Summary: PNHP founders Woolhandler and Himmelstein propose that progressive health reform needs updating to respond to the widespread takeover of providers by for-profit corporations. The original vision of insurance reform should be expanded to include ownership of provider organizations.

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We Don’t Just Need Medicare for All — We Need a National Health System, An Interview with Steffie Woolhandler and David U. Himmelstein, Jacobin, May 2, 2023

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The founders of Physicians for a National Health Program put single-payer health care on the map. Now, discussing the next phase of the movement, they say even single-payer won’t be enough to fix the problems caused by continued privatization. …

Steffie Woolhandler

There’s two countervailing things going on. One is that giant for-profit corporations have a much stronger hold on the health care system than they did when we started PNHP. So when we started, we were mostly up against the insurance industry and pharmaceutical industry. But now there’s all sorts of involvement by banks and for-profit ownership of health providers, so that makes things harder.

The other thing is that the health care system continues to be so dysfunctional. People with or without insurance face massive medical bills, the complete inability to afford lifesaving treatments like insulin and sometimes cancer treatments. The growing dissatisfaction among doctors is now often called burnout or sometimes moral injury. Whatever you call it, physicians recognize that the system’s not functioning very well. So the system’s own problems and dysfunctions continually create an interest in and constituency for fundamental health reform.

Giant for-profit corporations have a much stronger hold on the health care system than they did when we started PNHP.

David U. Himmelstein

We need to have a deep understanding of what the problems in the current system are, and the shifts in the organization of the current system need to guide both our program and our political work. So I think we need to update what the vision of single-payer health care is from when we first conceived of it.

We thought we could control the health care system by replacing insurance companies with a single public financing system. And I think that was true as long as health care was essentially carried out by small-scale practices, mostly individual hospitals, that were not parts of large chains, not controlled by giant corporations. But at this point, we have the vertical and horizontal integration of ownership of the health care system. So for instance UnitedHealthcare employs seventy thousand doctors. Just taking away the insurance business isn’t going to be an adequate reform of the health care system.

We need to reconsider our reforms to think about how we seize ownership of health care assets from the corporations that have come to dominate them, and how patients and people doing health care work can really take ownership of this system. I don’t think it’s possible any more by just taking control of insurance. I don’t see a lot of advocacy for radical reform of the health care system, and that I think is the next phase that either PNHP or some new form will need to take up.

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Comment:

By David Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.

Looking forward rather than backward, progressives need to update the vision of health reform that we and others articulated in the 1980s. Back then, a public financing program that displaced private ownership of health insurers would have had the leverage needed to broadly transform health care. But Wall Street’s subsequent takeover of health care delivery – hospitals and nursing homes, doctors’ practices, and even hospices – necessitates reform of who owns provider resources. Communities, not corporations should control care.

We hope that by speaking out on this issue, we can encourage the health reform movement to take on the critical ownership issues.

A few comments on the mostly accurate PNHP history presented in the article. It was founded 37, not 35 years ago. We note that Ron Sable, and subsequently Quentin Young, and then Claudia Fegan took over day-to-day oversight when PNHP moved from Cambridge to Chicago. Former Executive Directors Ida Hellander and Matt Petty made important contributions to PNHP. We are currently members, but not leaders, of the organization.

http://healthjusticemonitor.org…

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Summary: Aggressive collection tactics by a large bariatric surgery practice exemplify widespread problems with our health insurance: complex payment arrangements, confusing and misleading financial contracts, widely variable prices, medical debt, expensive litigation, and rising private equity.

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Lose Weight, Gain Huge Debt: NY Provider Has Sued More Than 300 Patients Who Had Bariatric Surgery, KFF Health News, April 20, 2023, by Fred Schulte

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Seven months after Lahavah Wallace’s weight loss operation, a New York bariatric surgery practice sued her, accusing her of “intentionally” failing to pay nearly $18,000 of her bill. …

Wallace denies the allegations, which the bariatric practice has leveled against patients in hundreds of debt-collection lawsuits filed over the past four years, court records in New York state show.

