) pilot to move forward. According to CMS, the GPDC pilot is expected to play out over a six-year period.

While lawmakers have largely been quiet about the Medicare experiment, a handful of Democratic members of Congress have echoed grassroots demands for an immediate end to the DC program in recent months.

“We appreciate that you paused implementation of the Geographic model,” Reps. Lloyd Doggett (D-Texas.) Bill Pascrell (D-N.J.), Mark Pocan (D-Wis.), Lloyd Doggett (D-Texas) wrote in a May letter to Becerra and then-Acting CMS Administrator Elizabeth Richter. “However, we remain worried that the 53 DCEs participating in the GPDC model, a policy launched under the Trump administration, lacks oversight to protect Medicare beneficiaries’ care.”

“As members of Congress committed to protecting Medicare beneficiaries,” the lawmakers continued, “we ask that CMS immediately freeze the harmful CMMI DCE pilot program including the Geographic model and the Global and Professional Direct Contracting Model and evaluate the impact to beneficiaries.”

In September, Porter took part in a PNHP-hosted webinar that spotlighted the potentially far-reaching harms of the DC pilot.

“This program was supposed to make Medicare more efficient,” said Porter. “But actually it does just the opposite. Rather than allowing patients to go to providers directly under traditional Medicare, DCEs invite insurers and investors to step in and interfere with the care that Americans get.”

“This Direct Contracting Entity model is just one more example of the Trump administration’s many attempts to wreck a functioning, successful, popular government program for the sake of lining the pockets of its corporate donors,” Porter added. “The bottom line for Direct Contracting Entities is not to improve the quality of care. They drive up costs for patients to maximize their profits.”

In a column earlier this month, the Houston Chronicle‘s Chris Tomlinson argued that the Biden administration’s decision to allow the DC program to continue “reflects for-profit health companies and investors’ power over both political parties.”

“Direct Contracting is also likely to kill any chance for progressive Democrats to make Medicare an option for any American who wants to enroll,” Tomlinson added. “If the government puts private companies in charge of all Medicare patients, it will eliminate any opportunity to overhaul our healthcare system truly.”

“Next year,” he added, “millions more Americans will find themselves in privatized Medicare, and most will never know what happened.”

https://www.commondreams.org…

Willie Sutton and the brave new world of Medicare privatization

By Marvin Malek, M.D., M.P.H.
VT Digger, November 30, 2021

In 1938, the notorious bank robber Willie Sutton was asked why he robbed banks. His response: “That’s where the money is.”

Were Willie Sutton alive today, he wouldn’t rob banks. He’d start a Medicare Advantage plan. If he did so, he wouldn’t have to face the risk of incarceration, and the booty would not be a one-time affair, but would instead continue to accumulate year after year.

Contrary to what we’ve been told by the Medicare administrators, Covid was not the main cause of the record 15% increase in Part B premiums announced this month, and will not be reversed in two years when Covid will likely have settled down. Instead, it is the corporate welfare program known as Medicare Advantage and its stealth sibling, the Direct Contracting Entity, that are depleting the trust fund and thereby prompting the higher premiums.

Due to the dominance of a neo-liberal mindset for most of the last 40-plus years, Medicare, the crown jewel of Lyndon Johnson’s Great Society, has turned into a feeding frenzy for private insurers and venture capital entrepreneurs.

During every single one of the 25-plus years since Medicare began outsourcing the Medicare benefit to Medicare Advantage HMOs, the taxpayers have lost money, paying the private plans more than it would have cost Medicare to simply insure these individuals directly through the Medicare program.

HMO/insurers have always been adept at picking off healthy seniors to insure, doing their best to avoid insuring patients with cancer, Alzheimer’s and other expensive illnesses. When this abuse received so much publicity that it became embarrassing, the Center for Medicare and Medicaid Innovation initiated a complex risk adjustment methodology to counter this “cherry picking” of healthier seniors.

