Resource – Page 57

Medicare Advantage Plans Denying Appropriate Care

Summary: This report from the US Dept of Health and Human Services Inspector General quantifies the high frequency of unjustified denials of care authorizations and payments by Medicare Advantage plans. This is private insurers maximizing profits at the expense of patients.

Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care, Office of Inspector General, US Dept of Health and Human Services, April 2022

What OIG Found:

Our case file reviews determined that MAOs sometimes delayed or denied Medicare Advantage beneficiaries’ access to services, even though the requests met Medicare coverage rules. MAOs also denied payments to providers for some services that met both Medicare coverage rules and MAO billing rules. Denying requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers. …

Prior authorization requests. We found that among the prior authorization requests that MAOs denied, 13 percent met Medicare coverage rules—in other words, these services likely would have been approved for these beneficiaries under original Medicare (also known as Medicare fee-for-service). We identified two common causes of these denials. First, MAOs used clinical criteria that are not contained in Medicare coverage rules (e.g., requiring an x-ray before approving more advanced imaging), which led them to deny requests for services that our physician reviewers determined were medically necessary. …

Second, MAOs indicated that some prior authorization requests did not have enough documentation to support approval, yet our reviewers found that the beneficiary medical records already in the case file were sufficient to support the medical necessity of the services.

Payment requests. We found that among the payment requests that MAOs denied, 18 percent met Medicare coverage rules and MAO billing rules. Most of these payment denials in our sample were caused by human error during manual claims-processing reviews (e.g., overlooking a document) and system processing errors (e.g., the MAO’s system was not programmed or updated correctly).

Comment:

By Don McCanne, M.D.

The private insurance companies have been very successful at marketing their private Medicare Advantage plans as a substitute for traditional Medicare under the Part C Medicare program. Since they are paid on a capitation basis rather than fee-for-service, once patients are enrolled, the insurers can increase their profits by denying requests for prior authorization of legitimate services or by simply denying payment for services that have already been provided in compliance with the rules. Prior studies have demonstrated that they do both, and this study from the OIG confirms that they continue to do so.

Mind you, these are legitimate services for which the insurers have already been paid through capitation. Keeping government funds under their control for their own profits that rightfully should be directed elsewhere (the insurance function) is dishonest. Regardless, the government has allowed the insurers to continue to market these plans in a manner that has resulted in ever increasing diversion of public funds to the private insurers through higher sales of Medicare Advantage plans.

Traditional Medicare can offer the same services for lower administrative costs and without the necessity to include extra charges for profits. Any extra benefits that would be appropriate for the Medicare Advantage plans would also be appropriate for traditional Medicare as well. The Medicare Advantage plans should be eliminated and the traditional Medicare program should be modified to provide the best deal for the Medicare beneficiaries and the taxpayers.

Haven’t we said this often enough? Why aren’t Congress and the Administration responding?

http://healthjusticemonitor.org…

Editor’s note: This behavior by private insurers is part of a broad societal trend favoring the rich. Today Heather Cox Richardson reviews our country’s historical cycling of rights for the many vs. for the few. We are living through a wealth inequality ascendant phase, on the cusp of oligarchy / fascism. Her analysis is critically important. It is imperative to reverse the trend, with real health care reform part of the solution. – JGK

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Medicare Advantage Plans Often Deny Needed Care, Federal Report Finds

Investigators urged increased oversight of the program, saying that insurers deny tens of thousands of authorization requests annually.

By Reed Abelson
New York Times, April 28, 2022

Every year, tens of thousands of people enrolled in private Medicare Advantage plans are denied necessary care that should be covered under the program, federal investigators concluded in a report published on Thursday.

The investigators urged Medicare officials to strengthen oversight of these private insurance plans, which provide benefits to 28 million older Americans, and called for increased enforcement against plans with a pattern of inappropriate denials.

Advantage plans have become an increasingly popular option among older Americans, offering privatized versions of Medicare that are frequently less expensive and provide a wider array of benefits than the traditional government-run program offers.

Enrollment in Advantage plans has more than doubled over the last decade, and half of Medicare beneficiaries are expected to choose a private insurer over the traditional government program in the next few years.

The industry’s main trade group claims people choose Medicare Advantage because “it delivers better services, better access to care and better value.” But federal investigators say there is troubling evidence that plans are delaying or even preventing Medicare beneficiaries from getting medically necessary care.

The new report, from the inspector general’s office of the Health and Human Services Department, looked into whether some of the services that were rejected would probably have been approved if the beneficiaries had been enrolled in traditional Medicare.

Tens of millions of denials are issued each year for both authorization and reimbursements, and audits of the private insurers show evidence of “widespread and persistent problems related to inappropriate denials of services and payment,” the investigators found.

The report echoes similar findings by the office in 2018 showing that private plans were reversing about three-quarters of their denials on appeal. Hospitals and doctors have long complained about the insurance company tactics, and Congress is considering legislation aimed at addressing some of these concerns.

In its review of 430 denials in June 2019, the inspector general’s office said that it had found repeated examples of care denials for medical services that coding experts and doctors reviewing the cases determined were medically necessary and should be covered.

Based on its finding that about 13 percent of the requests denied should have been covered under Medicare, the investigators estimated as many as 85,000 beneficiary requests for prior authorization of medical care were potentially improperly denied in 2019.

Advantage plans also refused to pay legitimate claims, according to the report. About 18 percent of payments were denied despite meeting Medicare coverage rules, an estimated 1.5 million payments for all of 2019. In some cases, plans ignored prior authorizations or other documentation necessary to support the payment.

These denials may delay or even prevent a Medicare Advantage beneficiary from getting needed care, said Rosemary Bartholomew, who led the team that worked on the report. Only a tiny fraction of patients or providers try to appeal these decisions, she said.

“We’re also concerned that beneficiaries may not be aware of the greater barriers,” she said.

Kurt Pauker, an 87-year-old Holocaust survivor in Indianapolis who has kidney and heart conditions that complicate his care, is enrolled in a Medicare Advantage plan sold by Humana.

