PNHP

Health care policy hurts Hawaii patients

Health care policy hurts Hawaii patients

By Stephen Kemble, M.D.
Honolulu Star-Advertiser, Nov. 19, 2024

The current health policy fad is “value-based payment” — blaming high health care cost on fee-for-service and overutilization of care and instead, offering upfront payment per member, or capitation, as an incentive to reduce utilization and control costs.

This analysis is contradicted by Hawaii’s experience. Hawaii’s Prepaid Health Care Act has included an employer mandate since 1974, with the broadest coverage of the population, richest commercial insurance benefits, lowest patient cost-sharing, and among the lowest insurance premiums in the country. And we had the lowest per-capita Medicare spending in 2009, when everyone was paid with fee-for-service.

But since widespread imposition of “value-based payment,” encouraged by the Affordable Care Act and aggressively implemented by HMSA and MedQUEST, health insurance premiums have more than doubled. By 2019 our per-capita Medicare spending had climbed from lowest up to 9th-lowest and rising. And many Hawaii doctors are quitting practice or exiting the state, leaving a severe and worsening doctor shortage and worsening access to care.

Capitation requires defined “members” to enable payment per-member, whether the payee is a health plan, such as a Medicare Advantage (MA) or Medicaid managed care plan, or an organized group of doctors or doctors and hospitals paid as an Accountable Care Organization (ACO). In any case, the performance of a capitated plan depends heavily on which “members” it captures.

Many studies claim to show that MA plans and ACOs can reduce Medicare spending and demonstrate improved quality measures. BUT, the savings for Medicare are quite small, and if the administrative costs for the MA plan or ACO are included, capitation always costs more than fee-for-service.

And very few studies account for the ability of capitated plans to capture healthier “members” and avoid or eject sicker, more expensive ones. If the pool of “members” in a plan or ACO is healthier than average, then of course cost will be lower and quality measures will be higher because the members were healthier to begin with, without any improvement in care.

Upfront payment with capitation introduces perverse incentives to capture the healthy and avoid the sick; to up-code to game the risk adjustment formula; and to skimp on care, necessary and unnecessary alike. And capitation of health plans creates major opportunities for profiteering, fraud and abuse in health care.

The poster child for these problems with “value-based payment” is Medicare Advantage. The Medicare Payment Advisory Commission has concluded that MA plans are overpaid by 22% compared to if the same beneficiaries were in traditional fee-for-service Medicare. Studies show MA plans do capture healthier-than-average members and up-code, often to the point of fraud, and they skimp on care, including denial of necessary care.

MA is the most profitable line of business for health insurance companies, far outstripping commercial insurance. It is rapidly draining the Medicare trust fund, threatening insolvency in less than a decade.

MA plans often restrict beneficiary choice with narrow and “ghost” networks of doctors not actually available to plan members. Doctors complain of excessive time wasted on prior authorizations. And worse, when for-profit insurance companies and private equity firms buy up physician practices and secure “value-based” government contracts with Medicare and Medicaid, they then seek return on investment by pressuring doctors to compromise patient care to serve their corporate owner’s financial goals, driving an epidemic of “moral injury” and burnout.

“Value-based payment” carries much higher administrative costs than fee-for-service, so capitated plans can be profitable only by gaming the payment formula to be overpaid and/or by denying care. This is no way to achieve real value in health care.

Dr. Stephen Kemble is a retired psychiatrist; in 2011, he was appointed to the now-inactive Hawaii Health Authority, charged with designing a universal health care system for Hawaii residents.

https://staradvertiser.com…

Medicare Advantage can’t deliver the moon

By Carol Paris, M.D.
Chattanooga Times Free Press, Letters, Nov. 16, 2024

During Medicare open enrollment, seniors are asked to choose from a dizzying array of plans. As a retired physician, and now a senior on Medicare, I know how confusing these choices can be, and what an impact they can have on our health and our pocketbooks.

Medicare Advantage plans, run by corporate health insurers, tend to promise the moon and the stars, but deliver aggravating restrictions. Not so with traditional Medicare.

Advantage plans also put a strain on the patient-doctor relationship. Many physicians are distressed when they feel corporate interests prevent them from delivering the care they know their patients need.

