May 1, 2022

President Biden’s recently proposed “Cancer Moonshot” has gynecologic oncologist and PNHP national board member Dr. Diljeet Singh thinking even bigger.

By passing improved Medicare for All, focusing on preventions and treatments that we know work, and directing research dollars based on medical need, Dr. Singh estimates that we could achieve the moonshot’s 25-year goal of reducing cancer death rates by 50 percent in only 10 years…and go much further in the long-term.

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

https://medicareforallexplained.podbean.com

By Ryan Cooper
The American Prospect, April 29, 2022

If you’ve ever watched cable news, where the average viewer is in their late sixties, you’ve probably seen an advertisement for a Medicare Advantage plan. They usually star some washed-up celebrity whose career peaked right around when today’s retirees were young adults (think Jimmy Walker or Joe Namath). And they always make a lot of big promises about how great Medicare Advantage coverage is.

There’s just one problem: The sales pitch is an abject lie. Medicare Advantage is much worse than traditional Medicare for people on the program and costs a great deal more to boot. But unless the Biden administration changes course, private companies will soon devour the rest of the program.

Medicare Advantage plans are typically a combination of “Medigap” plans, which cover services not included in the government plan like vision and dental, plus a privatized version of traditional Medicare. About 28 million American seniors are now on Advantage plans, or about 40 percent of the whole program. As Barbara Caress explains in the Prospect, it was set up back in the late 1990s as a way for those wonderful private insurance companies we all know and love to work their free-market magic on one corner of the system America carved out as publicly run. Once we got business involved, surely the quality of coverage would improve and costs would go down, right?

The problem with this logic, as people realized even back in the glory days of neoliberalism, is that there are a lot of perverse financial incentives in health insurance, particularly when it comes to seniors. Half the reason the government set up Medicare in the first place was that as people reach the end of life, they tend to become sick and require more treatment than they can personally afford. In the pre-Medicare days, private companies did all they could to keep them off the insurance rolls.

Introducing the profit motive into Medicare has led to considerable hoop-jumping just to prevent such cravenness. For instance, if the government were to calculate the average per-person cost of Medicare and pay private companies that much per enrollee, companies would scramble to snap up all the younger, healthier seniors with relatively few problems, and cream off some easy profits. As Matt Bruenig explains, that’s why the Centers for Medicare & Medicaid Services maintains a gigantic database of every single one of the roughly 64 million Medicare enrollees, and assigns them all a risk score based on their demographic and health characteristics. Advantage companies then get paid, in theory at least, according to how sick their risk pools are.

That is just one of scores of rules and regulations the government puts out to try to make these private companies behave. It’s a hugely expensive and difficult undertaking, and it turns out that it basically doesn’t work. The results have been exactly the opposite of free-market nostrums: worse coverage that costs more.

One rip-off strategy insurers use is improperly denying claims. A recent investigation from the Department of Health and Human Services inspector general found that companies improperly denied 13 percent of prior authorization requests, and refused to pay 18 percent of legitimate claims—or about 85,000 requests and 1.5 million payments, just in 2019. Paying lots of claims adjusters to fake up reasons to deny necessary treatment is a big reason why Advantage companies spend nearly 14 percent of their money on administration, as compared to traditional Medicare’s 2 percent.

Another strategy is rigging the risk pool. Advantage companies are notorious for pushing doctors to “upcode” as many diagnoses onto their patients as possible, thus increasing their risk score and payment, without having to pay for more treatment. That tactic alone cost the government $9 billion in 2019.

All this (plus a bunch of other complicated scams) means that Advantage enrollees receive something like 10 to 25 percent less in health care spending, but the program costs the government about 3 percent more per person than traditional Medicare. This absurd situation is actually getting worse. One recent study found that Advantage plans cost the government $106 billion in overspending from 2010 to 2019, and nearly a third of that came in just the last two years. The price tag is predicted to balloon to $600 billion over the next nine years.

One would think that the Biden administration would be looking to reverse course, but it isn’t. On the contrary, as Caress notes, it has so far proceeded with a Trump-era plan to privatize the remaining shreds of Medicare by letting private companies serve as payment middlemen through something the Trump team called “direct contracting.”

After an outcry from progressives, the administration altered the privatization plan, mainly changing the name (it’s now called ACO REACH), with the supposed goal of achieving “equitable outcomes.” But as Diane Archer explains at Social Security Works, at bottom it’s still the same idea, with a lot of obvious loopholes for quick profits by denying care, pushing more people into Advantage plans, gaming risk scores, and so on. Unless Biden changes his mind, America is going to let a bunch more foxes into the Medicare henhouse, including private equity firms, and half-heartedly try to limit the damage to the taxpayer with a bunch of ultra-complicated regulations of the type that are failing right before our eyes.

Medicare was a decent initial sketch of a health care system when it was set up back in the 1960s, but it had many bad design elements and left much out. Instead of fixing the problems directly, policymakers have attempted to either coax private companies to do it for them over and over, or simply give out corrupt handouts to their business cronies. The result has been worse coverage and skyrocketing spending that inflated up a huge industry of ruthless corporate parasites. Now those same companies have dragon hoards of government cash to spend on advertising to trick trusting retirees and lobby Congress.

In a sense, the free-marketeers of the 1990s were right to be skeptical of the government’s regulatory capacity. As we have seen, it has been consistently defeated by health care interests in its attempts to prevent profiteering. But that is all the more reason not to burden it with the most complicated health care regulations in the world. Big and simple is what the American state does best. An upgraded, streamlined Medicare that kicked out all the private companies, covered every type of medicine, and enrolled all Americans from birth would fit the bill nicely.

https://prospect.org…

All Sides with Ann Fisher, WOSU, April 29, 2022

Single-payer healthcare is a type of universal healthcare in which the costs of essential healthcare for all residents are covered by a single public system. The results of a 2020 Pew Research Study show there’s an increase in people saying health insurance should be provided by a single, national program.

The American Medical Association (A.M.A.) has long been an opponent of progressive health care reform, however, a younger generation of doctors are advocating for universal health care coverage.

We’ll look at whether single-payer health care is possible in the U.S.

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Guests:

• Dr. Clifford Marks, Emergency-medicine resident, Mount Sinai Hospital, New York
• Dr. Johnathan Ross, past president, Physicians for a National Health Program, associate clinical professor of medicine University of Toledo
• Robert E. Moffit, senior fellow Domestic Policy Studies, The Heritage Foundation

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https://news.wosu.org…

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…