PNHP

Achieving Racial and Ethnic Equity in US Health Care

Achieving Racial and Ethnic Equity in US Health Care

Summary: The Commonwealth Fund just released an important national and state-by-state review of inequities in health care. The findings are unsurprising and distressing – higher rates of access barriers and mortality from treatable conditions among people of color, and marked variation by state. If only there were a way to pay for health care to efficiently eliminate these inequities…

Achieving Racial and Ethnic Equity in U.S. Health Care: A Scorecard of State Performance, The Commonwealth Fund, November 18, 2021, by David C. Radley, et al

Black and American Indian/Alaska Native (AIAN) people live fewer years, on average, than white people. They are also more likely to die from treatable conditions; more likely to die during or after pregnancy and to suffer serious pregnancy-related complications; and more likely to lose children in infancy.

People’s health also varies markedly across and within states, as does access to health services and overall quality of care. Large racial and ethnic health inequities, driven by factors both inside and outside the health care delivery system, are common.

Issues around cost, affordability, and access to care also contribute to inequities. Black, Latinx/Hispanic, and AIAN populations are less likely to have health insurance, more likely to face cost-related barriers to getting care, and more likely to incur medical debt.

Decades of policy choices made by federal, state, and local leaders have led to structural economic suppression, unequal educational access, and residential segregation, all of which have contributed in their own ways to worse health outcomes for many people of color. The failure to ensure all Americans have reliable health coverage has paved the way to inequitable access to health care.

From Conclusion: Too often in the U.S., race and ethnicity are correlated with access to health care, quality of care, health outcomes, and overall well-being. This is a legacy of structural, institutional, and individual racism that predated the country’s founding and that has persisted to the present day, in large part through federal and state policy. By pursuing new policies that center racial and ethnic equity, expand access to high-quality, affordable care, and bolster the primary care workforce, we as a nation can ensure that the health care system fulfills its mission to serve all Americans.

Comment:

By Don McCanne, M.D.

Achieving racial and ethnic equity has been a goal for as long as I can remember, and after 80 plus years of my life, one devoted to health care, it still hasn’t been achieved, as this Commonwealth Fund report reveals.

Just think about what one public policy could accomplish: establishing an equitable, single payer, improved Medicare for All program. Yes, there would still be perpetual details to attend to, but just think of the gains we would make by taking that first step, making the rest of the gains semi-automatic once the principle of equity is established. Isn’t now the time to finally make that move?

http://healthjusticemonitor.org…

Thanks Giving

Summary: In recognition of this week’s US holiday, today’s post offers heartfelt thanks. First, for a terrific documentary film. Second, to all the groups contributing to the pursuit of single payer health care justice. All best wishes for the day.

Sex, Drugs, & Bicycles, 2020, directed by Jonathan Blank

Award-winning documentary about the Netherlands that exposes the nightmare [not!] of paid vacations, universal healthcare & windmills [among other attractions].

Film’s perspective on US healthcare: “I recently bought secondary health insurance to cover the depression and anxiety caused by my primary insurance.”

Comment:

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

Huge thanks (and kudos!) to the director and production team for this amazing film, which I watched recently with my wife. Captivating live footage, informative and entertaining narration and interviews, fabulous graphics often reminiscent of Monty Python, and stellar original music. And a powerful message: a country (the Netherlands) can combine democracy, progressive personal freedoms, and well-designed social programs to yield economic well-being, excellent health, and happiness. Comprehensive universal healthcare is central. We in the US need to keep absorbing success stories like this to further inspire our progressive change agenda.

Great holiday viewing with your family. You might even do a singalong with this blockbuster “I Love Healthcare”.

Now I’d like to riff on this week’s holiday theme, offering my gratitude to allies in the progressive health reform movement. My “thanks giving” is for:

  • Elected officials in DC and the states who lead the legislative charge for single payer.
  • Progressive lobbyists and activists who work with the elected officials and staff.
  • Healthcare provider groups pushing for single payer.
  • Prominent media voices beating the single payer drum.
  • Pollsters who document the broad public support for government-paid health care.
  • Community organizations that channel and organize public support.
  • >30 wealthy nations which demonstrate daily the elegance of “health care for all.”
  • Policy researchers who quantify the health and financial advantages of single payer.
  • Journalists who distill powerful stories and truth from the blizzard of daily events.
  • Colleagues in HJM, for their principled and incisive tracking of health justice issues.
  • Family members and colleagues who offer ongoing encouragement in this quest.
  • Finally, YOU, the readers of HJM, who join us in the fight for single payer.