In about 60 cases, the lawsuits demanded $100,000 or more from patients. Some patients were found liable for tens of thousands of dollars in interest charges or wound up shackled with debt that could take a decade or more to shake. Others are facing the likely prospect of six-figure financial penalties, court records show. …

[Wallace] said she turned over checks from her insurer to the bariatric group and was stunned when the medical practice hauled her into court citing an “out-of-network payment agreement” she had signed before her surgery.

“I really didn’t know what I was signing,” Wallace told KFF Health News. “I didn’t pay enough attention.” …

The bariatric group has cited these out-of-network payment agreements in at least 300 lawsuits filed against patients from January 2019 through 2022 demanding nearly $19 million to cover medical bills, interest charges, and attorney’s fees, a KFF Health News review of New York state court records found. …

In most cases, the medical practice had agreed to accept an insurance company’s out-of-network rate as full payment for its services — with caveats, according to court filings.

In the agreements they signed, patients promised to pay any coinsurance, meeting any deductible, and pass on to the medical practice any reimbursement checks they received from their health plans within seven days.

Patients who fail to do so “will be held responsible for the full amount charged for your surgery, plus the cost of legal fees,” the agreement states.

That “full amount” can be thousands of dollars higher than what insurers would likely pay, KFF Health News found — while legal fees and other costs can layer on thousands more. …

Wallace, the Brooklyn legal assistant, was billed $60,500 for her lap sleeve gastrectomy, though how much her insurance actually paid remains to be hashed out in court.

Michael Arrigo, a California medical billing expert at No World Borders, called the prices “outrageous” and “unreasonable and, in fact, likely unconscionable.” …

Private Equity Arrives

… In August 2019, the private equity firm Sentinel Capital Partners bought 65% of the MSO for $156.5 million, according to Garber’s affidavit. The management company is now known as New You Bariatric Group. The private equity firm did not respond to requests for comment.

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Comment:

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

This exposé of one firm exposes problems that plague all of health care. The aggressive legal tactics employed by this surgery practice drew press attention because they’re so egregious and extensive. But the fundamental issues permeate our insurance system.

1) Complex payment arrangements: Scores of public insurance programs (Traditional Medicare with and without direct contracting, Medi-gap policies, Medicare Advantage and Medicaid plans in profusion) and thousands of private insurance plans from work and ACA exchanges. Out-of-network payments regulated by ambiguous laws. All of this contributes hugely to more than $600 billion per year in excess administrative costs.

2) Confusing and misleading financial contracts with patients: The patients of this bariatric surgery practice were told that it would accept out-of-network payments offered by insurers … except if … here’s the fine print … they failed to take care of all tasks within 7 days, in which case their obligation would shift to “the full amount charged for your surgery, plus the cost of legal fees”. And, it seems, the practice charged very high prices.

3) Widely variable prices: Which brings us to prices. It turns out that prices listed by different practices for these standard surgeries vary widely in nearby areas. This is generally true of medical prices: the amount “charged” (aka “billed”, aka “chargemaster”) is entirely discretionary, and varies hugely across providers. Insurers typically negotiate much lower “allowed” charges. Discerning a truly fair local price is impossible. This surgical practice aims high, which means the sued patients are on the hook for amounts far in excess of actual costs.

4) Medical debt: Which leads to medical debt. As detailed in the article, this is the result for many sued patients. And, as covered in HJM, estimates of the current prevalence of medical debt are in the range of 40-50%, with a median debt of $2,500 or more.

5) Expensive litigation: Collections lawyers are happy to line up when liabilities of tens of thousands of dollars are in the offing from poorly-represented patients who didn’t read the fine print in their contracts, and the lawyers will keep 1/3 of the yield. That adds to administrative costs. And the litigation clogs the courts and traumatizes patients.

