By Russell Mokhiber
Corporate Crime Reporter, February 13, 2021

Carolyn Adessa worked for fifteen years as an art therapist for the Bronx Lebanon Hospital Center.

When she retired in 2010, she went on traditional Medicare.

But sometime in 2014 or 2015 her union, SEIU 1199, without her consent, switched her out of traditional Medicare.

This came at a time when Adessa was battling stage four lymphoma at Memorial Sloan Kettering Cancer Center in New York City.

“I was treating this cancer at Sloan Kettering when the union, without my knowledge or approval, switched me out of Medicare,” Adessa said. “This resulted in an incredible amount of stress, and hours on the telephone, in an attempt to have my enrollment in basic Medicare restored. I was sick as a dog. I was going to work every day. Apparently they had sent me a letter saying they were going to take me out of traditional Medicare unless I opted out. And I missed the letter. Suddenly, my bills weren’t being paid. I had to contact my Congressman to get it back.”

“I continue to be outraged by the fact that Medicare would allow any entity to disenroll people from the federal Medicare program under any circumstance,” Adessa said.

Then in November 2020, the union came after her again.

“I started getting letters saying that unless we filled in paperwork to opt out of the Aetna Medicare Advantage program we were going to be in this wonderful Advantage plan,” Adessa said. “My mailbox was deluged with material. Everyday my mailbox was stuffed with these letters. I was just so angry.”

“Why does the federal government allow private insurers to use the word Medicare to sell private insurance plans?” Adessa asks. ‘Most seniors don’t understand that when they sign up for — with the Advantage plan they’re effectively signing out of the traditional Medicare insurance program.”

A spokesperson for SEIU 1199 confirmed that in fact all of the more than 56,000 SEIU 1199 retirees are put into the Aetna Medicare Advantage plan unless they affirmatively opt out. Fewer than one percent have opted out. And in order to opt out, the retirees must meet certain conditions.

The union said in a statement that the Aetna plan does allow retirees to apply for a medical waiver to opt out of the Aetna plan but only “under certain circumstances — if the retiree is currently under treatment for a serious or chronic medical condition, if the retiree’s doctor does not participate in the plan and if a change in physician would jeopardize the retiree’s health.”

Does the union get paid by Aetna for doing this?

No.

Then why don’t the retirees get to choose between traditional Medicare and the Aetna Medicare Advantage plan?

The union could not provide an answer.

Does the union support a federal Medicare for All program that would eliminate private health insurance companies and take health insurance off the table when unions negotiate with their employers?

Again, the union could not provide an answer. (Off the Table, a film produced by Unions for Single Payer, shows how Canadian style Medicare could cover everyone in the US without co-pays, deductibles or premiums, and remove one of the biggest obstacles US labor negotiators face in contract negotiations.)

Adessa’s battle to stay on traditional Medicare comes at a time when private insurance companies have launched an all out barrage on seniors to get them to switch over to private Medicare Advantage plans.

Every senior with a mailbox gets flooded with misleading and outright deceptive mailers.

Just today we received a piece of mail that looked like a notice from the IRS.

The flyer is headlined “Medicare Notice.”

“‘Please call to confirm your eligibility.”

For Medicare?

No for a private Medicare Advantage plan.

In tiny print in the lower right hand corner is this:

“Medicare has neither reviewed nor endorsed the information contained in this advertisement.”

In 2020, 39 percent of all Medicare beneficiaries — 24 million out of 62.1 million Medicare eligible seniors — were in Medicare Advantage programs.

Kay Tillow is with Kentuckians for a Single Payer Health Care Law and Unions for Single Payer.

In an article titled Beyond the Medicare Advantage Scam, Tillow writes that under a Medicare Advantage plan “you may be okay for a time and save money monthly – as long as you don’t get sick.”

“Once you need to use the plan, you will discover the problems that come from being in a for-profit plan that makes more when it denies you care,” Tillow said. “Your choice of physicians will be restricted to a list. The specialist you need may not be anywhere near where you live. The hospitals and rehabs centers will be limited. The post-hospitalization facility available to you is likely to be the one with the worst reputation. The drugs you need may now cost a fortune.’

High profile Medicare Advantage pitchmen on television like former quarterback Joe Namath don’t tell you about that.