(Hope I haven’t missed any groups. Please excuse my not listing individuals … we’ll save that for the official single payer history!)

http://healthjusticemonitor.org…

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

Isn’t that what insurance is for?

By Rick Staggenborg, M.D.
Albany (Oregon) Democrat-Herald, Letters, November 23, 2021

As ads everywhere proclaim, it’s Medicare shopping season again!

If you’re shopping, remember that savvy buyers know if a deal seems too good to be true, it probably is. Don’t be tempted by offers of insurance with no out-of-pocket costs, no need for supplementary policies, and expanded coverage, all for the minor inconvenience of having a restricted network of providers instead of having the choice to see any Medicare provider.

What’s not to like? As usual, the devil’s in the details. Ever heard of surprise billing? That’s when you think you’re covered when you go to the hospital, only to find that one or more of the doctors doesn’t accept your insurance.

Similarly, if you have to see specialists for certain conditions and they’re not on the preferred provider list, you pay most or all of the bill. And don’t be surprised if you have to travel great distances to see your doctor and pay for medications that aren’t in the formulary of the drug benefit plan included in the policy.

How else do you think insurance companies make record profits from the unwary who choose Medicare Advantage over traditional Medicare, with a Medigap supplement? It’s all part of the stealth privatization of Medicare, designed to turn Medicare into a cash cow for insurance industry investors.

The wise shopper will choose traditional Medicare over the too-good-to-be-true Medicare “Advantage,” just in case they might actually need to use it for a costly condition. After all, isn’t that what insurance is for?

Dr. Rick Staggenborg is a member of Health Care for All Oregon.

https://democratherald.com…

Doctors to Biden: Don’t hand Medicare to Wall Street investors

Physicians demand an end to the Medicare Direct Contracting program, a Trump-era plan that will enroll millions of Traditional Medicare beneficiaries into for-profit managed care entities, without their knowledge or consent

FOR IMMEDIATE RELEASE: Nov. 30, 2021

Recording of today’s event:

Contact: Clare Fauke, Physicians for a National Health Program communications specialist: clare@pnhp.org

Today a group of physicians from across the U.S. gathered outside the headquarters of the Dept. of Health and Human Services (HHS) to deliver a petition demanding an immediate end to Medicare Direct Contracting (DC), a program launched in the final months of the Trump administration that could fully privatize Traditional fee-for-service Medicare in the next few years, without a vote by Congress. 

DC is a pilot program that aims to enroll every Traditional Medicare beneficiary into a third-party “Direct Contracting Entity” (DCE), often without seniors’ knowledge or consent. Instead of paying doctors and hospitals directly for care, Medicare gives DCEs a monthly capitation payment to cover a defined portion of each seniors’ medical expenses, allowing DCEs to keep as profit and overhead (up to 40% of revenues) what they don’t pay for in medical services — establishing a dangerous incentive for DCEs to restrict seniors’ care.

Virtually any type of company can apply to be a DCE, including commercial insurers, venture capital investors, and for-profit dialysis chains. Applicants are approved by CMS without oversight from Congress. The DC “pilot phase” includes 53 DCEs in 38 states, potentially covering 30 million Traditional Medicare beneficiaries. 

“Medicare Advantage — the first wave of Medicare privatization — showed us that inserting a profit-seeking middleman into public coverage does not save money for taxpayers, but rather costs more money while also taking away care choices from seniors,” said Dr. Ana Malinow, a physician from San Francisco who traveled to Washington to deliver the petition. “If left unchecked, the Direct Contracting program will hand Traditional Medicare off to Wall Street investors, without input from seniors, doctors, or even members of Congress. Health and Human Services Sec. Xavier Becerra has the power to stop this Trump-era program in its tracks, and must do so now.”

More information on Medicare Direct Contracting:

  • Direct Contracting one-page fact sheet
  • Direct Contracting policy primer (4 pages)
  • Form sent to seniors in Indiana University Hospital System requesting voluntary alignment to a DCE
  • Article about Direct Contracting in Health Affairs journal by former CMS Administrator Dr. Don Berwick and former CMS Innovation Center director Dr. Rick Gilfillan: PART ONE and PART TWO
  • List of current DCEs 
  • CONTRACT between CMS and Direct Contracting Entities 
  • Direct Contracting Entities’ Financial Operating GUIDE from CMS

Physicians for a National Health Program (pnhp.org) is a nonprofit research and education organization whose more than 24,000 members support single-payer Medicare for All reform.