In spite of recommendations from Mr. Pauker’s doctors, his family said, Humana has repeatedly denied authorization for inpatient rehabilitation after hospitalization, saying at times he was too healthy and at times too ill to benefit.

Last March, after undergoing hip surgery, Mr. Pauker was again told that he did not qualify for inpatient rehab but would be sent back to a skilled nursing center to recover, his family said.

During his previous stay at a skilled nursing center, he received little in the way of physical or occupational therapy, the family said. He has so far lost his appeals, and relatives have chosen to pay for care privately while continuing to pursue his case.

People “should know what they’re giving up,” said David B. Honig, a health care lawyer and Mr. Pauker’s son-in-law. People signing up for Medicare Advantage are surrendering their right to have a doctor determine what is medically necessary, he said, rather than have the insurer decide.

Humana, which reported strong earnings on Wednesday, said it could not comment specifically on Mr. Pauker’s case, citing privacy rules. But the insurer noted that it was required to follow the standards set by the Centers for Medicare and Medicaid Services.

“While every member’s experience and needs are unique, we work to provide health coverage that is consistent with what we believe C.M.S. would require in each instance and supports our members in achieving their best health,” Humana said in a statement.

Medicare officials said in a statement that they are reviewing the findings to determine the appropriate next steps, and that plans found to have repeated violations will be subject to increasing penalties.

The agency “is committed to ensuring that people with Medicare Advantage have timely access to medically necessary care,” officials said.

The federal government pays private insurers a fixed amount per Medicare Advantage patient. If the patient’s choice of hospital or doctor is limited, and if he or she is encouraged to get services that are less expensive but effective, then the insurer stands to profit.

Under traditional Medicare, there may be an incentive for hospitals and doctors to overtreat patients because they are paid for each service and test performed. But the fixed payment given to private plans provides “the potential incentive for insurers to deny access to services and payment in an attempt to increase their profits,” the report concluded.

Dr. Jack Resneck Jr., the president-elect of the American Medical Association, said the plans’ denials had become widespread. The organization has been aggressively lobbying lawmakers to impose stricter rules.

Prior authorization, intended to limit very expensive or unproven treatments, has “spread way beyond its original purpose,” Dr. Resneck said. When patients cannot get approval for a new prescription, many do not fill it and never tell the doctor, he added.

Appeals end up unfairly burdening patients and often take precious time, some doctors said.

“We are able to reverse this some of the time,” said Dr. Kashyap Patel, a cancer specialist who serves as chief executive of Carolina Blood and Cancer Care and president of the Community Oncology Alliance. But his efforts to “fight like a hawk” to get approvals for the care he recommends also leave him less time to tend to patients, he added.

The most frequent denials found by the investigators included those for imaging services like M.R.I.s and CT scans. In one case, an Advantage plan refused to approve a follow-up M.R.I. to determine whether a lesion was malignant after it was identified through an earlier CT scan because the lesion was too small. The plan reversed its decision after an appeal.

In another case, a patient had to wait five weeks before authorization to get a CT scan to assess her endometrial cancer and to determine a course of treatment. Such delayed care can negatively affect a patient’s health, the report noted.

But Advantage plans also denied requests to send patients recovering from a hospital stay to a skilled nursing center or rehabilitation center when the doctors determined that those places were more appropriate than sending a patient home.

A patient with bedsores and a bacterial skin infection was denied a transfer to a skilled nursing center, investigators found. A high-risk patient recovering from surgery to repair a fractured femur was denied admission to a rehab center, although doctors said the patient needed to be under the supervision of a physician.

In some cases, the investigators said Medicare rules — like whether a plan can require a patient to have an X-ray before getting an M.R.I. — needed to be clarified.

The plans may use their own clinical criteria to judge whether a test or service should be reimbursed, but they have to offer the same benefits as traditional Medicare and cannot be more restrictive in paying for care.

The investigators urged Medicare officials to beef up oversight of Advantage plans and provide consumers “with clear, easily accessible information about serious violations.”

https://www.nytimes.com…

The American Public Health Association Endorses Single-Payer Health System Reform

By Ben King, Ph.D., M.P.H.; Anthony Spadaro, M.D., M.P.H.; Gordon Schiff, M.D.; Rosa Rodriguez-Monguio, Ph.D., M.S.; Alison O. Jordan, L.C.S.W.; Lisa Flaherty, Pharm.D., M.P.H.; Wei-Chen Lee, Ph.D.; Julie Zito, Ph.D.; Oliver Fein, M.D.
Medical Care, Official Journal of the Medical Care Section, American Public Health Association, April 26, 2022

Abstract

Health care is a human right. Achieving universal health insurance coverage for all US residents requires significant system-wide reform. The most equitable and cost-effective health care system is a public, single-payer (SP) system. The rapid growth in national health expenditures can be addressed through a system that yields net savings over projected trends by eliminating profit and waste. With universal health insurance coverage through SP financing, providers can focus on optimizing delivery of services, rather than working within a system covered by payers who have incentives to limit costs regardless of benefit. Rather, with a SP, the people act as their own insurer through a partnership with provider organizations where tax dollars work for everyone. Consumer choice is then based on the best care to meet need with no out-of-pocket payments. SP financing is the best option to ensure equity, fairness, and public health priorities align with medical needs, providing incentives for wellness. Consumer choice will drive market forces, not provider network profits or insurer restrictions. This approach benefits public health, as everyone will have universal access to needed care, with treatment plans developed by providers based on what works best for the patient. In 2021, the American Public Health Association adopted a policy statement calling for comprehensive reforms to implement a SP system. The proposed action steps in this policy will help build a healthier nation, saving lives and reducing wasted health care expenditures while addressing inequities rooted in social, demographic, mental health, economic, and political determinants.

full commentary: https://journals.lww.com…

More Children Now Killed by Guns than Cars

Summary: Since 2017, for the first time, US child and young adult deaths from firearms exceeded those from motor vehicles. Why? Because we’ve improved car safety, and failed abysmally to improve gun safety. Why? Because gun organizations have opposed research and regulation. This must change.

