Resource – Page 70

Single Payer Overview 2021 & 2022

Summary: The 2021-2022 transition invites contemplation of health reform over the past year and upcoming. We process last year via a perusal of HJM. We offer thoughts on the future. And we solicit comments from you — HJM readers. Email us. We’ll share your musings in early 2022. Meantime, Happy New Year!

Comment:

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

How should we think about the 12 months past and next in the single payer movement? A review of HJM posts since our May launch guided me to key themes from 2021. I provide links to posts and a few other resources in case you want to dig in. Please also read and reflect on what might be in store for 2022. BTW I’m rather fond of alliterative triplets …

2021 – Revelations, Resolve, Resistance

Revelations – What did we learn (or learn again)?

Our system is failing, more clearly than ever: We see it in health, cost, and welfare statistics as well as shocking stories. Lacking insurance is deadly. So is underinsurance: financial barriers such as high deductibles and medication cost-sharing cause deaths, and are rising in ACA plans. Quality of chronic illness care is slipping. Insurance complexity imposes huge care and cost burdens for patients, alongside ever-rising costs for work-based insurance. Medical debt now surpasses all other debts, likely further harming health. Overall, high costs and poor performance: we’ve got nothing to crow about.

The US compares dismally with other wealthy nations: The diverging longevity and cost lines are stunning. Even the US privileged fare worse than average elsewhere, with cross-national mortality differences and racial disparities increasing since 1990. Why? The US underperforms other countries on dozens of health system performance measures, provides worse critical care, charges for medications, and has poor access to mental health care. And although excess mortality drops after age 65, financial barriers are increasing for seniors.

COVID revealed & exacerbated the problems: Millions lost insurance due to layoffs. Among the insured, testing and care costs borne by patients have sometimes been huge, despite promises of protection … even as insurers profited immensely from lower overall care utilization. Pandemic control lags other countries, increasing life expectancy gaps, while vaccine profit margins soar.

Racial disparities in health care are pervasive: There are large racial differences in insurance rates, as well as access and mortality. A universal public program like Medicare lowers disparities. With current insurance patterns, medical debts are more common in Black households. Social stresses exacerbate health differences.

System tweaks accomplish nothing: “Fix the current system” approaches aren’t working. Even a much-hyped Buffett-Bezos-et al work-based insurance scheme bailed. Pay for performance burdens physicians, and its showcase Accountable Care Organizations failed to save money for Medicare. Posting care prices is chaotic and unusable at hospitals and even when patients know prices it doesn’t influence care choices.

A growing profit focus is largely to blame: For-profit ownership of insurers and providers increasingly permeates our system, and even large non-profits focus on financial gain. This produces broad and worrisome distortions of care. Negative consequences are pervasive: providers burn out at higher rates, quality of care suffers, mortality rises. Gaming the rules through aggressive & illegal billing and restructuring businesses shift hundreds of billions from care to investors. This private for-profit threat is massive in Medicare.

Medicare is under attack: Our huge and revered public insurance program is in extremis. Medicare Advantage continues to cost the government more over time in part by skipping out on end-of-life care and imposing financial burdens on sick patients. Reports of excessive and fraudulent billing using risk reporting multiply: cheating, cheating, and cheapness combined with massive overpayment. MA plans suffer from variable mortality rates without disclosure. And now traditional fee-for-service Medicare is profoundly threatened with privatization via Direct Contracting Entities (DCEs), which will import the extractive profit style of Medicare Advantage.

Resolve – How did we demonstrate ongoing broad commitment to single payer?

Counteracting the bad news about our health system are several inspiring nuggets in our battle for single payer.

First, new evidence demonstrated that public insurance works. It provides better access, financial protection, and satisfaction than private insurance. Medicaid improves health and saves money for society. Medicare, as noted above, lessens disparities among US populations over 65 years old and compared with other nations.

Second, public support for single payer remains high. California polls in 2021 indicated >50% – 75% support among voters and key stakeholder groups. Past national polls have been similar.

Third, public discussion about reform retains a robust single payer component. The Healthy California for All Commission, which will report in early 2022, has seen much evidence favoring single payer and has strong commissioner advocates for it. In Washington DC, Rep. Pramila Jayapal (D-WA) submitted the latest single payer bill, HR 1976 The Medicare for All Act of 2021, with a record 118 co-sponsors.

Finally, the Build Back Better Act, now in final negotiations, though it falls far short of single payer, includes provisions that move in the right direction, most notably Medicare drug benefit price negotiations (for a few drugs) and out-of-pocket limits, a hearing benefit, and better ACA exchange subsidies for the poor in non-Medicaid expansion states.

