PNHP

Wendell Potter on MoveOn

Wendell Potter on MoveOn

Former Cigna VP (and insurance industry whistleblower) Wendell Potter spoke with MoveOn for a social media segment that was posted on September 29, 2024. Mr. Potter discussed the under-reported threat that Project 2025 poses to Medicare—by making so-called “Advantage” plans the default option for enrollees.

Under the Heritage Foundation plan, people on Medicare “will not have access to the doctors they want to see, or the hospitals they want to be treated at, or even the medications that they [need],” he said, “because the insurance companies will be in control of all of that.”

Medicare Advantage plans are the junk bonds of health care

By James Fieseher, M.D.
New Hampshire Union Leader, Sept. 24, 2024

September starts the open enrollment period for seniors choosing a health care plan, either traditional Medicare (TM) or any one of a number of commercial “Medicare Advantage” plans. Picking the one plan that is right for you depends upon your overall health status, your financial situation, and your ability to predict your health in the future.

For the next three or four months, you’re going to be flooded with advertisements for various Medicare Advantage plans, pitched by older celebrities. You’ll hear them say the word “free” a lot, and if you think commercial health care is being offered for free, there’s a famous bridge in Brooklyn you might be interested in buying.

Congress established Medicare in 1965 to provide a highly transparent, cost-effective way to publicly fund the health care needs of seniors. It came with a set of clear guidelines for doctors and patients letting them know which services would be paid and which were not. Then, 98% of taxpayers’ dollars through Social Security went directly back to medical costs for seniors while roughly 2% went to administrative fees. Once the doctor and patient agreed on the medical services needed, those costs were promptly paid. That same formula is still in effect today, 59 years later, although the administrative costs are now closer to 3%.

By contrast, Medicare Advantage plans started in the 1970s and came into their own in 2004, when commercial insurers started aggressive advertising. They boasted “free” everything as well as dental and eye coverage — “depending upon your zip code.” Clearly, their health care isn’t free, they bill the Medicare Trust Fund directly, with a built-in 10% profit margin for administrative services.

Commercial health insurers found loopholes in the way Medicare Advantage (a.k.a. Medicare Part C) was structured enabling them to increase profit margins at least threefold. One of these was that medical insurers would self-regulate, so little chance that outright fraud would be detected. Last year alone, commercial insurers overcharged CMS (the Center for Medicare and Medicaid Services) an estimated $88 billion. But because of a lack of transparency, that number could be as high as $140 billion.

What does that mean to you when deciding on a plan?

One of the ways commercial Medicare Advantage insurers can extract more money from the Medicare Trust Fund is through a process known as “upcoding.” This is a way of taking a past or present medical condition and redefining it as a more serious problem than your medical practitioner originally listed. Suddenly elevated blood pressure is redefined as a serious blood pressure problem, or pre-diabetes becomes uncontrolled diabetes. This enables the private insurer to bill CMS at a higher rate.

Commercial insurers have the right to “manage” your health care having a say whether or not they will pay for a medication or procedure that you and your doctor have decided is necessary through “prior authorization.” Waiting for a for-profit insurer to approve treatment has caused serious delays or outright denials of urgently needed care, often resulting in patients paying the entire cost out of pocket, saving the insurer millions.

Because of upcoding, Medicare Advantage patients appear to have more serious health problems than patients on traditional Medicare, while at the same time those same patients receive fewer medications and procedures due to prior authorization denials. Advantage plans may save money in the up-front costs and added benefits such as hearing and dental, but you’ll lose your shirt and a lot more if you develop more than a minor medical condition.

In many ways, Medicare plans resemble the bond market. Traditional Medicare, managed by the U.S. government is like treasury notes, they’re AAA rated, a guaranteed safe investment. Medicare Part C “Advantage” plans are like C rated bonds (a.k.a. “junk bonds”), they entice with higher yield offerings, but the pay-off is risky.

If you’re on a Medicare Advantage plan and want to switch back to traditional Medicare, you might not be able to, or it might cost you a higher rate depending upon your health and the number of years you’ve been on an Advantage plan. There are commercial plans that cover “gaps” in traditional Medicare, such as hearing, dental, and eye care. These can be covered at fairly low cost through supplemental plans known as “Medigap” plans. But if you have a pre-existing condition, especially if it’s serious, you might be ineligible or have to pay a much higher rate for any of the Medigap coverage plans. Plus, switching is intentionally difficult, even if you don’t have a pre-existing condition.

If you think you’ll never need any serious hospitalization or surgery for the rest of your life, an Advantage plan might be right for you. For the rest of us, I would suggest sticking to the tried-and-true; traditional Medicare will save you lots of money in the long run and will avoid the frustrating delays in care.

Dr. James Fieseher is a retired physician and member of Granite State Physicians for a National Health Program.

https://www.unionleader.com…

Twenty Years of Failing Health System Report Cards

Since 2004, the Commonwealth Fund has done annual comparisons of health system performance among wealthy nations. The US consistently underperforms the others, and 2024 extends the streak: we are the worst, by a wide margin. Replacing our massively dysfunctional insurance morass is long overdue.

Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System; Comparing Performance in 10 Nations, Commonwealth Fund, September 19, 2024, by David Blumenthal, et al.

Conclusion: The U.S. continues to be in a class by itself in the underperformance of its health care sector. While the other nine countries differ in the details of their systems and in their performance on domains, unlike the U.S., they all have found a way to meet their residents’ most basic health care needs, including universal coverage.

Comment:

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

My comment today is brief, because this is “just” another annual iteration of findings from the venerable Commonwealth wealthy nations health system comparison. As always: the US lags far behind other nations. If I’m permitted a little tongue-in-cheek for a dire situation: The US is a consistent global leader if the goal is to rank last on health system performance metrics of central importance to patients.

