PNHP

Medicare Advantage is a money grab by big insurers

Medicare Advantage is a money grab by big insurers

By Kip Sullivan, J.D.
Minnesota Reformer, November 3, 2023

The Sunday, Oct. 15 issue of the Minneapolis Star Tribune arrived on my door step wrapped in a four-page advertisement for something called Allina Health-Aetna. Allina is a 12-hospital multi-clinic chain; Aetna, which was bought out by the drug chain CVS for $69 billion five years ago, is a health insurance company.

The purpose of the ad was to urge the 20% of Minnesotans who are eligible for Medicare — the nation’s health insurance program for the elderly and the disabled — to enroll in Allina-Aetna’s “Medicare Advantage” plan.

“Medicare Advantage” is the misleading name given to the privatized portion of Medicare — the portion in which tax dollars are funneled through insurance companies so they can take 15% off the top to pay for administrative costs and profit before sending the other 85% to doctors and hospitals with strings attached. The traditional Medicare program — the unprivatized portion – does not funnel money through insurance companies; it pays doctors and hospitals directly, and it devotes around 2% of its expenditures to administrative costs. Today half of all Medicare beneficiaries are insured by insurance companies and the other half are insured by traditional Medicare.

Allina-Aetna’s ad boasted about extra services their “advantage” plan covers that Congress has never allowed the traditional Medicare program to cover. The upper half of the first page of the ad was taken up with these words: “Can I get dental, vision and hearing benefits in a Medicare plan?” Just below the fold were the words, “Yes, yes, and yes!”

What the ad didn’t explain was how health insurance companies not only survive within Medicare but make big profits. After all, Congress enacted Medicare in 1965 because the health insurance industry didn’t want to insure the elderly and the disabled. How is it that today insurance companies offer extra services and still make an outlandish profit despite their high administrative costs? American health insurance companies make 2.5 times as much profit per enrollee on Medicare as they do on their private-sector customers, according to a 2021 KFF paper on health insurer financial performance.

The answer: They are vastly overpaid. According to a report released earlier this month by Physicians for a National Health Program, which I helped write, the overpayment in 2022 was somewhere between 22% and 35%. In other words, the cost of insuring Medicare beneficiaries through Medicare Advantage was 22% to 35% higher, or somewhere between $88 billion and $140 billion more, than it would have been had those beneficiaries remained in traditional Medicare. Those are astronomical figures. That’s far more, for example, than the $75 billion the U.S. spent on humanitarian and military aid for Ukraine between February 2022 and October 2023.

The PNHP report documented five causes of these overpayments:

  • “Favorable selection,” which means insurance companies lure healthier-than-average beneficiaries away from traditional Medicare, but Medicare pays them as if they enrolled beneficiaries in average health (overpayment of 11% to 14%);
  • “upcoding,” the name given to the insurance companies’ practice of making their enrollees look sicker (and therefore warranting higher reimbursement) by adding diagnoses to patient medical records that are either false or irrelevant to the treatment given to the patient (5%);
  • pointless bonuses Congress requires Medicare to give to Medicare Advantage plans for high scores on a score card that is so inaccurate the Medicare Payment Advisory Commission has called for its termination (4%);
  • gratuitous bonuses Congress ordered Medicare to give to plans that sell insurance in more rural parts of the country that plans tend to avoid (2% to 3%);
  • and, a subsidy created by Medicare’s use of the average cost of insuring a traditional Medicare beneficiary as the baseline to determine plans’ payments, uncorrected for the portion of traditional Medicare costs paid for by supplemental (Medigap) coverage (9%).

PNHP’s estimate of the total overpayment does not take into account “favorable deselection” — driving sicker Medicare Advantage enrollees back to traditional Medicare by denying them necessary services. We have abundant evidence indicating Medicare Advantage plans deny necessary services to tens of thousands of their enrollees every year. But we don’t have any research on how much that adds to the overpayments. This abuse of enrollees is just one of the reasons research indicates Medicare Advantage plans have had, at best, a mixed effect on quality.

The Allina-Aetna four-page ad that now sits in my recycling bin made no mention of the overpayments, nor of the reasons why Medicare beneficiaries should consider avoiding enrolling in a Medicare Advantage plan (narrow networks and frequent denial of services being the most important).

Congress should put an immediate stop to the overpayments and, at the same time, authorize traditional Medicare to cover dental, vision and hearing services.

Kip Sullivan is a member of the policy committee of Health Care for All Minnesota. He has written extensively about health care reform.

https://minnesotareformer.com…

History of U.S. Medical Debt Collection

Summary: U.S. medical debt structure has substantially evolved from amounts negotiated among care participants in the 1980s, to commoditized assets and aggressive collection today. With sky-high deductibles and other cost-sharing, debt magnitude is rapidly growing. Single payer would end this painful complication of our health insurance.

Debt Collection in American Medicine – A History, New England Journal of Medicine, October 26, 2023, by Luke Messac

A historical lens reveals that since the 1980s, medical debts have shifted from obligations negotiated by doctors, patients, and hospitals to assets bought and sold by people with no role in patient care. In part because of the proliferation of insurance plans with higher copayments and deductibles, hospitals have faced more delinquent payments. Hospital administrators have turned away from charity care and have opted instead for aggressive debt collection.

Comment:

By Don McCanne, M.D.

This report discusses the all-too familiar topic of medical debt in the United States. Sections in the report include: “Debt in the Doctor-Patient Relationship,” “The Rise of the Collection Industry,” and “The Criminalization of Debt.” The concluding section is “The Physician’s Responsibility.”

The message that should come across today is that The New England Journal of Medicine recognizes that this topic of medical debt is not only important enough to feature in their journal, but the closing sentence of the article demonstrates that PNHP can be a part of the solution! The closing statement (bold type added for emphasis): For their part, doctors who seek to be a part of the solution can join ongoing grassroots efforts, including organizations such as Physicians for a National Health Program and the Debt Collective, to make medical debt, and its destructive consequences, a thing of the past.