I saw this firsthand when I visited an orthopedic surgeon for knee pain. He balked when I asked which he would recommend.

“It doesn’t matter what I recommend,” he said, “only what your insurance will authorize.” But when I explained that I had traditional Medicare instead of a corporate plan, his face brightened. “In that case,” he said, “I can give you my best advice and administer the injection today.”

We would all be better off with an improved version of traditional Medicare, and both patients and physicians are fighting to realize that vision. Until that day comes, seniors should be aware of the impact privatized plans can have on their quality of care and choose wisely.

https://timesfreepress.com…

HJM with the US Political Shift

HJM is refining its mission in light of political realignment in the U.S.

Comment:

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

First, sincere apologies for the two-week lapse in HJM postings. We were consumed with worry leading up to the election, followed by shock and despair with the result. For those of us on the Left, the upcoming period is fraught with major socio-political risks and challenges. HJM readers no doubt feel similar intense and complex emotions.

Where does HJM fit into this new and fraught political environment? We’ve been contemplating this tough question.

Without a doubt, we need to keep monitoring the performance of current health insurance, which is likely to deteriorate with pursuit of the Project 2025 health policies. Other advocates do that exceptionally well, including HEALTH CARE un-covered on private insurer misbehavior, JustCare on Medicare issues, and PNHP laser-focused on Medicare Advantage.

HJM will still highlight discussing research and policy news that reveals the inefficiencies and inequities of our fragmented insurance system. We will, as always, get geeky in the interest of understanding the dynamics behind the news, and of making connections between issues. We will always analyze and educate about single payer / improved Medicare-for-All.

And, we will increase our attention to front-and-center political issues: How does single payer help us meet the current challenge to US democracy? How can single payer broaden support for progressive policies? How can it help heal the left-right political rift, by demonstrating the compatibility of efficiency and equity? How can we best convince skeptical right-leaning audiences of the common sense of single payer?

We welcome HJM reader input on refining our mission. What do you most value in HJM? What topics would you like us to address? How can we best support the struggle for health care justice, and invigoration of American democratic ideals? You can reply to the HJM email, or email healthjusticemonitor@gmail.com.

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.

Our health care system includes a lot of hidden costs

By Daniel Bryant, M.D.
Bangor (Maine) Daily News, Nov. 12, 2024

One of my most unpleasant experiences as a physician was our small practice’s monthly review of patients’ unpaid bills. Our bookkeeper would ask me whether I wanted to call my delinquent patients about their bills, keep seeing them even if they weren’t paying or send them to a collection agency.

What I did about any of those delinquent patients, I don’t remember (or have repressed out of guilt), but their difficulty paying their medical bills has led me to look into why that problem exists in the health care system in which I worked for many years. I’ve learned two things: Health care prices in the U.S. are higher than in peer countries and many costs are hidden, making it hard for people to fully anticipate how much they will owe for their medical care.

The costs of health care in Maine extend far beyond what we see on our own medical bills. Workers contribute directly to Medicare through payroll deductions and indirectly through federal income taxes, with a significant portion of those taxes supporting Medicare, our federal health insurance program for seniors. And nearly a third of our state and sales taxes go to the Department of Health and Human Services and MaineCare, the state’s Medicaid program.

Also, employees bear the burden of their health care premiums and these include hefty administrative fees paid to insurance companies. Employers, facing rising health benefit costs, may hold back on wage increases, adding to the hidden cost of health care for workers.

Even property taxes contribute: I found in my town’s budget that 6 percent of those taxes go to funding health insurance for municipal employees, a cost passed on to homeowners and renters alike. As businesses spend roughly 7 percent of their labor costs on employee health coverage, the prices we pay for everyday goods and services, including utilities, groceries and entertainment, may be inflated to accommodate these expenses.

All these factors mean that Mainers are likely paying up to three times more for health care than they realize. We have to acknowledge and address these hidden costs in our ongoing discussions about health care reform.

To address these high and hidden health care costs, some propose replacing the current system with a simpler one where everyone pays a clear, straightforward premium based on their income, not their health care needs. This so-called single-payer system, which would continue free choice of private and public providers, would make costs and benefits more transparent. Nationally, it’s represented by the Medicare for All bill, and more than 20 states have considered similar single-payer plans at the state level. For most people, this income-based premium would be much simpler and, as I found in my research, published recently in the Maine Policy Review, should cost no more than what they are currently paying.