“When seniors first sign up for a Medicare plan, they are protected by law against discrimination for pre-existing conditions in the purchase of a Medigap plan,” Tillow writes. “But when a person tries to change back to traditional Medicare later, that protection is gone. Only four states have regulations to prohibit such practices.”

Joe Willie Namath doesn’t mention that either.

“Despite the problems of purchasing a Medigap plan, the negative experiences that Medicare Advantage patients encounter once they get sick induce many to return to traditional Medicare,” Tillow writes. “It all works so well for the insurance companies. While the patient is healthy with few expenses, the company rakes in the money. Once the patient becomes ill and needs more care, many patients, facing massive expenses, will return to original Medicare. Now the extra expenses of a sicker patient will fall on the public once again.”

“Not only do these Medicare Advantage Insurance companies profit at the public trough, they use the seniors who are signed up in their plans to lobby Congress to continue with these rip-offs,” Tillow writes. “America’s Health Insurance Plans (AHIP), the organization of health insurance companies, keeps the deceptions going by telling seniors to let their Congressperson know that their Medicare plan is in jeopardy. All legislative efforts to reduce the massive ill-gotten gains of these companies are defeated by AHIP’s shrewd use of the popular ‘protect Medicare’ sentiment to ward off any reform of the Medicare Advantage plans.”

Dr. John Geyman, author of soon to be released book The Mighty Medical Industrial Complex, says that the companies pushing Medicare Advantage on television claim new benefits for less money, but fail to tell listeners of the serious downsides of such “coverage,” including restricted choice of physician and hospital through narrowed networks, the exorbitant costs if one gets sick, and the difficulties of returning to traditional Medicare with a new pre-existing condition.

Dr. Don McCanne of Physicians for a National Health Program says that “traditional Medicare with a comprehensive Medigap supplement works better than Medicare Advantage for the patients when they need health care, though they are deceived by private plan marketing, nominal additional benefits, and are dissuaded by the high premiums charged for the Medigap plans.”

“Medigap plans add greatly to the administrative complexity when it would be far less expensive and less complex to eliminate the Medigap plans and fold the benefits into the traditional Medicare program – claims are processed only once instead of twice and there is no superfluous private insurance bureaucracy to pay for. Then the private Medicare Advantage plans could never compete with the traditional Medicare program.”

https://www.corporatecrimereporter.com…

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Comment:

By Don McCanne, M.D.

Medicare beneficiaries are now given a choice of the original government Medicare program or the private Medicare Advantage plans, often administered by for-profit Wall Street corporations. The private plans have been increasing in popularity and now provide services to about two-fifths of Medicare beneficiaries (this is demonstrated in a chart available in the original article at the link above). They are so popular that even unions, such as SEIU 1199, may select them for their retiree health plan, as explained in this article.

What explains this popularity? Many people believe that they are getting a better deal in these plans. They sometimes are receiving additional benefits not offered under traditional Medicare such as limited dental and eye care, or maybe the Silver Sneakers fitness program. More importantly, they receive catastrophic coverage that may limit their potential losses, a benefit not offered under the traditional Medicare program.

They still have the choice of the original program, but it is important that they protect against catastrophic loss. For that reason, individuals in the traditional program often will buy a Medigap plan which provides this protection. The problem is that these plans are quite expensive and look like a bad deal when compared to the private Medicare Advantage plans with their extra included benefits and catastrophic coverage. So an increasing percentage of Medicare beneficiaries are selecting the private Medicare Advantage plans.

Are these private Medicare Advantage plans really a better deal? If you are among the 80 percent of the population that is relatively healthy and do not anticipate needing much care in your declining Medicare years, you may be satisfied with this coverage for the time being. However, if you end up needing more comprehensive, specialized care (and many of you will), you may find that the preferred specialists and hospitals are not covered under the insurer’s provider networks, but would be covered under the traditional Medicare program. Also you will likely find out about the barriers to care such as prior authorization requirements. You may be lucky and get the coverage you want under your plan, but many find out that the barriers are too great, and that is why the Medicare Advantage plans have earned the reputation that “the healthy go in, and the sick come out.”