Now let’s mobilize to get the politicians on board.

http://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.

‘Deny, deny, deny’: By rejecting claims, Medicare Advantage plans threaten rural hospitals and patients, say CEOs

Medicare Advantage plans "are taking over Medicare and they are taking advantage of elderly patients," said the CEO of one Mississippi facility.

By Gretchen Morgenson
NBC News, October 31, 2023

For decades, Rose Stone counted on the Alliance HealthCare System in rural Holly Springs, Mississippi, for her medical needs. But after she retired and signed up for a Medicare Advantage plan, she was surprised to learn it didn’t cover her visits to nonprofit Alliance, the only health-care provider within 25 miles. Stone had a choice: use her own money to keep seeing her regular doctor or drive out of town to see a physician she didn’t know but whose costs were covered.

“It was a mess,” Stone told NBC News. “I didn’t go to the doctor because I was going to have to pay out-of-pocket money I didn’t have.”

Some 31 million Americans have Medicare Advantage plans, private-sector alternatives to Medicare introduced in 2003 by Congress to encourage greater efficiency in health care. Just over half of Americans on Medicare are enrolled in one of the plans offered by large insurance companies, including UnitedHealthcare and Humana.

Problems are emerging with the plans, however. Last year, a federal audit from 2013 was released showing that 8 of the 10 largest plans had submitted inflated bills to Medicare. As for the quality of care, the Medicare Payment Advisory Commission, a non-partisan agency of Congress, said in a March report that it could not conclude Medicare Advantage plans “systematically provide better quality” over regular Medicare.

Even worse, because the plans routinely deny coverage for necessary care, they are threatening the existence of struggling rural hospitals nationwide, CEOs of facilities in six states told NBC News. While the number of older Americans who rely on Medicare Advantage in rural areas continues to rise, these denials force the hospitals to eat the increasing costs of care, causing some to close operations and leave residents without access to treatment.

“They don’t want to reimburse for anything — deny, deny, deny,” Dr. Kenneth Williams, CEO of Alliance HealthCare, said of Medicare Advantage plans. “They are taking over Medicare and they are taking advantage of elderly patients.”

Williams is something of a local hero in Holly Springs. When the area hospital was in danger of closing in 1999, he marshaled resources and bought it to keep it open. Alliance serves a county with 38,000 people.

Still, this spring he had to shut down a long-time geriatric psychiatry program that had served the community for over eight years. Coverage denials from Medicare Advantage plans killed the program, Williams said.

Medicare Advantage plans are sold assiduously by celebrity pitchmen — one is Joe Namath — as a better way for Americans who qualify for Medicare to get insurance coverage. Many plans add services such as dental and hearing care and wellness programs not offered under traditional Medicare, for which beneficiaries pay extra.

The U.S. government pays most of beneficiaries’ premiums to the insurers offering the plans.

If the government hoped Medicare Advantage plans would reduce the costs of care, that has not been the outcome. Medicare pays the plans 6 percent more than it would spend if plan enrollees were covered under regular, fee-for-service Medicare, the MedPAC report found. Medicare payments to the plans will total $27 billion more in 2023 than if patients were enrolled in traditional Medicare, the report projected.

A new enrollment period for the plans began this month. State insurance commissioners told NBC News they, too, receive many complaints from customers saying they were sold Medicare Advantage plans without understanding their limitations. A major complaint, said Mike Chaney, the Mississippi Insurance Commissioner: “Consumers are not aware their doctors are likely to change under the Medicare Advantage plans.”

‘We can’t pay our bills’

Medicare Advantage plans have grown in popularity in recent years, with enrollment more than doubling nationwide since 2013. One explanation: The plans are often cheaper than paying for a Medicare supplement, sometimes referred to as Medigap.

Another reason for the growth may be the significantly larger commissions the government pays to brokers selling Medicare Advantage plans. In 2024, the Centers for Medicare and Medicaid will pay brokers a commission of between $611 and $762 for the first year of a Medicare Advantage plan, depending on the state, and roughly half that on annual renewals. On Medicare supplements, by contrast, brokers receive around $300 on average in year one.

Brokers selling the so-called advantage plans aren’t the only ones making money on them. UnitedHealth Group, the largest Medicare Advantage provider with 7.6 million people in its plans, generated $257 billion in premium revenues in 2022, some 13% over the previous year. A significant driver of that growth was its Medicare Advantage plans, the company’s financial filings said. Humana, the next largest provider, counts 5.3 million Medicare Advantage customers; during the six months that ended June 30, almost 80% of Humana’s $51 billion in premium revenues came from individual Medicare Advantage plans, its filings show.

Meanwhile, CEOs of rural nonprofit hospital systems in Arkansas, Colorado, Mississippi, Missouri, South Dakota and Texas told NBC News that Medicare Advantage plans repeatedly refuse to reimburse them for the care they provide. Some 170 rural hospitals are at risk of closing in those six states alone, according to a report from the Center for Healthcare Quality and Payment Reform, a nonprofit advocacy organization.

While there are multiple reasons for rural hospitals’ financial woes, coverage denials from Medicare Advantage plans play a big part, said Harold Miller, president of the Center that conducted the study. For years, Medicare Advantage plans had been rare in rural areas, now they are becoming ubiquitous. In 2022, enrollment in Medicare Advantage plans grew 13 percent in rural areas versus 7 percent in urban zones, according to the MedPAC report.

Mary Beth Donahue, president of the Better Medicare Alliance, an advocacy group that supports Medicare Advantage plans, said in a statement: “We acknowledge the challenges facing some health systems, but we need to ensure coverage is maintained for millions of seniors. As Medicare Advantage continues to grow, it is essential that hospitals provide access for seniors and people with disabilities who rely on this program.”