Resistance – Where did we fight back against anti-reform actions?

The huge threat in 2021 was – and remains – the CMS plan to replace traditional fee-for-service Medicare with mainly for-profit corporate DCEs using various financial designs including full capitation. If they can’t oppose “Medicare for All”, they’ll undermine Medicare. This is a complete shift from ACOs used in traditional Medicare, which although they didn’t work, at least focused on provider (non-investor) organizations and didn’t force enrollees to participate in capitation. DCEs started in the Trump administration, with corrupt corporate influence. Under Biden, the worst version (geographic) has been set aside, but CMS is forging ahead with other DCEs. PNHP, JustCare, and other groups are organizing public awareness and opposition.

Another, less immediate but more direct, threat to single payer is “Medicare Advantage for All”. This is a private insurance structure that will undermine the efficiency and generosity of public financing. We push back here.

2022 – Persistence, Pursuit, Partnership

Where do we expect and want to go in 2022? Please email your ideas and suggestions … which we’ll share.

Persistence – in fighting DCEs and Medicare Advantage. Both undermine our most successful public insurance program for the general population. Learn more about DCEs in particular, since the issue is urgent — and actively support efforts to force CMS to reverse course.

Pursuit – of single payer, of course. We have (at least) one more year of a Democratic Congress. Once work on COVID response and social infrastructure is complete, we can expect Congressional progressives to return to HR 1976, a Senate bill, and associated activities – hearings in DC and elsewhere, discussion of potential state experiments, and policy research.

And we’ll pursue state opportunities. Here in California, that means building on Commission findings and the state single payer bill (currently AB 1400) – publicizing the single payer results, conducting relevant follow-up research, linking community and business organizations, organizing meetings and hearings, discussing and launching strategy.

Partnership – Alliances with other progressive social causes is natural and essential. So is working with the business community, though many in that quarter may need convincing. We’ll write on this issue in 2022.

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.

Pressure Grows on Biden to Shut Down Trump-Era Medicare Privatization Scheme

A petition calling on the president to end the Medicare Direct Contracting pilot program has now garnered more than 10,000 signatures.

By Jake Johnson
Common Dreams, December 30, 2021

Calls are mounting for President Joe Biden to terminate an under-the-radar Trump-era pilot program that—if allowed to run its course—could result in the complete privatization of traditional Medicare by the end of the decade.

A petition recently launched by Physicians for a National Program (PNHP) has garnered more than 10,000 signatures as doctors and other advocates work to raise public awareness of the Medicare Direct Contracting program, which the Trump administration rolled out during its final months in power.

“Under this model,” the petition warns, “the Centers for Medicare and Medicaid Services (CMS) could move more than 30 million traditional Medicare beneficiaries into mostly commercial, for-profit plans called Direct Contracting Entities (DCE) without the enrollees’ understanding or consent.”

“In ways similar to commercial Medicare Advantage plans, DCEs have the potential to interfere with care decisions and waste taxpayer money when compared with the efficiency of traditional Medicare,” the appeal continues. “The Biden administration is moving the DCE program forward, threatening the future of Medicare as we know it. We, the undersigned, demand that CMS immediately stop the DCE program to keep Medicare public and nonprofit for future generations.”

Late last month, as Common Dreams reported, a group of physicians from across the U.S. traveled to the headquarters of the Health and Human Services Department in Washington, D.C. to demand that HHS Secretary Xavier Becerra halt the pilot program in its tracks.

The doctors were ultimately blocked from delivering a petition signed by around 1,500 physicians calling for an end to the privatization scheme, which inserts profit-seeking companies between traditional Medicare and healthcare providers.

“Just like corporate middlemen stand between patients and the healthcare they need, security staff stood between PNHP doctors and the policymakers who want to privatize Medicare,” PNHP tweeted during the demonstration at the nation’s capital.

While the doctor-led protest was followed by a brief uptick in reporting on the obscure initiative, Biden’s HHS has yet to act and few members of Congress have publicly spoken out against the Direct Contracting program despite the massive implications for the future of Medicare and its tens of millions of beneficiaries.

“People don’t know that it’s happening,” Dr. Ed Weisbart, chair of PNHP’s Missouri chapter, told Common Dreams in an interview last month. “Most people in Congress don’t know that it’s happening. We’ve started having some of these conversations with congressional staff… but it’s not on their radar either.”

