By Steffie Woolhandler, M.D., M.P.H. and David U. Himmelstein, M.D.
Medpage Today, May 25, 2022

The Biden administration rewarded private insurers with an 8.5% hike in Medicare Advantage payments in April, despite new evidence that these companies profiteered at Medicare’s expense during the first year of the pandemic.

While 2020 may have been a bad year for Americans, it was a great one for America’s health insurance firms. Profits at UnitedHealthcare, the nation’s largest private insurer, shot up 20%, reaching more than $12 billion. The second biggest, Anthem, collected $16.1 billion more in premiums than it paid out in benefits, a 30% jump over 2019, and CVS/Aetna’s take from its insurance business rose 29%.

It turns out that taxpayers footed the bill for this explosion in profits by, in effect, paying twice for healthcare. This only came to light in December 2021 when federal actuaries released their official tabulations of 2020 health spending.

The actuaries’ report documented a nearly 10% increase in overall health spending between 2019 and 2020 — more than double the average yearly increase over the previous decade. Two expenditure categories accounted for half of the 2020 cost growth, and almost all of the acceleration over past years: 1) government public health spending to combat the pandemic, and 2) private insurance overhead costs.

It’s obvious why public health spending would surge during a pandemic. But what could justify the nearly $65 billion increase in private insurers’ overhead? And how is it that two thirds of that increase came from private insurers’ subcontracts with Medicare and Medicaid?

Since the 1980s, federal and state governments have funneled a growing share of their reimbursement to healthcare providers through private insurers’ Medicare Advantage and Medicaid managed care plans. In effect, private insurers serve as middlemen between the government and care providers.

The enlarging stream of government dollars has been a godsend for private insurers. As enrollment in employer-sponsored insurance stagnated, private insurers have relied on this funding to grow their businesses. By 2020, public dollars accounted for the majority of private insurers’ premium revenues.

But much of that money never reaches a medical provider. It stays with the insurance companies as overhead. In the year before the pandemic, overhead for private Medicare Advantage plans averaged $1,824 per enrollee — 15% of their revenues and more than five times higher than Medicare’s 2% overhead.

In setting 2020 payment rates to Medicare Advantage plans, federal officials boosted payments by nearly $49 billion, anticipating the usual annual increases in medical care use and costs. But with many doctor visits and non-urgent surgeries during the pandemic cancelled, Medicare Advantage plans pocketed most of that increase. Their overhead rose to $2,256 per enrollee. Meanwhile, the overhead of private Medicaid managed care plans also surged.

Private insurers’ payments to hospitals actually fell in 2020, even as hospitals faced sharp increases in costs for the staff and equipment needed for the tsunami of COVID-19 patients. The financial distress of hospitals and health professionals triggered congressional bailouts — the Provider Relief Fund and Paycheck Protection Program — that totaled about $165 billion in 2020.

In essence, government paid twice for care: once through premiums paid to private insurers for Medicare Advantage and Medicaid managed care, and a second time to fill the hole in hospitals’ and doctors’ budgets caused by falling reimbursements from private insurers.

Insurers fleecing taxpayers in 2020 was in some respects a one-off event caused by the unexpected fall in non-COVID-19 care. But the Medicare Advantage rip-off began before 2020 and continues today.

By exaggerating how sick their enrollees are, private plans have extracted extra payments from Medicare, which pegs its funding of Medicare Advantage plans to the severity of enrollees’ illnesses. Congress’ official Medicare watchdog estimates that between 2008 and 2019, Medicare Advantage plans raised Medicare’s overall costs by $132 billion.

And even before the recent payment increase Medicare Advantage overcharges were on track to increase — costing Medicare and seniors (whose Medicare Part B premiums are deducted from their Social Security checks) as much as $355 billion by 2030.

Medicare Advantage plans use a fraction of that overpayment to entice enrollees with extra benefits like eyeglasses and discounts at fitness clubs. But most of it funds their exorbitant overhead, including PR campaigns and lobbying to prevent a crackdown that might derail this money train.