Crossing Lines — A Change in the Leading Cause of Death among U.S. Children, New England Journal of Medicine, April 16, 2022, by Lois K. Lee et al.

Injuries are the most common cause of death among children, adolescents, and young adults between 1 and 24 years of age in the United States; indeed, injuries are responsible for more deaths among children and adolescents than all other causes combined. For more than 60 years, motor vehicle crashes were the leading cause of injury-related death among young people. Beginning in 2017, however, firearm-related injuries took their place to become the most common cause of death from injury. This change occurred because of both the rising number of firearm-related deaths in this age group and the nearly continuous reduction in deaths from motor vehicle crashes. The crossing of these trend lines demonstrates how a concerted approach to injury prevention can reduce injuries and deaths — and, conversely, how a public health problem can be exacerbated in the absence of such attention. Between 2000 and 2020, the number of firearm-related deaths among children, adolescents, and young adults increased from 6998 to 10,186, according to the Centers for Disease Control and Prevention (CDC).

In 2000, motor vehicle-related injuries resulted in 13,049 deaths among young people. Twenty years later, there has been a nearly 40% decrease, with 8234 motor vehicle traffic deaths recorded in 2020.

Although substantial federal funding has been devoted to research on motor vehicle crashes, the firearm industry and gun-rights organizations, led by the National Rifle Association (NRA), have been effective at keeping federal dollars from financing firearm-related research. Between 1996 and 2019, little federal research funding was appropriated for firearm-injury prevention.

Comment:

By Don McCanne, M.D.

We do have some good news. Our industry designed to provide the beneficial essential task of transporting human beings has been effective in reducing injuries and deaths through better design of vehicles and improvement of public safety standards. The industry and our public stewards are to be commended.

On the other hand, we have an industry designed to produce detrimental lethal projectiles, and what do we do? We protect and embellish that industry to the degree that it has moved into first place as the most common cause of death among children and young adults.

Think about that. We sacrifice our children to an industry that many believe does not provide substantial benefit to society. We defer to gun-rights organizations despite broad public support for gun regulation.

Look at the tremendous gains we made with traffic safety – for an enormous industry that is essential to our commerce. The gun industry? Some of us wish it would disappear, but since its preservation seems assured, let’s focus on harm mitigation. The horrendous record on injury and death tells us we’re long past due for accelerated research and regulation to improve safety. Our children deserve no less, especially after seeing the tragic consequences of our decades of delay.

http://healthjusticemonitor.org…

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California Commission Affirms Unified Financing

Summary: The Healthy California for All Commission issued a final report laying out the huge benefits to be derived from “unified financing” – one payment mechanism for all health care. Costs down, health care up. The impressive affirmation of fundamental principles plus technical findings bolster efforts for single payer.

Key Design Considerations for a Unified Health Care Financing System in California, Report to the Healthy California for All Commission, April 2022

[T]he concept of unified financing [UF] describes a statewide system to arrange, pay for, and assure health care in which:

All Californians will be entitled to receive a standard package of health care services;
Entitlement will not vary by age, employment status, disability status, income, immigration status, or other characteristics; and
Distinctions among Medicare, Medi-Cal, employer-sponsored insurance, and individual market coverage will be eliminated within the system of unified financing.

The analysis done in connection with the Commission’s work found that:

Under almost all scenarios analyzed, in the first year of implementation unified financing is expected to result in lower total health care expenditures than under the status quo;
If, as expected, UF reduces the rate of growth of health spending, savings over time would be achieved under all scenarios examined, even when long-term care services and supports (LTSS) are included as covered services;
Assuming that the federal and state governments support UF at the level they would have supported under status quo fragmented financing, the savings from UF will accrue to California employers and households, who will on average pay less to support UF than they pay in the status quo;
Financing can be stable over time, but will depend on controlling cost growth and securing agreements with the federal government about the rate of growth in federal payments.

Next Steps …

4. Role of Health Plans: Evaluate whether health plans under the status quo add value by furthering access, affordability, quality and equity while accounting for excessive administrative costs and profits and burden on providers. If health plans are retained and reimagined under UF, what functions would they perform?

5. Uniform Clinical Data Record: [E]xplore the potential benefits …

Comment:

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

Don’t let the precise technical prose fool you – this is a full-throated endorsement of the critical core of single payer: unified financing for universal coverage. That is, replacing our cacophony of insurance products and uninsurance with 100% coverage with standard comprehensive benefits saves money while protecting family health and finances.

The Healthy California for All Commission is an outgrowth of AB 1400, and has been working hard since January 2020, guided by the State of California and supported by University of California experts. The single payer voice within the Commission was strong, and came through in this report’s principles and findings.

Importantly, the report (Fig. 1) confirms that savings from simpler administration and lower drug prices (15.4%) exceed increases in utilization (11%, or 7% if income-related copays). This is the pivotal dynamic and irresistible appeal of unified financing: streamlining permits more health care, with net savings. It is the “free lunch” so rare in economics.

Thus, we move a little closer to single payer. The report lays out important next steps, both technical (e.g., better data on health spending) and bureaucratic / political (e.g., seeking federal waivers and cooperation).

Two tasks from the report excerpt above warrant emphasis:

Role of Health Plans: “excessive administrative costs and profits and burden on providers … if retained and reimagined, what functions?” Exactly. Health plans are an expensive & inexcusable drain on our current system. There is no evidence of net benefit. They should be eliminated entirely (in deference to direct fee-for-service), or radically restructured into claims processors.

Uniform Clinical Data Record: Ooh, I get to talk geeky. Currently we struggle with incompatible electronic health records and claims files. Assembling this information into one integrated data system would enhance patient care, research on treatment effectiveness, and detection of fraud and waste. Gotta love top notch data!