Anyone interested in pursuing this approach has several options to do so. Contact organizations supportive of the single-payer model, such as Maine AllCare or Physicians for a National Health Program, to learn more. Submit testimony to the new Maine Office of Affordable Health Care at one of their annual hearings, asking them to study it and compare it to the public option (a state plan that would compete with commercial plans) they are now considering. Ask their U.S. senators and representatives to co-sponsor the Medicare for All Act as well as the State Based Universal Health Care Act, passage of which would facilitate further study of a single-payer plan for Maine.

That’s what I should have talked to my patients about when I called them.

Daniel Bryant is a retired internist who practiced in Portland, as well as at Naval Air Station Jacksonville in Florida.

https://bangordailynews.com…

Medicare Advantage plans are a huge rip off

By H. Dixon Turner, M.D.
Portsmouth (N.H.) Herald, Letters, Nov. 6, 2024

To the Editor:

It’s that time of year again, namely the annual Medicare Enrollment period. At times it seems that every other commercial on TV is for another Medicare Advantage plan. I would urge people to be very cautious when considering enrolling for one of these plans as opposed to remaining in Traditional Medicare. A report by the organization, Physicians for a National Health Program, titled “Our Payments Their Profits” revealed that insurance companies offering Medicare Advantage plans can “earn” profits that are estimated at 88 to 140 Billion dollars every year!! That is money from the Medicare Trust Fund which is NOT going to direct medical care for seniors, but instead is lining the pockets of these companies.

Medicare Advantage (MA) companies reap these exorbitant profits through various means: First, MA companies charge overhead expenses averaging 15-20% whereas Traditional Medicare has an overhead of 2-3%. MA companies aim to enroll healthier patients than the average Medicare recipient and they function like an HMO, often with a very limited panel of providers. Prior approval is often required for procedures which result in delays or denials of necessary care–services which would normally be covered under Traditional Medicare. Upcoding of patient diagnoses frequently occurs by adding on non-existent diagnoses or by exaggerating the severity of existing diagnoses to increase payments. Finally, if a patient does develop a serious illness, such as cancer, those patients – either voluntarily or involuntarily – are often dropped from the MA program.

An additional problem which may occur when patients switch from a MA plan back to Traditional Medicare is that they may not be able to get a Medigap or supplemental insurance policy at all or only at a very high cost. Currently only 4 states (Connecticut, New York, Massachusetts and Maine) mandate that Medigap plans must be offered at community rates. Attempts to pass such a mandate in NH failed to pass in the legislature this year.

The ”Our Payments Their Profits” report estimates that Medicare and Medicaid could cover dental, hearing and vision benefits for ALL Medicare and Medicaid recipients for $80 billion per year, which is less than the lowest estimate of the profits which MA companies are projected to receive this year. These huge profits very likely will rapidly deplete and could bankrupt the Medicare Trust Fund.

Thus, I believe that Medicare Advantage plans are a huge rip off foisted on the American public and should be avoided. I encourage seniors to sign up for or to stick with Traditional Medicare. Also, please lobby our national representatives to terminate or restrict these MA plans and seek instead to increase the benefits currently available under Traditional Medicare.

https://seacoastonline.com…

Dr. H. Dixon Turner is a member of the Granite State (N.H.) chapter of Physicians for a National Health program.

Rebecca Cerese on NBC News

Rebecca Cerese, health policy advocate at the North Carolina Justice Center and a member of PNHP, was interviewed by NBC Nightly News for a segment on September 20, 2024. Ms. Cerese discussed the surprise announcement by Advocate Health that it would cancel outstanding medical debts and put a halt to its aggressive collections—following an unflattering national news story.

“Dealing with an illness or loss of a loved one is hard enough,” she said. “We should not be compounding that with this additional stress of facing financial ruin.”

The Single Solution for a Myriad of Health Care Challenges

Esteemed medical academics are adept at documenting and debating the failings of our health care system. Yet they fail to focus on the technically superior insurance solution used around the world. Our job is to bring US public discussion and policy action to single payer.