But in the ultimate game of Whac-A-Mole, the scheme to prevent private-sector HMOs from bilking Medicare has led to even greater overpayments to the private companies. They still try to pick off healthy people, but have now made a science out of “upcoding” — gaming the risk adjusters to make their enrollees appear to be harboring horrendous chronic illnesses — even their enrollees who appear to be perfectly healthy.

While a beneficiary without risk adjustment will yield these insurers a payment from Medicare of $4,000 a year, Medicare would pay $19,800 for a patient with major depression, morbid obesity and a Stage 3 foot ulcer — year after year! It wouldn’t seem that there is much incentive from the insurers’ point of view to treat the depression, promote weight loss and get the ulcer healed.

The Medicare Trust Fund loses billions on this dysfunctional policy every year — but Wall street investors think the scheme is fabulous.

The overpayments are so great that now most Medicare Advantage plans have the funds to charge only modest premiums or none at all, and provide a small dental and vision benefit not present in traditional Medicare — and, as we’ve seen even more this year than previously, spend millions on advertising.

Don Berwick, M.D., a past director of the Medicare program, correctly characterized it as a money machine. But despite these enticements, the majority of Medicare beneficiaries know that when something seems too good to be true, it probably isn’t true: Medicare Advantage enrollees who actually get sick quickly rack up significant bills. And even if they have an unusual illness, they are forced to stay within the plan’s network of doctors even if an outside specialist is called for.

They won’t have expensive drugs covered if the plan feels that a less expensive drug would be a good alternative (good for the insurance plan, that is), and have to worry that their doctor may lose a preauthorization battle if the insurance company decides a test or treatment the doctor ordered isn’t really necessary.

And if they want to get out of the Medicare Advantage program and return to traditional Medicare with a supplemental plan, the plan is permitted to raise your premium indefinitely, or even refuse to insure you altogether.

So it isn’t surprising that 93% of retired doctors choose to remain within traditional Medicare with a supplemental plan rather than opt for a Medicare Advantage plan. And it isn’t surprising that, during the final year of life when patients almost always face complex medical problems, patients are 10 times more likely to leave a Medicare Advantage plan than try to get into one.

But over just the last two years, Medicare’s administrators have transcended the wasteful stupidity of the last three decades and embarked on a path that can rightfully be regarded as outrageous.

They have decided to auction off traditional Medicare to private plans.

Don’t be deceived by the innocuous term they’re using for these companies: “Direct Contracting Entities.” They’re the same old HMO insurer and venture capital companies with which we’re all familiar: Humana, Cigna, United Health Care, etc. They go from one primary care practice to the next, offering to pay doctors to join their DCE network and allow the insurer to “coordinate” the care they give to the doctors’ entire panel of patients.

Medicare beneficiaries who want nothing to do with a Medicare Advantage plan are paying more up front — approximately $2,000 per year for a supplemental plan and drug coverage — specifically to avoid the intrusion of HMO/insurers into their health care. The Medicare program is now making these people “covered lives” in the Direct Contracting Entity’s networks without even bothering to tell them.

The DCE program was cooked up by a team of harebrained bureaucrats in the Medicare bureaucracy with encouragement from ecstatic insurance company lobbyists eager to take advantage of yet another scheme to bilk the taxpayers for years to come. It will surprise no one when, after this novel corporate welfare program is fully implemented in a few years, the protagonists in the Medicare bureaucracy who concocted this outrage will abandon their jobs in the Medicare program, and find themselves earning six-figure compensation packages at the very insurance companies to which they just handed over the Medicare program.

The stated rationale of the bureaucrats who create these privatization schemes is to eliminate the incentive of the fee-for-service system to overtreat. Unfortunately, all the strategies they devise — without exception — add so much administrative cost that they have the perverse effect of actually increasing total system cost.