There remain many challenges ahead. But today I feel really good about the great State of California so clearly and unequivocally confirming the principles we’ve been fighting for.

http://healthjusticemonitor.org…

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How Financial Incentives for Quality Metrics Hurt Us

Summary: An excellent commentary describes how two decades of paying to improve quality metrics has failed. Quality hasn’t improved, and we’ve spent billions of dollars and hours on quality indicators of dubious validity. We’ve compromised the practice of medicine, and increased disparities. Universal insurance is the foundation for improving quality.

Reassessing Quality Assessment – The Flawed System for Fixing a Flawed System, New England Journal of Medicine, April 13, 2022, by Lisa Rosenbaum, M.D.

[R]ecently, there has been growing recognition of the QI movement’s shortcomings. One study, for instance, showed that only 37% of MIPS measures for ambulatory internal medicine were valid, and even CMS and the Government Accountability Office have acknowledged the need to improve the quality of measuring quality. …

[O]nce a measure is implemented and tied to a financial incentive, an entire industry arises to boost organizations’ scores on that measure. Consultants get hired. Electronic health records (EHRs) are changed. And the measures become a source of intense organizational focus. Not only does it become difficult to modify measures that aren’t clearly working, but a tremendous amount of resources are directed toward the appearance of quality rather than its substance. …

[V]alue-based payment initiatives can also worsen inequities, even though addressing them ought to be at the forefront of our QI efforts. Indeed, after implementation of CMS’s value-based purchasing programs, safety-net hospitals disproportionately bore the brunt of financial penalties. In 2019, hospitals caring for a high percentage of Black patients were disproportionately likely to incur financial penalties. And hospitals serving the highest-risk patients incurred the largest penalties under the HRRP, independent of quality of care. Billions of dollars are thus being transferred from poorly resourced hospitals or those serving the sickest patients to well-resourced hospitals, worsening the disparities we claim to be trying to fix.

Punishing the hospitals and patients most in need of support makes “zero sense,” says Wadhera. He notes the broader irony of attempting to reduce spending with programs that create untold administrative costs and possibly greater net costs to the system long term. For instance, smaller practices that are unable to afford these administrative costs are increasingly being bought by larger health systems that sometimes charge higher prices. And though such consequences create hard-to-quantify indirect costs, truly unquantifiable is the loss to society as consummate community physicians become a dying breed. “Community doctors want to practice medicine,” said Wadhera. “They don’t want to practice quality measurement.”

Some early QI leaders recognized the risk of demoralizing the workforce.

Comment:

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

This thoughtful perspective highlights critical points about our efforts to improve quality with financial incentives, often under the rubric of “value-based care”.

First, financial incentives largely failed to improve quality. There have been a few focal benefits, but rare.

Second, they harm the practice of medicine, by distracting physicians from a focus on clinical care to documentation of quality metrics.

Third, and related, the imperative to increase revenue with quality scores makes coding even more onerous. Unwelcome added time in the EHR is the result.

Fourth, medicine “plays to the code” – any modest gains in measured tasks result in less attention to important quality activities that aren’t in the metric set.

Fifth, the onerous requirements for all this coding, too much for small physician offices, instigated a shift to corporate ownership of providers. That increases costs. (And makes medicine more corporate, which many of us dislike.)

Finally, disparities – inferior resources for the poor and sick – are exacerbated. Exactly the opposite of what we want.

The poor theoretical basis of financial incentives in medicine was pointed out long ago, by among others two HJM bloggers and a behavioral economist. Financial incentives diminish the intrinsic motivation that is so widespread and valuable in medicine.

Recently, several leaders in quality improvement described well the failings of numerical quality scores and proposed a new “criterion” approach. The details need working out, but the move away from competitive scoring linked to reimbursement is very welcome indeed.

The other critical element of improving quality is to remove the distraction of missing, inadequate, and inconsistent insurance. Just cover everybody, with exactly the same benefits and same payments. (Single payer!) Let physicians focus on their clinical mission, provide resources to help them keep improving, and measure success with non-punitive outcome tracking and by talking with patients.

http://healthjusticemonitor.org…

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Congenital Syphilis Deaths Should Be a Wake-Up Call

Summary: More fetuses and babies are dying from syphilis, a completely preventable outcome with adequate access to quality prenatal care. This is a another marker of failure of our systems for health care financing and public health.

Babies Die as Congenital Syphilis Continues a Decade-Long Surge Across the US, California Healthline, April 12, 2022, by Anna Maria Barry-Jester

For a decade, the number of babies born with syphilis in the U.S. has surged, undeterred. Data released Tuesday by the Centers for Disease Control and Prevention shows just how dire the outbreak has become.

In 2012, 332 babies were born infected with the disease. In 2021, that number had climbed nearly sevenfold, to at least 2,268, according to preliminary estimates. And 166 of those babies died.

About 7% of babies diagnosed with syphilis in recent years have died; thousands of others born with the disease have faced problems that include brain and bone malformations, blindness, and organ damage.

“The really depressing thing about it is we had this thing virtually eradicated back in the year 2000,” said William Andrews, a public information officer for Oklahoma’s sexual health and harm reduction service.

From 2011 through 2020, congenital syphilis resulted in 633 documented stillbirths and infant deaths, according to the new CDC data.

Comment:

By Don McCanne, M.D.

Though we spend far more per capita on health care than any other nation, we have a flawed health care financing system that leaves millions who are insured in financial hardship and millions more with no insurance coverage at all. We finance our health care delivery system in a manner designed to create personal wealth for a few while failing to ensure health care access for all.

At least in the past we could be proud of some of the basics of our health care system such as the provision of prenatal and other public health services that reduced afflictions such as congenital syphilis. But public health capacity has decreased, and recent statistics demonstrate that we are moving backwards even in basic disease control that we previously took for granted. Shockingly, maternal mortality is also rising.