Charity Doesn’t Fill the Health Care Void

Summary: St. Jude Children’s Hospital in Memphis TN promises not to bill families for medical care. And they don’t. But parents travel long distances to get this free care, incurring new living expenses and losing job income. Even as St. Jude amasses huge reserves from highly effective charitable fund-raising. With single payer, everyone could get needed care, usually locally. Isn’t that more charitable?

St. Jude Hoards Billions While Many of Its Families Drain Their Savings, ProPublica, November 12, 2010, by David Armstrong and Ryan Gabrielson

St. Jude Children’s Research Hospital promises not to bill families. But the cost of having a child at the hospital for cancer care leaves some families so strapped for money that parents share tips on spending nights in the parking lot.

St. Jude is the largest and most highly regarded health care charity in the country. Each year, the Memphis hospital’s fundraisers send out hundreds of millions of letters, many with heart-wrenching photographs of children left bald from battling cancer.

Last year, St. Jude raised a record $2 billion. U.S. News & World Report ranked it the country’s 10th-best children’s cancer hospital, and St. Jude raised roughly as much as the nine hospitals ahead of it put together. It currently has $5.2 billion in reserves, a sum large enough to run the institution at current levels for the next four and a half years without a single additional donation.

But for many families, treatment at St. Jude does not relieve all the financial burdens they incur in getting care for their children, including housing, travel and food costs that fall outside the hospital’s strict limits, a ProPublica investigation has found.

While families may not receive a bill from St. Jude, the hospital doesn’t cover what’s usually the biggest source of financial stress associated with childhood cancer: the loss of income as parents quit or take leave from jobs to be with their child during treatment. For many families, the consequence is missed payments for cars, utilities and cellphones. Others face eviction or foreclosure because they can’t keep up with rent and mortgage payments.

A substantial portion of the cost for treatment is paid not by St. Jude but by families’ private insurance or by Medicaid, the government insurance program for low-income families. About 90% of patients are insured, bringing in more than $100 million in reimbursements for treatment a year.

Parents at St. Jude have exhausted savings and retirement accounts, borrowed from family and friends or asked other charities for aid.

Comment:

By Don McCanne, M.D.

Although the United States has a very well-funded health care system, its financing is highly dysfunctional. Too many are left either partially or completely out of the system. This is particularly tragic when a child with cancer is left uncovered, but at least some of us have charitable instincts. This accounts for the success of the nation’s most comprehensively funded children’s cancer hospital: St. Jude.

This is the best we have to offer those of limited means. But, based on this comprehensive report by ProPublica, it is still clearly insufficient, leaving many families destitute. Rather than relying on charity, wouldn’t it be better for the nation to join together and restructure our health care financing system so that it works for all of us, where we live? We certainly have enough funds. We merely need to establish an equitable, single payer, Medicare for All system.

Google “Charity.” The first item that comes up is St. Jude. With no increase in our current national spending, the first item that could come up in our hearts might be “a single payer national health program that covers everyone.” Wouldn’t that be much more effective in fulfilling our charitable aspirations?

http://healthjusticemonitor.org…

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

Inside the Medicare Advantage plans, many now being probed

By Stephen Kemble, M.D.
Honolulu Star-Advertiser, “Island Voices,” November 21, 2021

This is open enrollment season for Medicare Advantage (MA) plans, and the public is being inundated with celebrity TV ads promising expanded benefits and low or no premiums and urging viewers to choose a Medicare Advantage plan now, with no mention of the option of traditional Medicare plus a “Medigap” supplement plan. So, what is Medicare Advantage and how does it work?

Medicare Advantage is a privatized form of Medicare. Instead of Medicare paying doctors and hospitals directly, it pays an insurance company intermediary a fixed amount per member and the insurance plan negotiates payment rates with providers of care. Unlike regular Medicare, MA plans are managed care plans and often use restricted networks of doctors and hospitals and they can impose prior authorizations and formulary restrictions.

So how can they offer expanded benefits and low or free premiums? They market to the healthy with gym memberships and other perks, and they often restrict their formularies and physician networks to discourage patients with expensive conditions from joining or staying in the plan. This is called “cherry-picking” and “lemon dropping,” and it is a consequence of per-member pre-payment with the opportunity to profit or lose if less or more is spent on health care than the capitated amount. The strongest determinant of financial success is securing a favorable risk pool of healthier than average subscribers.