High-functioning health care systems internationally do this by using negotiated global annual budgets for hospitals. Other highly effective cost-control strategies are also available, but never seem to gain the attention they deserve: Creating a single software system and providing it to every hospital and doctor in the country free of charge would facilitate information flow and eliminate duplicative testing, creating a national online marketplace of available short- and long-term positions, and lowering malpractice costs would all effectively reduce system cost.

And the most potent of all would be to bring every American into an improved, unprivatized Medicare program with minimal or no out-of-pocket costs.

Rather than costing more, the reduced administrative expense and ability to negotiate down prices of drugs, devices and other system inputs could by itself reduce costs by 15 to 20%. And it would have another impact: It would eliminate the immense financial and physical suffering Americans endure by being priced out of accessing health care.

This “Direct Contracting Entity” scheme began during the final year of the Trump administration, and most observers thought it would be ditched by the Biden administration. But that didn’t happen.

It is time for every concerned American to act. The Medicare program should be enhanced, not fed to ravenous HMOs and venture capital groups or there may be very little left of it in another decade. Medicare must stop wasting our money on privatization schemes.

Contact Sens. Sanders and Leahy and Rep Welch and tell them:

  • Enhance the Medicare benefit to eliminate its unaffordable deductibles and copays and add coverage for eyeglasses, hearing aids and a dental benefit for every single beneficiary, not only those who gamble their health on risky Medicare Advantage plans.
  • Stop the overpayment of Medicare Advantage plans. And eliminate the Medicare Advantage program entirely within five years while the enhanced Medicare benefits are implemented. Truth is, if the overpayments were ended, the companies would exit the Medicare program voluntarily.
  • Immediately end the Direct Contracting Entity scheme, and instead begin a public examination of how this program was quietly implemented without bothering to inform the public or seek meaningful legislative oversight.

The founding mission of the Medicare program should be restored: To ensure the health and financial security to our seniors in an efficient manner, rather than serving as a money machine for the current generation of Willie Suttons.

This commentary is by Dr. Marvin Malek, an internal medicine specialist working at Springfield Hospital. He is also on the executive committee of Vermont Physicians for a National Health Program.

https://vtdigger.org…

Achieving Racial and Ethnic Equity in US Health Care

Summary: The Commonwealth Fund just released an important national and state-by-state review of inequities in health care. The findings are unsurprising and distressing – higher rates of access barriers and mortality from treatable conditions among people of color, and marked variation by state. If only there were a way to pay for health care to efficiently eliminate these inequities…

Achieving Racial and Ethnic Equity in U.S. Health Care: A Scorecard of State Performance, The Commonwealth Fund, November 18, 2021, by David C. Radley, et al

Black and American Indian/Alaska Native (AIAN) people live fewer years, on average, than white people. They are also more likely to die from treatable conditions; more likely to die during or after pregnancy and to suffer serious pregnancy-related complications; and more likely to lose children in infancy.

People’s health also varies markedly across and within states, as does access to health services and overall quality of care. Large racial and ethnic health inequities, driven by factors both inside and outside the health care delivery system, are common.

Issues around cost, affordability, and access to care also contribute to inequities. Black, Latinx/Hispanic, and AIAN populations are less likely to have health insurance, more likely to face cost-related barriers to getting care, and more likely to incur medical debt.

Decades of policy choices made by federal, state, and local leaders have led to structural economic suppression, unequal educational access, and residential segregation, all of which have contributed in their own ways to worse health outcomes for many people of color. The failure to ensure all Americans have reliable health coverage has paved the way to inequitable access to health care.

From Conclusion: Too often in the U.S., race and ethnicity are correlated with access to health care, quality of care, health outcomes, and overall well-being. This is a legacy of structural, institutional, and individual racism that predated the country’s founding and that has persisted to the present day, in large part through federal and state policy. By pursuing new policies that center racial and ethnic equity, expand access to high-quality, affordable care, and bolster the primary care workforce, we as a nation can ensure that the health care system fulfills its mission to serve all Americans.

Comment:

By Don McCanne, M.D.