We’re last on access, equity, and outcomes. The only result that baffled me is administrative efficiency, with Switzerland reported as worse than the US. Turns out, that’s because the metric doesn’t include the hundreds of billions diverted to insurers for profits, which Swiss insurers don’t get on the primary insurance plan. So, really, we’re last in that category too. We do well on care processes – we offer amongst the best care in the world, if you can afford it.

Why are other nations doing so much better? Because “have found a way to meet their residents’ most basic health care needs, including universal coverage.” Sounds like single payer to me (or, in some nations, identical broad benefits managed by not-for-profit insurers).

Check out the full report. It’s elegantly conceived and written. We can only hope that in the next 20 years, the findings will evolve to place the US among other wealthy nations in health system performance.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

UK National Health Service Resuscitation Implications for the US

In the United Kingdom, the first Labor government in 14 years must deal with Conservative fiscal and policy neglect of the National Health Service. This serves as a tough reminder of the US need for a durable social consensus on a public solution to our health care crisis.

Prime Minister Keir Starter sets out NHS plans following Darzi report, YouTube, Sept. 12, 2024

Lord Darzi today has published his independent report on the state of our NHS.

As everyone in the country knows, the last government broke the NHS.

Let me be clear from the outset, what reform does not mean. First, it does not mean abandoning those founding ideals of a public service, publicly funded, free at the point of use – the basic principle of dignity. “When you fall ill, you should never have to worry about the bill.” Second, reform does not mean just putting more money in. Now, of course, even in difficult financial circumstances, a Labor government will always make the investment in our NHS if it is needed. But we have to fix the plumbing before turning on the tap. So, hear me when I say this, no more money without reform.

The last Labor government reformed the NHS to deliver better outcomes for patients and better value for taxpayers. The Conservative government then undid that good work, which only goes to prove, once again, that only a Labor government can reform the NHS.

If we get this right, people can look up and say, “this was the generation that took the NHS from the worst crisis in its history, got it back on its feet, and made it fit for the future.”

Independent Investigation of the National Health Service in England, September 2024, by The Rt. Hon. Professor the Lord Ara Darzi of Denham

The National Health Service is in serious trouble.

This report sets out where the NHS stands now, how we arrived at this point, and some of the key remedies.

The NHS budget is not being spent where it should be – too great a share is being spent in hospitals, too little in the community, and productivity is too low.

Conclusions:

The NHS is in critical condition.

Some have suggested that this is primarily a failure of NHS management. They are wrong.

Despite the challenges, the NHS’s vital signs remain strong.

Nothing that I have found draws into question the principles of a health service that is taxpayer funded, free at the point of use, and based on need, not ability to pay.

It has taken more than a decade for the NHS to fall into disrepair so improving it will take time.

There are some important themes that have emerged for how to repair the NHS, which will need to be considered alongside strategies to improve the nation’s health and reforms to social care:

  • Re-engage staff and re-empower patients.
  • Lock in the shift of care closer to home by hardwiring financial flows.
  • Simplify and innovate care delivery for a neighborhood NHS.
  • Drive productivity in hospitals.
  • Tilt towards technology.
  • Contribute to the nation’s prosperity.
  • Reform to make the structure deliver.

The NHS is now an open book. The issues are laid bare for all to see. And from this shared starting point, I look forward to our collective endeavor to turn it around for the people of this country, and to secure its future for generations to come.

Comment:

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

For decades, progressives in the US have been striving to enact and implement an affordable, high-performance system which would provide health care access for everyone. We favored government control over the payment mechanism since private insurers have demonstrated an enduring desire and ever-increasing ability to divert our funds to their private wealth. This diversion would end with publicly funded and administered insurance.

In recent years, progressives have expressed renewed interest in public ownership of health care delivery itself, since entrepreneurial groups (e.g., private equity) entering the provider side have diverted payments for care to their own financial gain. In effect, progressive interest has expanded from universal public insurance as in Canada, to public ownership of the delivery system through a national health service such as the British NHS, valued since post-WWII.

Yet now both Canadians and the British are having problems with their public programs. A critical factor in both nations is ongoing political conflict over the proper role of government versus private sector in health systems. Patients who have great medical needs may find a public system to serve their interests very well by assuring that health care is always affordable. However, individuals with health care costs that are not personally burdensome may prefer to pay less in the taxes that make health care accessible and affordable for everyone.

In all nations and to varying degrees, voters align as either conservatives or progressives. When one of the political interests gains control, as with UK Conservative rule 2010-2024, the NHS suffered budget stasis and privatization. This conflicted with the core NHS goal of ensuring health care for all, regardless of personal financial means. This period of NHS austerity markedly damaged it, as noted in the YouTube and report above.

The lesson for US progressives is that when we propose either single payer or a national health service, it is imperative to create policies and controls that will ensure the maintenance of public programs regardless of the political control of the moment. The ordeal that the British are suffering to recover and repair their health care system demonstrates the consequences of failing this protection. The Conservatives took an electoral drubbing in part due to NHS problems, but the price to patients has been very high.

Recently we discussed a poll commissioned by Bernie Sanders demonstrating that views on public coverage of health care are more consonant across political divides than people realize. Wouldn’t it be amazing if individuals of all political persuasions could join and agree on a system that assures that we all have the health care that we need?

Realistically, we face challenges.

Major party politics in the US have shifted from a conservative-progressive spectrum to a narrower conservative-neoliberal spectrum. This reflects a Democratic understanding that more moderate political positions would be more appealing to voters. An example is the current US presidential election wherein one candidate remains conservative while the other has shifted from a progressive to a neoliberal political position, certainly on health care. We must empower progressive positions, as happened substantially (but insufficiently) under President Biden.

The progressive tax policies needed to power a government-run health care system appear to conflict with the wealth-enabling tax policies of conservatives and neoliberals. Yet, compared with the extremely progressive tax rates following WWII, the progressivity required for single payer is modest. Perhaps there’s a middle ground, whereby the already financially well-situated can continue to grow their wealth, albeit more slowly, while growing health and social cohesion via public insurance.