How well does leaving the plan work? First of all, you have to wait for the special enrollment period which may seem inordinately long and dangerous if you are waiting for cancer treatment. Then, because you may be facing catastrophic losses, you will want to purchase a Medigap plan, only to discover that you can be denied Medigap coverage for a preexisting disorder (guaranteed issue is available only when you first become eligible for Medicare but not in later years). So you may be stuck only because you previously chose a private Medicare Advantage plan, and you want out of it.

Congress has played a very important role in this. They have continued to cater to the private Medicare Advantage insurers while neglecting the traditional Medicare program. Although the private plans must accept all applicants, that does not prevent them from selectively marketing to healthier populations (do the chronically ill really want the Silver Sneakers fitness program?). Even worse, they continue to add incidental diagnoses to their patients to qualify for extra risk bonuses, at taxpayer expense, so they are being paid more than the primary diagnoses warrant. Each year, adjustments are made by Congress and the administration that benefit the private plans but not those in traditional Medicare. As part of the Affordable Care Act, they even removed Medigap Plan F for those who were not grandfathered so you can no longer protect yourself from some out-of-pocket expenses – obviously preventing a marketing advantage for traditional Medicare over the private Medicare Advantage plans, which brings up the question, who receives the advantage from the Medicare Advantage plans? The patient or the private insurer?

It really is time that Congress takes an honest appraisal and corrects the deficiencies in the Medicare program. They should stop catering to the private insurers at the expense of the taxpayers (including misuse of Medicare payroll taxes, Medicare Part B and D premiums, and general revenues for Part A). On the other hand, the traditional Medicare program should be expanded to cover cost sharing barriers to care (deductibles, coinsurance, etc.) and especially catastrophic losses. It is also unfair to allow private plans to include extra benefits while excluding them from the traditional program. If we had an improved traditional Medicare program, then it could be used as the infrastructure for a single payer improved Medicare for All.

And all of this is a matter of fairness. Remember, the mission of private, for-profit Medicare Advantage insurers is to make money, whereas the mission of our traditional Medicare program is to provide health care. We are supporting a program that deferentially caters to the private insurers and their interests when we should be supporting a program that is designed to take care of patients. Those being deceived by the private Medicare Advantage marketing materials really do not realize the bad deal they may be getting until they face the private insurer barriers to needed care. Silver Sneakers won’t take care of that.

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By Austin Frakt and Tynan Friend
The Incidental Economist, February 10, 2021

The complexity of Medicare Advantage (MA) physician networks has been well-documented, but the payment regulations that underlie these plans remain opaque, even to experts. If an MA plan enrollee sees an out-of-network doctor, how much should she expect to pay?

The answer, like much of the American healthcare system, is complicated. We’ve consulted experts and scoured nearly inscrutable government documents to try to find it. In this post we try to explain what we’ve learned in a much more accessible way.

Medicare Advantage Basics

Medicare Advantage is the private insurance alternative to traditional Medicare (TM), comprised largely of HMO and PPO options. One-third of the 60+ million Americans covered by Medicare are enrolled in MA plans. These plans, subsidized by the government, are governed by Medicare rules, but, within certain limits, are able to set their own premiums, deductibles, and service payment schedules each year.

Critically, they also determine their own network extent, choosing which physicians are in- or out-of-network. Apart from cost sharing or deductibles, the cost of care from providers that are in-network is covered by the plan. However, if an enrollee seeks care from a provider who is outside of their plan’s network, what the cost is and who bears it is much more complex.

Provider Types

(Explains participating providers – 97%, non-participating providers – 2%, and opt-out providers – 1%.)

How Out-of-Network Doctors are Paid

So, if an MA beneficiary goes to see an out-of-network doctor, by whom does the doctor get paid and how much? At the most basic level, when a Medicare Advantage HMO member willingly seeks care from an out-of-network provider, the member assumes full liability for payment. That is, neither the HMO plan nor TM will pay for services when an MA member goes out-of-network.

The price that the provider can charge for these services, though, varies, and must be disclosed to the patient before any services are administered. (Complicated – depends on provider type, HMO or PPO, and payment options that the out-of-network provider may select. Read the article for the details.)

There are two major caveats to these payment schemes (with many more nuanced and less-frequent exceptions). (See article for details.)

