PNHP

How Medicare ACOs restrict care and offer dangerous incentives

How Medicare ACOs restrict care and offer dangerous incentives

By Brenda Gazzar
Code Wack Podcast, February 26, 2024

Why is tying a medical provider’s pay to the outcomes of their patients a bad idea? Why else should we be concerned about Accountable Care Organizations (ACOs) and the privatization of traditional Medicare?

To find out, we spoke to Dr. Ana Malinow,  who spent three decades working as a pediatrician with immigrant, refugee and underserved children before retiring as Clinical Professor of Pediatrics from the University of California San Francisco School of Medicine. She’s past president of Physicians for a National Health Program and is currently a lead organizer for National Single Payer and The Movement to End Privatization of Medicare.

This is the second episode in a two-part series with Dr. Malinow.

Check out the Transcript and Show Notes for more!

https://heal-ca.org…

Failure to Address Homelessness Harms Health

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

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

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

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

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

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

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

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

How is the U.S. addressing homelessness?

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

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

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

Comment:

By Don McCanne, M.D.

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

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

https://healthjusticemonitor.org…

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

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

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

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

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

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

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

How So Many Seniors Are Lured Into Medicare Advantage

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

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

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

Friends in High Places

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

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

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

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

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

Bankruptcy and Another Name Change

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

https://prospect.org…

Not One of the Nineteen Doctors in Congress Support Single Payer

Single Payer Action, February 20, 2024

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

The majority of doctors in most polls support single payer.

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

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

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

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

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

So then how do you explain this?

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

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

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

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

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

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

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

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

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

https://singlepayeraction.org…

‘You’re not safe’: How middlemen are corrupting traditional Medicare

By Brenda Gazzar
Code Wack Podcast, February 19, 2024

You’ve probably heard about the dangers of Medicare Advantage, but did you know that traditional Medicare is being privatized too? How is this corrupting our healthcare system even more and what does this mean for patients?

To find out, we spoke to Dr. Ana Malinow, who spent three decades working as a pediatrician with immigrant, refugee, and underserved children in Ohio, Texas, Pennsylvania, and California before retiring as Clinical Professor of Pediatrics from the University of California San Francisco School of Medicine. She’s past president of Physicians for a National Health Program and is currently a lead organizer for National Single Payer and The Movement to End Privatization of Medicare.

This is the first episode in a two-part series with Dr. Malinow.

Check out the Transcript and Show Notes for more!

https://heal-ca.org…

Presidential Leadership in US Health Reform

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

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

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

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

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

But then his fortunes turned.

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

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

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

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

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

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

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

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

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

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

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

Historical Examples:

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

Comment:

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

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

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

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

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

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

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

https://healthjusticemonitor.org…

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

Dr. Paul Song on “Nuances”

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

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

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

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

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

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

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

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

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

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

No Surprises Act has Unpleasant Surprises for Providers & Patients

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Comment:

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

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

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

Other recent examples of regulatory capture covered in HJM include:

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

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

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

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

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

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

https://healthjusticemonitor.org…

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Medicare for All Explained Podcast: Episode 108

A Prologue to the Future

February 15, 2024

Podcast host Joe Sparks brings up the drastic measures imposed by the University of Delaware to confront rising health costs: everything from freezing hiring, to pausing university projects, to curbing employee travel.

“If we would switch from employers paying for health care to a single-payer Medicare for All system,” he says, “then universities and businesses would not have to worry about health insurance.”

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

https://medicareforallexplained.podbean.com

Reversing the Corporate Practice of Medicine

A new organization, Take Medicine Back, is sounding the alarm about the corporate acquisition of medicine, which disrupts clinical care – harming both patients and doctors. The solution: enforce existing laws, create new laws, align physician organizations against corporate control, and unionize physicians.

A Call To Action To Take The Profession Back from Corporate Interests, TAKE MEDICINE BACK, October 2023, by Mitchell Li, M.D.; Sailesh Konda; and Robert McNamara

Conclusion:

The corporate practice of medicine doctrine was integral in providing an ethical basis for the practice of medicine. Today, the AMA explicitly tolerates the corporate practice of medicine, and state prohibitions on CPOM are broadly unenforced. The vast majority of physicians are now employees of increasingly consolidated corporations, while moral injury and burnout among physicians are at unsustainable levels. Rapid horizontal and vertical consolidation of non-physician healthcare corporations that employ physicians not only increases monopoly power over consumers, which in return increases costs, but also increases monopsony power over physician labor. This has resulted in anti-competitive labor practices that lead to intimidation of, and retaliation against physicians who advocate for patients. This places the public at risk through greater corporate influence over the practice of medicine. …