Medicare added risk adjustment, which is intended to pay more for sicker, “higher risk” members so as not to discourage covering sicker people. The initial formula was based on demographics such as age, sex, and income, but it only predicted about 2% of the variability in cost and failed to deter “cherry-picking.”

In 2004, Medicare added diagnoses to their risk adjustment formula, and this improved its accuracy from 2% to 12% of cost variability. This is still way too inaccurate to discourage cherry- picking, and it introduces a great new way for MA plans to game payment — upcoding!

The MA plans soon discovered that by persuading their network doctors to give patients the most severe diagnoses they possibly could, they could rake in a lot more money. If a patient is diagnosed with diabetes, obesity, and mild heart failure, Medicare might pay the MA plan $9,000 per year, but if the
diagnoses are changed to “morbid obesity,” “diabetes with retinopathy,” “chronic obstructive pulmonary disease,” and a “stage 3 ulcer,” their payment jumps to $32,000 per year.

The MA plans soon deployed representatives to patient homes and doctors’ offices looking for any justification they can find to inflate diagnoses. Some have resorted to using hints in the patient’s record to add diagnoses that were never given by a doctor. Even worse, if a patient leaves a MA plan to go back to regular Medicare and tries to buy a “Medigap” supplement, the Medigap plan can hold their inflated diagnoses against them and charge them more, even if the diagnoses are not real.

Recent business news articles have reported multiple whistleblower complaints by employees against MA plans for fraudulent upcoding, and DOJ is now investigating MA plans run by Kaiser, Cigna, Anthem, United Health Group, Sutter, Humana and Aetna for widespread Medicare fraud, to the tune of $30 billion per year at the expense of the Medicare Trust Fund.

A healthy risk pool does not cost the plan too much to insure, and the MA plan can report favorable “quality” measures because healthier people have better outcomes. They can then easily afford gym memberships and extra benefits and low premiums and still make huge profits by billing Medicare for inflated diagnoses.

https://www.staradvertiser.com…

Working Families and Businesses Need Medicare for All Now

Summary: Job-based health insurance premiums increased twice as fast as inflation over the past year, despite 2020 being a year of very low medical payouts and very high profits for insurers. Both employees and employers continue to struggle with the current work-based system. It’s time to separate insurance from the workplace.

2021 Employer Health Benefits Survey, Kaiser Family Foundation, November 11, 2021

In 2021, the average annual premiums for employer-sponsored health insurance are $7,739 for single coverage and $22,221 for family coverage. The average single and family premiums increased 4% over the past year. During this period, workers’ wages increased 5% and inflation increased 1.9%.

The average premium for family coverage has increased 22% over the last five years and 47% over the last ten years. …

Most covered workers make a contribution toward the cost of the premium for their coverage. On average, covered workers contribute 17% of the premium for single coverage and 28% of the premium for family coverage. Covered workers in small firms on average contribute a higher percentage of the premium for family coverage than covered workers in large firms (24% vs. 37%). Covered workers in firms with a relatively large share of lower-wage workers have higher average contribution rates for family coverage than those in firms with a smaller share of lower-wage workers (35% vs. 27%).

http://healthjusticemonitor.org…

Comment:

By Eagan Kemp

Every year we see the cost of insurance go up for working families and businesses of all sizes. The most recent increases highlight that even after a year where many insurers were able to avoid major health costs because many people were forced to put off elective care, insurers are still massively raising rates.

With more than 155 million Americans at the whim of employer-sponsored insurance, it is no wonder people are fed up with the current system and demanding Medicare for All. Seeing more and more of your paycheck eaten up by the cost of health care is depressing enough, without knowing that it is primarily lining the pockets of corporate CEOs making tens of millions of dollars a year while denying Americans the care that they need.

And as the recent fight of Biden’s Build Back Better Act showed, corporations are more than willing to throw around cash to stop reforms that would make it cheaper and easier for people to get the care they need.

These growing costs aren’t hurting just families, they are making it harder for businesses that are already struggling with the losses sustained due to the COVID-19 pandemic, a key reason more business leaders are banding together to fight for Medicare for All.

The only people that want to keep the status quo are those that are profiting from it. It is time to put people over profit by making Medicare for All the law of the land.

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

Aducanumab as a Lens on U.S. Health Care

Summary: The June 2021 FDA approval of Aducanumab for Alzheimer’s, despite absent evidence of clinical benefit, and now a sharp increase in Medicare Part B premiums, reflects much of what’s wrong with our healthcare system: huge profits enabled by flawed medical care policies and extortionate prices, racism in clinical trial design, and financing burdens transferred to those who can least afford them.