Achieving racial and ethnic equity has been a goal for as long as I can remember, and after 80 plus years of my life, one devoted to health care, it still hasn’t been achieved, as this Commonwealth Fund report reveals.

Just think about what one public policy could accomplish: establishing an equitable, single payer, improved Medicare for All program. Yes, there would still be perpetual details to attend to, but just think of the gains we would make by taking that first step, making the rest of the gains semi-automatic once the principle of equity is established. Isn’t now the time to finally make that move?

http://healthjusticemonitor.org…

Thanks Giving

Summary: In recognition of this week’s US holiday, today’s post offers heartfelt thanks. First, for a terrific documentary film. Second, to all the groups contributing to the pursuit of single payer health care justice. All best wishes for the day.

Sex, Drugs, & Bicycles, 2020, directed by Jonathan Blank

Award-winning documentary about the Netherlands that exposes the nightmare [not!] of paid vacations, universal healthcare & windmills [among other attractions].

Film’s perspective on US healthcare: “I recently bought secondary health insurance to cover the depression and anxiety caused by my primary insurance.”

Comment:

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

Huge thanks (and kudos!) to the director and production team for this amazing film, which I watched recently with my wife. Captivating live footage, informative and entertaining narration and interviews, fabulous graphics often reminiscent of Monty Python, and stellar original music. And a powerful message: a country (the Netherlands) can combine democracy, progressive personal freedoms, and well-designed social programs to yield economic well-being, excellent health, and happiness. Comprehensive universal healthcare is central. We in the US need to keep absorbing success stories like this to further inspire our progressive change agenda.

Great holiday viewing with your family. You might even do a singalong with this blockbuster “I Love Healthcare”.

Now I’d like to riff on this week’s holiday theme, offering my gratitude to allies in the progressive health reform movement. My “thanks giving” is for:

  • Elected officials in DC and the states who lead the legislative charge for single payer.
  • Progressive lobbyists and activists who work with the elected officials and staff.
  • Healthcare provider groups pushing for single payer.
  • Prominent media voices beating the single payer drum.
  • Pollsters who document the broad public support for government-paid health care.
  • Community organizations that channel and organize public support.
  • >30 wealthy nations which demonstrate daily the elegance of “health care for all.”
  • Policy researchers who quantify the health and financial advantages of single payer.
  • Journalists who distill powerful stories and truth from the blizzard of daily events.
  • Colleagues in HJM, for their principled and incisive tracking of health justice issues.
  • Family members and colleagues who offer ongoing encouragement in this quest.
  • Finally, YOU, the readers of HJM, who join us in the fight for single payer.

(Hope I haven’t missed any groups. Please excuse my not listing individuals … we’ll save that for the official single payer history!)

http://healthjusticemonitor.org…

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Isn’t that what insurance is for?

By Rick Staggenborg, M.D.
Albany (Oregon) Democrat-Herald, Letters, November 23, 2021

As ads everywhere proclaim, it’s Medicare shopping season again!

If you’re shopping, remember that savvy buyers know if a deal seems too good to be true, it probably is. Don’t be tempted by offers of insurance with no out-of-pocket costs, no need for supplementary policies, and expanded coverage, all for the minor inconvenience of having a restricted network of providers instead of having the choice to see any Medicare provider.

What’s not to like? As usual, the devil’s in the details. Ever heard of surprise billing? That’s when you think you’re covered when you go to the hospital, only to find that one or more of the doctors doesn’t accept your insurance.

Similarly, if you have to see specialists for certain conditions and they’re not on the preferred provider list, you pay most or all of the bill. And don’t be surprised if you have to travel great distances to see your doctor and pay for medications that aren’t in the formulary of the drug benefit plan included in the policy.

How else do you think insurance companies make record profits from the unwary who choose Medicare Advantage over traditional Medicare, with a Medigap supplement? It’s all part of the stealth privatization of Medicare, designed to turn Medicare into a cash cow for insurance industry investors.