One notable exception is Rep. Pramila Jayapal (D-Wash.), chair of the Congressional Progressive Caucus. Earlier this month, Jayapal penned an op-ed with PNHP president Dr. Susan Rogers urging Biden to stop the Direct Contracting program “while we have the chance.”

According to PNHP, Jayapal is collecting signatures from fellow lawmakers’ for a letter pressuring Biden to shut down the pilot, which sparked legal concerns and general revulsion among career CMS staff when it was launched toward the end of former President Donald Trump’s White House tenure.

“This shit is so fucking gross,” one staffer wrote in a group text viewed by The Intercept.

In their op-ed for The Hill earlier this month, Jayapal and Rogers warned that the Direct Contracting program “could radically transform Medicare within a few years, without input from seniors or even a vote by Congress.”

“After our experience with commercial Medicare Advantage plans,” they added, “we already know that inserting a profit-seeking middleman into Medicare ends up costing taxpayers more, with fewer choices and worse outcomes for seniors.”

https://www.commondreams.org…

Stealthy effort to privatize Medicare should alarm all Americans

Scheme initiated in waning days of Trump administration poses an existential threat; Biden should repeal it

By George Bohmfalk, M.D.
The Pulse Blog, NC Policy Watch, December 30, 2021

As someone who has spent his professional life in healthcare, it’s clear to me that Medicare for All is the best solution to nearly all of our nation’s healthcare shortcomings. However, as of the last days of the Trump administration, Medicare itself is being subjected to a potentially fatal attack.

Without congressional authorization, bureaucrats in Trump’s administration developed a program openly designed to privatize Medicare. Called Medicare Direct Contracting (DC), this program allows commercial insurers and other for-profit middlemen to “manage” care for seniors enrolled in Traditional Medicare. This is in addition to the for-profit Medicare Advantage programs, which for years have cost taxpayers more than Traditional Medicare while restricting their choice of physicians and hospitals and providing no improvement in healthcare outcomes. Beginning this year, millions of seniors who deliberately chose Traditional Medicare are quietly being enrolled into Direct Contracting Entities (DCEs) without their full knowledge or consent.

Virtually any type of company can apply to be a DCE, including venture capital investors. There isn’t even a requirement that DCEs be majority-owned by health care providers, opening the door to ownership by profit-driven entities with no health care expertise whatsoever.

Traditional Medicare spends an impressive 98 percent of its budget on patient care. But DCEs are allowed to operate with very loose restrictions on how much of their revenues must go to patient care. This incentivizes them to limit payouts by rationing care and keep even more than the 15 percent that Medicare Advantage programs are allowed for their own profit and overhead. This detail alone should alarm taxpayers.

As this is a creation of the Center for Medicare and Medicaid Services’ “Innovation Center,” this pilot program can be scaled up to cover all of Medicare without so much as a vote or hearing in Congress. Very few Members of Congress appear to be even aware of its existence or its existential threat to Traditional Medicare. To prevent Medicare from becoming completely and stealthily privatized, this program must be stopped in its tracks. The only way to stop it is by order of President Biden or insistence by enough Members of Congress.

Please help me, and the millions of seniors and Americans living with disabilities who depend on Medicare, bring this nefarious program to a quick end. Please contact your Congressional representatives and implore them to instruct Health and Human Services Secretary Xavier Becerra to terminate the Direct Contracting program immediately.

Most seniors love Medicare. It is simple, efficient, and empowers them to manage their own health. Traditional Medicare has proven its value for more than half a century. Rather than sell it off to the highest profit-driven bidder, we should strengthen and improve its benefits while working to expand it to cover every American.

Dr. George Bohmfalk is a retired neurosurgeon and a member of Physicians for a National Health Program (PNHP.org) and the North Carolina Medicare for All Coalition (NCM4A.org).

https://pulse.ncpolicywatch.org…

Bonuses Fail to Improve Clinical Quality in Medicare Advantage

Summary: A new study finds that financial incentives failed to raise clinical quality measures in Medicare Advantage plans. This completes HJM Medicare Advantage week, in which we highlighted the numerous serious problems arising from using private insurers as intermediaries for public health insurance.

Next week we’ll relax our usual blogging pace. We’ll offer some reflections on the year past and what lies ahead. Happy Holidays! – JGK

The Medicare Advantage Quality Bonus Program Has Not Improved Plan Quality, Health Affairs, December 6, 2021, by Adam Markovitz et al.