Some in Congress claim they can’t find the money to continue funding COVID-19 vaccinations and care, child tax credits, or green energy. Reclaiming the hundreds of billions wasted by subcontracting Medicare and Medicaid coverage to private insurers would be a good place to look.

Steffie Woolhandler, M.D., M.P.H. and David U. Himmelstein, M.D. are both distinguished professors at the City University of New York at Hunter College, research associates for Public Citizen’s Health Research Group, and long-time advocates for national health insurance.

https://www.medpagetoday.com…

By Maureen Tkacik
The Lever, May 20, 2022

A private-equity-owned emergency room staffing firm co-founded by a wealthy Republican congressman has been openly hailing a coming “oversupply” of doctors, promising prospective investors that a surplus of emergency physicians — soon projected to reach nearly 10,000 — will drive doctors’ wages low enough to offset the haircut that health care reforms have imposed upon its profit margins.

The physician glut was highlighted in a recent pitch deck prepared by the cash-strapped Nashville ER staffing firm American Physician Partners (APP). The company, which operates ERs in 155 hospitals, has been trying — and failing — for months to raise $580 million to pay off creditors, including Rep. Mark Green (R-Tenn.), who holds somewhere between $5 million and $25 million of the company’s debt.

Like most of its competitors, APP has watched its profit margins and credit ratings sink since various laws banning surprise billing were enacted last year. While APP claims it never sent surprise bills to patients, it has also told its doctors in email exchanges reviewed by The Lever that various laws banning the practice had resulted in a 50 percent drop in the company’s revenues from certain large insurers.

But in its November 2021 pitch deck to investors, APP tells a different story, promising the company will more than make up for the expected $5.8 million to $11.6 million hit to its $122 million in annual gross earnings, by slashing some $19.6 million from its payroll costs. APP can do this in the midst of a once-in-a-generation health care labor shortage, according to the presentation, thanks to a coming glut of ER doctors.

This ER doctor glut was primarily caused by a recent explosion in the number of emergency medicine residency programs founded to train medical school graduates in the specialty — and was part of a deliberate scheme by vulture capitalists to flood the health care system with cheap medical labor.

“It is remarkable to me that in the midst of a global pandemic where health care workers have sacrificed so much, APP brazenly shares its plans to further exploit physicians,” said Philip Sossenheimer, a Stanford Health Care physician who helped organize a recent landmark union victory at the Palo Alto, California-based hospital system.

While this physician glut is currently a phenomenon specific to emergency medicine, Sossenheimer suspects more specialties will soon face similar problems. As he put it, “I hope all physicians see this as the harbinger of what corporate health care will bring.”

The Doctor Glut Has Arrived

This “oversupply” of emergency physicians will likely never be apparent to the average patient sitting in an ER waiting room, where skeleton staffing has been thoroughly baked into the business model.

As the APP presentation points out, 70 percent of hospital ERs are outsourced, and most contracts are awarded to the lowest bidder. Nearly all of the biggest bidders on ER contracts — Envision Healthcare, TeamHealth, SCP Partners, ApolloMD, and APP — are owned by private equity firms that have accumulated nine- or ten-figure sums of debt buying out smaller competitors. Making the interest payments required by that debt leaves no room for extravagances like higher doctor-patient ratios.

Indeed, as the media will often remind us, we are by most standards a nation in the throes of an acute physician shortage. Most countries have far higher numbers of doctors per capita than the United States, partly because we force doctors to endure three or four times as many years of postgraduate education as most European countries, pay an average of $300,000 for the privilege to save lives, and partake in a cutthroat competition for a fixed number of residency positions.

Each year more than a thousand new medical school graduates, most of them deeply in debt, fail to “match” into residency programs and fall into a kind of professional limbo. This is in part because Congress, in 1997, froze the number of residency slots it would allow Medicare to subsidize — a Republican policy the conservative Wall Street Journal editorial board last year shamed congressional Democrats for failing to reverse, in light of what it characterized as a rampant “shortage” of doctors, particularly emergency physicians.

Assessing the physician labor market in February, The Atlantic argued that the barriers to achieving a medical license in America amount to “a conspiracy to limit the amount of doctors practicing in America.”