So where are we? Our partly public health care financing system is becoming more privatized, and our health care delivery system is experiencing increasing dominance by private equity firms and other corporate middlemen. And now our public health delivery is becoming more reliant on the private sector. On all three levels – our system of financing health care, ownership of health care delivery, and our support of our public health services – we are failing. We spend enough money (the public’s money either directly or indirectly) but fall short on much-needed public oversight.

One little niche in which we are beginning to fulfill the American entrepreneurial dream – the manufacture and marketing of infant caskets. (Excuse me while I attempt to wipe the tears from my eyes.)

http://healthjusticemonitor.org…

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Medicare for All Explained Podcast: Episode 75

Congressional testimony from economist Jeffrey Sachs

April 15, 2022

Podcast host Joe Sparks highlights the testimony of economist Jeffrey Sachs during a recent U.S. House Committee on Oversight and Reform hearing on “Examining Pathways to Universal Health Coverage.” During his opening remarks, Sachs told the committee that we don’t have a health care system in the U.S.

“What we have is a scam.”

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

https://medicareforallexplained.podbean.com

Full opening remarks from Jeffrey Sachs

Medicare Advantage Costly Diagnostic Upcoding

Summary: Investigative reporting by Bloomberg highlights the work of whistleblowers and the federal government to combat fraudulent upcoding by Medicare Advantage plans. But Medicare itself greatly worsens the problem, by failing to properly regulate aggressive (largely legal) upcoding.

Major Insurers Are Scamming Billions from Medicare, Whistle-Blowers Say, Bloomberg, April 12, 2022, by John Tozzi

Each year, [Medicare Advantage] plans submit giant data files to Medicare with diagnostic codes meant to reflect their members’ illnesses. Those codes determine how much they get paid. A federal watchdog warned in March that coding differences brought Medicare Advantage plans $12 billion in excess payments in 2020, compared to what traditional Medicare would have paid to cover the same population. The cumulative extra payments since 2007 will soon top $100 billion, according to the Medicare Payment Advisory Commission, or MedPAC. …

The Department of Justice called policing Medicare Advantage an important priority on its anti-fraud agenda. The agency said in February that it pursued health plans that gamed the system “by submitting unsupported diagnosis codes to make their patients appear sicker than they actually were,” …

Health-care companies developed increasingly sophisticated methods to maximize payments. A cottage industry of vendors emerged to help them. They mine data from patient charts, send staff to do health-risk assessments in patients’ homes and prod doctors to review potentially missed diagnoses. …

[Whistleblower] Ross recalls her managers lit up when they realized how much money it might bring in. Reviewing two years of data, DxID added thousands of potential diagnoses that increased Group Health’s revenue by $32 million, the U.S. alleged. But when Ross checked DxID’s work, she found that three-quarters of the diagnostic codes it submitted for payment lacked proper documentation and didn’t stand up to scrutiny, according to her complaint.

The plan got paid for one patient’s depression diagnosis even though a physician said it had resolved and the patient now had “an amazingly sunny disposition,” according to Ross’s complaint. It claimed another patient had kidney complications from diabetes even after a doctor had explicitly ruled that diagnosis out.

Comment:

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

This article highlights how even the most respected HMOs, like Group Health and Kaiser, fall prey to the temptations of increased revenue from highly suspect diagnostic upcoding practices. It’s terrific that whistleblowers and the federal government team up to catch and punish offenders, and perhaps discourage others.

However, the real money isn’t in the fraud, it’s in the legal upcoding that Medicare Advantage plans do and Medicare (CMS) fails to properly regulate. It’s well understood that MA plans have a much greater incentive than traditional Medicare to find and document diagnoses, because these added codes raise the capitation payments to MA whereas they don’t affect traditional Medicare reimbursements. CMS knows about this bias, and is permitted to adjust the payment levels to counteract it. But they put a cap on the size of the adjustment, even as upcoding grows rapidly in magnitude. The difference between upcoding and the allowable adjustment represents pure profit for MA plans.

The amounts at risk are staggering. CMS estimates $100 billion so far. Rick Kronick, a prominent health policy researcher, looks at trends and estimates a far greater toll in years to come. In a Nov 2021 article on the impact of sharply rising Medicare Advantage coding intensity he estimated that “total Medicare payments to MA will be $600 billion higher over the 2023-2031 period than … if the coding intensity adjustment were set [accurately] … $85 billion will be paid by beneficiaries in higher Part B premiums, and $515 billion in higher net Medicare spending.”

That’s highway robbery (by the MA plans) and dereliction of duty (by CMS).

Risk adjustment is being massively gamed by private insurers. Time to change the game, to single payer.

http://healthjusticemonitor.org…

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Major Insurers Are Scamming Billions from Medicare, Whistle-Blowers Say

Billing for illnesses that don’t exist, like prostate cancer in a woman.

By John Tozzi
Bloomberg, April 12, 2022

Teresa Ross had been raising objections at work for months when her bosses brought in a psychologist hoping to make her question her own sanity.

A longtime manager at a Seattle health plan called Group Health Cooperative, Ross had opposed changes to the way the company billed Medicare. With the help of a new vendor, the insurer identified new diagnoses for patients, bringing in millions of extra dollars from the government. Ross insisted much of it was fraud. She says she was cut out of meetings.

Then she was invited to one with the psychologist. He asked how she was feeling and revealed that a senior executive had sent him to discuss her objections.

“People aren’t seeing you as a team player,” she recalls him saying. “They’re concerned that you have a loud voice within the organization. And you’re objecting to this thing that’s making us lots of money and everybody’s happy.”

Ross felt blindsided and insulted. The visit made no difference.

Ross had already filed a sealed whistleblower suit against the company, which later merged with Kaiser Permanente in 2017. After years of investigating, the Justice Department took up her case last year. Other whistleblowers came forward too, with allegations accusing Kaiser and some of its competitors of inflating how sick their members appeared to be to get higher payments from Medicare.