‘Reckless’ FDA and Big Pharma Greed Blamed for Medicare Premium Hike, Common Dreams, November 16, 2021, by Jake Johnson

Medicare Part B recipients will soon be hit with one of the biggest premium increases in the history of the government program, a hike driven in large part by the Food and Drug Administration’s scandalous approval of a costly—and, according to many experts, dubious—Alzheimer’s drug.

“Medicare’s inability to negotiate lower drug prices means that Big Pharma companies can charge whatever they want.” Last week, the Centers for Medicare and Medicaid Services (CMS) announced that monthly Medicare Part B premiums will be raised to $170.10 in 2022, up from this year’s level of $148.50.

While CMS officials cited several factors in their explanation of the premium boost—including costs imposed by the coronavirus pandemic—they attributed roughly half of the increase to “additional contingency reserves due to the uncertainty regarding the potential use of the Alzheimer’s drug, Aduhelm™ (aducanumab), by people with Medicare.”

Medicare is currently in the process of deciding whether to cover the drug, which is priced at a staggering $56,000 per year.

A June analysis by the Kaiser Family Foundation estimated that if 500,000 Medicare recipients are prescribed Aduhelm, total spending on the drug in a single year would be close to $29 billion—”an amount that far exceeds spending on any other drug covered under Medicare Part B or Part D, based on 2019 spending.” …

The FDA’s accelerated approval of aducanumab sparked outrage among public health experts and prompted the resignations of several agency advisers, who said there was not enough evidence showing the drug actually works to slow Alzheimer’s-induced cognitive decline.

On top of concerns about the treatment’s lack of effectiveness as well as potentially unlawful coordination between the FDA and manufacturer Biogen throughout the approval process, advocacy groups warned the decision to greenlight the exorbitantly priced drug “threatens to bankrupt the Medicare program.”

Dr. Michael Carome, director of Public Citizen’s Health Research Group [said] “To protect the many Medicare beneficiaries who cannot afford the unacceptable 15% jump in Part B premiums, CMS must promptly announce that it will exclude aducanumab from coverage under the Medicare program until there is definitive evidence that the drug provides substantial evidence of cognitive benefit to Alzheimer’s disease patients.”

F.D.A. Approves Alzheimer’s Drug Despite Fierce Debate Over Whether It Works, New York Times, June 7, 2021, by Pam Belluck and Rebecca Robbins

Aducanumab, or Aduhelm, is the first new Alzheimer’s treatment in 18 years and the first to attack the disease process. But some experts say there’s not enough evidence it can address cognitive symptoms.

Nothing is right about the approval of aducanumab—and nothing’s new, The BMJ Opinion, November 4, 2021, by Nancy Olivieri

[ More on the science and on flawed FDA regulatory history ]

What the Aducanumab Approval Reveals About Alzheimer Disease Research, JAMA Neurol, October 4, 2021, by Jennifer Manly and Maria Glymour

FDA approval was based on trials that were not inclusive of the people who bear a disproportionate burden of disease. Only 0.6% of participants (ie, 19 individuals) identified as Black … Older Black adults are estimated to have AD incidence up to double the rates in older White people. Despite this, Biogen reported that only 6 Black people were randomized to the treatment dose approved by the FDA.

Instead of wasting money on aducanumab, pay for programs proven to help people living with dementia, J American Geriatrics Society, August 2021, by Lauren Hunt et al.

[W]e are heartbroken at the opportunity cost that may result from spending of limited resources on aducanumab versus the many ways we could help PLWD [persons living with dementia] … we expand on several specific approaches that we believe could have the highest yield in improving care for PLWD and their caregivers. Home-based Personal Care … Comprehensive Dementia Care … Community-Based Palliative Care.

Comment:

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

Here’s how health policy is supposed to function, IMHO: new interventions are demonstrated effective in relevant populations, and then added to the healthcare toolkit, with all efforts made to assure affordability for patients and the system.

Here’s what happened with aducanumab: the intervention doesn’t work (according to clinical trials), it wasn’t tested in high risk black populations, and it was approved by the FDA anyway, with undue manufacturer influence. The Medicare program is not permitted to negotiate prices, so the drug is sold at a massive price per patient per year (enriching the manufacturer Biogen), and the cost is passed along to Medicare enrollees, coming out of their social security income. Programs for PLWD that are known to work remain unfunded.

Note – these big price boosts are for traditional Medicare, thus enhancing the marketing position of private Medicare Advantage plans. The CMS officials in the thrall of private insurers didn’t mind that a bit, no doubt.