In 2012 Medicare introduced the quality bonus program, linking financial bonuses to commercial insurers’ quality performance in Medicare Advantage (MA). Despite large investments in the program, evidence of its effectiveness is limited. We analyzed insurance claims from the period 2009–2018 from the nation’s largest MA claims database for 3,753,117 MA beneficiaries (treatment group) and 4,025,179 commercial enrollees (control group). Using a difference-in-differences framework, we evaluated changes in performance on nine claims-based measures of quality [for disease screening & monitoring, medication adherence] in both groups before and after the start of the bonus program and with adjustment for differential pre-period trends. We observed no consistent differential improvement in quality for MA versus commercial enrollees under the quality bonus program. Program participation was associated with significant quality improvements among MA beneficiaries on four measures, significant declines on four other measures, and no significant change in overall quality performance (+0.6 percentage points). Together, these results suggest that the quality bonus program did not produce the intended improvement in overall quality performance of MA plans.

Comment:

By Isabel Ostrer, M.D.

Despite the federal government pouring $6 billion dollars into the quality incentive program for Medicare Advantage (MA) plans, the effectiveness of the program is sorely lacking.

A new study in Health Affairs finds that despite this huge investment, the program failed to actually improve the quality of MA plans. The authors state, “In this national study of the impact of the Medicare Advantage quality bonus program, we observed little evidence that the program was associated with incremental improvements to quality performance for MA beneficiaries.”

42% of Medicare beneficiaries, which translates to millions of elderly Americans, are now enrolled in MA plans. These plans are often billed as cheaper, more robust, and higher quality than other health plans. In his HJM piece earlier this week, Don McCanne debunked the claims that MA plans are cheaper than traditional Medicare plans and provide better benefits. This study debunks the final claim – even when offered billions of dollars in incentives, the quality of care in MA hasn’t budged.

It’s time to eliminate the MA quality incentive program. And while we’re at it, we should turn our focus towards streamlining health care delivery in the U.S. As Don wrote, “What we need is an equitable, publicly administered and publicly financed health care program for everyone: a single payer, improved Medicare for All.”

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 Advantage for All: A Bad Idea for Single Payer

Summary: A recent commentary in JAMA proposed using private insurance health plans as intermediaries in a universal health insurance system, instead of direct payments from a public payer to providers, as under “traditional” Medicare for All / single payer. The supporting arguments, though perhaps appealing on a first read, don’t withstand scrutiny.

Medicare Advantage for All: A Potential Path to Universal Coverage, JAMA, December 16, 2021, by Greg J. Zahner et al.

Medicare Advantage (MA) for All—which would create a national guarantee for health insurance while maintaining private-sector involvement in health insurance administration—represents an alternative path to achieving universal health insurance that could mitigate many of the disadvantages of Medicare for All. This Viewpoint outlines what MA for All might look like and describes potential benefits, limitations, and risks.

MA for All: How It Might Work:

The MA program allows MCOs to provide coverage for Medicare-eligible populations and has become increasingly popular, with an estimated 42% of Medicare beneficiaries now enrolled in MA plans. At a high level, MA for All could be structured and funded as follows: all existing non-Medicare insurance funding (eg, employer-sponsored coverage, commercial insurance, Children’s Health Insurance Program, and Medicaid federal funding) would initially flow through CMS. Employers would pay a health benefit tax to CMS rather than directly pay for health insurance, and state contributions for Medicaid would shift to federal responsibility. Private health plans would then apply to become CMS-approved MA MCOs. These MCOs would provide coverage not just for Medicare beneficiaries but also for children, low-income individuals, and people previously insured through employer-sponsored plans.

Flexibility and Equity:

Unlike Medicare for All, which would restrict a person’s flexibility to choose the best health plan for them, MA for All could help ensure that individuals continue to have multiple options and the opportunity to select an MCO that covers their preferred clinicians or health care organizations. This model could accommodate regional differences in the health care landscape by continuing to enable flexibility in how payers and health care organizations work and partner together. For example, accountable care organizations could continue to grow, and local and state governments could retain a level of autonomy and apply for waivers to create MA plans for select populations (eg, individuals with low income).

Equity is also a key concern. Today’s environment, with commercial insurers paying significantly higher rates than public payers, incentivizes clinicians and health care entities to selectively pursue commercially insured patients. Greater payment parity, such as through comprehensive risk adjustment for all individuals, greater control over rates in noncompetitive markets, and greater rewards for offering plans that cover higher-risk populations, may help reduce these resultant disparities. Additionally, CMS could expand innovative programs that target high-need and underserved populations, such as clinically aligned payment models like the Program for All-Inclusive Care for the Elderly, which provides nursing home–level care at home, or special-needs plans designed to help patients with mental health and chronic conditions.

Comment:

By Jim Kahn, M.D.