A UnitedHealthcare spokeswoman said in a statement, “Over 6,000 hospitals participate in our UnitedHealthcare network, and we have built collaborative relationships with them to help ensure we are meeting our shared goal of providing quality care to the people we serve.”

By law, Medicare Advantage plans are supposed to base their reimbursements on Medicare rules. But there’s room for interpretation, says the Department of Health and Human Services. For example, insurers can use their own clinical criteria to determine whether to authorize or pay for care. A report last year by the department’s Inspector General found that in June 2019, the 15 top Medicare Advantage plans denied authorization for 13 percent of claims that had met Medicare rules. The plans also denied payment for 18 percent of claims that met Medicare coverage and billing rules, the report said.

Even when the plans pay, they reimburse providers far less than traditional Medicare, rural hospital CEOs and doctors told NBC News. The plans are effectively rationing health care, these providers said.

For example, the hospital officials cited specific cases in which plans take a week to approve care but agree to pay only for a three-night stay; deny coverage after approving it, clawing money back from hospitals; or contend a provider is “out of network” when it isn’t. They also deny routine tests and refuse to pay for rehabilitation, saying patients should go home before their doctors think it’s wise.

“Any study we order — X-ray, CT scan, MRI, stress tests — they’re going to deny,” said Craig Pendergrass, a doctor at Ozarks Community Hospital, a nonprofit critical access hospital in Gravette, Arkansas, in the northwest corner of the state. “With straight Medicare we just schedule it.” He estimated that his staff spends one-quarter of each week trying to persuade the plans not to deny the tests or treatment.

Large hospital systems with big staffs can dedicate time and energy to fighting claims denials, the American Hospital Association says. Small rural hospitals cannot. In response, some smaller systems are starting to reject Medicare Advantage plans. This summer, Jason Merkley, chief executive of Brookings Health System, a highly rated nonprofit hospital chain in South Dakota, stopped accepting the plans because of coverage denials and pre-authorization problems. Only a small percentage of the system’s patients had Medicare Advantage plans, Merkley told NBC News, but the effort required to battle the denials was considerable.

A Humana spokesman provided this statement: “In our Medicare Advantage hospital contracts, Humana pays rates, on average, that are above fee-for-service Medicare rates. Moreover, the fee-for-service Medicare reimbursement model is focused on patient volume and the quantity of services provided, whereas we are focused on delivering better outcomes for patients.”

In mid-September, Samaritan Health Services, a five-hospital system in Oregon, said it ended its contract with UnitedHealthcare, including its Medicare Advantage plans. “United Healthcare’s processing of requests and claims has made it difficult for Samaritan to provide timely access to the appropriate care to United’s members,” the system said.

Refusing to accept Medicare Advantage plans is not an option for hospitals with many plan customers and whose facilities are the only ones in their rural areas, the CEOs say. If they stopped accepting the plans, their communities would have to forego local health care.

“We’re a system with a proud history of taking all patients, insured or not,” said Paul Taylor, CEO of the 25-bed Ozarks Community Hospital. “But this makes it really difficult for us to continue to care for at-risk patients. We can’t pay our bills.” Medicare Advantage plans make up 40% of his reimbursements now, up from 20% a few years ago, he said.

Taylor recently conducted a two-year study of what his hospital received treating traditional Medicare patients versus what it received from Medicare Advantage plans. He found that the plans paid $4.5 million less than he received under Medicare for the same treatments. That’s roughly what his facility generates in revenues each month.

Ozarks Community, which serves approximately 30,000 people, narrowly averted a bankruptcy filing this spring, Taylor said. He is selling assets to stay afloat.

$29,458 of care denied

In late August, a patient with chronic obstructive pulmonary disease and Covid arrived at San Luis Valley Health Regional Medical Center, a 49-bed, level 3 trauma center in Alamosa, Colorado. The nonprofit hospital serves a six-county region in south central Colorado that’s home to about 50,000 people. Roughly the size of Delaware, the area is one of the poorer in the state, said Konnie Martin, San Luis Valley Health’s chief executive.

The doctor handling the patient recommended admitting her to the hospital, but her UnitedHealthcare Medicare Advantage plan balked. They agreed to pay only for “observation” of the patient, a lower standard of care that generates much smaller reimbursements.

The facility went ahead and treated her as an inpatient for two weeks, a stay that cost $29,458, all of which San Luis Valley Health absorbed, it said. Had the Medicare Advantage plan agreed to cover the claim, it would have paid one-third, the hospital estimated.

“This is the norm — they push back on people to try to keep them out of the hospital or delay their hospital care,” Martin said. The hospital’s staff has to spend time resubmitting claims, she added, saying: “It costs us 2 or 3 times the amount of labor and investment to collect on one claim.” Her staff provided documentation of four recent denials of coverage by United Healthcare in one week.

The coverage denials the CEOs described to NBC News are similar to those found in last year’s Health and Human Services report. They included erroneous rejections of MRIs and CT scans, paying only for “observation” rather than inpatient care, denials of long-term acute care, rehab, lab tests and medical equipment.

The Inspector General said that “human error” and “system processing error” caused most of the denials by Medicare Advantage plans. But the hospital executives NBC News spoke with say they believe the denials are a strategy by insurers to improve their profits by refusing to pay claims.

“This world of medical billing is so automated if you’re denying a claim, you’re doing it intentionally,” said Martin, of San Luis Valley Health.

UnitedHealthcare declined to comment.

The Cuero Regional Health System, a small hospital in Cuero, Texas, serves a population of 22,000. Its officials say Medicare Advantage plans often deny care based on the insurers’ internal determinations about the type of care required, overruling the physicians handling the cases. When the hospital questions a determination — called a peer-to-peer review — officials often have to argue with a physician who doesn’t specialize in the care the patient requires, said Lynn Falcone, its chief executive.