Perspective Roundtable: Critical Health Care Challenges for the Next U.S. President, New England Journal of Medicine, October 16, 2024, by Robert J. Blendon, et al.

The next U.S. president, as well as Congress and state governments, will have to address some major challenges to Americans’ health and health care. On September 27, 2024, the Journal and the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health hosted a symposium exploring three critical topics: access to health care, affordability of care, and health and health care equity.

Comment:

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

This NEJM article is quite long because it is a transcript of the entire symposium, but you should read it anyway because it represents where we are on the policy issues that currently impact our health care system in the United States, and where we should be going, in the opinion of these noted health policy experts.

So where do our policy academics and the government policy community stand today?

Much of the discussion you will be able to relate to since it addresses issues covered by the press and in the lay literature. You will find points with which you agree and other points with which you either disagree or which have not been addressed adequately by the policy community.

Since many of you are quite knowledgeable about health policy and the single payer model of reform, you will likely discover that most of the policy issues for which these experts have not provided satisfactory solutions can be quite satisfactorily addressed in a well-designed single payer model. We discussed this failure of health policy economists and other policy experts last week.

Our tasks:

  1. Read the symposium transcript.
  2. Join together with colleagues to create a short, bold explanation of what is wrong with our current fragmented system: most expensive among wealthy nations, nonetheless falling far short of providing high quality, affordable, equitable health care to everyone. And why: Rife with financial incentives that undermine the mission of a health care system. And, how we can fix it: describe simply how the streamlined and generous approaches in single payer should appeal to everyone, regardless of political affiliation.
  3. Join with other individual advocates and organizations to deliver that message to the public at large. Use all the communication tools available to us, just like an election campaign: in person, in traditional media, in social media.
  4. Inspire the public to use all communication resources, including direct contact, to persuade our legislators that this is the reform that we need and that we demand.
  5. Rejoice as our president responds to the will of the people by signing legislation enacting a single payer, improved version of Medicare that will provide affordable, equitable, comprehensive, high quality health care for absolutely everyone.

Of course, we (still) face an uphill battle. Yet we must preserve and pursue this vision. We must eventually break through the US inertia and conflicts of interest, with so many other countries showing the way of efficient, generous, and effective health care.

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 Advantage is no advantage to patients

By Henry Kahn, M.D.
The Atlanta Journal-Constitution, Letters, Oct. 28, 2024

It’s true that rural communities suffer when insurance payment practices erode patient care (AJC Opinion, Oct. 20).

Two years ago, the Atlanta Medical Center stopped serving its inner-city patients for similar reasons. Hospitals, doctors and patients across Georgia struggle to survive in an environment dominated by commercial insurance plans called “Medicare Advantage.”

By contrast, some of us elders are fortunate to get care through the federal program of nonprofit, traditional Medicare. This is a nationwide, universal plan in which all hospitals and doctors participate. When we need care, we aren’t burdened with long waits for prior authorization, frequent denials of payment or restricted panels of doctors and hospitals. These burdens are an “advantage” only for the profits of the commercial plans. They can offer free sneakers and lower premiums because privatized plans receive 22% more funding than traditional Medicare for covering similar beneficiaries.

The government should redirect its funding from the privatized plans to improve the benefits of traditional Medicare.

Dr. Henry Kahn is a retired primary care physician.

https://ajc.com…

Republicans’ healthcare proposal if Trump wins? More private Medicare

Medicare Advantage plans promise enticing benefits such as free monthly premiums for drugs benefits, but problems start when people fall ill

By Jessica Glenza
The Guardian, Oct. 26, 2024

The television ads show seniors playing tennis, golfing and riding motorcycles. In others, celebrity pitchmen seniors will know – such as actor William Shatner, NFL star Joe Namath and former Republican Arkansas governor Mike Huckabee – promise new benefits alongside pictures of government-issued ID cards.

All of these are ads for Medicare Advantage and if Donald Trump wins the White House, Americans might be seeing a lot more of them.

That’s because one of Republicans’ only healthcare policy specifics involves further privatizing the program – selling more plans that commercials just like these advertise.

“We groan when we see [Medicare] Advantage as insurance,” said Dr Karen Kinsell, the only doctor in Fort Gaines, Georgia, a rural community where more than a third of the population lives below the poverty line.