We should set limits on wealth accumulation, when it is at the expense of social welfare. Do we really need rockets that carry rich people to outer space? Real estate tycoons making fortunes while leaving people living in the streets? Trillionaires? Government and courts controlled by the wealthy?

What is a reasonable social contract? We believe that the wealthy have ample opportunity in this free market world to maintain and build their wealth. It’s time for a robust social contract that ensures that we meet health care and other social needs. Humanity and wealth can co-exist.

From a political perspective, can we mend divisions and work together on policies that serve our collective well-being? We need to be nimble as we pursued the very lofty goal of achieving health care justice for all, as a social consensus, robust across political fluctuations.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Medicare for All Explained Podcast: Episode 115

The Advantages and Disadvantages of Electronic Health Records

September 15, 2024

Podcast host Joe Sparks discusses the pros and cons of electronic health records (or EHRs) within the context of our profit-driven health care system.

“Instead of focusing on patient care,” he says, “the EHRs are focused on billing.”

Additional episodes will be uploaded monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

Health Policy Issues in the Presidential Race

Donald Trump would replace the ACA, he says, but with what? His past proposals suggest ACA and Medicaid tightening. Kamala Harris would strengthen the ACA, she says, and limit out-of-pocket drug costs in Medicare and beyond. Neither supports single payer.

The “Concept of a Plan” President Trump Proposed to Replace the ACA, KFF QUICKTAKES, September 11, 2024, by Larry Levitt

When asked in the debate whether he had a replacement plan for the Affordable Care Act, former President Donald Trump said he had the “concepts of a plan.”

If you look at Trump’s record as president, there is truth in that statement. He did, in fact, propose the concept of an ACA replacement plan in his 2020 budget, though it has never gotten much attention.

Trump’s conceptual ACA replacement plan would have repealed the ACA’s premium subsidies and Medicaid expansion, replacing them with a block grant to states. It also would have capped federal Medicaid spending. All told, Trump’s plan would have reduced federal spending on the ACA and Medicaid by over $1 trillion over a decade.

Trump also proposed providing “relief” from the ACA’s “insurance rules and pricing restrictions.”

Trump has long talked about making the ACA less expensive, but the question is less expensive for whom. Trump’s past proposals would certainly have made the ACA less expensive for the federal government, but with the trade-off of higher out-of-pocket premiums for people, more uninsured, and higher spending and greater risk for states.

Polling: Harris v. Trump on Key Health Care Issues, KFF, September 10, 2024, by Ashley Kirzinger, et al.

How Voters Are Prioritizing Health Care Issues in 2024: The economy and inflation continue to dominate the list of issues that voters are focusing on during this year’s presidential election with four in ten voters (38%) saying it is the most important issue determining their vote in the 2024 presidential race. Following the economy is threats to democracy (22%), immigration and border security (12%), then several individual health care issues including: abortion (7%), Medicare and Social Security (7%), and health care costs including prescription drugs (5%). Altogether, health care issues are seen as the most important issue by about one in five voters (19%). Gun policy (3%) and the war between Israel and Hamas in Gaza (2%) rank the lowest among the issues included in the list provided to voters.

Voters Want to Hear Candidates Talk About Lowering Health Care Costs: An indication of how the economy and health care consistently overlap for voters, economic concerns also rear up when voters are asked what health care issue they most want to hear the candidates talk about. Across partisans, the recurring theme is costs. Responses related to health care costs are offered by four in ten (42%) Democratic and Democratic-leaning independent voters when asked to say in their own words what is the one health care issue they would most like Vice President Harris to talk about. This includes voters who mentioned general health care costs (20%), prescription drug costs (15%), and the cost of insurance or reducing their monthly premiums (6%). About one in seven offered abortion as the one health care issue they want Harris to talk about and 13% mentioned universal health care – an issue that was largely debated during the 2020 Democratic primaries.

Comment:

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

Health issues are fairly high profile In this presidential campaign – collectively, the most important issue for one in five voters. Abortion is seen as the leading election issue for 7% of voters. Medicare & social security (combined, oddly in my view) are also at 7%, and health care costs are at 5%.

Trump proposes to replace the ACA with something TBD cheaper and better. His actual approach, per his 2020 federal budget request, seems to be repealing ACA premium subsidies and Medicaid expansion, placing these programs into state block grants. Which would cut federal costs by >$1 trillion over 10 years. Also, end the ACA’s “insurance rules and pricing restrictions.” This is all consistent with Project 2025, as summarized in HJM. He waffles on abortion, but is largely seen as a threat to abortion rights.

Harris aims to strengthen the status quo. She proposes to strengthen the ACA: to make permanent COVID subsidy increases and fix a “family glitch”. For drug prices she favors accelerating Medicare drug price negotiations, and extending two caps in Medicare ($35 insulin copay and drug out-of-pocket total) to the entire population. She wants to end drug companies blocking competition and abusive practices of drug intermediaries. She avidly supports abortion rights.

See a side-by-side comparison here.

Drew Altman notes that the “do not mention” program is Medicaid, since Medicare and the ACA are considered higher priority for voters. Yet the consequences for Medicaid are substantial, per above.

Of course, Medicare for All / single payer gets no favorable mention – despite its ability to sharply reduce health care costs for families, a leading concern of voters. Instead, it is used by Trump to attack Harris since pre-2020 she endorsed Bernie Sanders M4A bill. Don’t expect Harris to return to single payer. But if state reform efforts, such as currently in Oregon and California, are to garner federal regulatory cooperation (“waivers”), a Harris administration may be more flexible.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Incredible (Terrible) Shrinking Physician Supply

Waiting times for physician appointments are growing. The immediate cause is contraction of the physician workforce. The root cause is clinician burnout, in large part due to fragmented insurance and resulting make-work inefficiencies. Single payer will help.

Health shrinkflation: Patients wait more for less, Axios, September 3, 2024, by Tina Reed

The U.S. spends more on health care than almost anywhere else. But increasingly patients are getting less in return, and enduring long waits to get not as much face-time with their clinician.