A Medicare Advantage plan recently denied a referral to long-term acute care for a patient with sepsis, Falcone said. When the family practice doctor overseeing the case asked for a peer-to-peer review, the insurance company physician defending the denial was an ob-gyn specialist. “A surgeon that delivers babies maybe isn’t used to handling sepsis,” Falcone said.

‘It had to be extreme’

Sandra Tate of Cuero, Texas, said her family’s Medicare Advantage plan created problems for her family in Feb. 2022. Her husband required physical and respiratory therapy after a 10-day stay in the ICU at Cuero Regional Health, she said; although a previous plan from Humana had paid for this treatment four years earlier, the second request for reimbursement was denied under her new plan from United Healthcare. After arguing with the insurer for 30 minutes, Tate, a former school nurse, said she was never told why.

“I pay my Medicare premiums and also my insurance premiums,” Tate told NBC News. “I don’t understand why Medicare Advantage is not wanting to pay the rural hospitals that are taking care of you.”

The UnitedHealthcare spokeswoman said the company could not comment on Tate’s experience unless she signed a waiver; Tate declined to do so.

In its financial filings, United Healthcare describes how rates paid by the government on Medicare Advantage plans can fall below what the insurer calls its “cost trends.” To combat these profit pressures, the insurer said, it “can seek to intensify our medical and operating cost management” and “adjust member benefits.”

For eight-and-a-half years, Alliance HealthCare System’s inpatient geriatric psychiatry program helped older patients in Holly Springs, Mississippi, with depression and other mental health issues. The 15-bed facility offered group and family therapy as well as an inpatient program that could run from one to three weeks, said Ejerra J. Selma Dukes, its former director.

Medicare always paid for the services, Dukes said. But a few years ago, she started seeing more patients with Medicare Advantage plans declining to pay. The insurers would reject claims for patients with depression and dementia, she said, agreeing to reimburse only for those who were suicidal, paranoid or homicidal. “It had to be extreme for them to say we will allow you all to bring them in,” Dukes told NBC News.

On March 28, the program closed its doors, Dukes said, a result of the denials. “It was heartbreaking, especially with those who had been dealing with us a long time,” she recalled. “You know you can help, but you can’t bring people in for free.”

Meanwhile, Rose Stone is once again receiving care at Alliance HealthCare System. She junked her Medicare Advantage Plan and returned to Medicare, with a supplement. “Everything is fine now,” she said.

https://www.nbcnews.com…

Seniors, beware: Medicare open enrollment feels like ‘open season’ on older Americans

A bipartisan group of senators found that greed is fueling deceptive marketing practices in the Medicare Advantage market.

By Carol Paris, M.D.
The Tennessean, October 30, 2023

Open enrollment goes through Dec. 7. My mailbox is already filling with official-looking letters from commercial insurance companies posing as Medicare.

They tout the advantages of their particular plan while conveniently withholding information that we seniors need and deserve in order to make a truly informed decision about our choice of health insurance.

So what should you know that the billboards, mailers, and Joe Namath TV ads aren’t telling you?

Congressional investigations are exposing problems like up-coding

How about that Senate Finance Committee Chair, Sen. Ron Wyden, D-Oregon, released a report in 2022 confirming deceptive marketing practices in Medicare Advantage plans and is convening hearings on the matter.

How about that, according to Becker’s Hospital CFO Report, hospitals are dropping Medicare Advantage plans in record numbers due to excessive prior authorization delays and denials of care and slow payment of claims? In the words of Chris Van Gorder, president and CEO of San Diego-based Scripps Health: “Patients need to be aware of how this system works. Traditional Medicare is not an issue. With these other models, seniors need to be wary and savvy buyers.”

How about that Sen. Bill Cassidy, R-Louisiana, and Sen. Jeff Merkley, D-Oregon, introduced a bill this year to address the rampant up-coding by Medicare Advantage plans that is draining the Medicare Trust Fund?

Up-coding is the practice of making a patient appear sicker and more complexly ill than they really are for the purpose of getting a higher reimbursement rate for providing that patient’s care. “Federal audits have found that taxpayers have been overpaying bad actors running Medicare Advantage plans by billions of dollars every year,” Merkley said. “This fraud has to end.”

Get rid of bad actors in Medicare Advantage

And finally, how about that, along with overpayments due to up-coding, so-called Medicare Advantage plans are robbing taxpayers of an estimated $88 billion to $140 billion dollars a year?

These groundbreaking findings were reported recently in The Lever, which quoted Physicians for a National Healthcare Program (PNHP) Board Secretary Dr. Ed Weisbart saying: “Insurers are quietly plundering the Medicare trust fund for their own profits and compromising the health of senior citizens and people with disabilities.”

I can think of several things we could do with that Medicare Trust Fund money like improving the benefits in traditional Medicare, so senior citizens could just choose Medicare and be done with it.

I agree with Senators Cassidy, Merkley, Wyden and others that it is time to end the insatiable greed of bad actors. Tell Congress to get rid of the bad actors in Medicare Advantage and to stop this yearly “open season” on senior citizens.

Dr. Carol Paris is past president and a member of the Board of Physicians for a national health program.

https://www.tennessean.com…

Survey Confirms (Again) that US Health Insurance Makes Us Sicker & Poorer

Summary: A Commonwealth Fund survey thoroughly documents that US health insurance of all types poses widespread financial barriers to care, and thus leaves us sicker. Not news, but essential to repeatedly document. The only solution: comprehensive universal public coverage.