Medicare Advantage is private insurance paid for by the federal government, a program authorized in 1997 amid concerns about Medicare’s cost. Insurance companies promised cheaper plans with better benefits.

One of the most important differences for patients is the imposition of “networks” in Medicare Advantage plans, or a limited number of doctors and hospitals a patient can see at a discounted rate. Traditional Medicare does not include networks – 98% of providers in the US participate. Most people pay a standard monthly rate of $174.70 for both Medicare and Medicare Advantage.

Medicare Advantage plans can be enticing because they often include food or transportation cards, $0 monthly premiums for drugs benefits, and hearing, vision and dental benefits – none of which are included in traditional Medicare.

Kinsell notes that the problems usually start when people get sick.

“Patients have been unable to get into rehab, or stay,” she said. Others were charged $50 a day for rehab when the service is normally free for a short period in traditional Medicare.

“We’ve spent a lot of time in our district office with seniors who got hoodwinked by these corporate insurance plans,” said Democratic US representative Pramila Jayapal of Washington state. Jayapal has called for “urgent reforms” and consumer protections to be added to Medicare Advantage.

“They took the name – so seniors actually think they’re signing up for Medicare,” she said.

Despite complaints from doctors and patients, fraud investigations, allegations insurers used artificial intelligence models to deny care to seniors, and a pile of evidence that Medicare Advantage costs taxpayers more, Republicans have continued to boost the program. The most specific healthcare policy proposals are set forth by Project 2025, the conservative playbook by the Heritage Foundation.

Amid a thicket of gripes about vaccine mandates and no less than 199 mentions of abortion, the document also proposes further privatizing Medicare through Medicare Advantage.

Medicare Advantage “provides beneficiaries with a wide range of competitive health plan choices – a richer set of benefits than traditional Medicare provides and at a reasonable cost”, Project 2025 argues. Republicans should make it the default enrollment option and “remove burdensome policies that micromanage” plans, the document said.

The document also proposes to “give beneficiaries direct control of how they spend Medicare dollars”, which Democrats argue describes a voucher program, something Republicans tried to push in the Trump administration.

“That has been the playbook for privatization of Medicare really since these corporate Medicare ‘dis-Advantage’ plans – that’s what I call them – started,” said Jayapal. “It was their in-road.”

That, like a lot of Donald Trump’s proposals, is likely to cost the federal government a lot of money.

“The federal government is significantly overpaying Medicare Advantage plans in relation to what it spends on an individual and traditional Medicare – without corresponding significant gains to show for it,” said David Lipschutz, co-director of the Center for Medicare Advocacy.

Studies show Medicare Advantage plans will cost the federal government an estimated $83bn more than traditional Medicare in 2024 without corresponding improvements in health, according to the congressionally commissioned nonpartisan research agency Medicare Payment Advisory Council. Using default enrollment could increase that cost to an additional $2tn over 10 years, according to the left-leaning Center for American Progress.

The stakes for private health insurers are equally huge. One of the largest Medicare Advantage providers, United Healthcare, earned 46% of its $281bn in total revenue from Medicare Advantage enrollees, even though they represent only 15% of the company’s beneficiaries, an Accountable.US analysis found. The analysis was shared exclusively with the Guardian.

“The fact this is becoming something conservatives are trying to push as a universal model is alarming, because it’s a way to just increase profits for insurance companies,” said Tony Carrk, Accountable.US executive director.

Problems with the program are so acute that, at one point in 2022, eight of the 10 largest insurance companies selling Medicare Advantage plans were defendants in federal fraud or whistleblower lawsuits.

“Part of the problem of having private plans involved in Medicare, or really any healthcare space, is the promise they could provide better care more efficiently,” Lipschutz said. “And neither has happened.”

Although the Republican deficit hawks of yesteryear might balk at such a cost, the proposal to further privatize Medicare goes to a long-held Republican philosophy that survived Trumpism: the government is inherently untrustworthy and regular people need a financial reason to do the right thing.

“The problem with the left is they don’t think in economic terms,” said John Goodman, an economist who has advised nearly every Republican presidential candidate on health since George W Bush. He said he is currently working with America First Policy Institute, a pro-Trump thinktank.

Philosophically, Goodman believes Americans need “economic incentives” to do the right thing.