6) Rising private equity: As the last excerpted paragraph notes, the surgery practice payment lawsuits accelerated once private equity entered the scene. Private equity is rapidly expanding its role in provider ownership, as reported in HJM. Pursuit of income and profit as their guiding light.

Single payer would solve problems 1, 2, 3, 4, and 5. And greatly mitigate 6.

http://healthjusticemonitor.org…

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Summary: Oracle Health, acquired by Cerner, is pursuing a global cloud-based health records repository. Except that they can’t even succeed in five Veteran’s Administration hospitals. And their grand vision fails to address core healthcare financing challenges. When will we turn our attention from profit-seeking business models to health coverage basics?

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Oracle’s plan to build national health records database ‘going great,’ Feinberg says, Healthcare Dive, April 21, 2023, by Rebecca Pifer

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(David Feinberg was CEO of Cerner and then became chairman of Oracle Health when it acquired Cerner.)

Healthcare Dive: When the deal closed, Oracle said it planned to focus the unit on medical software usability and voice-enabled user interfaces, and would expand Cerner’s business to more countries. Can you give me an update on these priorities?

Feinberg: I remember those three things being listed. It’s more now. Our vision is to create a cloud-enabled health platform that brings all kinds of information together to make individuals and communities healthier around the world. That includes the electronic health record, and Oracle’s human capital management, enterprise resource planning, supply chain management, claims processing, clinical trials – so we have a platform that normalizes data and then tees it up for whoever needs it, a mom taking care of kids at home, or a government looking at public health issues.

Healthcare Dive: Larry Ellison announced Oracle has plans to build a health records database to link the thousands of separate hospital databases. How is this going?

Feinberg: It’s going great. We have a new product we just launched called Seamless Exchange. A clinician gets a new patient, and this patient has records from multiple places. With one click, we take all of that information and we make a longitudinal story of that patient.

Healthcare Dive: What are the next steps?

Feinberg: I want all information that’s applicable to my health. That includes social determinants, that includes claims processing, so many other pieces of information.

Healthcare Dive: How will Oracle pull that additional data?

Feinberg: Oracle Financial Services processes 80% or 90% of the world’s credit card transactions… So we have the clinical data. Oracle Financial Services also does claims data. We think we can be the trusted intermediary between clinical care and the payment of clinical care that dramatically decreases the cost.

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VA Halts Future Launches of its Oracle Cerner Health Record System, Military.com, April 21, 2023, by Patricia Kime

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The Department of Veterans Affairs has abandoned plans to introduce its new electronic health records system at more facilities, announcing Friday that it has halted all future deployments as if moves to fix the system at the five places where it is currently used.

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Comment:

By Don McCanne, M.D.

So it looks like Oracle wants to take over the entire health care information technology system. In whose interest is this?

In these days when the medical-industrial complex dominates, it seems that Oracle’s designs are on enhancing shareholder value, probably not just for individual shareholders and for the corporate executives, but especially for the dominant shareholders representing the shift of wealth from the masses to the billionaire element in our society.

Is this in the interest of the health care professionals and the health care industry at large? It does provide a framework for an overlay of their health information technology, but for the purpose of enhancing income produced by the IT system. Any income for the actual health care delivery system would be to keep them satisfied so they would continue to use Oracle products.

But shouldn’t the health care delivery system be designed to, above all, meet the needs of patients? What does this IT system do for those individuals who could qualify for Medicaid but are left out because of political decisions in their states? What about for those who are left un- or under-insured because of employer-labor disputes? What about those who are medically underserved due to well-documented problems such as racial inequities? Why would we ignore all our health policy lessons about how to provide optimal care for everyone?

Creating more wealth-generators in health care without fixing the profound deficiencies in our health care system is obviously continuing down the wrong path, blatantly disregarding real needs. At least they understand this at the VA. They’ve halted the launch of the Oracle Cerner Health Record System because it is not working for the patients, and the patients are what health care is all about. Oracle can’t manage data for five health facilities, but they’re eager to take on health data around the world.