Paying for It: How Health Care Costs and Medical Debt Are Making Americans Sicker and Poorer, Findings from 2023 Health Care Affordability Survey, The Commonwealth Fund, October 26, 2023, by Sara R. Collins, Shreya Roy, Relebohile Masitha

Highlights [HJM * bolded summaries]

  • Large shares of insured working-age adults surveyed said it was very or somewhat difficult to afford their health care: 43 percent of those with employer coverage, 57 percent with marketplace or individual-market plans, 45 percent with Medicaid, and 51 and percent with Medicare. *43-57% of insured working-age adults find health care difficult to afford.
  • Many insured adults said they or a family member had delayed or skipped needed health care or prescription drugs because they couldn’t afford it in the past 12 months: 29 percent of those with employer coverage, 37 percent covered by marketplace or individual-market plans, 39 percent enrolled in Medicaid, and 42 percent with Medicare. *Over 12 months, 29-42% of insured adults or family delay or skip needed care due to unaffordability. This is higher for poor families, and reaches 64% for uninsured (see figure below).

  • Cost-driven delays in getting care or in missed care made people sicker. Fifty-four percent of people with employer coverage who reported delaying or forgoing care because of costs said a health problem of theirs or a family member got worse because of it, as did 61 percent in marketplace or individual-market plans, 60 percent with Medicaid, and 63 percent with Medicare. *54-63% of those delaying or skipping care got sicker as a result.
  • Insurance coverage didn’t prevent people from incurring medical debt. Thirty percent of adults with employer coverage were paying off debt from medical or dental care, as were 33 percent of those in marketplace or individual-market plans, 21 percent with Medicaid, and 33 percent with Medicare. *21-33% of adults are paying off medical debt.
  • Medical debt is leading many people to delay or avoid getting care or filling prescriptions: more than one-third (34%) of people with medical debt in employer plans, 39 percent in marketplace or individual-market plans, 31 percent in Medicaid, and 32 percent in Medicare. *31-39% of those with medical debt delay or skip care as a result.

Comment:

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

This survey powerfully quantifies the failure of our insurance system to assure financial access to care. The findings aren’t new (eg, see a similar survey by KFF), but they’re still shocking.

Which raises the question: What’s the purpose of US health insurance?

For me, the answer is clearer with each report released and each year passed: the fragmented health insurance system is designed to benefit powerful interest groups: insurers, pharma, and large providers.

Who are the losers? All of us needing medical services that – even with insurance – are often financially out of reach.

Dozens of other countries have solved the health insurance challenge. Universal lifelong coverage with identical comprehensive benefits, and without opportunity for profiteering. Far lower costs, and far better overall health outcomes.

Embarrassing and painful survey results like this will disappear only once we adopt single payer insurance.

http://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.

Hospitals, doctors drop private Medicare plans over payment disputes

By Ken Alltucker
USA TODAY, October 27, 2023

One large health system with hospitals in Virginia and Ohio this year cut off in-network access to consumers enrolled in some Anthem Blue Cross Blue Shield Medicare and Medicaid health insurance plans.

Two doctors groups with Scripps Health in San Diego are terminating contracts with private Medicare plans over concerns about payments and routine denials.

For years, hospitals, doctors and health insurance companies have squared off over how much to pay for medical services. Insurers negotiate contracts with hospitals and doctors so their customers can get lower, in-network rates at those facilities. These negotiations, usually hammered out behind the scenes, are becoming increasingly tense and public as hospitals seek adequate payments and health insurance companies attempt to check spiraling medical bills.

Experts say these disputes could be an early warning sign of more contract terminations ahead as hospitals and large doctor groups seek lucrative payments to offset inflation, healthcare workers’ double-digit raises and escalating prices for medical supplies.

But for patients caught in the middle of these disputes, the results can be devastating. Some need to switch doctors or insurance plans or potentially pay higher, out-of-network rates at a time when half of Americans are struggling to afford the rising cost of medical care.

Scripps Health ended the 2024 Medicare Advantage plan contracts with two medical units, called Scripps Clinic and Scripps Coastal. The decision will affect about 32,000 patients who will either need to switch Medicare plans or find new doctors.

“We’re unfortunately on the vanguard of what I think is going to be a very ugly few years between hospitals and commercial insurance companies,” said Chris Van Gorder, President and CEO, Scripps Health.

Hospitals target private Medicare plans

Many contract terminations involve hospitals rejecting terms for private Medicare insurance plans, known as Medicare Advantage plans. While traditional, government-run Medicare allows enrollees to choose from a wide variety of doctors and hospitals, private Medicare plans restrict access through networks and impose some cost-sharing requirements such as copayments or deductibles.

Hospitals that are rejecting private Medicare plans say they don’t reimburse at the same levels as traditional Medicare, delay or deny care through prior authorizations or impose other limitations.

Van Gorder said Scripps’ Medicare Advantage exit was a “very difficult decision” but one he had to make due to more than $75 million in annual losses. He tried to negotiate more lucrative reimbursement rates, but those talks fizzled.

While private Medicare plans are funded by government-run Medicare, they’re also profitable because insurers keep a portion of those payments before paying for care, he said.

Van Gorder described private Medicare offerings as “delay, deny or don’t pay” plans. “They’re in the business of making money,” he said.

Hospitals cut off insurers that ‘don’t reimburse us adequately’

Doctors groups and hospitals are more willing to air frustrations over private Medicare plans after think tanks and government watchdog agencies have issued critical reports about these insurers’ profits and practices, said David Lipschutz, associate director and senior policy attorney for the Center for Medicare Advocacy.

In 2022, a government watchdog report said private Medicare plans routinely rejected claims that should have been paid and denied services found to be medically necessary. These private plans rejected nearly one in five claims allowed under Medicare coverage rules and denied 13% of authorizations for medical services that government-run Medicare would have allowed, the U.S. Department of Health and Human Services inspector general investigators found.

Doctors and hospitals “are more willing to publicly express their frustration,” Lipschutz said, because these private Medicare plans get what “many people would characterize as overpayments.”

More than a half dozen other hospital systems from Bend, Oregon to Nashville, Tennessee have announced private Medicare contract terminations or lapses.

St. Charles Health System in Bend said it will end Medicare contracts next year with Humana, HealthNet and WellCare.