Why it matters: Shrinkflation is hitting a sector that accounts for almost one-fifth of the economy, eroding the doctor-patient relationship and leaving many turning to urgent care clinics or telehealth services.

  • Some who can afford it are gravitating to concierge practices that offer fewer hoop jumps and more add-on services with office visits.

The latest: The trend is being felt especially in primary care, but also in many specialties.

  • An Axios-Ipsos survey last month found that nearly one in five respondents said they had to wait more than two months to see a primary care physician or specialist, with waits trending longest in the Midwest.
  • NYC Health + Hospitals recently told primary care doctors to cut appointment times in half to 20 minutes, in order to squeeze in more patients, Gothamist reported.
  • A spokesperson told Axios that the public health system is grappling with 50,000 more primary care patients who’ve been added since 2021. The average number of days to the third next available appointment jumped from 12 days to 22 days.

By the numbers: 17% of patients had to wait one to three months for their latest doctor’s appointment, per electronic health records company Tebra.

  • The most frequently cited specialties with long wait times included neurology (26%), ear, nose, and throat (26%), psychiatry (20%), and OB/GYN (17%). Primary care stood at 19%.
  • 43% of patients reported experiencing longer wait times for appointments since the pandemic, per the Tebra survey.
  • The surge in demand for in-person care since the crisis has been well-documented. AMN/Merritt Hawkins found that the average wait time for a physician appointment in 15 large metro markets surveyed in 2022 was 26 days, up from roughly 24 days in 2017, and about 21 days in 2004.

The big picture: This is what shrinkflation in healthcare looks like as the industry struggles with supply and demand issues, Robert Pearl, a Stanford University professor and former CEO of The Permanente Medical Group, told Axios.

  • There’s been across-the-board growth in patient volumes largely from pent-up demand for services many put off during the pandemic.
  • At the same time, tens of thousands of doctors have left the field due to burnout and other factors, and surveys indicate even more plan to retire early.
  • Red tape around insurance and rising out-of-pocket costs are leaving patients frustrated and confused, and in some cases burdened by more medical debt.

“You’re paying actually more for your health coverage, but you’re not getting more. You’re actually getting less,” Pearl said.

Comment:

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

The physician supply is steadily contracting, especially in primary care. This lengthens waits for clinical visits, not to mention the challenge of finding a new provider. Each year we pay more in premiums and cost-sharing, yet we suffer increasing challenges getting the care we need.

What’s going on? This tightening of physician supply reflects some simple math: more individuals leave clinical medicine than new trainees enter. Increasing the number of mid-level providers, like nurse practitioners, is a viable and valuable option. However, the physician flow dynamics remain critical. And recent trends are not encouraging:

This is ongoing: 7% of physicians left the workforce in 2021 and 2022. Nearly 1 in 4 physicians stated an intention to leave practice within two years. Long-term projections for physician supply are dire.

Why are so many doctors leaving? The short answer is growing burnout:

And why the burnout?

  • Too many bureaucratic tasks (eg, charting, paperwork): 62%
  • Too many hours at work: 41%
  • Lack of respect from administrators / employers, colleagues, staff: 40%
  • Insufficient compensation: 38%
  • Lack of control / autonomy: 32%
  • Full list here

All of these causes reflect, in substantial degree, our fragmented insurance system and the central role of for-profit insurers and provider groups. Here’s how single payer would help with each:

  • Reduce bureaucracy: eliminate an hour/day of billing & insurance-related tasks done by physicians.
  • Reduce hours at work: less time on bureaucracy; more providers especially in primary care.
  • Build respect: bolster the clinical role of physicians, and foster clinician-run practices.
  • Correct compensation inequities: Increase payment rates for primary care.
  • Build autonomy: make clinician-run practices more financially and administratively viable.

Single payer isn’t a magic potion for physician emotional well-being. But it is a viable framework to build clinical focus and autonomy, and to foster equity among specialties (and of course among populations groups). It is the only way to break out of our burnout quagmire.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

“Shocking”: Experts warn “irresponsible” Project 2025 Medicare proposal would harm seniors

"We've invited for-profit corporations to drain the Medicare Trust Fund … and we overpay them to kill people"

By Cara Michelle Smith
Salon, September 3, 2024

Something still haunts Ed Weisbart, MD, from his days in the health insurance business.

It was 1999, and Weisbart was the medical director of a Chicago medical group that managed care for more than 140,000 people. The enterprise was running like a well-oiled machine — until one day, a man presented with a rare blood clotting disorder that would cost the company $1 million a year to treat. At that sum, one of its regional offices would likely go out of business.

Weisbart caught himself entertaining dark thoughts. What if the company just gave this guy the cold shoulder? Could they simply not answer his calls? These were “paper records days,” he said — in theory, the company could lose his medical records. If he showed up at the office to meet with anybody, maybe they could make him wait an hour or two.

“And then, what? He would complain to us, and say this used to be a good office, and it’s not anymore – I’m going to go somewhere else,” Weisbart said. “And I would be thinking, I won.”

Weisbart never acted on any of these impulses, he said, nor did he tell anybody about those thoughts until years later. The office didn’t go out of business, either, and the man received his treatments. But the temptation toward corruption left a deep impact.

“It’s haunted me ever since,” Weisbart said. “I consider myself a generally ethical patient advocate, and yet, I was so corrupted by the finances of the system that I was actually developing schemes to make a very sick person not want to get health care with us. And isn’t the point of a health care system that you should want to get health care?”

Today, Weisbart is the national secretary for Physicians for a National Health Plan (PNHP), an advocacy group representing more than 25,000 physicians who support a national health insurance plan and oppose a profit-driven health insurance system in which companies can choose profits over patients. That system’s interests are at the heart of a stunning Medicare proposal in Project 2025, the Heritage Foundation’s 900-page right-wing agenda for a second Trump administration that experts say would harm patients while enabling insurance companies to funnel billions of dollars in desperately needed funds from the Medicare program.

