Greetings HJM readers ā Iām using a different format today.
#1 ā Round-up.Ā Plenty of recent news items exemplify the usual rocky functioning of US health care. Hereās a sampling:
Medicaid:Ā Eligibility assessment post-COVID proceeds apace, withĀ 4 million disenrolledĀ so far, widely variable by state (Texas is highest). CMS has asked some states toĀ pause due to problemsĀ with the eligibility redetermination. One company isĀ profits very wellĀ with this process. Meantime, the DHHS Inspector General found thatĀ prior authorization denial rates are especially high in Medicaid, which is 70% under managed care. So, in summary, itās harder to stay on Medicaid and on Medicaid harder to get care, and private companies profit in the process.
Medicare:Ā Risk selection of healthier individuals (within diagnosis) by Medicare Advantage plans yields 11% lower medical costs than enrollees in traditional fee-for-service Medicare. Higher diagnostic coding intensity adds 6%. TheĀ total cost difference of 17%Ā represents $70 billion per year, or $1500 per MA enrollee. AnotherĀ estimate comes in at 20%. AndĀ artificial intelligence (AI) is being misused to arbitrarily limit care. Meantime, drug companies areĀ suing to stop price negotiationsĀ in the Inflation Reduction act. Who profits? MA plans and Pharma, of course.
Patients:Ā Administrative barriers to getting care can beĀ very dangerous and extraordinarily expensive. This brings to life the stats ā individuals spendĀ 8 hours per month coordinating health care, and one in four insured patientsĀ delay or forego care due to administrative hurdles. Medical debt and bankruptcy are pervasive.
Insurers:Ā Profits galore, billions and billions. Definitively covered in Wendell PotterāsĀ HEALTH CARE un-covered. Largely due to Medicare Advantage and Medicaid managed care (see above).
Hospitals:Ā Dubious hospital billing practicesĀ areĀ being challenged, as hospital profits grow. Meantime, many rural hospitals suffer existential threats fromĀ low private insurer payment rates.
Thereās more ā¦ thereās always more; our fragmented and dysfunctional insurance approach can be counted on to generate stories of care denied coupled with profits maximized. But enough for today.
#2 ā Pause for Reflection
Reading a terrific book,Ā The Persuaders: At the Front Lines of the Fight for Hearts, Minds, and DemocracyĀ by Anand Giridharadas. For those committed to progressive policy change, itās revelatory ā laying out vividly what persuasive strategies work. Iām contemplating how the insights can bolster single payer advocacy.
Iām also busy this summer with family travel and cataract / glaucoma surgery (luckily, I have very good insurance, and terrific ophthalmologists).
So, HJM posts will slow.
#3 ā Makeover
The HJM website will be reborn later this year in much grander fashion. It will still have all the blog posts, plus some from Donās prior āquote of the dayā, with an advanced search capacity. Plus a glossary and FAQs, as well as visuals and resources for activism. Some short videos too. Stay tuned. If you want to be a ābeta testerā, let me know.
Hope youāre having a great summer. ā JGK (Dr. Jim Kahn)
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