Under single payer, aducanumab would be reimbursed only once shown effective, and only once the price was negotiated down to an affordable level. Meantime, proven community programs would be funded.

http://healthjusticemonitor.org…

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

We Cringe When Hospital “CMO” Means “Chief Marketing Officer”

Summary: Big academic hospitals like Harvard’s Mass General Brigham now mount huge marketing efforts, similar to those of consumer products corporations. The message is clear: big academic hospitals are big business. Many health care providers wince.

Mark Bohen, Chief Marketing Officer, Hired September 2020, Mass General Brigham, Website accessed Nov 15, 2021

Mark Bohen, MBA is the Chief Marketing Officer for Mass General Brigham. He is responsible for building and leading a world class marketing and communications organization and ensuring that people in the nation and around the globe know about the world class research, clinical care, innovations and education taking place throughout the Mass General Brigham system. Mark is also bringing classical marketing principles, science, and discipline to the organization. In addition, Mark is leading all marketing and communication functions, including brand management, data analytics, consumer research and insights, digital/social, service line and hospital marketing, marketing strategy, and internal and external system-wide communications.

Prior to joining Mass General Brigham in September 2020, Mark spent the previous four years at Beaumont Health, the largest health system in Michigan, where he led all marketing and communications strategies and tactics. While at Beaumont, Mark built and developed new marketing capabilities for better patient outreach while also focused on continued enhancement of Beaumont’s reputation and position in the state’s competitive health care marketplace. He also brought together three legacy marketing and communication departments and created system capabilities and roles that offered his team exciting growth opportunities. Mark led brand management at Beaumont after the merger of three health systems and built a new brand architecture. He has partnered with hospital, physician, and service line leaders to create marketing plans that drive growth.

Previously, Mark was the Senior Vice President of Marketing and Innovation at Assurant, Inc., and he spent more than ten years in the consumer-packaged goods industry, including time at Nabisco where he worked on some of the world’s best-known brands like Oreos and Ritz crackers. Mark earned his BS degree in Marketing from Syracuse University and his MBA from Duke University.

Comment:

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

Partners Health Care, the amalgamation of Boston’s Massachusetts General and Brigham and Women’s Hospitals – “non-profits” that are major teaching hospitals for Harvard Medical School – recently spent $100 million rebranding itself as “Mass General Brigham”.  Meanwhile, in the past 9 months the system’s two banner hospitals had “surpluses” (AKA profits) of $223 million (Brigham) and $147 million (Mass General).

We doubt that the hospitals’ patients or communities would see rebranding or marketing as priorities. But this otherwise grim story has a humorous twist. Toward the end of the CMO’s bio we learn of his previous experience marketing Ritz Crackers and Oreos.

http://healthjusticemonitor.org…

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

Medicare for All Explained Podcast: Episode 67

Interview with Dr. Judith Albert

November 15, 2021

PNHP national board member Dr. Judith Albert reminds us that health is lifelong concern for patients…which is why health coverage needs to be lifelong for everybody, with no gaps and no barriers that prevent people from seeking care.

“You can’t set a stop time for when you deserve to have health care and when you don’t.”

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

https://medicareforallexplained.podbean.com

Veterans Health Administration Under Attack

Summary: Veterans Day weekend is the perfect moment to contemplate actions from Washington that threaten the Veterans Health Administration, one of the finest elements of the US healthcare system. The VHA is government single payer, providing very high access to and quality of care. Or was until recent aggressive privatization started to undermine it. The VHA must be saved. Our veterans deserve nothing less.

Broken promises: Veteran health care is being replaced by the private sector, The Hill, November 5, 2021, by Russell B. Lemle and Suzanne Gordon

In 2018, Congress passed then-President Trump’s signature veterans’ legislation, the VA MISSION Act, which was designed to shift many more patients from the Veterans Health Administration (VHA) to the private sector through a newly formed Veterans Community Care Program (VCCP). Lawmakers assured wary stakeholders that the VCCP would “supplement, not supplant” the VHA. This law was about options, they were told, not privatization.

Three years on, it’s clear that those were empty promises. VHA services are being rapidly replaced by private-sector care, even as studies continue to confirm that non-VA care generally is of lower quality and higher costs.