And yet, younger ER doctors will tell you a starkly different story — one in which ER specialists toil four years in med school and another three or four in residencies, only to spend another six months looking for a job, during which they find that employers are delegating an increasing number of their former duties to nurse practitioners.

A surging rate of doctor resignations in response to the pressures of the pandemic has done little to improve the remaining physicians’ lot. While nurses who are willing and able to quit their jobs and become travel nurses have had little problem quadrupling their short-term pay, doctors who become travel physicians are regularly hit with more pay cuts.

In August 2021, a statistical analysis published in the Annals of Emergency Medicine put hard numbers to the sense of disposability doctors had been experiencing: A near-doubling in the number of emergency room visits being handled by nurse practitioners and physician assistants had conspired with a boom in the number of med school students specializing in emergency medicine to produce an ER doctor glut that was growing bigger every year. The study projected the ER physician oversupply will reach 7,485 doctors by 2030.

By all accounts, the glut has already arrived. A recent thread on a popular ER physician forum dissected two emergency room job listings offering $125 an hour — one a day shift travel nurse on the west coast, and the other a midwestern emergency physician gig with unspecified teaching responsibilities involved. Other discussions have focused on how doctors are increasingly getting paid the same amount as registered nurses. More recently, a labor lawyer posted an employment contract with Apollo-controlled ER staffing firm US Acute Care Solutions, specifying an hourly base physician pay of $21 an hour.

“This should be a wake-up call to the speciality that emergency medicine is becoming a less desirable specialty due to its reputation for increasing corporatization, loss of autonomy, and exploitation,” said Mitch Li, a traveling emergency room physician who also runs Take Back Medicine, a grassroots support network for doctors grappling with private equity buyouts.

The Residency Gravy Train

There’s an obvious reason for the doctors’ unique lack of labor market leverage: The emergency medicine specialty is bringing in nearly twice as many med school grads as it did a decade ago, and almost triple the number it attracted in 1998.

That is thanks to a near doubling of residency programs designed to train doctors in emergency medicine since 2008; no other medical specialty has experienced such a boom. The residency surge became particularly overheated in the years before the pandemic, when the Accreditation Council for Graduate Medical Education accredited 77 new emergency residencies in three years alone — only 19 of which claimed any affiliation with a university medical school.

And while most of those programs would be profitable solely on the basis of the deeply discounted medical labor and physician recruitment costs associated with hosting a residency, the government subsidies associated with most residencies, most of which are subsidized by Medicare, make them bona fide gravy trains. When Philadelphia’s Hahnemann hospital auctioned off its 550 residency slots in 2019 in the aftermath of a complex private equity acquisition and looting of the facilities, the residencies fetched $55 million. And according to its pitch deck, APP calculates that the expansion of a Medicaid-subsidized residency program it manages in a chain of Michigan hospitals will add an extra $3 million to its annual earnings.

Residency programs’ financial rewards likely would have caused a physician glut much sooner, had Congress not frozen the number of Medicare-funded medical residency spots as part of its 1997 Balanced Budget Amendment. In the years that followed, hospital lobbies began complaining that the caps were causing a “doctor shortage.”

The scare tactics worked. In 2013, after local newspapers eagerly reported on the coming dearth of doctors, Florida hospitals convinced then-Gov. Rick Scott (R) to earmark an extra $80 million a year in Medicaid funds to subsidize new medical residencies.

The most prominent driver of the ER doc glut, doctors say, is the hospital giant HCA Healthcare, which has emerged as the nation’s largest single sponsor of post-med school residency programs.

This is a recent development: Until 2015, HCA’s annual report contained a boilerplate sentence about how its hospitals “do not typically engage in extensive medical research and education programs.” Last year, the company issued a press release welcoming an incoming class of two thousand medical residents and boasting of being the “largest provider of graduate medical education” in the country.

Physicians with experience in various outposts of the hospital chain’s burgeoning educational empire say that HCA is exploiting residents at the expense of their educations and future patients. Doctors familiar with HCA residencies in Florida, for example, say the programs are often run by physicians with flimsy-to-nonexistent academic credentials, and many say they are mystified as to how the programs first gained accreditation.