Conclusion

Outside of the pandemic and emergency situations, knowing how much you’ll need to pay for out-of-network services as a MA enrollee depends on a multitude of factors. Though the vast majority of American physicians contract with Medicare, the intersection of insurer-engineered physician networks and the complex MA payment system could lead to significant unexpected costs to the patient.

https://theincidentaleconomist.com…

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Personal communication from Diane Archer

I read the Frakt et al. article this morning. They buried the lead. Plans often pay only 60 percent of Medicare’s approved amount, leaving people with twice as high out of pocket costs as traditional Medicare. Also, plans can retroactively deny coverage for out of network care. While the provider cannot bill the patient for the 60 percent, the provider might not want to provide the care and assume the risk of a denial. The provider can request an advance determination from the MAO, but might not want to go through the hassle, limiting access. Lastly, people in MA PPO have an out-of-pocket cap of $11,300, that’s easily more than three times the cost of Medicare supplemental coverage.

One other point. There is no data on average out-of-pocket costs in MA, in network or out of network, overall, or by plan or type of service.

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Comment:

By Don McCanne, M.D.

As the Frakt/Friend article states, “the intersection of insurer-engineered physician networks and the complex MA payment system could lead to significant unexpected costs to the patient.”

Many people believe that they like their private Medicare Advantage plan. It seems to work well for the 80% of people who use only 20% of the care, and the plans make sure that they are marketed primarily to that healthy sector. Other studies have shown that the healthy go into the plans and the sick come out once they find out the truth.

Actually, traditional Medicare with a comprehensive Medigap supplement works better for the patients when they need health care, though they are deceived by private plan marketing, nominal additional benefits, and are dissuaded by the high premiums charged for the Medigap plans. Medigap plans add greatly to the administrative complexity when it would be far less expensive and less complex to eliminate the Medigap plans and fold the benefits into the traditional Medicare program (claims are processed only once instead of twice and there is no superfluous private insurance bureaucracy to pay for) . Then the private Medicare Advantage plans could never compete with the traditional Medicare program.

It’s time that Congress quit catering to the private plans and turned their attention to improving the traditional program – but true improvements and not privatization schemes. (See Gerald Friedman and Travis Campbell, The Hill, “Medicare expansion is a discount compared to ObamaCare“)

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Steffie Woolhandler and David Himmelstein, Co-chairs, with 31 other authors
The Lancet Commissions, February 11, 2021

Executive Summary (Short Version)

Convened shortly after President Trump’s inauguration in 2017, the Lancet Commission on public policy and health in the Trump era offers the first comprehensive assessment of the detrimental legislation and executive actions during Trump’s presidency with devastating effects on every aspect of health in the USA. The Lancet Commission traces the decades of policy failures that preceded and fueled Trump’s ascent and left the USA lagging behind other high-income nations on life expectancy. The report warns that a return to pre-Trump era policies is not enough to protect health. Instead, sweeping reforms are needed to redress long-standing racism, weakened social and health safety nets that have deepened inequality, and calls on the important role of health professionals in advocating for health care reform in the USA.

• Section 1: The missing Americans
• Section 2: White supremacy and the history of racism in the USA
• Section 3: The assault on immigrants
• Section 4: The modern opioid epidemic
• Section 5: Slowing the progress toward UHC
• Section 6: Food, nutrition, and public health
• Section 7: The environment, workplace, and global climate
• Section 8: Reproductive rights under threat
• Section 9: Globalising harm
• Section 10: Mobilising for change

From the Conclusion

A new politics is needed, whose appeal rests on a vision of shared prosperity and a kind society. Health-care workers have much to contribute in formulating and advancing that vision, and our patients, communities, and planet have much to gain from it.

https://www.thelancet.com…

PDF version:
https://www.thelancet.com…

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Comment:

By Don McCanne, M.D.

This 49 page report and its supporting documents are too much to summarize here. Simply stated, the report describes what has gone wrong with public policy and health in the United States, with suggestions on how we can fix it. You will want to set aside adequate time to read and study this report.

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TODAY! Feb. 11, 12:00-1:00 Eastern: Health in the Trump Era

You are invited to the global launch event of the Lancet Commission on public policy and health in the Trump era: February 11, 12:00-1:00 Eastern, 9:00 am Pacific

The Lancet Commission on public policy and health in the Trump era is the first comprehensive assessment of the health effects of President Trump’s policies. Led by 33 leading experts from the US, UK and Canada, the Commission was tasked with chronicling the repercussions of the administration’s actions and charting policies for a healthy future.