The wise shopper will choose traditional Medicare over the too-good-to-be-true Medicare “Advantage,” just in case they might actually need to use it for a costly condition. After all, isn’t that what insurance is for?

Dr. Rick Staggenborg is a member of Health Care for All Oregon.

https://democratherald.com…

Doctors to Biden: Don’t hand Medicare to Wall Street investors

Physicians demand an end to the Medicare Direct Contracting program, a Trump-era plan that will enroll millions of Traditional Medicare beneficiaries into for-profit managed care entities, without their knowledge or consent

FOR IMMEDIATE RELEASE: Nov. 30, 2021

Recording of today’s event:

Contact: Clare Fauke, Physicians for a National Health Program communications specialist: clare@pnhp.org

Today a group of physicians from across the U.S. gathered outside the headquarters of the Dept. of Health and Human Services (HHS) to deliver a petition demanding an immediate end to Medicare Direct Contracting (DC), a program launched in the final months of the Trump administration that could fully privatize Traditional fee-for-service Medicare in the next few years, without a vote by Congress. 

DC is a pilot program that aims to enroll every Traditional Medicare beneficiary into a third-party “Direct Contracting Entity” (DCE), often without seniors’ knowledge or consent. Instead of paying doctors and hospitals directly for care, Medicare gives DCEs a monthly capitation payment to cover a defined portion of each seniors’ medical expenses, allowing DCEs to keep as profit and overhead (up to 40% of revenues) what they don’t pay for in medical services — establishing a dangerous incentive for DCEs to restrict seniors’ care.

Virtually any type of company can apply to be a DCE, including commercial insurers, venture capital investors, and for-profit dialysis chains. Applicants are approved by CMS without oversight from Congress. The DC “pilot phase” includes 53 DCEs in 38 states, potentially covering 30 million Traditional Medicare beneficiaries. 

“Medicare Advantage — the first wave of Medicare privatization — showed us that inserting a profit-seeking middleman into public coverage does not save money for taxpayers, but rather costs more money while also taking away care choices from seniors,” said Dr. Ana Malinow, a physician from San Francisco who traveled to Washington to deliver the petition. “If left unchecked, the Direct Contracting program will hand Traditional Medicare off to Wall Street investors, without input from seniors, doctors, or even members of Congress. Health and Human Services Sec. Xavier Becerra has the power to stop this Trump-era program in its tracks, and must do so now.”

More information on Medicare Direct Contracting:

  • Direct Contracting one-page fact sheet
  • Direct Contracting policy primer (4 pages)
  • Form sent to seniors in Indiana University Hospital System requesting voluntary alignment to a DCE
  • Article about Direct Contracting in Health Affairs journal by former CMS Administrator Dr. Don Berwick and former CMS Innovation Center director Dr. Rick Gilfillan: PART ONE and PART TWO
  • List of current DCEs 
  • CONTRACT between CMS and Direct Contracting Entities 
  • Direct Contracting Entities’ Financial Operating GUIDE from CMS

Physicians for a National Health Program (pnhp.org) is a nonprofit research and education organization whose more than 24,000 members support single-payer Medicare for All reform.

Charity Doesn’t Fill the Health Care Void

Summary: St. Jude Children’s Hospital in Memphis TN promises not to bill families for medical care. And they don’t. But parents travel long distances to get this free care, incurring new living expenses and losing job income. Even as St. Jude amasses huge reserves from highly effective charitable fund-raising. With single payer, everyone could get needed care, usually locally. Isn’t that more charitable?

St. Jude Hoards Billions While Many of Its Families Drain Their Savings, ProPublica, November 12, 2010, by David Armstrong and Ryan Gabrielson

St. Jude Children’s Research Hospital promises not to bill families. But the cost of having a child at the hospital for cancer care leaves some families so strapped for money that parents share tips on spending nights in the parking lot.