“These hospitals have so few nurses left that the residents are stuck doing all the IV bags, changing the sheets, while any patient with a moderately complex case is going elsewhere,” said one physician familiar with HCA residency programs, who asked to remain anonymous because they live in a state where the company has substantial market power. “Now, there’s nothing wrong with doing a few IV bags or doing what needs to be done in a crunch, but a residency is where you’re supposed to learn how to handle the big complex cases. HCA is just destroying the educational experience of a lot of these young docs.”

HCA’s entrance into the residency business opened the floodgates, paving the way for dozens of smaller health systems to launch residency programs and lobby their state Medicaid agencies to subsidize them. Unsurprisingly, many of these efforts also offer subpar training opportunities.

And one APP physician shared details of a side gig supervising a new EM residency program launched by a struggling nonprofit hospital in what they called an “apocalyptically poor” Rust Belt town.

“[It has] no business running a residency program,” said the physician, adding that the hospital hadn’t even employed a board-certified ER doctor prior to launching the program. “But they’re desperate to bring in money and they’re desperate to bring in doctors.”

Stuck On The Corporate Medicine Hamster Wheel

While APP might be expecting the growing ER doctor glut to pad its bottom line, that hasn’t stopped it from resorting to questionable tactics to slash services and pay in the meantime.

For years, contract management groups like APP have used their ability to bill affluent patients at “out of network” rates as a calling card to squeeze extra revenue out of patients and insurance companies, and their private equity overlords exploited this calling card by financing the vast majority of their small practice buyout sprees with junk debt. But since various laws began to chip away at surprise billing in late 2020, these staffing firms have been left deeply indebted, and bordering on insolvent.

APP is probably among the least overleveraged companies in the private equity ER business right now — and still the company has struggled to refinance its half-billion dollar debt load. In response, several employees say APP is taking its financial woes out on doctors and using surprise billing legislation as an excuse to enact deep cuts.

A doctor whose practice was acquired by APP in 2019 says the company has repeatedly made contradictory statements about revenue in what the doctor perceived as an attempt to force through gratuitous wage and staffing cuts. “They’re using the legislation to mask their own looting,” the doctor says, who asked to remain anonymous for fear of retaliation.

Like most doctors working full-time for private equity-backed ER contractors, APP’s physician pay is calculated using a complex formula that theoretically compensates doctors based on the revenues their ERs generate during their shifts. But even though ER volumes have now fully recovered to pre-pandemic levels, the APP doctor said their pay is still roughly 30 percent lower than it was before 2020.

Similarly, a Texas lawsuit filed against APP by nine physicians in March accuses the company of using its wage formulas as a smokescreen for arbitrarily slashing pay. The lawsuit claimed APP was funneling wages from physicians in a bid “to artificially inflate its books to appeal to investors and avoid insolvency by maintaining cash flow at the direct expense of the doctors.”

While their wages are falling, doctors say these private equity-imposed compensation schemes and staffing cuts are leading them to see more patients than they can handle.

Li of the anti-private equity group TMB said the proliferation of such private equity-imposed pay formulas is another factor pushing doctors in his specialty to consider labor unionization. “Basically, these pay structures create a really toxic workplace culture even when they don’t jeopardize patient safety, where doctors are fighting one another for [high revenue] patients,” said Li, whose popular Facebook group has attracted nearly 4,000 members, mostly physicians. “And I think doctors are sick of being pitted against one another.”

In early May, Li’s Take Medicine Back group hosted a forum with physician union organizer Joe Crane. Nursing unions, Crane pointed out, had not simply achieved higher wages and work-life balance for the profession, but safer staffing ratios in the hospitals in which they organized and even whole states like California. The message had a special resonance, said Li, for ER doctors stuck on the “corporate medicine hamster wheel of doing more work for less pay.”

As Li added, “There are probably regional exceptions to this, but the basic fact is that we wouldn’t have an ‘oversupply’ of ER doctors if ERs were staffed appropriately.”

https://www.levernews.com…

By Rick Timmins
Common Dreams, May 19, 2022

When I became eligible for Medicare I had to make the choice between Traditional Medicare and Medicare Advantage (MA), the version of Medicare run by for-profit insurance companies. At first glance, it was a no-brainer: Compared to Traditional Medicare, MA offered additional coverage such as vision, hearing, and dental, with a cap on out-of-pocket expenses. I took the bait and signed up for MA, but soon discovered this was a big mistake.