Zahner and colleagues propose that Medicare Advantage offers a good model for how to implement single payer. They point to lower care costs, some higher quality metrics, and political viability. Here I address their main assertions. Pardon the longer-than-usual comment.

Assertion #1: Insurance companies could serve a central role in a single payer system.

Structuring single payer around private insurers would garner their political support. However, doing so would fundamentally undermine single payer design.

Insurance companies are central to current health system problems. They earn and extract high profits based largely on limiting access through care denials and financial barriers (for the home health example, see Monday’s HJM). They fail to provide the detailed data that would reveal what’s working well or poorly for access and health.

Insurance companies as we know them are incompatible with efficient and generous health coverage. In some countries, insurers have a major role, but they are non-profit and effectively claims administrators, selling a single insurance product with standard medical necessity and payment protocols, unlike what’s proposed in the US.

Assertion #2: Medicare for All would remove important economic activity that people want.

Not true. Medicare for All (single payer without private insurers) would remove the dead weight of insurance profits and administrative burden, and largely replace that with clinical services, including much-needed increases in long-term care.

As for polls indicating support for keeping private insurers, it’s all in the wording. If respondents are provided a fair description of how single payer would work – including choice of any doctor and elimination of cost-sharing – they don’t pine for private insurers.

Assertion #3: Medicare Advantage for All would increase efficiency and equity.

MA4A might trim a small portion of the horrendous administrative bloat in our current system, and reduce inequitable coverage. But not nearly as much as true single payer.

Administrative costs at insurers would remain high, because it’s a lot of work to oversee care approvals and complex payment arrangements. Not to mention profits (oops, did mention that). Administrative costs for providers would drop a little, if indeed they dealt with fewer MA plans than the current morass of private and public payers. But most doctors and hospitals in this “single payer” system would have to deal with multiple MA plans, each with different rules.

Equity – more similar insurance across individuals – would be enhanced versus today. (How could it be worse?) But differences in benefits scope, coverage rules, provider network design, and payment levels and structures would leave ample room for disparities.

Economic feasibility would benefit from a muted rise in utilization, as colleagues and I published recently (and they cite). But that’s a stronger argument for true single payer – you can fully remove restrictions on care access and still avoid overwhelming utilization growth.

Assertion #4: Medicare Advantage for All would allow choice – of health insurance plan.

People want choice among doctors and hospitals, not insurance plans. This is especially important when they have complex medical conditions. And choice imposes costs.

Selecting among health plans is nerve-wracking and nearly impossible for people to optimize. Consumers have almost no usable information about plan rules and performance or out-of-pocket costs, and huge uncertainty about their own future health needs

And provider choice is sacrificed. MA plans usually sharply restrict choice of doctors, by relying on narrow provider networks and excluding many top referral doctors – all to trim costs.

Furthermore, the profusion of plan options is extremely disruptive. It forces doctors to deal with multiple payers (and payment models) and patients to change doctors if they switch plans (or doctor networks shift), creating costs and hassles, all distractions from optimal clinical care.

Assertion #5: Medicare Advantage has higher quality metrics.

MA plans know how to play to the measure – raise targeted quality metrics. But much more importantly, mortality is highly variable across MA plans, unrelated to quality ratings, with no way for beneficiaries to know. And quality is useless if MA enrollees experience financial barriers to care.

Assertion #6: Medicare Advantage reduces health care spending compared with traditional Medicare.

Finally, with gusto: Untrue in any meaningful way. Because:

First, reported savings are for medical care payments, not total costs. The care savings are more than offset by MA plan profits and administrative costs. Overall, MA increases insurance cost: medical spending down, profits and overhead up even more. This problem is accelerating in MA as private equity ramps up its role.

Second, savings in medical care costs are achieved by reducing service use in ways that are often harmful to patients. Plans deny care via prior authorization using obscure criteria. Small provider networks can mean the best care is out of network. And MA plans impose out-of-pocket costs, such as high deductibles and other cost-sharing, that is often unmanageable when people get sick and thus need more care.

Third, MA selects for lower cost individuals, leaving higher cost enrollees in traditional Medicare. The clearest recent evidence of this comes from a 2019 study of spending prior to MA enrollment.

Authors’ financial conflict of interest.

The authors disclose, as required by medical journals, significant financial connections to the private insurance industry. Does this influence their views? Impossible to say, but important to have this information.

Let’s stick with the plan: single payer, Medicare for All, with direct payment from the public funder to providers. No for-profit insurers in the mix. This is what works in all the other wealthy countries. It will work for us.