A recent study reveals the situation has become dire. Between April 2019 and December 2020, VHA’s total monthly encounters shrank by 25 percent. Over that same period, VCCP continued its non-stop expansion, rising to 34 percent of all care delivered to veterans at taxpayer expense. …

The hollowing out of the VHA is a direct result of MISSION Act provisions that were then exploited by the Trump administration in developing eligibility regulations for private sector care. When the VCCP was implemented in 2019, one-third of all veteran patients suddenly became automatically eligible for non-VA care if driving to a VHA facility takes more than a half-hour. A referral is offered even if a VHA clinic/hospital is geographically closer than a non-VA one, which is often the case.

Although wait times in the VHA are typically shorter than those in the private sector, regulations nonetheless cause massive numbers of veterans to be sent to the private sector if the VHA cannot schedule an appointment within 20 or 28 days. … Once in the VCCP, which has no wait time requirement, veterans often languish for months to be seen.

VHA Caregivers Provide Privatization Reality Check, The American Prospect, September 30, 2021, by Suzanne Gordon

[J]ust as MISSION Act critics predicted, using private-sector contractors is no guarantee that veterans will get equivalent or better care in more timely fashion.

Two small but important surveys of well-informed VHA caregivers, along with interviews conducted by the Prospect itself, confirm that “community care” is neither quicker nor subject to effective federal oversight, despite its ballooning cost to the VHA. …

While some veterans haven’t experienced long delays to see a private-sector provider, most are waiting between one and four months for mental-health, medical, and surgical appointments, according to VHA nurses who answered the NOVA survey. When patients do end up going outside the VHA, nurses often don’t receive required progress reports from private-sector providers. …

Mental-health services are particularly at risk under the CCN. Some observers who have been following VA mental health are concerned by reports that, in some VA medical centers around the country, hundreds of veterans who were referred to private-sector mental-health professionals were waiting for up to three months for just a telehealth appointment. …

One nurse surveyed by NOVA reported that their teams may be spending from 10 to 60 hours a week trying to monitor private-sector care, which means they can’t provide direct care to veterans. In some facilities, one or two mental-health professionals may be shifted from taking care of veterans to chasing down information from private-sector providers.

Comment:

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

The Veterans Health Administration is a fine example of single payer, indeed of a national health service, like in the United Kingdom. It has a long history of high quality of care.

But Washington is eager to privatize, especially aggressively with Trump administration regulation manipulations. As reported by these two recent articles, the rules used to guide veterans to the private sector are irrational and biased. And the result is diverting critical resources – funding and staff time – from VHA clinical capacity. Care is shunted to inferior private sector providers; as we recently reported, clinical outcomes suffer.

There are efforts to protect the VHA. Suzanne Gordon, author of both reported articles today and Wounds of War: How the VA Delivers Health, Healing, and Hope to the Nation’s Veterans, is a senior analyst at the Veterans Healthcare Policy Institute (VHPI), which provides detailed analysis of legislation affecting VHA and studies the benefits provided by the nation’s largest government-run healthcare system. She also works with Save Our VA Project (SOVA), which issues Calls to Action (CTAs) — letters to Congress and the administration on issues crucial to halting and reversing the privatization of VHA.

In honor of the veterans, support the high quality VHA care.

http://healthjusticemonitor.org…

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

Medicare is on the menu

By Robert S. Kiefner, M.D.
Concord (N.H.) Monitor, November 12, 2021

Since 1965, Medicare has been the foundation of medical care for millions of seniors and those with disabilities in this country. Now, however, it is on the dinner table, being served as an appetizer and main course to ravenous for-profit corporate entities as never before.

Once a relatively straightforward plan, publicly financed and privately delivered care with extremely low overhead, Medicare has become hopelessly complex and impossible to navigate, complements of health insurers, Big Pharma, enabling legislators, think tank “geniuses” and a great multitude of wealthy lobbyists.

For all of its shortcomings, traditional Medicare has provided reasonable security for those in need of patient-centered, comprehensive and affordable healthcare. Indeed, if we had simply followed the lead of other industrialized countries with a comprehensive not-for-profit model, we could have offered truly universal coverage (including all expenses related to inpatient and outpatient care, and complete benefits relating to drug costs, dental, vision, hearing, mental health and even paid family leave) at one half of the per capita costs which we now incur in this country. But a majority of legislators fed the rich and addictive diet of corporate contributions and, entertained by the seductive dance of lobbyists, will not let a publicly funded and not-for-profit program gain traction.

Medicare Advantage is, perhaps, the most blatant for-profit distortion of the traditional Medicare model. With the yearly Medicare enrollment window now being open, we are subject to the hyper-caffeinated cacophony of pitchmen like Joe Namath and J.J. Walker, who we perhaps thought were dead, only to return to after 30 years of irrelevance to grab a few bucks and to entice a clueless audience of Medicare-eligible folks with visions of free dental care, glasses, hearing aids, refund checks, free rides, groceries, the sun, moon and the stars.