“It’s kind of shocking, when it comes to how irresponsible it is,” Andrea Ducas, vice president of health policy at the Center for American Progress, told Salon of Project’s 2025 proposed change to Medicare. “It’s emblematic of a desire to, essentially, increase corporate power.”

Project 2025 proposes making Medicare Advantage, as opposed to traditional Medicare, the default plan for all enrollees. Medicare Advantage has been around for decades; it was signed into law in 1997 as part of a bipartisan reform bill to balance the federal budget. Under Medicare Advantage, insurance companies offer plans that cover Medicare benefits. In turn, Medicare pays the insurance companies based on an estimate of an individual’s annual health care costs.

In theory, the Medicare Advantage program was supposed to help the government benefit from the private sector’s efficiencies. In practice, many insurers overcharge the federal government hundreds of billions of dollars in inflated estimates, often by adding diagnosis codes that make individuals appear sicker on paper than they are in reality. MedPac, a nonpartisan Congressional advisory committee, estimates that in 2024, inflated estimates will translate to $50 billion in overpayments. An analysis from PNHP, published in 2023, estimates that Medicare overpays insurers by as much as $140 billion per year.

In one analysis of Medicare Advantage data, The Wall Street Journal found that between 2019 and 2021, individuals enrolled in Medicare Advantage through UnitedHealth were roughly 15 times as likely to be diagnosed with diabetic cataracts than traditional Medicare beneficiaries. Payments to insurers for diabetic cataracts totaled $700 million in that period; most diagnoses were added by the insurers.

“The plans will get more for people who are more sick, so there’s significant incentive for the plans to make their enrollee population appear as sick as possible,” David Lipschutz, co-director of the Center for Medicare Advocacy, told Salon.

According to an analysis from Lever, an investigative newsroom, the private insurance giant Humana — one of the largest providers of Medicare Advantage plans — recorded $2.8 billion in profits in 2022. Without federal government overpayments into Medicare Advantage plans, though, Humana may have lost nearly $900 million that year.

“We overpay them to kill people”

Outside those abuses, Medicare Advantage doesn’t offer a better patient experience. In many instances, it can be worse.

Medicare Advantage beneficiaries are often limited to a smaller provider network, deal with more prior authorizations and are more often “inappropriately denied approval for necessary health care,” according to PNHP. In 2022, KFF found that those enrolled in Original Medicare were more often treated in higher-rated specialty healthcare facilities than those in Medicare Advantage.

Those consequences don’t exist in a vacuum: Medicare Advantage patients undergoing surgeries for certain liver, pancreas and stomach cancers had higher mortality rates than similar patients on Original Medicare, according to PNHP.

“We’ve created a system where we’ve invited for-profit corporations to drain the Medicare Trust Fund . . . and we overpay them to kill people,” Weisbart said.

A broader implication for the conservative movement

That Medicare Advantage’s patient harms are so well-documented, and that Project 2025 recommended that the plan replace Original Medicare, may belie a core truth of the modern American conservative movement, Kim Phillips-Fein, a historian and professor at Columbia University, told Salon.

“A lot of the less-visible parts of the project are going to wind up reinforcing economic inequality,” Phillips-Fein said of Project 2025. “They talk one way, but are very likely to govern another.”

Much of today’s modern conservative movement is rooted in the business community’s antagonism against the New Deal, Phillips-Fein said, which ushered in what corporate stakeholders saw as a large labor movement that threatened business interests. But by promoting a health care plan proven to harm individuals, Project 2025’s Medicare Advantage proposal — as well as the broader Project 2025 agenda — suggests that corporate interests aren’t just a component of the American conservative movement. Rather, it suggests that those interests are at the core of the movement — even at the known harm of the American worker.

“It’s just telling that you’ve got an authoritarian playbook that sort of, at every pass, seems to be more focused on driving up corporate profits at the expense of the American people,” Ducas said.

Reinvesting “the giant bag of cash” in traditional Medicare

Medicare Advantage was pitched as a private market solution to traditional Medicare. It exists because of the flaws of traditional Medicare. But experts say Medicare Advantage’s own shortcomings present a timely opportunity for the program to reign in fraudulent spending and reinvest funds into the original program.

“We can take these significant and wasteful overpayments, reinvest them into the Medicare program . . . and that rising tide would help all Medicare beneficiaries, because that would then become a new baseline,” Lipschutz said.

One badly needed reform? Adding an out-of-pocket cap to traditional Medicare plans. With no limit on out-of-pocket spending, beneficiaries can spend more than $5,000 per year on premiums. In 2018, those enrolled in traditional Medicare spent an average of $6,168 per year on premiums and services.

Another area ripe for reform: covering vision, dental and hearing under traditional Medicare, Ducas said. Under the current program, Medicare enrollees have to purchase a supplementary plan that covers the above health care as well as an extra plan known as Medigap, which reduces out-of-pocket costs associated with Medicare and the supplemental coverage.  On average, Medigap monthly premiums can range from $50 to more than $300.

Without reform to Medicare Advantage, the broader Medicare program is projected to overpay insurers by more than $7 trillion over the next ten years, according to the Department of Health and Human Services.

“As it would happen, there is a giant bag of cash we are, right now, throwing every year at Medicare Advantage plans,” Ducas said. “If we took that waste out . . . you could get to that reform future. That’s what excites me.”

https://salon.com…

Greenbrier employees plight shows need for different system

By Dan Doyle, M.D.
The Real WV, Letters, September 1, 2024

The nearly 2000 employees of the Greenbrier Resort were informed on August 19 that they would lose their health care insurance because the company had not paid their insurance premiums for the past four months. A last-minute deal on August 29 continued their coverage for now, but the future remains uncertain.

As a family physician with over 40 years practice in southern West Virginia, I find this cruel and outrageous.