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 Advantage Places Us at a Disadvantage

Summary: This week we scrutinize Medicare Advantage (MA). Today: A survey from the Center for Medicare Advocacy found that MA plans deny, reduce, delay, and charge beneficiaries more for home health services. And a leading researcher estimated that Medicare overpaid MA plans by $106 billion over ten years for sicker patients. So … overpaying for worse care. Hmm.

Home Health Survey: Medicare Beneficiaries Likely Misinformed and Underserved, Center for Medicare Advocacy, December 2021

From April 28, 2021 – November 19, 2021, the Center for Medicare Advocacy conducted a survey of 217 Medicare-certified home health agencies in 20 states to learn what beneficiaries may experience when seeking home care.

The Medicare Act mandates that Medicare Advantage plans cover, at least, all the medically necessary services that traditional (also known as “original”) Medicare covers. However, when surveyed home health agencies were asked if there were differences in the services they could provide to clients enrolled in Medicare Advantage plans versus clients with traditional Medicare coverage, their comments describe a very different reality.

Major themes among agency comments were that Medicare Advantage plans deny more services, allow fewer visits per care modality, delay onset of care, lead to more changes to provider-approved plans of care, are significantly harder for agencies to work with, and require greater out-of-pocket costs. Many agencies also mentioned discrepancies in care caused by the pre-authorization process.

Examples:

“Abso-freakin-lutely! Medicare Advantage plans in our area are rotten.”
“Very much so, there’s a difference. Medicare Advantage plans don’t approve as much services.”
“Medicare Advantage patients are reimbursed for less, and do not have therapy covered. Typically they only provide nursing services.”
“The payment model is different so we can’t take as many Medicare Advantage beneficiaries. Traditional Medicare is better.”
“Medicare Advantage plans typically offer less coverage.”
“Medicare Advantage plans can be very limiting. Anthem and Humana are terrible, and very often do not cover services that patients need.”
“Medicare Advantage plans often fight tooth and nail on the number of visits they will allow. Anthem is the worst. They use MyNexus, a company for prior authorization work, and allow very few visits.”
“MA authorizations are limited. We [the agency] fight and appeal for more services. United Healthcare and Aetna provide particular coverage challenges.”
“Managed Medicare seems to be a lot stingier with what they authorize than traditional Medicare.”

Researcher: Medicare Advantage Plans Costing Billions More Than They Should, KHN, November 11, 2021, by Fred Schulte

Switching seniors to Medicare Advantage plans has cost taxpayers tens of billions of dollars more than keeping them in original Medicare, a cost that has exploded since 2018 and is likely to rise even higher, new research has found.

Richard Kronick, a former federal health policy researcher and a professor at the University of California-San Diego, said his analysis of newly released Medicare Advantage billing data estimates that Medicare overpaid the private health plans by more than $106 billion from 2010 through 2019 because of the way the private plans charge for sicker patients. “They are paying [Medicare Advantage plans] way more than they should,” said Kronick.

Kronick called the growth in Medicare Advantage costs a “systemic problem across the industry,” which CMS has failed to rein in. He said some plans saw “eye-popping” revenue gains, while others had more modest increases.

Making any cuts to Medicare Advantage payments faces stiff opposition, however.

On Oct. 15, 13 U.S. senators, including Sen. Kyrsten Sinema (D-Ariz.) sent a letter to CMS opposing any payment reductions. (Sen. Manchin also signed – DMc)

Comment:

By Don McCanne, M.D.

We have been witnessing the privatization of the Medicare program through the introduction of the private Medicare Advantage plans, and, more recently, the Direct Contracting Entities as a means of converting much of the remaining traditional Medicare program into private plans.

We have recently been inundated with heavy marketing of these plans during the open enrollment period, promising eligible Medicare beneficiaries much better benefits at considerably lower costs.

Better benefits? Look at the report on services provided by home health agencies, the type of services the marketing suggests are superior when provided by the Medicare Advantage plans. This study showed that services were emphatically inferior to services provided under the traditional Medicare program.

And lower costs? The other report cited above indicates that Medicare Advantage plans were overpaid by tens of billions of dollars.

When there is a popular movement to eliminate private plans and establish a single payer Medicare for All program, it is ironic that our government is establishing policies to suppress our existing Medicare program and replace it with private plans when the evidence is that they are a major source of much of the detrimental dysfunction in health care financing.

What we need is an equitable, publicly administered and publicly financed health care program for everyone: a single payer, improved Medicare for All. But we do need to consider getting rid of the politicians who want to use our public funds to support the private health plans while suppressing our public programs.