Most of the major health insurance companies also hawk their own Medicare Advantage program with advertising dominated by entitled, perky and smart-appearing old people who annoyingly want you to know they’ve found a great deal. Here’s the real deal, though. The federal government seriously overcompensates private insurers offering this bounty of services, counting upon the astigmatism of seniors trying to read the fine print, the unchecked power of big business, and the inability of federal regulators to nail down the true cost of care.

Medicare Advantage plans have a simple business plan, which involves making bigger profits by actually paying for less care, jacking up co-pays, and restricting care to narrow networks of providers.

These plans tend to be very popular until you need them for an expensive illness.

And every fiscal conservative should be outraged by the unregulated flow of taxpayer dollars to private insurers who “control” costs by restricting care and channeling funds into their coffers.

A Wall Street Journal article on Sept. 23 by Anna Wilde Mathews highlighted the findings by the Office of the Inspector General, focusing upon the gaming of the system by the major insurers from 2016-2017.

This systematic deceit is costing taxpayers billions of dollars per year while undermining traditional Medicare.

In many cases, insurers clearly falsified the medical conditions of their clients or upcoded them relative to medical severity in order to gain higher payments to Medicare Advantage plans from the federal government. And because medical expenses may well be greater at the end of life, Medicare Advantage plans are finding ways to encourage the sickest patients to return to traditional Medicare, and thus weasel out of paying for expensive conditions. By exaggerating the severity of beneficiaries’ illnesses, Medicare Advantage plans have been able to surreptitiously increase their charges for the care of those patients, often to the tune of thousands of dollars per year per beneficiary.

According to former CMS Administrator Dr. Don Berwick, the Medicare Payment Advisory Committee (MedPAC) has documented $140 billion in overpayments to Medicare Advantage Plans over the past 12 years, and with risk adjustment overpayments on the rise, up to $355 billion will be overpaid to the plans in the next eight years. Simply put, Medicare Advantage has devised ways of signing up low-cost patients (cherry-picking) while dis-enrolling high-cost patients (lemon dropping) all while misrepresenting the severity of the illness to obtain higher payments. Recently, if you can believe it, we have become aware of an even more insidious threat to your traditional Medicare. In a scheme first floated by the Trump Administration, but still sanctioned by the Biden Administration and the Centers for Medicare Services (CMS), the creation of “Direct Contracting Entities” (DCEs) empowers middlemen (including venture capitalists) to actually manage the care of beneficiaries in traditional Medicare. DCEs will have many of the nasty features of Medicare Advantage Plans relative to the ability to inflate service codes and thereby deceitfully pad their revenues while operating with limited oversight.

Of the 53 DCEs now active in 43 states, 28 are investor-owned, six are insurer based and the rest are provider controlled (physician and hospital). Insurers control the majority of potential patients, some 57% of traditional Medicare fees for service patients.

Here’s the clincher — patients can be enrolled in a DCE without their knowledge or consent! Their doctors may end up participating in a DCE with a tempting 40% increase in provider Medicare reimbursement and a reduction in the need to comply with a set of core quality measures. Once doctors sign up with a DCE, their patients are automatically signed up. Patients may receive a letter, typically incomprehensible and quickly tossed in the trash.

While defending “Medicare for All” over many years, I was often met with the objection that “I don’t want government-controlled health care.” Well, now you will have health care decisions made by corporate types in the luxurious C-suites of health insurance companies or venture capitalists cruising the Bahamas in gigantic yachts who really want to sign you up on their plans, only to throw you overboard if you get too expensive.

Medicare Advantage may actually work well for some seniors for a period of time, before serious illness occurs and before the amassed bills exhaust the Medicare Trust Fund and bring about the collapse of traditional Medicare.

Well-funded lobbying organizations such as the Partnership for America’s Healthcare Future and the Better Medicare Alliance are spending millions of dollars daily to convince those in Congress and their constituents that a bunch of upfront freebies is more important than being able to choose your healthcare provider and to guarantee affordable healthcare in the future.

Before you dial the number for a Medicare Advantage Plan at the urging of a celebrity du jour, start a conversation with your congressional reps, your doctors and your hospital to find out just how fragile your healthcare coverage might be going forward.

Dr. Robert S. Kiefner is a retired family physician. He lives in Concord.

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