The trauma suffered by these employees is one more example of why the current Employer Sponsored Insurance (ESI) system does not serve the American people well. Even with Medicare and Medicaid, the current system still leaves 28 million Americans and 106,000 West Virginians uninsured. Instead, we should have a non-profit, single-payer system that covers every American from birth to death. Workers’ health insurance would be portable instead of constantly endangered by corporate decisions, layoffs, or just plain corrupt management.

Self-employed workers, low-income service workers, and young people (19-24) are the ones most likely to go bare facing potential bankruptcy every day from an accident, sudden illness, or complications of chronic disease.

Two bills introduced before the U.S. Congress would correct this situation. HB3421 with lead sponsor Pramila Jayapal (D-WA) and SB.1655 with lead sponsor Bernie Sanders (I-VT) lay out details for transitioning US health care from an employer-based system to an improved Medicare for All system. Everyone would be covered birth to death and not face the uncertainty currently experienced by the Greenbrier employees.

The moral case for such a system is easy. Health care is a human right. No man, woman, or child in the wealthiest nation on earth should go without.

The economic case is also strong. Numerous policy studies have demonstrated that for what the U.S. is spending on health care now, every one could be covered. But it would require controlling run-away drug prices and corporate greed that places profits over patient care.

That’s why the politics is hard. There is so much money at stake to keep the current unjust, dysfunctional system in place.

Physicians for a National Health Program (PNHP) has been educating and advocating for such a system since 1985. The WV chapter of PNHP is working statewide to inform our patients, our colleagues, health professions students, and our elected representatives about the availability and feasibility of improved Medicare for All.

We won’t quit until everyone is covered. Everybody in, nobody out.

https://therealwv.com…

Saving Private Practice

The American Medical Association (the AMA) is pleading with Congress to save teetering independent medical practice. Of course, one ask is higher pay. But equity and lower administrative burden are right up there. Is organized medicine finally supporting single payer?

Is private practice collapsing? Congress can help stem the tide, AMA, August 23, 2024, by Tanya Albert Henry

It’s time for lawmakers to recognize the threats to independent medical practices and time to take “immediate and decisive actions” to stop driving physicians away from private practice, the AMA told Congress.

“The fabric of our health care system, woven with the dedication and expertise of these practices, is unraveling under the compounding pressures of unsustainable financial models, burdensome regulations and systemic inequities,” the AMA said in a statement submitted to the House Ways and Means Committee (PDF) for its hearing entitled, “The Collapse of Private Practice: Examining the Challenges Facing Independent Medicine.”

The AMA urged Congress to pass comprehensive legislative reforms that create:

  • Equitable payment models.
  • Reduced administrative burdens.
  • Expanded support for rural and underserved areas.
  • A health care infrastructure secured from emerging threats.

Re: The Collapse of Private Practice: Examining the Challenges Facing Independent Medicine, STATEMENT of the American Medical Association, U.S. House of Representatives Committee on Ways and Means, May 23, 2024

The American Medical Association (AMA) appreciates the opportunity to submit the following Statement for the Record to the U.S. House Committee on Ways and Means as part of the hearing entitled, “The Collapse of Private Practice: Examining the Challenges Facing Independent Medicine.” The AMA commends the Committee for addressing this critical issue that threatens the very existence of private medical practices. The AMA is fighting tirelessly to combat the financial and regulatory challenges that jeopardize the survival of these practices. The situation is dire and multifaceted, involving not only the fallout from the COVID-19 pandemic, but also drastic cuts in physician practice payments relative to inflation, surging practice costs, and overwhelming administrative burdens. These payment reductions and burdens are forcing more and more physicians to either close their doors or merge with larger health care systems, severely limiting competition and patient choice. While the pandemic has amplified existing financial pressures and highlighted the urgent need for continued legislative intervention, the relentless cuts in physician practice payments present an immediate and existential threat to private practices.

CONCLUSION

The AMA implores Congress and all stakeholders to recognize the imminent and severe threats to independent medical practices. The fabric of our health care system, woven with the dedication and expertise of these practices, is unraveling under the compounding pressures of unsustainable financial models, burdensome regulations, and systemic inequities. We urge immediate and decisive action to correct the course with comprehensive legislative reforms that ensure equitable payment models, reduce administrative burdens, expand support for rural and underserved areas, and secure our health care infrastructure against emerging threats. The AMA and physician community stand ready to work with Congress to preserve the legacy and future of independent physician practices, ensuring that they continue to provide high-quality, personalized care to all communities across the nation. This is not just a call for action; it is a plea to safeguard the heart of American health care before it is too late.

Comment:

By Don McCanne, M.D.

For well over half a century, the AMA has seemed to be opposed to government involvement in health care such as through a national health care program like single payer Medicare for All. Although the original Medicare program was accepted because it did provide coverage to all of our senior citizens, including those previously unable to afford medical care, there was some reluctance because of concerns about the government being involved in ensuring adequate funding and appropriate regulatory oversight. There was still strong support for private funding through cash payments or private insurance, especially employer-sponsored plans. There was also the recognition of a need for funding care for the truly indigent, such as Medicaid and other government programs.

So what has happened to this system that the AMA refused to replace with a comprehensive system for everyone? The physicians believed that, as long as they remained in control, they could continue to practice on their own terms, taking good care of the physicians, even though the patients may not have fared as well without more comprehensive government oversight.

But look at what has happened as they encouraged the private sector to maintain and expand control of health care in America. Private equity has moved in and managed to convert the primary mission of the health care system from maintaining the health of the patients to placing the creation of individual wealth of the owners as the highest priority. The private insurance industry has been particularly adept at gaining control of the medical-industrial complex with a private regulatory system that is designed to move those health dollars to their own coffers. The physicians who believed that they could continue to practice on their own terms have now found out that their terms are being dictated to them as they have actually been placed in a position of themselves being chattel that are bought and sold by this nefarious industry.

Now how does the AMA feel about the government being involved in the provision of health care? The system is such a disaster that has created a massive burnout of the profession that they are actually going to Congress – the government! – to plead that the government finally does something about it.