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.

Failure of Nursing Home Safety Monitoring

Summary: NY Times research found a huge gap between safety problems found in nursing homes and the public reporting of those problems. Quality star ratings are misleading. Consumers are not being protected.

How Nursing Homes’ Worst Offenses Are Hidden From the Public, New York Times, Dec. 9, 2021, by Robert Gebeloff, Katie Thomas, and Jessica Silver-Greenberg

A New York Times investigation found that at least 2,700 similarly dangerous incidents were also not factored into the rating system [Care Compare] run by the federal Centers for Medicare and Medicaid Services, or C.M.S., which is designed to give people reliable information to evaluate the safety and quality of thousands of nursing homes.

Oklahoma’s inspections agency referred to nursing homes as its ‘clients,’ according to a letter from the agency reviewed by The Times. Inspectors in Pennsylvania complained about being told to be ‘kinder and gentler’ with nursing homes, according to the 2013 survey. Last year, in the depths of the pandemic, the California department of health told inspectors to act as safety “consultants” to nursing homes and to not take on an enforcement role. (The policy was scrapped after inspectors objected.)

Jonathan Blum, the chief operating officer for C.M.S., said that citations are omitted during state-level appeals to be fair to nursing homes that are disputing inspectors’ findings. He acknowledged that even after appeals are exhausted, some citations still don’t appear on Care Compare. He said C.M.S. is ‘working to correct this issue.’

The Times asked public health agencies in all 50 states how often citations were upheld, reduced in severity or deleted entirely since 2016. Eighteen states provided figures. About 37 percent of the time, the nursing homes succeeded in getting citations removed or reduced in severity.

Studies have found that federal inspectors tend to find more serious problems than their state counterparts during these examinations. But the Medicare agency does not publish the reports of its own inspectors — even when they turn up dangerous or deadly conditions — or factor them into homes’ star ratings.

http://healthjusticemonitor.org…

Comment:

By Allison K. Hoffman, J.D.

The COVID-19 pandemic revealed the depths of problems in U.S. nursing homes, but it is also clear that nursing homes have had serious deficiencies leading up to the pandemic. Worse, even when these problems are uncovered, they are sometimes later buried. There are many reasons why nursing homes became an epicenter for the pandemic, but one has been well illuminated by recent New York Times reporting: the failure of regulatory monitoring and reporting systems, including Care Compare and star ratings, which were intended to reflect nursing home quality.

These types of ratings systems are part of a consumerist turn in health care, based on the idea that with all the right information, patients will be able to navigate the system to choose among care providers and balance things like quality and price. There are many flaws in these assumptions. The N.Y. Times reporting over the past year shows that one necessary piece of the consumerist model is completely lacking: the quality of information to inform decisionmaking. This article, in particular, illuminates the fact that even after major problems were uncovered in surveys and inspections, nursing homes had too many tools to keep those problems from coming to light and eventually making it into Care Compare. The problems don’t harm their star ratings – a scale from 1 to 5 that is supposed to—but often fails to— indicate nursing home quality.

The failure of these ratings to capture what is actually happening in settings where residents often cannot advocate for themselves is tragic. When the faults in such a system intersect with a pandemic, people who think they have chosen quality nursing homes for loved ones learning that they are tragically wrong.

Even the best nursing homes went through extremely trying times over the past two years. But some nursing homes began this period in a state of poor oversight, management, staffing, and operations that never should have been tolerated.

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.

There’s a Revolution Happening in Harm Reduction for Drug Users. Can Our Broken Health Care System Handle It?

In the face of unprecedented opioid overdose deaths, the people most at risk can’t reliably access care—including life-saving treatments like methadone and buprenorphine.

By Laura Weiss
The New Republic, December 17, 2021

After decades of efforts by advocates fighting in the trenches of America’s ongoing opioid crisis, harm reduction is finally having its day. Late last month, New York City opened the doors of its first supervised injection sites, or overdose prevention centers—the first such facilities in the nation. On day one, the staff saved two people’s lives.

It’s taken a long time for supervised injection sites to open, mainly because they operate in a legal gray area. But overdose deaths have reached record levels because fentanyl, a painkiller 50 times more potent than heroin, is increasingly being laced into heroin supplies and putting users at unprecedented risk of overdosing. The fallout of the Covid-19 pandemic hasn’t helped: In 2021, a record-breaking 100,0000 people have died from drug overdoses in the United States.

Overdose prevention centers give participants a safe place to use, under supervision of medical staff who have clean needles and naloxone on hand, as well as equipment to test drugs for fentanyl. These centers also provide resources for health and social services, including treatment for substance use disorders.