For patients, for example someone who is diabetic, that might mean low-cost insulin (a carrot) and the specter of a big bill if you don’t manage your diabetes and end up in the hospital (a stick). For doctors, it might mean jumping through bureaucratic hoops to get approval for a procedure, called prior authorization, to avoid being wasteful.

Critics argue debates about “economic incentives” mask what are in fact “catastrophic” health costs. Medicare Advantage plans are allowed to require patients to spend as much as $13,300 per year for out-of-network providers in 2024. More than one-third of all Medicare Advantage enrollees live on less than $10,000 per year, according to the Commonwealth Fund. Nearly 95% of all seniors have a chronic health condition, and more than 78% have two or more, according to the National Council on Aging.

Although Trump has disavowed Project 2025, he has deep ties to its authors. Its health proposals were written by Roger Severino, his own former director of the Office of Civil Rights in the Department of Health and Human Services.

Notably, Goodman thought Project 2025 was a “poor document” whose many references to abortion would turn voters off. But he agrees with proposals on Medicare.

In the 2024 GOP Platform, Trump pledged to, “not cut one penny from Medicare”, but does not provide further specifics. That comports with the Project 2025 plan – which would require a lot more money to expand Medicare Advantage enrollment.

For Goodman, there is at least one piece of humor in this branch of health policy – the idea that the left would propose a health system where people don’t have to pay for healthcare.

“In fact, the Bernie Sanders types do not think economic incentives should play any role in healthcare,” Goodman said.

https://theguardian.com…

Medicare or Medicare Advantage? One of them doesn’t give you what you pay for.

Medicare open enrollment is here. It’s time for Congress to level the playing field.

By Andrea Ducas and David Lipschutz
Market Watch, Oct. 25, 2024

Medicare’s open-enrollment period is here, meaning millions of older Americans and people living with disabilities can compare plans and make changes to their healthcare coverage. If recent trends hold true, more than half of all enrollees will choose a Medicare Advantage (MA) plan — the private alternative to traditional Medicare.

What many enrollees don’t understand is that their “choice” has effectively been made for them.

The U.S. government now pays MA plans at least 22% more per enrollee than it would cost to cover the same person under traditional Medicare. But more money doesn’t mean enrollees get better care. MA plans perform no better and in some aspects are worse than traditional Medicare. Nor does the money appear to provide enrollees with meaningful control over their coverage decisions. Instead, MA plans bombard enrollees with a complicated array of options so overwhelming that almost 70% of people don’t even try to compare what’s available to them.

Most alarmingly, in spite of massive federal subsidies, MA plans are erecting more and more barriers to patient care, including arduous prior authorization requirements that can delay necessary procedures, and narrow networks that may exclude higher-quality providers — all while often failing to save enrollees money on care.

Nevertheless, the MA program continues to grow because for many enrollees, traditional Medicare — with its 20% coinsurance and lack of an out-of-pocket spending limit — isn’t financially viable. For an older American living on a low or fixed income, making the choice between a zero-dollar-premium MA plan that claims to cover all the necessities, or paying upwards of $200 a month for a supplemental Medigap policy to guard against financial catastrophe — plus additional premiums for a supplemental prescription-drug plan and any dental, vision and hearing services — isn’t really a choice at all.

In recent years, the Biden administration has tried to address some of MA’s limitations by bringing more consumer protections, transparency and accountability to the program. While these efforts need to continue, we also need congressional action to improve the Medicare program for everyone so the choice between MA and traditional Medicare becomes a meaningful one.

If Congress instead doubles down on the further privatization of Medicare, the results could be disastrous. For example, the far-right authoritarian playbook known as Project 2025 calls for making MA the “default” for all enrollees. This would effectively push even more people into the program. If, as a result, just 50% more people enrolled in MA, the Center for American Progress estimates it would contribute toward $2 trillion in waste over the next decade while providing no meaningful health benefit to enrollees.

On the other hand, Congress could level the playing field by giving Medicare enrollees a real choice between MA and traditional Medicare. To put the full scale of the government’s investment in MA into perspective: The Center for American Progress estimates the program will be overpaid by as much as $127 billion in 2024 alone, with any “savings” many MA plans achieve accruing to shareholders.