At the launch, the authors will present key findings and recommendations from the Commission. The presentations will be followed by a question and answer session chaired by Richard Horton, Editor-in-Chief, The Lancet.

Register here: https://community.hunter.cuny.edu…

Presenters and speakers include:

• Richard Horton, Editor-in-Chief, The Lancet
• Steffie Woolhandler (City University of New York at Hunter College, New York; Harvard Medical School, Boston)
• David Himmelstein (City University of New York at Hunter College, New York; Harvard Medical School, Boston)
• Mary T Bassett (Harvard University, Boston)
• Kevin Grumbach (University of California, San Francisco)
• Congressman Ro Khanna (D-California)

This event is hosted by Roosevelt House Public Policy Institute at Hunter College.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Reed Abelson
The New York Times, February 10, 2021

In an unusual display of unity, groups representing nearly all the major players in the American health care system — hospitals, doctors, insurance companies and employers — are joining forces to urge Congress to embrace President Biden’s broad vision of building on the Affordable Care Act to reach the long elusive goal of universal coverage.

It released a detailed set of proposals on Wednesday morning, including an increase in the federal subsidies available to help people afford coverage and a three-year re-establishment of the generous match in federal funding to states to entice more of them to expand their Medicaid programs. The coalition also urged the government to spend more money on enrolling people in plans offered by the insurance markets established under the law, efforts that were slashed by the previous administration.

The recommendations signal a strong show of support for the beleaguered health care law, which had been under fierce attack not only from Republicans under the Trump administration but from progressive Democrats who have urged replacing it altogether with a government-run “Medicare for all” system.

https://www.nytimes.com…

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Affordable Coverage Coalition Principles for Extending Coverage and Protecting Patients

Affordable Coverage Coalition, February 2021

We represent the nation’s doctors, hospitals, employers and health insurance providers. Collectively, our organizations include hundreds of thousands of individual physicians, thousands of hospitals, and hundreds of employers and health insurance providers that serve hundreds of millions of American patients, consumers and employers every day across the United States.

With the key objectives of improving all Americans’ access to care, stopping the COVID-19 pandemic and advancing health equity, we support the following steps to make coverage more available and affordable (for details, read the report at the link):

• Tax Credits and Cost-Sharing Reductions
• Insurance Affordability Fund
• Automatic and Facilitated Enrollment
• Federal Funding for Outreach and Enrollment Programs
• Incentives to Close the Low-Income Coverage Gap
• Preventing Increases in the Uninsured

Sincerely,

America’s Health Insurance Plans
American Academy of Family Physicians
American Benefits Council
American Hospital Association
American Medical Association
Blue Cross Blue Shield Association
Federation of American Hospitals
U.S. Chamber of Commerce

https://s3.amazonaws.com…

Press release:
https://s3.amazonaws.com…

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Comment:

By Don McCanne, M.D.

It looks like America’s formidable medical-industrial complex is about to lock in the Affordable Care Act for the indefinite future, as they lock out any consideration of single payer Medicare for All.

This approach does not save money but rather pours more money into the most expensive system in the world. The administrative excesses are to blame for much of the high costs, yet this only adds more administrative services to benefit the industry itself. Innumerable studies have shown that we need to restructure the financing system by removing the private insurers, saving billions of dollars that can be used for health care.

The steamroller is on its way. Can we redirect it to where it is needed?

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Robert P. Kocher, M.D.
JAMA, February 2, 2021

The US health care system is famous for its expense and its waste.

The US health care system is administratively complex by design. Inherently, a multipayer system offering many variations of benefits, paying for care in a fragmented delivery system, and using a multitude of different payment models is administratively complex. Each health plan incurs cost to build sales and marketing function, deliver customer service, possess actuarial and benefit design functions, form a health care network, credential physicians and other health care practitioners, develop payment rules, set up payment operations, and ensure regulatory compliance.

Medicare achieves lower administrative expenses because it has no sales and marketing expenses, no network expenses, standardized benefit design, and simpler payment processes.