The industry vehemently contests the allegations and says that plans get paid appropriately for the risk they take on. But the disputed billing practices at the heart of Ross’s case have become central to the health-care business and, as baby boomers retire, to America’s fiscal future. Medicare covers 64 million people and will spend $900 billion this year, or 4% of U.S. gross domestic product. Almost half of people on Medicare now get their benefits through Medicare Advantage — private plans like the one Ross worked for, which get paid more for patients with more severe illnesses. That means a growing share of Medicare’s billions flows through arrangements susceptible to the kind of manipulation that Ross described.

Each year, the plans submit giant data files to Medicare with diagnostic codes meant to reflect their members’ illnesses. Those codes determine how much they get paid. A federal watchdog warned in March that coding differences brought Medicare Advantage plans $12 billion in excess payments in 2020, compared to what traditional Medicare would have paid to cover the same population. The cumulative extra payments since 2007 will soon top $100 billion, according to the Medicare Payment Advisory Commission, or MedPAC.

Those payments mounted as American seniors flocked to the private version of Medicare. Enrollment in Medicare Advantage doubled in the last decade to more than 26 million people, on pace to cover a majority of Medicare beneficiaries.

Insurance companies have built billion-dollar businesses propelled by this growth. UnitedHealth Group Inc., Humana Inc., and CVS Health Corp.’s Aetna unit combined enroll more than half of Medicare Advantage members. Kaiser Permanente, with about 7% of the market, isn’t far behind, according to data from the Kaiser Family Foundation, a research group unaffiliated with the health plan.

The industry calls the program a win-win. Medicare Advantage caps members’ out-of-pocket costs and offers extra benefits like dental, vision and hearing coverage that traditional Medicare doesn’t. Private plans also send clinicians on house calls, deliver meals and offer rides to medical appointments, stitching together medical care with services intended to address members’ social needs.

The program’s growing popularity has made it politically powerful. Republicans extoll its private-sector innovation while Democrats know that enrollees are disproportionately low-income and people of color. An industry coalition recently touted a letter signed by 346 U.S. representatives — more than 80% of the House — urging the Biden administration to “provide a stable rate and policy environment” for the program. Soon after, Medicare proposed payment rates for 2023 that an analyst for Veda Partners called “surprisingly good news for industry.”

Yet rising Medicare Advantage enrollment has also prompted warnings about the cost. The program’s hospital trust fund is projected to be depleted in 2026. “Failure to stem the excess spending created by coding intensity further jeopardizes the Medicare program’s already challenging fiscal sustainability,” MedPAC wrote in a comment letter to Medicare officials in March.

The industry has billions at stake in how the payments are calculated. In February, UnitedHealth asked the Supreme Court to review a case it lost on appeal challenging a policy to make insurers return payments for unsupported diagnoses. The policy “imposes potentially billions of dollars in additional payment obligations” on plans and would destabilize the Medicare Advantage program, the company said in its petition. Letting the decision stand threatens to reduce benefits and increase costs for seniors in the program, UnitedHealth argued.

Official scrutiny is growing. The Department of Justice called policing Medicare Advantage an important priority on its anti-fraud agenda. The agency said in February that it pursued health plans that gamed the system “by submitting unsupported diagnosis codes to make their patients appear sicker than they actually were,” and cited Ross’s case as an example. Ross’s attorneys estimate the scope of such frauds reaches into the billions of dollars.

Ross filed her complaint against Group Health under seal a decade ago, and it remained a secret for seven years. With the aid of other whistleblowers, the Justice Department has also sued industry giants including UnitedHealth, Anthem Inc. and Cigna Corp. over similar allegations in recent years. The companies are fighting the cases.

Now it’s up to the courts to decide which practices are legitimate and which constitute fraud. Ross remains shaken by her experience. Coming forward wasn’t easy, she said. “The easy thing would’ve been to sit down and just let it happen.”

Ross, 57, grew up outside Seattle, a math whiz in a family that kept busy with music lessons and school activities. Her father had a heart attack while she was in high school, and she spent a lot of time at the hospital, pressing his doctors for information. That early exposure coupled with her mathematical acumen led Ross into a career in an obscure corner of the health-care industry. In 1998, she arrived at a nonprofit insurer called Group Health Cooperative to lead a division building statistical models of patient risk.

In the 2000s, these models became central to the growing Medicare Advantage industry. Money hinged on the illnesses that plans documented for their members. Traditional Medicare pays doctors and hospitals directly for each test or service. In Medicare Advantage, health plans get a fixed payment from the government for each member they take on. The program will spend on average about $14,000 per enrollee this year. Through a process called risk adjustment, added diagnoses typically bump payments by $1,000 to $5,000, sometimes even $10,000, according to MedPAC. It’s meant to compensate insurers for taking on sicker patients and discourage them from cherry-picking healthy people.

Ross said she and Group Health originally embraced the system as a way to identify patients who needed care but weren’t getting it. “It’s not just digging for dollars,” she said. “It’s improving care.”

Her whistleblower suit and the Justice Department complaint that followed describe a growing pressure within the company to engineer higher risk scores for greater payments. She rebuffed one vendor called Leprechaun LLC hired in 2008 that wanted to submit claims “based on documentation that was clearly inadequate,” according to Ross’s complaint.

By 2011, Group Health’s finances deteriorated, and it was facing downgrades from credit raters. That fall, Group Health’s chief executive officer met a counterpart from a Buffalo plan called Independent Health, which had just formed a new subsidiary focused on risk adjustment called DxID, according to Ross’s complaint. In an early pitch, DxID CEO Betsy Gaffney told one of Ross’s colleagues that Group Health’s internal approach to risk-adjustment “is really putting you back financially,” according to the Justice Department complaint. “I get what the purpose of the policies are theoretically, and even kind of agree philosophically, but it is very restrictive,” she wrote in a November 2011 email.

Group Health hired DxID the next month on a contingency basis. The vendor would keep 20% of any new revenue it brought in from combing old patient charts to uncover missed diagnoses. Gaffney proposed new ways to identify patients who suffered from illnesses like chronic kidney disease or low oxygen levels, a condition called hypoxia, according to the Justice Department complaint.