Mark Hallett, St. Charles’ chief clinical officer, said sticking with those private Medicare plans would “result in restrictions to patient care, longer hospital stays and administrative burdens” for doctors.

How To Get Health Insurance in Other Countries: Be Born

Summary: Dr. Danielle Ofri, an insightful commentator on the practice of medicine, overlooked annual re-enrollment for her health insurance at work due to an email glitch. So she was automatically bumped to “basic coverage”, excluding her husband and kids. Panic ensued. Other wealthy nations avoid this inefficient and upending bureaucratic hoop. So would single payer.

It Shouldn’t Be This Easy to Lose Your Health Insurance, New York Times, October 25, 2023, by Danielle Ofri (NYC primary care doctor & thoughtful author on the practice of medicine)

A few days before New Year’s Eve, an unfamiliar health insurance card for me arrived in the mail. I assumed there must have been an error and called the human resources department of the medical center where I’m employed as a doctor.

“No,” the representative replied, “it’s not a mistake. You didn’t enroll this year, so you automatically got put on the basic plan.”

“That’s … that’s impossible,” I stammered. “I’ve always signed up my family for the same health plan.”

“I’m sorry, Dr. Ofri,” the representative said, rechecking her records, “but you didn’t enroll this year.”

Could that be? Could I have somehow forgotten? Or missed the notification? “But don’t worry,” she said. “We’ve put you on the basic plan.”

“OK,” I said, starting to relax and thinking out loud. “I guess my kids will get to meet some new doctors.”

But the representative did not match my tone. “I’m sorry, but the basic plan is just for the employee,” she said, “not your family.”

[Dr. Ofri recounts the emotional and bureaucratic turmoil this created, and ends by stating …)

Of course, none of this would be necessary if the only requirement for getting insurance was – as it is in most countries – being born. Instead, Americans are forced to live within an illogical patchwork of plans and regulations that so easily allows people to fall through the cracks.

Comment:

By Don McCanne, M.D., et al.

To no surprise, this New York Times article provoked a large number of reader responses, still pouring in as this was composed. A handful of selected excerpts from their responses:

“As the good doctor has said, ‘There’s gotta be a better way.’”

“I just wish that America had even one political party that believed in Universal Healthcare. Not ’near universal.’ Not ‘a path to universal.’ Not ‘affordable.’ But actual, everyone-is-covered, universal healthcare.”

“Most Europeans I know do not have this problem. Their healthcare systems are focused on healthcare and not the care of and feeding of corporations and esp corporate execs and shareholders.”

“Even better: a single-payer system like the one in Canada. You don’t have to sign up.”

“The people of this country clearly want the national health plan like other developed countries enjoy.”

“Time to evict private/for-profit players from the health care system and turn to universal, single payer.”

“It would be far better to have a single payer or national coverage.”

“That Congress, for many decades, has not passed single payer/universal health care legislation is proof of the insanity & or greed in our country.”

“A problem easily solved. Medicare for All. Original Medicare. Not Medicare Advantage.”

“Every comment I read here appeals for single payer health care.” (Not quite, but impressive. – DMc)

“The AMA confirmed Thursday that it is leaving the Partnership for America’s Health Care Future, an industry group that opposes Medicare for All. The decision does not signal a policy change.” (I’m a special lifetime member of AMA, and I strongly support Medicare for All. – DMc)

“The only genuine workable system is single-payer Improved Medicare for All. It’s time to start listening.”

“We’re at a point where a little over 60 percent of Americans support single-payer healthcare for all.”

“Medicare for All”

“Yet another problem universal health care would solve.”

“Or maybe we just need universal health insurance?!”

“We need a national health care system.”

“It’s high time to have Medicare for All.”

“Medicare for All is the only sensible, fair and equitable way to distribute the financial burden of health care in this country.”

“Healthcare should be a right for all of our citizens.”

“A single payer system is far simpler, less costly, has better outcomes.”

“We need Medicare for All.”

“Agree that it’s time for Medicare for All.”

“Say it, Dr. Ofri – Medicare for All! We’re finally hearing about the widespread egregious problems with U.S. healthcare, for which the only realistic solution is Medicare for All.” (finally?! for decades! – DMc)

“I’m surprised that no one has pointed out that doctors don’t want a single payer system.” (I suppose that it is time for those of us at Physicians for a National Health Program to turn up the volume again! – DMc)

From Don McCanne: “An improved version of Medicare for All as a SINGLE PAYER, takes care of the problem for everyone, forever!”

The point is, support for a single payer, Medicare for All program in this nation is very strong, and we are long overdue for our political leaders to move forward with bringing health care justice to all of us by enacting and implementing such a system.

http://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.

Queer Women Select Health Care Access as #1 Priority

Summary: A new poll finds that queer women, asked for policy priorities, most often named universal health care at the top, following by climate change. Health care for all is a critical, central, and motivational component of progressive priorities.

Queer women are prioritizing climate and health issues over LGBTQ+ rights, new poll shows, The 19th, October 20, 2023, by Orion Rummler

Expanding health care access, addressing climate change and protecting reproductive rights all matter more to queer women polled in a recent survey than furthering LGBTQ+ rights. These issues need to be reflected in LGBTQ+ rights organizations, researchers and advocates say.

The survey captured the experiences of thousands of queer women, as well as the experiences of anyone in the LGBTQ+ community who has previously identified as a woman and who centers their emotional, sexual or family life around women. It encouraged transgender men, as well as gender-fluid people, to share their views.

Respondents were asked to write in their own answers about their top policy priorities, their various gender identities and favorite things about being queer, and what kind of accessibility barriers they face to reach LGBTQ+ services.

When the survey asked queer women for their top three policy priorities, respondents were not given a list to choose from; they were asked to write in their own three core issues. Still, clear trends emerged.