That’s more than enough money to expand traditional Medicare coverage to include dental, vision, and hearing benefits and introduce an annual cap on out-of-pocket expenses — reforms that would help all Medicare beneficiaries. The money could also be used to fund home-based caregivers, a critical Medicare coverage gap.

As Medicare beneficiaries navigate potential changes to their coverage during this open-enrollment period, the reality is that far too many enrollees won’t have a meaningful choice set before them — but lawmakers do.

Andrea Ducas is the vice president of health policy at the Center for American Progress.

David Lipschutz, J.D., is the co-director of law and policy at the Center for Medicare Advocacy.

https://marketwatch.com…

Watch out for unwelcome surprises this Medicare open enrollment period

By Thomas Lane and Lin Brown, M.D.
New Hampshire Bulletin, Oct. 25, 2024

This fall, countless New Hampshire seniors will be reexamining their Medicare coverage options for 2025 during the open enrollment period, which runs from Oct. 15 to Dec. 7. One of us, Thomas Lane, is far from Medicare eligibility age, but as a health economist, he is frequently asked by friends and family about what plan they should choose. After all, health insurance is complicated, and it’s very hard to find unbiased advice.

Usually, Thomas responds to the question with a question of his own: What kind of a plan are you considering?

Often, the response is some sort of a Medicare Advantage plan, and every time, he is shocked at how little folks know about the risks associated with signing up for that program instead of Original Medicare. Seniors should know that while Medicare Advantage may sound enticing in the advertising that blankets the airwaves each fall, it’s better known as “Medicare Disadvantage” because it can expose you and your family to big risks.

Dr. Lin Brown is both a physician and a Medicare beneficiary. As a physician, she considered herself knowledgeable and modestly intelligent, which she assumed would allow her to make a wise choice for her first Medicare plan. The initial allure of Medicare Advantage sucked even her in. The ads promised lower rates and more services! Who could resist? She is also healthy, minimizing the risk she would need complicated care. However, she soon realized she had made a mistake.

First of all, what is Medicare Advantage? Its formal name is Medicare Part C, and it serves as a single-package replacement for Medicare parts A (hospital care); B (physician services); and D (prescription drugs). However, it’s deceptively named because it isn’t real Medicare.

Original Medicare (Parts A and B) is operated by the federal government, while Part C is essentially just heavily subsidized private insurance that companies are allowed to label Medicare. Part D is operated by private companies. Insurers often try to make Medicare Advantage plans seem like a sweet deal through lower premiums and extra benefits like hearing and dental not covered under Original Medicare, but as the saying goes, putting lipstick on a pig doesn’t change the fact that it’s still a pig.

Under Original Medicare, there is little question about what care will be covered, a fact doctors like Dr. Brown appreciate because it means less paperwork for them and more time to provide actual care. But because Medicare Advantage isn’t real Medicare, private insurers can play all sorts of games to boost their profits by delaying or denying care. Often, this is through what is called a prior authorization, or extra paperwork for your doctor, forcing them to extensively justify why you need the care they seek to give you.

For Dr. Brown, this meant that in her practice, prior authorizations were the rule, not the exception. They wasted valuable physician practice time and delayed care. For you as a patient, this means that should a major issue or even an emergency arise, your insurer may turn around and surprise you by claiming the care your doctor says you need isn’t “medically necessary” and refuse to pay for it. Dr. Brown and her physician colleagues do not appreciate that there are two types of Medicare, especially given one of them works so well and the other does not.

Medicare Advantage denials are becoming increasingly common. Just between 2022 and 2023, denials skyrocketed by 55.7 percent. They also tend to be quite arbitrary; the reviewer, who has never met the patient, may not even read the patient’s records but deny care anyway. Increasingly, denials aren’t even done by real people, let alone clinicians, and are being taken over by poorly designed AI algorithms that are notoriously erroneous; 82 percent of denials that are appealed are overturned, showcasing the poor quality decision-making that goes into them. But just 11 percent of denials get appealed because many patients aren’t aware they can appeal or don’t want to undergo the burdensome process.

Delays and denials are more than just inconvenient. They can worsen illness and even kill. But, they are a great way for insurers to boost their profits. Obviously, we all hope to never have a health emergency, but should one occur, Medicare Advantage may well stand in the way of you getting the care you need.