Ross recalls her managers lit up when they realized how much money it might bring in. Reviewing two years of data, DxID added thousands of potential diagnoses that increased Group Health’s revenue by $32 million, the U.S. alleged. But when Ross checked DxID’s work, she found that three-quarters of the diagnostic codes it submitted for payment lacked proper documentation and didn’t stand up to scrutiny, according to her complaint.

DxID would pull illnesses from the “problem list” doctors maintained in electronic medical records, a section of the chart that sometimes contained old or resolved conditions, Ross said. The company also used lab tests or other orders as proxies to infer diagnoses, even when clinicians had not documented the illnesses. For example, patients getting supplemental oxygen were assumed to have hypoxia, even though oxygen can be prescribed for less serious problems like sleep apnea, the complaint says. Later DxID would send physicians “addendum” forms to update charts with suggested diagnoses, paying them $25 to fill them out, the U.S. alleged.

This approach produced some unlikely results. One patient’s depression was supposedly documented during a visit to an ophthalmologist, according to Ross’s complaint. In another case, when Gaffney was working for Independent Health, a woman was coded for prostate cancer, because “when a married couple has any disease, both were assigned to that disease,” she wrote in an email, according to the Justice Department complaint.

As Ross and her colleagues reviewed the submissions, they found DxID was adding diagnoses that doctors hadn’t made. “Coders are not allowed to diagnose anything,” Ross said. “That’s for doctors.”

Despite Ross’s protests, Group Health adopted most of the coding policies DxID proposed, Ross and the Justice Department allege. Her managers spurned her, she said, and eventually brought in the psychologist. Ross’s attorney, Mary Inman, a partner at whistleblower law firm Constantine Cannon, said Ross’s experience fits a pattern of tactics used to isolate corporate dissenters. “This is where you get the whistleblower to start to doubt herself,” Inman said. “That’s part of the corporate playbook that we see in these cases.”

Ross wasn’t dissuaded. In April 2012, after 14 years in a job she loved, she filed her complaint in federal court for the Western District of New York, where DxID was based. “The company that I had known to be ethical all of a sudden wasn’t,” she said. “They didn’t care about whether or not it was compliant. At least in my eyes, they were more concerned about what Betsy Gaffney was hanging out in front of them, which was millions and millions of dollars.”

Attorneys for Gaffney didn’t respond to multiple requests for comment. In a statement to the Buffalo News last year, they said she was “unfortunate victim of an ancient lawsuit premised on inaccurate allegations.” In legal filings seeking to dismiss the case, the defendants characterized the dispute as “good faith disagreements over objectively ambiguous coding criteria” and said that the allegations from Ross and the Department of Justice don’t meet the standards of a False Claims Act claim.

Whistleblowers file their initial complaints under seal to give the government time to investigate and decide whether to proceed. In Ross’s case, it lasted years. She left Group Health the year after she filed her complaint and moved on to other jobs while her case sat sealed on the docket.

Mostly unknown to Ross, other whistleblowers were coming forward with similar accounts at other companies, and federal investigators were building cases of their own. Both targeted some of the largest companies in the industry, which increasingly relied on Medicare Advantage as a source of profitable growth.

In 2017, the Justice Department intervened in a case against UnitedHealth, the largest Medicare Advantage provider. It sued Anthem in 2020. A whistleblower suit against Cigna was also unsealed that year. The companies are fighting the cases and have disputed allegations of wrongdoing. CVS Health and Humana have also both disclosed investigations into their risk adjustment practices and said they’re cooperating with the probes. UnitedHealth and CVS declined to comment for this story. Representatives for Anthem, Cigna and Humana didn’t respond to requests for comment. The Department of Justice declined to comment.

In 2017, Group Health was acquired by Kaiser Permanente, the giant California-based HMO. Ross’s own suit was unsealed in 2019, when the U.S. initially said it would not intervene but would keep investigating.

Kaiser Permanente’s Washington state subsidiary denied Ross’s allegations. Without admitting liability, the health plan resolved the lawsuit in 2020 in a settlement for $6.3 million — about one-fifth of the revenue increase Ross attributed to the practices in two years of its engagement with DxID. Ross was awarded $1.5 million, with the rest recovered by the government.

Kaiser Permanente spokesman Marc Brown said in an email that Group Health “submitted its data in good faith and in reliance on recommendations by DxID, its contracted risk adjustment vendor, which purported to be an expert in this area.”

DxID ceased operations last summer. But the U.S. attorney in the Western District of New York is pursuing the civil fraud claims Ross initiated against the vendor, its parent company Independent Health, and Gaffney as an individual defendant.

Independent Health and DxID deny wrongdoing and have moved to dismiss the lawsuit. “We believe the coding policies being challenged here were lawful and proper and all parties were paid appropriately,” Independent Health said in a statement. “Independent Health and DxID diligently navigate complex and vague coding criteria to ensure that all diagnosis and billing codes properly reflect our members’ medical conditions and are supported with documentation in the members’ medical records.” The company also said its plans received high ratings from Medicare.

Last summer, the Department of Justice intervened in six other cases against Kaiser Permanente filed by separate whistleblowers alleging that it defrauded Medicare through inflated risk codes. The health system says it will fight the suits and defended its audit record with Medicare. “Our policies and practices represent well-reasoned and good-faith interpretations of sometimes vague and incomplete guidance,” Kaiser Permanente said. The company declined interview requests.

The cases could take years to resolve. Ross, who struggled initially with her decision to come forward, has been heartened by the number of counterparts across the industry who raised similar concerns. “It took a long time for the government to really understand what was happening to them in this space,” she said.

https://www.bloomberg.com…

US Physician EHR Burden = Less Clinical Focus, More Burnout

Summary: The electronic health record is now ubiquitous. Doctors complain about its time demands and its emphasis on billing. This review quantifies that burden – more than 4 hours per day, far higher than in countries with simpler insurance.