A few years passed with no issues, but an old injury progressed to a need for knee replacement surgery. The MA plan required my doctor to submit a request for approval for any referral. I was caught by surprise when the MA plan denied my doctor’s referral to a well-known surgeon, because he was not on their preferred “network”—a decision not based on my health, but on the insurer’s bottom line. I limped along until the end of the year when I switched MA plans to one that covered my chosen surgeon. The fact that a for-profit insurance company could overrule my doctor’s recommendation and my own medical choices was a warning sign that there was a problem with my Medicare choice. And things only got worse.

A couple years later, a small lump on my ear that had been diagnosed previously as benign began to grow and became painful. My primary care provider was concerned about a melanoma, so he quickly submitted a request to refer me to a dermatologist that had been strongly recommended and was in the MA plan’s network. Knowing that early diagnosis and immediate treatment is key to managing melanomas, I became worried when the insurance company hadn’t responded within a couple of weeks.

I called the insurance company and was told that there was no record of this request for authorization. My doctor re-submitted the request. Over the next five months, I made multiple phone calls to the MA insurer, and my doctor again re-submitted the request.

Meanwhile, the lump grew larger and more painful, and I was getting very stressed.

Finally, a customer service representative admitted that the insurer had subcontracted the prior authorization process to another company, and somehow lost the request in the shuffle. This was not very reassuring and I was very anxious.

Nine months after the original request was submitted, I am now recovering from a surgery to remove a malignant melanoma and to search for possible metastases in local lymph nodes. Because of the size and aggressive nature of the tumor, I am being assessed for immunotherapy. If I had been on Traditional Medicare, I could have made the appointment directly with the dermatologist when the symptoms first occurred. I could have potentially avoided major surgery, immunotherapy, and the stress of uncertainty .

I am not alone in this situation. Every day millions of other seniors and adults with disabilities experience denials and delays in needed medical care because MA insurance companies put profits before patients. In a survey by the American Medical Association, a majority of doctors said that prior authorization prolongs illnesses and worsens outcomes for patients. An investigation by the Department of Health and Human Services found that MA plans were inappropriately denying care for patients that would have been approved under Traditional Medicare.

Despite undeniable evidence that Wall Street middlemen drive up costs and deny care, the Center for Medicare and Medicaid Services has begun to move Traditional Medicare beneficiaries into a program called Direct Contracting, now rebranded as “ACO REACH,” which inserts profit-driven middlemen between seniors and their health care. Even worse, seniors who chose Traditional Medicare are being automatically enrolled into this program, without their knowledge or consent.

Direct Contracting/REACH may not be the same as Medicare Advantage, but it’s also sure not the same as Traditional Medicare. At least not when you follow the money. Profits that go into the pockets of investment firms and insurance companies come from taxpayers, and threaten to shrink the Medicare Trust Fund.

We can end Medicare Direct Contracting and REACH, but we need everyone to join in. On Monday, May 23, we’re launching a powerful national movement of seniors, doctors, nurses,  and community leaders who are ready to fight back against Medicare profiteering. At our “Turning up the Heat on Medicare Direct Contracting and REACH” event, you’ll hear from seniors like me and also from Congressional leaders such as Reps. Pramila Jayapal and Katie Porter. The event is free and open to all, but you must register in advance HERE.

I learned the hard way. If Wall Street firms are allowed to make decisions about your health care, their profits will always come first. Help me make sure that Medicare puts patients over profits, and join me on May 23.

Rick Timmins is a retired veterinarian who has been in private practice in Oregon, worked in the pet food industry and taught at the School of Veterinary Medicine in Davis, CA, and at Carroll College in Helena, MT. He is active in the Puget Sound Advocates for Retirement Action, which works across generations for social justice, economic security, dignity, and a healthy planet.

https://www.commondreams.org…