Dr. Brown herself experienced a related issue when she was a Medicare Advantage beneficiary. She was disappointed when her plan really did not cover anything related to her hearing aids, since the care was “out of network.” And it covered nothing on a crown from her dentist, also “out of network.” In order to maximize their profits, Medicare Advantage plans tend to have limited and unclear provider networks that allow them to dodge responsibility for patient health needs. Original Medicare, in contrast, covers almost all providers.

Medicare Advantage is so heavily advertised because private insurers make lots of money on the program. Unfortunately, they often do so by gaming the system, siphoning off our tax dollars by exaggerating the health needs of covered patients to the tune of $88 billion to $140 billion annually. Dr. Brown experienced this too, with her Medicare Advantage plan insisting that she and her husband receive a nurse visit. This was likely so that her plan could add diagnoses to their health records, which enable them to receive higher government subsidies.

Most private health insurers in the program have been accused of fraud and are starting to face some accountability in the form of lawsuits and investigations to recoup overpayments, but there is little chance that all of the lost money will ever be recovered. Private insurers have been fighting accountability for years, exemplified by recently released court records that show how they pressured the Obama administration into killing proposed regulations in 2014 that sought to reduce overbilling. Unsurprisingly, these efforts continue to this day.

As a young person, this is what makes Thomas especially upset. He’s happy to pay his taxes and contribute to the care of all the incredible seniors in his life, but watching that money disappear into the Medicare Advantage money-incinerating bonfire for no good reason is depressing, to say the least. It also endangers Medicare’s solvency and decreases the chance that it will be there for him when he eventually becomes eligible.

To make matters worse, New Hampshire seniors on Medicare Advantage are facing even bigger difficulties than their peers nationwide. Insurers are so upset over even the limited scrutiny and declines in their profits that they have begun to face that some of them are now pulling back from a number of states, one of which is New Hampshire. Over a million seniors have been dumped by their Medicare Advantage plans as a result.

You’re likely asking yourself: This sounds awful, so how do I avoid this? The safest route to reliable health insurance coverage that will keep you protected in the face of whatever life may throw at you is Original Medicare. However, because the Original Medicare coverage package was designed all the way back in the 1960s when medical care was much simpler, you will likely need to bolster it with additional coverage, such as a Part D plan and/or Medigap policy. Supplemental plans are private insurance plans just like Medicare Advantage, but they are regulated through different mechanisms and entail somewhat less risk for patients.

Why is Original Medicare the safest option for all seniors and not just those who have significant medical needs?

Because Medicare Advantage premiums are generally cheaper than the alternatives, some wonder why not start on Medicare Advantage and then switch to traditional Medicare later on when health risks are higher. Theoretically, this may be possible for some. However, switching back to Original Medicare after starting out on Medicare Advantage is quite risky because supplemental policy insurers can take into account preexisting conditions, leaving you with much higher premiums or even a refusal to insure.

Dr. Brown experienced this, too. Due to a hiccup with her pension plan, she needed to rethink her Medicare enrollment and reached out to a Medicare navigator for help. He guided her to Original Medicare, but switching back was not easy. A lengthy health evaluation was required to determine her premium. She was lucky that she remained healthy and was able to make the switch.

Starting on Original Medicare plus supplemental insurance tends to cost a bit more per month in premiums than Medicare Advantage, but it is the only way to ensure you will have quality and affordable coverage later on in life when the risk of a significant health need is unavoidably greater. In the long run, it may even be cheaper, too. Do yourself a favor and stay away from Medicare Disadvantage.

Thomas Lane is a health economics, policy, and management master’s student at the Karolinska Institute in Stockholm, Sweden. He recently graduated with a bachelor’s in economics and public policy from Dartmouth College in Hanover, New Hampshire. There, he was a member of the steering committee of Granite State Physicians for a National Health Program.

Lin Brown, MD, FACR, MACP is a retired rheumatologist from Dartmouth Health. Over the years she has practiced as a rheumatologist, a section chief, a fellowship program director for training rheumatologists at DH, and the coordinator of the rheumatology course at Dartmouth Geisel School of Medicine. A member of Granite State Physicians for a National Health Program, she is now almost fully retired.

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