It is interesting that most of the requests are not simply to increase their net income, but also to make the system work better by creating an environment in which physicians are more comfortable in caring for their patients. Many of the these proposed changes will create a health care environment that does improve care for the patients as well. You see, though physicians want a system that works well for them, they are not opposed to a system that works well for the patients.

As you examine the list of improvements that the physicians are requesting (See Statement to Congress), you can see that the list could be readily modified to create a system that works well for both physicians and their patients. And we already know that enacting and implementing a single payer Medicare for All system would be the most effective for all parties concerned.

We really do want the government involved, and the AMA has now opened the doors as they stand ready to work with Congress. As they say in their Statement to Congress, “This is not just a call for action; it is a plea to safeguard the heart of American health care before it is too late.”

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Feds killed plan to curb Medicare Advantage overbilling after industry opposition

By Fred Schulte
CBS News via KFF Health News, August 28, 2024

A decade ago, federal officials drafted a plan to discourage Medicare Advantage health insurers from overcharging the government by billions of dollars — only to abruptly back off amid an “uproar” from the industry, newly released court filings show.

The Centers for Medicare & Medicaid Services published the draft regulation in January 2014. The rule would have required health plans, when examining patient’s medical records, to identify overpayments by CMS and refund them to the government.

But in May 2014, CMS dropped the idea without any public explanation. Newly released court depositions show that agency officials repeatedly cited concern about pressure from the industry.

The 2014 decision by CMS, and events related to it, are at the center of a multibillion-dollar Justice Department civil fraud case against UnitedHealth Group pending in federal court in Los Angeles.

The Justice Department alleges the giant health insurer cheated Medicare out of more than $2 billion by reviewing patients’ records to find additional diagnoses, adding revenue while ignoring overcharges that might reduce bills. The company “buried its head in the sand and did nothing but keep the money,” DOJ said in a court filing.

Medicare pays health plans higher rates for sicker patients but requires that the plans bill only for conditions that are properly documented in a patient’s medical records.

In a court filing, UnitedHealth Group denies wrongdoing and argues it shouldn’t be penalized for “failing to follow a rule that CMS considered a decade ago but declined to adopt.”

This month, the parties in the court case made public thousands of pages of depositions and other records that offer a rare glimpse inside the Medicare agency’s long-running struggle to keep the private health plans from taking taxpayers for a multibillion-dollar ride.

“It’s easy to dump on Medicare Advantage plans, but CMS made a complete boondoggle out of this,” said Richard Lieberman, a Colorado health data analytics expert.

Spokespeople for the Justice Department and CMS declined to comment for this article. In an email, UnitedHealth Group spokesperson Heather Soule said the company’s “business practices have always been transparent, lawful and compliant with CMS regulations.”

Missed diagnoses

Medicare Advantage insurance plans have grown explosively in recent years and now enroll about 33 million members, more than half of people eligible for Medicare. Along the way, the industry has been the target of dozens of whistleblower lawsuits, government audits, and other investigations alleging the health plans often exaggerate how sick patients are to rake in undeserved Medicare payments — including by doing what are called chart reviews, intended to find allegedly missed diagnosis codes.

By 2013, CMS officials knew some Medicare health plans were hiring medical coding and analytics consultants to aggressively mine patient files — but they doubted the agency’s authority to demand that health plans also look for and delete unsupported diagnoses.

The proposed January 2014 regulation mandated that chart reviews “cannot be designed only to identify diagnoses that would trigger additional payments” to health plans.

CMS officials backed down in May 2014 because of “stakeholder concern and pushback,” Cheri Rice, then director of the CMS Medicare plan payment group, testified in a 2022 deposition made public this month. A second CMS official, Anne Hornsby, described the industry’s reaction as an “uproar.”

Exactly who made the call to withdraw the chart review proposal isn’t clear from court filings so far.

“The direction that we received was that the rule, the final rule, needed to include only those provisions that had wide, you know, widespread stakeholder support,” Rice testified.

“So we did not move forward then,” she said. “Not because we didn’t think it was the right thing to do or the right policy, but because it had mixed reactions from stakeholders.”

The CMS press office declined to make Rice available for an interview. Hornsby, who has since left the agency, declined to comment.

But Erin Fuse Brown, a professor at the Brown University School of Public Health, said the decision reflects a pattern of timid CMS oversight of the popular health plans for seniors.

“CMS saving money for taxpayers isn’t enough of a reason to face the wrath of very powerful health plans,” Fuse Brown said.

“That is extremely alarming.”

Invalid codes

The fraud case against UnitedHealth Group, which runs the nation’s largest Medicare Advantage plan, was filed in 2011 by a former company employee. The DOJ took over the whistleblower suit in 2017.

DOJ alleges Medicare paid the insurer more than $7.2 billion from 2009 through 2016 solely based on chart reviews; the company would have received $2.1 billion less if it had deleted unsupported billing codes, the government says.

The government argues that UnitedHealth Group knew that many conditions it had billed for were not supported by medical records but chose to pocket the overpayments. For instance, the insurer billed Medicare nearly $28,000 in 2011 to treat a patient for cancer, congestive heart failure, and other serious health problems that weren’t recorded in the person’s medical record, DOJ alleged in a 2017 filing.

In all, DOJ contends that UnitedHealth Group should have deleted more than 2 million invalid codes.

Instead, company executives signed annual statements attesting that the billing data submitted to CMS was “accurate, complete, and truthful.” Those actions violated the False Claims Act, a federal law that makes it illegal to submit bogus bills to the government, DOJ alleges.

The complex case has featured years of legal jockeying, even pitting the recollections of key CMS staff members — including several who have since departed government for jobs in the industry — against those of UnitedHealthcare executives.

Red herring

Court filings describe a 45-minute video conference arranged by then-CMS administrator Marilyn Tavenner on April 29, 2014. Tavenner testified she set up the meeting between UnitedHealth and CMS staff at the request of Larry Renfro, a senior UnitedHealth Group executive, to discuss implications of the draft rule. Neither Tavenner nor Renfro attended.