More accessible health care was the most commonly prioritized. Forty-five percent said in the survey that more affordable or accessible health care – which they also described as universal health care or Medicare for all – is their top concern. Universal health care means that health insurance coverage is available to everyone and is provided by the government or private companies, or a combination of both. Medicare for all, a separate policy, would expand Medicare to replace other public and private health insurance plans.

Meanwhile, 37 percent of surveyed queer women said combating environmental and climate change is one of their top three priorities, Thirty-six percent listed reproductive justice, abortion access and bodily autonomy as one of the issues that matter most to them.

Comment:

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

It might be expected that queer women would experience socioeconomic pressures that might make them a valuable resource on what policies might improve the status of their group and thus, by extension, the status of everyone. It is instructive and encouraging that, without being given a list to choose from, they spontaneously selected accessibility to health care as their most important priority with the environment (which some progressives rank as first) and reproductive health (a leading political advocacy issue) ranking as second choices.

Once again, we have a group which has had reason to give considerable thought to these important issues and has concluded, as we have, that affordable, accessible, universal health care – Medicare for All – is their most important priority. Implied in that is sharing an affordable health care system that serves all of us equitably, and they so astutely remind us that “equitable” includes all individuals, regardless of sexual preferences.

This has potent implications for political alliance and synergy. Movements for gay / bisexual / transgender rights, against racism, to reduce economic inequality, to protect democracy, and for universal health care align in the broad rubric of preserving and advancing human rights. Access to health care is something everyone wants. The more we recognize the links among these social causes, the more effectively we can work powerfully together.

http://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.

Nahiris M. Bahamón, MD

Pediatrics

Dr. Nahiris M. Bahamón is a community pediatrician at Lowell Community Health Center in Lowell, MA. She is an experienced advocate for increased access to high quality health care, especially for immigrant and other marginalized communities. Dr. Bahamón has also worked with the American Academy of Pediatrics to increase awareness about the needs of immigrant families, and to increase access to culturally sensitive, high quality care. Originally from Colombia, she moved to the U.S. as a refugee with her family.

Dr. Bahamón has been active in the movement for Medicare for All since medical school. She was a co-founder of Residents for a National Health Program and served on the PNHP Board of Directors. Dr. Bahamón earned her medical degree from Boston University and completed her residency in pediatrics at the University of Chicago. She is available to speak in English and Spanish.

‘Not Being Blindsided’

By Patty Harvey
North Coast Journal (Humboldt County, Calif.), Letters, October 19, 2023

It’s that time again. If you’re thinking goblins and scary monsters, think again. Humboldt County seniors are being inundated with slick ads, mailers and presentations designed to lure them into the private health insurance plans known as Medicare Advantage (MA). (“California Says No to Privatizing Medicare,” Sept. 21.)

These plans are fraught with pitfalls and misconceptions, the first being you are not joining Medicare. You may, in fact, save money at the outset but there are long-term deficits. It is important if you choose such a plan to ask questions first. For example, you may want to know:

  • In workshops you ask that I decide how much health care I am going to need in the future in order to determine my plan’s parameters. How can I be expected to anticipate the future?
  • What local doctors and hospitals can I access? (It turns out there are only 12 physicians and two hospitals here in the program network.)
  • Which of the many perks you offer are actually available here and how much does the plan pay for each?
  • Can I return to traditional Medicare with a Medigap policy after being on Medicare Advantage after one year?
  • What is the maximum out-of-pocket I would have to pay in one year, in network and out?
  • If I need care in a specific hospital or from a specific specialist of my choice will I be covered?
  • Publicity around MA details massive fraud and abuse by these companies that overcharge the Medicare trust fund by billions of dollars every year. Hospitals and physicians are refusing to accept MA patients due to repeated delays and denials of treatments and layers of paperwork. Does this plan ever deny treatment and for what reasons?

What seems too good to be true often is neither good nor true. Being prepared means not being blindsided.

https://www.northcoastjournal.com…

Strong Swiss Support for a Single National Health Insurer

Summary: Switzerland if often cited as an example of how private insurance (highly standardized and not-for-profit) can achieve universal coverage. Yet, a recent poll found 3 to 1 support for a single national health insurer, and only 1 in 5 favor retention of private insurance.

Majority of Swiss want single national health insurer, survey finds, SWI Swissinfo, October 4, 2023

A majority of Swiss would support the creation of a single health insurer, rather than the multiple options currently available.

According to the online poll by the Ipsos Switzerland institute between September 27 and 29, 61.2% of the 800 respondents said they were in favor of a single health insurer. Some 21.1% were opposed and 17.7% had no opinion.

A majority of 58% also approved the idea of adjusting premiums according to income levels.

While respondents supported changes in the financing of compulsory health insurance, they rejected the idea of limiting benefits in exchange for paying a lower premium.

As for tackling costs, the left-wing Social Democrats have launched an initiative demanding that no insured person should pay more than 10% of their income on health insurance premiums. The text demands that federal and cantonal authorities contribute more to reducing premiums.

The Swiss have already twice refused the creation of a single national health insurer in popular votes.

Comment:

By Don McCanne, M.D.

There has been a popular drive in the United States to improve traditional fee-for-service Medicare and then expand it to include everyone in the form of a public single payer insurer. At the same time, a private version of Medicare – Medicare Advantage – has been heavily marketed with increasing sales in spite of evidence such as recently released by Physicians for a National Health Program that shows that these private plans are overpaid by more than $100 billion per year in patient and taxpayer dollars.

Those supporting the use of private insurance for national health programs often cite the Swiss system of compulsory private insurance. This argument could make some sense if the private insurers would make no profit on a truly standard universal insurance, as in Switzerland and other nations. But not if the private insurers profit from highly variable and inadequate insurance, as in the US. Moreover, based on the current poll, even in Switzerland support may be shifting to a single payer system, progressively financed. In a recent survey of what worried the Swiss most, health insurance premiums ranked first.