Shouldn’t we get serious about health system improvement? Clear goals on how to optimize access to care for everyone (not maximize profits), using proven methods (not shoddy IT).

http://healthjusticemonitor.org…

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Summary: In Part 1, we discussed how primary care is being acquired and distorted by huge corporations pursuing massive profits. Today, we present a competing vision: a broad social movement to reclaim primary care as a “common good” focused on public benefit.

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Forging a Social Movement to Dismantle Entrenched Power and Liberate Primary Care as a Common Good, Annals Of Family Medicine, March/April 2023, by Kevin Grumbach

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Abstract

The state of family medicine and primary care in the United States is precarious, afflicted by chronic underinvestment. Family physicians and their allies should not expect different policy outcomes without adopting a different theory of change and tactical approach to reform. I argue: (1) high-quality primary care is a common good, as asserted by the National Academies of Sciences, Engineering, and Medicine; (2) a market-based health system captured by extractive capitalism is inimical to primary care as a common good; (3) professionalism has both aided and constrained family physicians as agents of change for primary care as a common good; and, (4) to actualize primary care as a common good, family physicians must embrace “counterculture professionalism” to join with patients, primary care workers, and other allies in a social movement demanding fundamental restructuring of the health system and democratization of health that takes power back from interests profiting from the status quo and reorients the system to one grounded in healing relationships in primary care. This restructuring should take the form of a publicly financed system of universal coverage for direct primary care, with a minimum of 10% of total US health spending allocated to Primary Care for All.

Over past decades, several waves of health reform and advocacy efforts offered hope of revitalizing the specialty of family medicine and the primary care sector: the rise of managed care in the 1990s; the Joint Principles of the Patient- Centered Medical Home in 2007; enactment of the Patient Protection and Affordable Care Act in 2010; the launching of Family Medicine for America’s Health in 2013. Yet the reality on the ground has not fundamentally improved for family physicians and others working in primary care, or for patients struggling to obtain high-quality primary care. Between 2005-2015, the number of primary care physicians per capita in the United States declined, primary care visits per capita decreased, and waiting times for new primary care appointments lengthened. The earnings gap between primary care physicians and physicians in other specialties widened and burnout remains high. Most tellingly, only about 5% of national health expenditures in the United States are spent on primary care—one-half or less than the proportion spent in Canada and Europe. …

A Social Movement for Primary Care as a Common Good

To actualize primary care as a common good, family physicians must embrace what I call “counterculture professionalism” to join with patients, community members, primary care workers, and other allies to build a broad-based social movement demanding a fundamental restructuring of the health system and democratization of health that takes power back from interests profiting from the status quo and reorients the system to one grounded in healing relationships in primary care. A social movement must have clarity about what it wants to achieve, and how to achieve it. …

By social movement, I mean a coming together of people and organizations united by a sense of common purpose counter to the dominant power. The consequential issues of our times—climate change, systemic racism, inequality of wealth, gun violence, reproductive rights, among others—are all contests for the common good. Progress requires an activated citizenry working in solidarity to challenge profits, power, and privilege that harm collective well-being. High quality primary care for all is not simply a parochial interest for family medicine. In the US context, it is a radical proposition that calls for family physicians to find common cause with others who share this goal.

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Comment:

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

Kevin Grumbach (a colleague at UCSF) is a long-time leader in the single payer movement and in family medicine. He is thoroughly frustrated by the failure of typical policy tools – laws and high-profile reports – to mitigate the declining role of primary care in US health care. Our population suffers as a result.

Addressing family medicine doctors, Kevin proposes a broad-based social movement to reclaim primary care. His call to action is stirring. Kevin is realistic about the challenges facing social change, given powerful entrenched opponents. Yet he sees a movement as the only chance to revive primary care, given the futility of traditional policy levers.