Two UnitedHealth Group executives on the call said in depositions that CMS staffers told them the company had no obligation at the time to uncover erroneous codes. One of the executives, Steve Nelson, called it a “very clear answer” to the question. Nelson has since left the company.

For their part, four of the five CMS staffers on the call said in depositions that they didn’t remember what was said. Unlike the company’s team, none of the government officials took detailed notes.

“All I can tell you is I remember feeling very uncomfortable in the meeting,” Rice said in her 2022 deposition.

Yet Rice and one other CMS staffer said they did recall reminding the executives that even without the chart review rule, the company was obligated to make a good-faith effort to bill only for verified codes — or face possible penalties under the False Claims Act. And CMS officials reinforced that view in follow-up emails, according to court filings.

DOJ called the flap over the ill-fated regulation a “red herring” in a court filing and alleges that when UnitedHealth asked for the April 2014 meeting, it knew its chart reviews had been under investigation for two years. In addition, the company was “grappling with a projected $500 million budget deficit,” according to DOJ.

Data miners

Medicare Advantage plans defend chart reviews against criticism that they do little but artificially inflate the government’s costs.

“Chart reviews are one of many tools Medicare Advantage plans use to support patients, identify chronic conditions, and prevent those conditions from becoming more serious,” said Chris Bond, a spokesperson for AHIP, a health insurance trade group.

Whistleblowers have argued that the cottage industry of analytics firms and coders that sprang up to conduct these reviews pitched their services as a huge moneymaking exercise for health plans — and little else.

“It was never legitimate,” said William Hanagami, a California attorney who represented whistleblower James Swoben in a 2009 case that alleged chart reviews improperly inflated Medicare payments. In a 2016 decision, the 9th Circuit Court of Appeals wrote that health plans must exercise “due diligence” to ensure they submit accurate data.

Since then, other insurers have settled DOJ allegations that they billed Medicare for unconfirmed diagnoses stemming from chart reviews. In July 2023, Martin’s Point Health Plan, a Portland, Maine, insurer, paid $22,485,000 to settle whistleblower allegations that it improperly billed for conditions ranging from diabetes with complications to morbid obesity. The plan denied any liability.

A December 2019 report by the Health and Human Services Inspector General found that 99% of chart reviews added new medical diagnoses at a cost to Medicare of an estimated $6.7 billion for 2017 alone.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

https://cbsnews.com…

The Pursuit of Single Payer: Toppling, or Tipping Point?

November 2024 is thirty years after we lost California’s single payer ballot initiative. I look back at what has happened since, and see promise ahead.

Comment:

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

This morning, as I pondered writing a broad update on our quest for single payer, I realized that the movement in California, and my involvement, is fast approaching its 30th birthday. In November 1994, Proposition 186 was on the California ballot. We won … in San Francisco and Berkeley … but lost statewide, by the lopsided margin of 27% yes, 73% no. We were seriously outgunned by the insurers, abetted by various health care interest groups protecting their profitable interests in the existing system.

A lot has happened and changed in the intervening three decades. It’s not a pretty picture. US health care spending jumped from twice the average of other wealthy nations to three times as high, while our longevity fell from roughly equal to four years behind. The Affordable Care Act passed in 2010, cutting the uninsured rate from about 16% to 8%, while hugely boosting under-insurance by encouraging high deductible plans. Medicare Advantage, accelerated by the ACA, caught up and surpassed traditional Medicare, with annual overcharges in excess of $100 billion, making insurers the largest beneficiary of US government largesse. UnitedHealth, a massive insurer, became a multisector leviathan, adding pharmacy benefit management, pharmacies, and physicians. Private equity now controls broad swaths of the provider world. We spend at least $700 billion per year — $2000 per person – in profits and administrative waste, as nearly half of adults report financial barriers to care each year. Overall, we might say that the corporatization of medicine has triumphed over using health care funds for health care. All while three dozen other wealthy nations demonstrate the efficiency and effectiveness of providing universal standardized not-for-profit health coverage. American exceptionalism at its worst.

Has single payer reform definitively toppled? Amazingly, I’m not despondent with our chances. Instead, many factors favor its success. Public anxiety about access to (including affordability of) health care is higher than ever. Awareness of the structural failings of the system is pervasive. Pushback, e.g., against forced Medicare Advantage for union retirees, is rising. Political leaders in both parties are challenging private insurer abuses. Support for a central government role is inching up, with 2/3 support for Medicare for All, if the question is asked neutrally (“your taxes will rise, but you’ll no longer have premiums or cost-sharing, and you can choose your doctor”). Several states are actively pursuing major reform – single payer, or substantial steps on the path to single payer. There are federal bills. The leading candidate for president understands and has in the past supported single payer. Policy and advocacy experts are engaging with each other, as well as with elected officials and health agencies. I’m thrilled to be connected with these individuals and groups, doing all that I can with technical work like online household cost calculations and paths to slashing administrative waste (and, of course, with HJM).

There is a renewed determination to break the logjam, now that we clearly see the abject failure of “path dependence” – sticking with the approach started in World War II, when health insurance originated as an alternative to prohibited wage increases. We should have recognized long ago that the trajectory was off … since 1972, when the Nobel Prize in Economics went to Kenneth Arrow for showing that health care cannot work as a free market good. It’s not soybeans or mobile phones, it’s literally our lifeblood. Health care must be treated, as it is elsewhere around the globe, as a public good, to be disseminated, protected, and cultivated.

These times are fraught and exciting. The upcoming election is pivotal in US history: democracy, freedom, and community are at stake. Single payer is, likewise, resonant with American ideals of freedom (from worry and in choosing doctors) and, of course, community. The vitality we bring to the election and the vitality of health care reform efforts can, must, and will be reinforcing.

It’s hard to say when, but I see a tipping point ahead. I hope you do too. Stay the course.

https://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.