St. Jude is the largest and most highly regarded health care charity in the country. Each year, the Memphis hospital’s fundraisers send out hundreds of millions of letters, many with heart-wrenching photographs of children left bald from battling cancer.

Last year, St. Jude raised a record $2 billion. U.S. News & World Report ranked it the country’s 10th-best children’s cancer hospital, and St. Jude raised roughly as much as the nine hospitals ahead of it put together. It currently has $5.2 billion in reserves, a sum large enough to run the institution at current levels for the next four and a half years without a single additional donation.

But for many families, treatment at St. Jude does not relieve all the financial burdens they incur in getting care for their children, including housing, travel and food costs that fall outside the hospital’s strict limits, a ProPublica investigation has found.

While families may not receive a bill from St. Jude, the hospital doesn’t cover what’s usually the biggest source of financial stress associated with childhood cancer: the loss of income as parents quit or take leave from jobs to be with their child during treatment. For many families, the consequence is missed payments for cars, utilities and cellphones. Others face eviction or foreclosure because they can’t keep up with rent and mortgage payments.

A substantial portion of the cost for treatment is paid not by St. Jude but by families’ private insurance or by Medicaid, the government insurance program for low-income families. About 90% of patients are insured, bringing in more than $100 million in reimbursements for treatment a year.

Parents at St. Jude have exhausted savings and retirement accounts, borrowed from family and friends or asked other charities for aid.

Comment:

By Don McCanne, M.D.

Although the United States has a very well-funded health care system, its financing is highly dysfunctional. Too many are left either partially or completely out of the system. This is particularly tragic when a child with cancer is left uncovered, but at least some of us have charitable instincts. This accounts for the success of the nation’s most comprehensively funded children’s cancer hospital: St. Jude.

This is the best we have to offer those of limited means. But, based on this comprehensive report by ProPublica, it is still clearly insufficient, leaving many families destitute. Rather than relying on charity, wouldn’t it be better for the nation to join together and restructure our health care financing system so that it works for all of us, where we live? We certainly have enough funds. We merely need to establish an equitable, single payer, Medicare for All system.

Google “Charity.” The first item that comes up is St. Jude. With no increase in our current national spending, the first item that could come up in our hearts might be “a single payer national health program that covers everyone.” Wouldn’t that be much more effective in fulfilling our charitable aspirations?

http://healthjusticemonitor.org…

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Inside the Medicare Advantage plans, many now being probed

By Stephen Kemble, M.D.
Honolulu Star-Advertiser, “Island Voices,” November 21, 2021

This is open enrollment season for Medicare Advantage (MA) plans, and the public is being inundated with celebrity TV ads promising expanded benefits and low or no premiums and urging viewers to choose a Medicare Advantage plan now, with no mention of the option of traditional Medicare plus a “Medigap” supplement plan. So, what is Medicare Advantage and how does it work?

Medicare Advantage is a privatized form of Medicare. Instead of Medicare paying doctors and hospitals directly, it pays an insurance company intermediary a fixed amount per member and the insurance plan negotiates payment rates with providers of care. Unlike regular Medicare, MA plans are managed care plans and often use restricted networks of doctors and hospitals and they can impose prior authorizations and formulary restrictions.

So how can they offer expanded benefits and low or free premiums? They market to the healthy with gym memberships and other perks, and they often restrict their formularies and physician networks to discourage patients with expensive conditions from joining or staying in the plan. This is called “cherry-picking” and “lemon dropping,” and it is a consequence of per-member pre-payment with the opportunity to profit or lose if less or more is spent on health care than the capitated amount. The strongest determinant of financial success is securing a favorable risk pool of healthier than average subscribers.

Medicare added risk adjustment, which is intended to pay more for sicker, “higher risk” members so as not to discourage covering sicker people. The initial formula was based on demographics such as age, sex, and income, but it only predicted about 2% of the variability in cost and failed to deter “cherry-picking.”