Should the single payer movement endorse “primary care for all”, leaving specialist and hospital care for the time being in the hands of existing insurers and providers? Kevin proposes that a “successful PC4All program might prompt the nation to consider not only primary care, but all health care, to be a common good, and to join other countries with advanced capitalist economies in implementing a comprehensive, tax-financed universal health care program.”

Is “primary care for all” a stepping-stone for “health care for all”?

Maybe the more circumscribed revolution has a greater chance of success, demonstrating the value of a public approach to health care financing, and building the large and strong coalition needed for comprehensive health system transformation.

Lots to contemplate here.

http://healthjusticemonitor.org…

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Summary: Check out this terrific online conference.

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The theme is “Everybody In: Racial Equity & Medicare for All.”

Lots of great speakers—knowledgeable activists.

Register here: https://medicareforall23.sched.com

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Summary: In the first of two posts, we discuss a blog on how primary care is being acquired and distorted by huge corporations seeking massive profits by exploiting CMS value-based care, specifically capitation. The excerpt, a bit more than usual, is worth a read. Next time we’ll examine a proposal for making primary care a publicly-financed common good.

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Explaining Corporate America’s Aggressive Investment In Primary Care, Health Affairs Forefront, April 5, 2023, by Paul A. Branstad & Claude R. Maechling

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Not that long ago, primary care practices sold for hundreds of dollars per patient, depending on how “fat” their files were and what proportion were economically undesirable Medicare patients. …

Now, suddenly, the likes of Amazon, CVS Health, Walgreens, Walmart, UnitedHeath, and Humana are vying to acquire and build primary care practices targeted at serving the US’s seniors. …  and the competition has driven prices north of $50,000 per patient. When the US finally grasps what is going on, how this competition was triggered in the first place, and what the long-term consequences will be, none of us will like it. …

Too late will we realize we have lost our last best chance to reinvent a health care system centered around the large-scale provision of high-quality primary care—even though this is what value-based contracts started out trying to do. The problem lies not with the Centers for Medicare and Medicaid Services’ (CMS’s) intentions, but with how the game they have structured plays out. …

The root cause of the $50 billion investment frenzy is the financial opportunity created by CMS’s commitment to convert all Medicare beneficiaries to accountable care relationships with value-based payment models. … [this] is just table stakes to vie for the $1 trillion prize that McKinsey and Company estimates will be claimed by the winners among the consumer oligopolists competing for the prize. …

CMS seems to lack the foresight to anticipate how market forces will adapt and respond to its policies, so it is not able to foresee unintended consequences of its reimbursement and insurance practices. … CMS’s tortuous primary care reimbursement practices have been more than 30 years in the making and have led directly to the erosion of the central role that primary care physicians could and should play. …

Our conclusion is: CMS’s commitment to value-based contracting is simply the next stage of its long-standing, philosophical aversion to fee-for-service reimbursement. This aversion is reflected in the increasing justification and reporting requirements imposed on primary care physicians, requirements that represent an affront to their integrity and challenge their medical judgment. The resulting suppression of practice revenue and increased administrative burden have pushed many previously independent primary care physicians past their breaking point and into the arms of hospital-based health systems.

It is not mere coincidence that, over the past decade, the percentage of primary care physicians employed by a hospital-based health system or corporate entity has increased from 36 percent to 74 percent, while MA coverage of Medicare beneficiaries increased from 27 percent to nearly 50 percent.

The issue is not about who owns primary care practices but about how the proliferation of value-based contracts in Medicare is leading to a profound change in the historic physician-patient relationship. The health systems and corporations that own primary care practices often find it most efficient to organize care delivery around CMS’s process-of-care measures to maximize their reimbursement opportunity. So physicians who, heretofore, practiced patient-centered medicine that earned trust by focusing on personalized diagnostic and treatment services, are now obliged to align with these same quality protocols. They are being told how to drive from the passenger’s seat, while the patient is moved to the back.