It may be that the Swiss have been observing the pathological U.S. markets of private health insurance and have decided that a health care financing system owned and administered by the people is really a better way after all. Importantly, the British have demonstrated that they must elect government stewards who are actually willing to fund their system fully enough to meet all of their health care needs. But what they don’t want to do is to cut the funds, hand them over to private administrators who then shunt whatever they can to billionaire healthcare investors.

If only we in the U.S. can learn from our own mistakes, dump private Medicare Advantage, and adopt a public single payer Medicare for All program. The Swiss seem to agree.

http://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 keeps growing. Tiny, rural hospitals say that’s a huge problem.

By Sarah Jane Tribble
NPR, All Things Considered, October 17, 2023

Jason Bleak runs Battle Mountain General Hospital, a small facility in a remote Nevada gold-mining town that he describes as “out here in the middle of nowhere.”

When several representatives from private health insurance companies called on him a few years ago to offer Medicare Advantage plan contracts so their enrollees could use his hospital, Bleak sent them away.

“Come back to the table with a better offer,” the chief executive recalls telling them. The representatives haven’t returned.

Battle Mountain is in north-central Nevada, about a three-hour drive from Reno and four hours from Salt Lake City. Bleak (whose name is pronounced “Blake”) suspects insurance companies simply haven’t enrolled enough of the area’s seniors to need his hospital in their network.

Medicare Advantage insurers are private companies that contract with the federal government to provide Medicare benefits to seniors in place of traditional Medicare. The plans have become dubious payers for many large and small hospitals, which report that the insurers are often slow to pay or don’t pay.

Private plans now cover more than half of those eligible for Medicare. And while enrollment is highest in metropolitan areas, it has increased fourfold in rural areas since 2010. Meanwhile, more than 150 rural hospitals have closed since 2010, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina. States such as Texas, Tennessee and Georgia have had the most closures.

Medicare Advantage growth has had an outsize impact on the finances of small, rural hospitals that Medicare has designated as “critical access.” Under the designation, government-administered Medicare pays extra to those hospitals to compensate for low patient volumes. Medicare Advantage plans, on the other hand, offer negotiated rates that hospital operators say often don’t match those of traditional Medicare.

“It’s happening across the country,” says Carrie Cochran-McClain, chief policy officer of the National Rural Health Association, whose members include small-town hospitals.

“Depending on the level of Medicare Advantage penetration in individual communities, some facilities are seeing a significant portion of their traditional Medicare patient or beneficiary move into Medicare Advantage,” Cochran-McClain says.

Kelly Adams is the CEO of Mesa View Regional Hospital, another rural hospital in Nevada. He says he applauds Battle Mountain’s Bleak for keeping Medicare Advantage plans out of his hospital “as long as he has.”

Mesa View, which is a little more than an hour’s drive east of Las Vegas, has a high percentage of patients enrolled in Medicare Advantage plans.

“Am I going to say I’m not going to take care of 40% of our patients at the hospital or the clinic?” Adams says, adding that it would be a “tough deal” to be forced to reject patients because they didn’t have traditional Medicare.

Mesa View has 21 Medicare Advantage contracts with multiple insurance companies. Adams says he has trouble getting the plans to pay for care the hospital has provided. They are either “slow pay or no pay,” he said.

In all, the plans owe Mesa View more than $800,000 for care already provided. Mesa View lost about $1.3 million taking care of patients, according to its most recent annual cost report.

Cochran-McClain, of the National Rural Health Association, says the growth in the plans also narrows options for patients because “the contracting that is happening under Medicare Advantage frequently has an influence on steering patients to specific types of providers.” If a hospital or provider does not contract with a Medicare Advantage plan, then a patient may have to pay for out-of-network care. That generally wouldn’t happen with traditional Medicare, which is widely accepted.

At Mesa View, patients must drive to Utah to find nursing homes and rehabilitation facilities covered by their Medicare Advantage plans.

“Our local nursing homes are not taking Medicare Advantage patients because they don’t get paid. But if you’re straight Medicare, they’d be happy to take that patient,” Adams says. (Medicare pays for limited nursing home stays post-surgery or injury. Long-term care is covered only by Medicaid, for those who qualify.)

David Allen, a spokesperson for AHIP, an industry trade group formerly known as America’s Health Insurance Plans, declined to respond to Bleak’s and Adams’ specific concerns. Instead, he says enrollees are signing on because the plans “are more efficient, more cost-effective, and deliver better value than original Medicare.”

Sara Lonardo, press secretary for the Centers for Medicare & Medicaid Services, says CMS has acted to ensure “that private insurance companies are held accountable for providing quality coverage and care.”

The reach of private Medicare Advantage plans varies widely in rural areas, says Keith Mueller, director of the Rural Policy Research Institute at the University of Iowa’s College of Public Health. If recent trends continue, enrollment could tip to 50% of rural Medicare beneficiaries in about three years — with some regions like the Upper Midwest already higher than 50% and others lower, such as Nevada and the Mountain States, but trending upward.

In June, a bipartisan group of Congress members, led by Sen. Sherrod Brown, D-Ohio, sent a letter urging federal agencies to do more to force Medicare Advantage insurers to pay health systems what they owe for patient care.

In an August response, CMS Administrator Chiquita Brooks-LaSure wrote that a final rule issued in April made “impactful changes” to speed up care and address concerns about prior authorization — when a hospital and patient must get advance permission for care to ensure it will be covered by an insurer. Brooks-LaSure noted another proposed rule that, once finalized, could mandate that insurers provide specific reasons for denying care within seven days.

Hospital operators Adams and Bleak also want more federal action, and fast.

Bleak at Battle Mountain says he knows Medicare Advantage plans will eventually move into his area and he will have to contract with them.

“The question is,” Bleak says, “how can we match the reimbursement so that we can sustain and keep our hospitals in these rural areas viable and strong?”

https://www.npr.org…