Essentially, administrators for payers and health care centers are trying to accomplish a relatively straightforward goal: ensure that a patient is eligible for care based on their insurance and benefit design, the patient receives care from qualified clinicians, the care is appropriate and of high quality, and the correct amount is collected from the patient and paid to the clinicians. Completing this process requires an extraordinary amount of labor. Hospitals employ up to 1 full-time person per bed to support billing. In total, nearly 4 full-time employees per physician work on administrative tasks, and this ratio is increasing.

Both payers and health care organizations have incentive to keep adding more people and creating new processes to gain temporary economic advantage. Payers add more prior authorization steps, increase first-pass claims denials, and use payments as a tool to collect additional data points on claims for short-term medical loss ratio gains. Health care organizations work with electronic health records to add decision support to guide clinicians to more highly paid diagnosis codes; hire scribes, coders, and chart reviewers to find more items to bill; and work with third parties to get more procedures authorized and denials overturned for short-term revenue gains.

Because the US health care system is so fragmented, there is not a clearly dominant entity to set administrative standards and force adoption. The federal government is the largest payer, but its market power is not concentrated because its payments flow through hundreds of different programs, including 50 unique Medicaid programs, Medicare, hundreds of Medicare Advantage plans, ACA insurance exchanges, federal employee health benefits, the military health system, Veterans Affairs, and the Indian Health Service. Each of these programs has governance over its administrative rules. Some programs, such as Covered California, use their local market power to force standardization of administrative elements, such as benefit design. The private sector alternatives lack either geographic reach or local market scale. The largest private sector entities are the payers United Healthcare and Anthem. However, neither of these companies are positioned to be administrative standard setters. United Healthcare lacks local market scale because it usually only accounts for 10% to 20% of patients for clinicians. Anthem lacks geographic scale because it only operates in 23 states. Only the Medicare system operates in all states and is accepted by nearly all health care organizations, which means changes to Medicare’s administrative rules are adopted nearly universally. Medicare is also a large payer, through the Medicare Advantage program, to the largest commercial payers, which could enhance Medicare’s ability to serve as an administrative standard setter. This makes Medicare the only participant with the market power to set administrative standards.

The federal government can use regulatory authority to reduce administrative costs. The opportunity today is both larger than in 2010 when the ACA targeted administrative simplification and more readily capturable as a result of improvements in information technology. The authority derived from the ACA should be used to implement the third wave of administrative simplification regulations, which requires autoadjudication of claims and prior authorizations and, as a by-product, creates long-awaited payment system and electronic health record interoperability. The Trump administration launched the Patients Over Paperwork program to reduce administrative burden. This program has simplified documentation for office visits and reduced reporting burden for many programs, and claims to have saved health care organizations an estimated $6.6 billion and 42 million hours of labor through 2021. More opportunity likely exists to rationalize the more than 1700 metrics that Medicare collects, which is estimated to incur $15.4 billion in annual data collection and reporting costs. There are additional opportunities that technology such as artificial intelligence may be capable of addressing, including a national clinician credentialing system; risk adjustment relying on data science models instead of physicians coding hierarchical condition categories; and identifying fraud, waste, and abuse.

Dr Kocher reported being a partner at the venture capital firm Venrock, where he invests in health care technology and services business, serving as a board member for Premera and Devoted Health.

https://jamanetwork.com…

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Comment:

By Don McCanne, M.D.

This article acknowledges the tremendous administrative waste in the U.S. health system and concedes that it is administratively complex by design, employing a multipayer system, each with its separate, complex administrative functions, serving a fragmented delivery system.

The author concedes the efficiency of the Medicare system, but then proposes to apply Medicare functions to the private insurance industry, leaving the source of the administrative complexity intact.

This compulsion to search for private sector solutions to what should be a government function, in this case health care financing, has perpetuated our costly but inefficient health care financing system. The author, Dr. Robert Kocher, is a partner in Venrock, a venture capital firm, which states on its website, “Our collaboration – engagement, network, passion and experience – gives entrepreneurs the unfair advantage needed to win, and win big.” Does this translate into giving the private insurance sector an unfair advantage so that it can win big?

We do need to do something about the profound administrative waste, and Medicare does have some lessons to offer, but considering that the system is complex by design, that means that we need to change the design. What we need is a single payer, improved Medicare for All. Providing the private insurance sector some Medicare tweaks simply will not do.

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