The economic heart of value-based contracts is negotiation over capitation, in which aspiring MA plans bid to manage all care for a group of patients, according to prescribed CMS protocols, for a fixed price per patient. …

The [price] benchmark is subject to … adjustments. First, the benchmark can be increased by 5 percent, a “quality” bonus, if the MA plan earns a four on CMS’s star rating performance measurement system. The system is based on 46 measures of access, process, patient experience, and clinical quality and is indexed such that, last year, 90 percent of MA enrollees were in plans rated four stars or higher.

Second, the benchmark is adjusted in subsequent years for the risk score of the enrolled population. … [I]ntensive coding efforts translate into higher risk scores when the plan comes up for annual renewal.

[Discussion of risk selection, which lowers costs in Medicare Advantage and assures that individuals remaining in traditional Medicare – which determines payment benchmarks – will be increasingly expensive over time.]

What will be the consequences for Americans?

[C]onsolidation will raise the cost of care without any improvement in care capacity or quality….

Researchers estimate that Medicare Advantage will cost CMS $75 billion more in each of the coming years … less than 2 percent of national health expenditures … But it becomes far more significant when we think of it in terms of primary care. The US spends about $100 billion on primary care physician consultations … the money wasted on VBC overpayments could be put to very productive use remedying primary care underinvestment.

Spent correctly, this $75 billion could make a huge contribution to solving the biggest health care problem we have in this country—a lack of primary care to address the high burden of chronic disease. Reinvesting the funds could create comprehensive, relationship-based, personalized care overseen and coordinated by trusted, in-charge primary care physicians who have the time to make full use of their clinical reasoning …

Tragically, conversion to VBC plans will also undermine efforts to address the social determinants of health for disadvantaged communities. When we sacrifice higher-quality, relationship-based primary care medicine, we also sacrifice the opportunity for a physician to understand each patient’s biography, or lived experience, which arguably contributes as much to their ill-health as their biology or genetics.

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Comment:

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

This article ably reviews how CMS’ extreme focus on value-based care undermines rather than strengthens primary care. My only addition is to highlight that ACO REACH, in traditional Medicare, is headed down the same path, as we’ve previously discussed in HJM.

Key points:

• CMS capitation rules, most visibly in Medicare Advantage, offer corporations – especially those owning primary care practices – massive profit opportunities.
• As a result the value and price of primary care practices has shot up more than 100-fold.
• Profit tactics include risk selection (finding and keeping less expensive enrollees), exaggerated diagnostic coding, and maintaining process-of-care quality scores. Corporate maneuvers to manipulate these mechanisms outflank CMS technical and political abilities to oversee them.
• A long-standing aversion to fee-for-service payment leads to onerous requirements imposed on primary care doctors, driving them to sell to and work for corporations.
• Corporate tactics to maximize profits often conflict with and displace comprehensive, high quality primary care.
• Physicians become cogs in this machine, their pursuit of quality primary care shunted aside. Patients must follow along. The physician-patient relationship is undermined.
• $75 billion dollars per year in overpayments, largely directed to profits, could save primary care.
• The opportunity to address patient-specific social determinants of health – critical to pursuing equity – is squeezed out.

Next time – a proposal for doctors and allies to join in a social movement to make primary care a publicly-financed common good.

http://healthjusticemonitor.org…

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Summary: CMS just finalized the 2024 payment rule for Medicare Advantage, weakening the draft rule. There remain massive overpayments and widespread barriers to care. These fundamental problems are inevitable with reliance on private insurer intermediaries.

