By Robert S. Kiefner, M.D.
Concord (N.H.) Monitor, November 12, 2021
Since 1965, Medicare has been the foundation of medical care for millions of seniors and those with disabilities in this country. Now, however, it is on the dinner table, being served as an appetizer and main course to ravenous for-profit corporate entities as never before.
Once a relatively straightforward plan, publicly financed and privately delivered care with extremely low overhead, Medicare has become hopelessly complex and impossible to navigate, complements of health insurers, Big Pharma, enabling legislators, think tank “geniuses” and a great multitude of wealthy lobbyists.
For all of its shortcomings, traditional Medicare has provided reasonable security for those in need of patient-centered, comprehensive and affordable healthcare. Indeed, if we had simply followed the lead of other industrialized countries with a comprehensive not-for-profit model, we could have offered truly universal coverage (including all expenses related to inpatient and outpatient care, and complete benefits relating to drug costs, dental, vision, hearing, mental health and even paid family leave) at one half of the per capita costs which we now incur in this country. But a majority of legislators fed the rich and addictive diet of corporate contributions and, entertained by the seductive dance of lobbyists, will not let a publicly funded and not-for-profit program gain traction.
Medicare Advantage is, perhaps, the most blatant for-profit distortion of the traditional Medicare model. With the yearly Medicare enrollment window now being open, we are subject to the hyper-caffeinated cacophony of pitchmen like Joe Namath and J.J. Walker, who we perhaps thought were dead, only to return to after 30 years of irrelevance to grab a few bucks and to entice a clueless audience of Medicare-eligible folks with visions of free dental care, glasses, hearing aids, refund checks, free rides, groceries, the sun, moon and the stars.
Most of the major health insurance companies also hawk their own Medicare Advantage program with advertising dominated by entitled, perky and smart-appearing old people who annoyingly want you to know they’ve found a great deal. Here’s the real deal, though. The federal government seriously overcompensates private insurers offering this bounty of services, counting upon the astigmatism of seniors trying to read the fine print, the unchecked power of big business, and the inability of federal regulators to nail down the true cost of care.
Medicare Advantage plans have a simple business plan, which involves making bigger profits by actually paying for less care, jacking up co-pays, and restricting care to narrow networks of providers.
These plans tend to be very popular until you need them for an expensive illness.
And every fiscal conservative should be outraged by the unregulated flow of taxpayer dollars to private insurers who “control” costs by restricting care and channeling funds into their coffers.
A Wall Street Journal article on Sept. 23 by Anna Wilde Mathews highlighted the findings by the Office of the Inspector General, focusing upon the gaming of the system by the major insurers from 2016-2017.
This systematic deceit is costing taxpayers billions of dollars per year while undermining traditional Medicare.
In many cases, insurers clearly falsified the medical conditions of their clients or upcoded them relative to medical severity in order to gain higher payments to Medicare Advantage plans from the federal government. And because medical expenses may well be greater at the end of life, Medicare Advantage plans are finding ways to encourage the sickest patients to return to traditional Medicare, and thus weasel out of paying for expensive conditions. By exaggerating the severity of beneficiaries’ illnesses, Medicare Advantage plans have been able to surreptitiously increase their charges for the care of those patients, often to the tune of thousands of dollars per year per beneficiary.
According to former CMS Administrator Dr. Don Berwick, the Medicare Payment Advisory Committee (MedPAC) has documented $140 billion in overpayments to Medicare Advantage Plans over the past 12 years, and with risk adjustment overpayments on the rise, up to $355 billion will be overpaid to the plans in the next eight years. Simply put, Medicare Advantage has devised ways of signing up low-cost patients (cherry-picking) while dis-enrolling high-cost patients (lemon dropping) all while misrepresenting the severity of the illness to obtain higher payments. Recently, if you can believe it, we have become aware of an even more insidious threat to your traditional Medicare. In a scheme first floated by the Trump Administration, but still sanctioned by the Biden Administration and the Centers for Medicare Services (CMS), the creation of “Direct Contracting Entities” (DCEs) empowers middlemen (including venture capitalists) to actually manage the care of beneficiaries in traditional Medicare. DCEs will have many of the nasty features of Medicare Advantage Plans relative to the ability to inflate service codes and thereby deceitfully pad their revenues while operating with limited oversight.
Of the 53 DCEs now active in 43 states, 28 are investor-owned, six are insurer based and the rest are provider controlled (physician and hospital). Insurers control the majority of potential patients, some 57% of traditional Medicare fees for service patients.
Here’s the clincher — patients can be enrolled in a DCE without their knowledge or consent! Their doctors may end up participating in a DCE with a tempting 40% increase in provider Medicare reimbursement and a reduction in the need to comply with a set of core quality measures. Once doctors sign up with a DCE, their patients are automatically signed up. Patients may receive a letter, typically incomprehensible and quickly tossed in the trash.
While defending “Medicare for All” over many years, I was often met with the objection that “I don’t want government-controlled health care.” Well, now you will have health care decisions made by corporate types in the luxurious C-suites of health insurance companies or venture capitalists cruising the Bahamas in gigantic yachts who really want to sign you up on their plans, only to throw you overboard if you get too expensive.
Medicare Advantage may actually work well for some seniors for a period of time, before serious illness occurs and before the amassed bills exhaust the Medicare Trust Fund and bring about the collapse of traditional Medicare.
Well-funded lobbying organizations such as the Partnership for America’s Healthcare Future and the Better Medicare Alliance are spending millions of dollars daily to convince those in Congress and their constituents that a bunch of upfront freebies is more important than being able to choose your healthcare provider and to guarantee affordable healthcare in the future.
Before you dial the number for a Medicare Advantage Plan at the urging of a celebrity du jour, start a conversation with your congressional reps, your doctors and your hospital to find out just how fragile your healthcare coverage might be going forward.
Dr. Robert S. Kiefner is a retired family physician. He lives in Concord.