A new era of robust antitrust enforcement in healthcare is needed. Past FTC actions against the AMA restricting the ability to impose ethical restrictions on its members should be re-examined in the context of unintended consequences of enabling corporatization and consolidation. A national prohibition on the corporate practice of medicine is necessary to accompany the strengthening, and enforcement of existing state-based prohibitions. Physician organizations must collectively reject non-physician corporate ownership of medical practices. Reclaiming the profession from corporate interests will take time, and greater protections for employed physicians are needed now in order to protect patients. In the face of legislative inaction at the state and federal level, employed physicians should use the tools available to labor and organize through unionization.

[HJM bolding]

The Corporate Practice of Medicine By The Numbers

  • 74% – Physicians employed by corporate entities
  • 34 – States prohibit the corporate practice of medicine to protect patients – and enforced in none of them
  • 87% – Of physicians say patients trust them less than they did a decade earlier
  • 140 million – Americans facing financial hardship due to healthcare bills
  • $1 Trillion – Worth of private equity transactions in healthcare over the past decade
  • 63%  – Of physicians reporting burnout in 2020 – an all-time high, and rising
  • 2.51 – Replacement ratio of physicians by non-physician practitioners in private-equity owned medical practices
  • 1 in 4 – U.S. Medical Students are considering quitting their studies
  • 58% – of U.S. Medical and Nursing students do not intend to treat patients
  • 1 in 10 – physicians working under or for United Health

Comment:

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

In 1980, NEJM editor Arnold Relman, M.D. issued the warning of the relatively unheralded rise of a huge new industry that supplies health-care services for profit which he labeled the “medical-industrial complex.” He concluded, “How best to ensure that the medical-industrial complex serves the interests of patients first and of its stockholders second will have to be the responsibility of the medical profession and an informed public.”

Apparently the medical profession and the public have largely failed in this responsibility – based on the statistics showing that private ownership and profits are shifting to private equity, yielding dissatisfaction of both health care professionals and, most importantly, patients.

Today’s HJM directs our attention to an organization that is sounding a call to action to “take the profession back from corporate interests.” The name of their organization is simply TAKE MEDICINE BACK. They have produced a very easy-to-read 63-page paper. Their recommendations are complementary to those of Physicians for a National Health Program and other organizations that support health care justice for all.

We should work together to take medicine back from private equity and the corporate world and use it to fulfill our dreams of realizing comprehensive, equitable, affordable, high quality care for absolutely everyone. Those of us who really care are now busy aligning ourselves in the direction that will get us there. Let’s go!

https://healthjusticemonitor.org…

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

Medicare subsidies prop up profits

By Ken Dolkart, M.D.
Valley News (Lebanon, N.H.), Letters, February 9, 2024

Traditional Medicare excels in administrative efficiency. The privatization of Medicare via contracts with intermediary Medicare Advantage (MA) megaliths has required subsidies of $613 billion to reduce premiums for subscribers. Many seniors welcome those negligible premiums offered by MA and the modest-costing additional “bells and whistles” that are so heavily marketed. However, denial and increasing restriction of services, subtle “lemon-dropping” of sicker patients into traditional Medicare, not so subtle coding fraud and the need for added subsidies to assure private profit threatens the financial integrity of Medicare. Patients are starting to share horror stories of denial of specialist care, not to mention the administrative burden on clinicians in trying to get approval for that care. We are recapitulating the 1990s, prior to the ACA, when public disgust arose due to denial of care and rising costs of the deregulated, interstate managed-care industry.

As a subscriber to traditional Medicare, I recently learned that my traditional Medicare premiums have been raised to pay for those subsidies that enable profit by MA plans! MA’s profitized inefficiencies should not require raising premiums on subscribers of traditional Medicare. Those subsidies would be better spent expanding the services of traditional Medicare. Our must trusted form of “universal care” for American seniors is being scavenged by those who turn Reaganesque, anti-regulatory fervor into ways to creatively siphon money off public health dollars.

Promotion of the financial interests of the publicly traded, for-profit medical industry seems to be the chief concern of Health & Human Services, CMS and Congress. We must ask our representatives to develop a coordinated, regulated, care-directed program that integrates clinicians, hospitals, community services and payment programs.

https://www.vnews.com…