How much time do physicians spend in the EHR?, KevinMD, April 10, 2022, by Thrisha Gogineni, James G. Kahn, Sigal Maya

Doctors often find the Electronic Health Record (EHR) time-consuming and annoying. … We assembled evidence on hours dedicated to the EHR each day by physicians. The result is impressive – 4.5 hours.

Ninety percent of office-based physicians in the US use an EHR system. However, many report negative experiences. Two recent studies found that physician EHR effort lowers clinical focus and contributes to burnout. EHRs are often described as having poor usability and being unintuitive and inefficient, detracting from clinical focus and sometimes even leading to patient harm.These systems also decrease collaboration and communication between doctors and nurses.

… To estimate the magnitude of EHR burden in the U.S. and potential savings with streamlined EHR function, we collated existing published evidence. …

The figure summarizes what we found. Median daily physician EHR time ranged from 3.5 to six hours with the observation, log file, and web tracking methods. … The time burden of the EHR in US was significantly higher than in other countries where reported daily EHR time was one hour.

This is a striking amount of time.

Greater demands in the U.S. for billing and regulation related documentation contribute to the excess time burden of EHR systems compared with other countries. …

Only half of a doctor’s day remains for direct clinical interactions with patients.

The essential lesson from this EHR evidence is that the time burden it imposes on physicians is substantial in the US, occupying hours that could otherwise be spent building truly meaningful relationships with patients (not “meaningful use” metrics!) and providing quality care.

Comment:

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

Doctors are forced to use the electronic health record, including entry of large amounts of clinically-irrelevant data, especially billing-related details about procedures and overly precise diagnostic codes. This degrades the clinical experience for doctor and patient alike.

This study (full disclosure: I’m an author) assembles evidence on the time burden. It is indeed large.

Although the EHR can improve access to medical information, it is a data-hungry beast that exacts a huge toll as measured in hours, clinical focus, communication quality, and quite likely clinical outcomes.

Single payer would permit us to streamline the EHR to focus on clinically relevant information, as in other wealthy countries.

(P.S. a podcast on this is coming, I’ll let you know)

http://healthjusticemonitor.org…

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US Women of Reproductive Age Hurt by Insurance Barriers

Summary: “Among women of reproductive age in high-income countries, rates of death from avoidable causes, including pregnancy-related complications, are highest in the United States. U.S. women of reproductive age are significantly more likely to have problems paying their medical bills or to skip or delay needed care because of costs.” This says it all.

Health and Health Care for Women of Reproductive Age, The Commonwealth Fund, April 6, 2022, by Munira Z. Gunja et al

The maternal mortality crisis in the United States has been well documented: U.S. women have the highest rate of maternal deaths among high-income countries, while Black women are nearly three times more likely to die from pregnancy-related complications than white women are. But maternal deaths and complications may be a bellwether for the U.S.’s wider failures with respect to women’s health and health care.

Among women of reproductive age in high-income countries, rates of death from avoidable causes, including pregnancy-related complications, are highest in the United States.

U.S. women of reproductive age are significantly more likely to have problems paying their medical bills or to skip or delay needed care because of costs.

U.S. women of reproductive age have among the highest rates of multiple chronic conditions and the highest rate of mental health needs.

High health care costs are significant burdens for many U.S. households, even those covered by health insurance. Over one-quarter of women of reproductive age in the U.S. and Switzerland spend USD 2,000 or more in out-of-pocket medical costs, as compared with less than 5 percent of women in the U.K., France, and Netherlands.

Half of women of reproductive age in the U.S. reported skipping or delaying needed care because of costs. U.S. survey respondents were significantly more likely to report skipping care than respondents in all other countries. In the Netherlands, only 12 percent of women said they had forgone care for cost reasons. America’s outlier status on this measure likely stems from the large number of women who lack health insurance — 10 million — as well as the high copayments, coinsurance, and deductibles that many U.S. women enrolled in commercial health plans face when seeking care.

Compared to their counterparts in the other 10 countries, women of reproductive age in the U.S. were significantly more likely to report one or more medical bill problems, with over half saying they had experienced one or more. Only one in 10 women in the U.K., which provides free care to all residents through the country’s National Health Service, reported a medical bill problem.

When looking at all women, we found that those in the U.S. have the highest rate of avoidable deaths: nearly 200 in 100,000 deaths could have been prevented or treated with the right care provided at the right time.

Research shows that investing in women’s health results in a healthier overall population, healthier future generations, and greater social and economic benefits. Yet the U.S. remains the only wealthy country without universal health care, leaving about 10 million women without insurance.

Comment:

By Don McCanne, M.D.

How is the United States doing in providing adequate health care for its residents? Let’s just look at women of reproductive age – a group that plays such an important role in family and community life and should not be afflicted by medical risks more characteristic of older age.

Compared to other wealthy nations that spend less on health care than us, our record is miserable. Not only do our insurance programs leave many unacceptable gaps in coverage, we leave ten million women with no insurance coverage at all, thus potentially unnecessarily exposed to physical and financial suffering and even death. We are already spending the funds that could prevent this, but we are spending them on the wrong health care financing system – a highly dysfunctional, fragmented system designed to benefit venture capitalists and private equity investors, with insurance and much patient care being primarily a tool to enable wealth accumulation.

We are spending enough money to do it right, but it appears that our health care infrastructure is now so distorted by capital interests that even single payer Medicare for All may not be enough to ensure adequate health care for all. Maybe all of us, as communities, need to play a greater role. For those who missed it, several HJM contributors last week published an article in The Nation how communities, not corporations, should own our most vital health care assets.

With public financing and community control, women of reproductive age would no longer have to worry about their own health care access and affordability, and also would no longer have to worry about health care for their loved ones, or for everyone else.

Maybe women are best positioned to lead the march toward health care justice for all.

http://healthjusticemonitor.org…

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What OIG Found:

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Full opening remarks from Jeffrey Sachs

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