In 2004, Medicare added diagnoses to their risk adjustment formula, and this improved its accuracy from 2% to 12% of cost variability. This is still way too inaccurate to discourage cherry- picking, and it introduces a great new way for MA plans to game payment — upcoding!

The MA plans soon discovered that by persuading their network doctors to give patients the most severe diagnoses they possibly could, they could rake in a lot more money. If a patient is diagnosed with diabetes, obesity, and mild heart failure, Medicare might pay the MA plan $9,000 per year, but if the
diagnoses are changed to “morbid obesity,” “diabetes with retinopathy,” “chronic obstructive pulmonary disease,” and a “stage 3 ulcer,” their payment jumps to $32,000 per year.

The MA plans soon deployed representatives to patient homes and doctors’ offices looking for any justification they can find to inflate diagnoses. Some have resorted to using hints in the patient’s record to add diagnoses that were never given by a doctor. Even worse, if a patient leaves a MA plan to go back to regular Medicare and tries to buy a “Medigap” supplement, the Medigap plan can hold their inflated diagnoses against them and charge them more, even if the diagnoses are not real.

Recent business news articles have reported multiple whistleblower complaints by employees against MA plans for fraudulent upcoding, and DOJ is now investigating MA plans run by Kaiser, Cigna, Anthem, United Health Group, Sutter, Humana and Aetna for widespread Medicare fraud, to the tune of $30 billion per year at the expense of the Medicare Trust Fund.

A healthy risk pool does not cost the plan too much to insure, and the MA plan can report favorable “quality” measures because healthier people have better outcomes. They can then easily afford gym memberships and extra benefits and low premiums and still make huge profits by billing Medicare for inflated diagnoses.

https://www.staradvertiser.com…

Working Families and Businesses Need Medicare for All Now

Summary: Job-based health insurance premiums increased twice as fast as inflation over the past year, despite 2020 being a year of very low medical payouts and very high profits for insurers. Both employees and employers continue to struggle with the current work-based system. It’s time to separate insurance from the workplace.

2021 Employer Health Benefits Survey, Kaiser Family Foundation, November 11, 2021

In 2021, the average annual premiums for employer-sponsored health insurance are $7,739 for single coverage and $22,221 for family coverage. The average single and family premiums increased 4% over the past year. During this period, workers’ wages increased 5% and inflation increased 1.9%.

The average premium for family coverage has increased 22% over the last five years and 47% over the last ten years. …

Most covered workers make a contribution toward the cost of the premium for their coverage. On average, covered workers contribute 17% of the premium for single coverage and 28% of the premium for family coverage. Covered workers in small firms on average contribute a higher percentage of the premium for family coverage than covered workers in large firms (24% vs. 37%). Covered workers in firms with a relatively large share of lower-wage workers have higher average contribution rates for family coverage than those in firms with a smaller share of lower-wage workers (35% vs. 27%).

http://healthjusticemonitor.org…

Comment:

By Eagan Kemp

Every year we see the cost of insurance go up for working families and businesses of all sizes. The most recent increases highlight that even after a year where many insurers were able to avoid major health costs because many people were forced to put off elective care, insurers are still massively raising rates.

With more than 155 million Americans at the whim of employer-sponsored insurance, it is no wonder people are fed up with the current system and demanding Medicare for All. Seeing more and more of your paycheck eaten up by the cost of health care is depressing enough, without knowing that it is primarily lining the pockets of corporate CEOs making tens of millions of dollars a year while denying Americans the care that they need.

And as the recent fight of Biden’s Build Back Better Act showed, corporations are more than willing to throw around cash to stop reforms that would make it cheaper and easier for people to get the care they need.

These growing costs aren’t hurting just families, they are making it harder for businesses that are already struggling with the losses sustained due to the COVID-19 pandemic, a key reason more business leaders are banding together to fight for Medicare for All.

The only people that want to keep the status quo are those that are profiting from it. It is time to put people over profit by making Medicare for All the law of the land.

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.