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Biden Just Took the First Step to Overhaul Medicare Advantage. Many More Must Be Taken, Common Dreams, April 7, 2023, by Diane Archer

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The corporations that run Medicare Advantage plans are engaged in widespread waste, fraud and abuse, resulting in tens of billions of dollars of overpayments to them every year. The advocates and government agencies overseeing Medicare Advantage have spent nearly two decades reporting on this fraud and waste and urging Congress to overhaul the program. Few in Congress or the administration were listening. Now, the Biden administration is finally taking action, but it’s only a first step.

The Biden administration has just finalized a rule that begins to rein in these overpayments, at last putting a spotlight on an issue that Congress and the public have long overlooked. The new rule is a small step towards reining in some of the overpayments to the Medicare Advantage plans and protecting the integrity of the Medicare Trust Fund, though it is not nearly enough.

The insurance industry’s fierce opposition and the multi-million dollar fear campaign the health insurance corporations launched against the proposed rule was their admission that Medicare Advantage plans can’t provide coverage at a reasonable cost. Medicare Advantage only works for the insurers if they are wildly overpaid and profiting exorbitantly. It was their admission that they cannot do what they were created to do and are legally obligated to do. They cannot deliver Medicare coverage anywhere near as cost-effectively as traditional Medicare, let alone at lower cost, as they had promised.

The fight over small improvements to the flawed Medicare Advantage payment system reveals how challenging it is to fix Medicare Advantage and free it of the bad actors who are engaged in massive — sometimes fraudulent — overbilling of Medicare. Medicare Advantage is in need of a substantial overhaul, as the advocates, along with the Medicare Payment Advisory Commission, the Government Accountability Office and the Office of the Inspector General, have all been saying for years. …

The Biden administration also recently finalized another rule, aimed at addressing widespread and persistent inappropriate delays and denials of care in Medicare Advantage. Among other things, the rule attempts to streamline the Medicare Advantage prior authorization process. It spotlights and begins to address the serious risks some Medicare Advantage plans pose to the health and well-being of their enrollees — our nation’s sisters and brothers, parents and grandparents.

Though it goes further than any past rule in its attempt to protect Americans from the bad actor Medicare Advantage plans, it does not provide the public with important information as to which plans are the bad actors. Nor will it lead to the government’s cancellation of contracts with the worst-performing Medicare Advantage plans. Therefore, it will not keep the bad actor Medicare Advantage plans from continuing to inappropriately delay and deny critical care.

[HJM bolding]

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Comment:

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

Lobbying elected representatives and public scare campaigns are high-yield investments for health insurers. Their profits these days derive mainly from serving as intermediaries for Medicare Advantage and other public insurance programs. They spend millions to safeguard billions in excess payments from CMS. The rate of return may exceed 100:1. The Biden administration is starting to address overpayment, but their effort is undercut by massive industry push-back.

The final rule spreads the modest and overdue proposed adjustments over three years. If you want a good technical summary, look at the fact sheet. The net result is a payment increase of 3.3% for 2024, as compared with 1% in the draft rule. How much is the difference? $10 billion. All into profits.

And that doesn’t begin to represent the scale of the overcharging documented by the Medical Payment Advisory Commission (MedPAC) and others. Up to $50 billion per year.

The insurers no doubt also hope that delay will further benefit them — a more sympathetic administration might abandon the out-year adjustments. They might also argue that other much-needed broader changes must wait until these three years of slow adjustment are done.

This is a rules-based approach. Very long and complicated rules attempt to rein in private sector entities which spend every working day scheming how to evade and game those rules, to shift more of the Medicare Trust Fund to shareholder profits.

Diane does an excellent job describing the sweep of problems plaguing Medicare Advantage. She rightly calls for a major overhaul.

What kind of major overhaul would really work? So complete we might not want to use the word “overhaul”. We need to abandon the financial intermediary structure, which guarantees bloated costs and aggressive limits on access to care, especially expensive care.

We need to jettison the insurers, and use a structure like traditional Medicare, with payments directly from the program to providers. For everyone. Single payer, Medicare for All.

http://healthjusticemonitor.org…

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