Harm reduction “used to be a totally taboo subject,” according to Maritza Perez, director of the Office of National Affairs at the Drug Policy Alliance. Now, she says, more people are recognizing that harm reduction “actually meets people where they are at and [does] work to save lives and ultimately hopefully connect people to health services.”

Joe Biden has become the first U.S. president to speak publicly in favor of harm reduction, after decades of failed enforcement policies that purport to police their way out of a public health issue. Last week, the Substance Abuse and Mental Health Services Administration announced the first round of federal grants for harm-reduction programs. There are efforts on the Hill to make it easier to access drug treatment, which the Biden administration has already made some effort to relax. However, the administration stopped short of explicitly endorsing the overdose prevention centers.

“It’s a promising time,” said Dr. Bruce Trigg, a longtime harm-reduction and addiction medicine doctor who works with the Bronx-based St. Ann’s Corner of Harm Reduction. “But the crisis is worse than it’s ever been.” Since Thanksgiving, two patients at his facility have overdosed.

The depth of the opioid epidemic—and the graveyard of overdose deaths it has produced—has forced the administration to admit that the status quo doesn’t work. Even tepid acknowledgments that there might be something to harm reduction is a huge step. But it’s only a small part of the effort to shift drug policy from the purview of the criminal justice system into the public health sphere.

In order to take a larger step toward solving the overdose crisis, we must face the failures of our health care system. People at higher risk of developing an opioid use disorder—including those with chronic physical and mental health conditions and trauma, uninsured people, and low-income communities of color—face barriers to life-saving comprehensive medical care. Legal restrictions add further barriers, subjecting those with opioid use disorder to a dizzying, fragmented maze of coverage plans and regulations. The opioid epidemic can’t be fully overcome without a new approach to our privatized insurance and health care system.

Our current system makes it extremely difficult to access effective treatment. While nearly two million people report having an opioid use disorder in the U.S., less than 10 percent of those who need treatment are receiving it. Although a 2008 law that sought to require most insurance plans to include substance use and mental health treatment was strengthened by the Affordable Care Act and Medicaid expansion, the definition and application of that treatment has varied widely in practice. Notwithstanding the millions of people without insurance, those with Medicaid or private insurance face a daunting patchwork of networks, authorizations, and requirements to access covered care.

The use of evidence-backed medications, particularly methadone and buprenorphine (brand name Suboxone), to treat opioid dependence is a vital tool in the fight. Most state insurance plans cover buprenorphine and naltrexone, but just over half cover methadone, according to a trove of data from the Prescription Drug Abuse Policy System. Less than two-thirds also include coverage for behavioral health services related to opioid use disorder. (The majority of private rehab centers don’t use medication.)

Those with private plans are by no means better off. Only eight states require commercial insurance to cover medication-based treatment for opioid use disorder. And about a fifth of adults with an opioid use disorder are uninsured, making them particularly vulnerable to overdose and death.

Moreover, private insurance coverage restrictions differ from state to state and plan to plan, forcing doctors and billing staff to dedicate massive amounts of time to determine who and what is in-network and who and what is out. Participants are limited by age, number of refills, quantity of pills, and cost caps and are usually subject to prior authorization requirements. Some insurance companies will only cover certain clinics or only portions of the costs. Trigg called the requirements “complete nonevidenced bullshit.”

Methadone, which has been highly successful in helping people stop heroin, can only be dispensed at specialized clinics and often requires people under its treatment to spend hours every day for dosing and supervision, explained Trigg. That burden is such that two of Trigg’s patients dropped out of their methadone programs during Covid-19. “They had children and jobs, and couldn’t go every day,” he said. Both have since relapsed.

“The system used to look for excuses not to treat people. Now we should be bending over backward to get anyone into treatment who wants it,” said Trigg.

Buprenorphine, for its part, may be more promising in providing low-threshold treatment to patients. It’s safer than methadone because it’s nearly impossible to overdose on, and some patients prefer it because it’s less sedating and less disruptive to life. It can be prescribed in a primary care setting by any prescribing health professional with the appropriate waiver. Getting that waiver used to require doctors to attend an eight-hour training, but that requirement has been dropped in a bid to get more doctors to agree to treat people with opioid use disorders, explained Dr. Daniel Alford, a primary care physician and director of the Safe and Competent Opioid Prescribing Education, or SCOPE of Pain, program at the Boston University School of Medicine.

Still, just 7 percent of primary care providers have that waiver. Due to the stigma that people with addiction are untrustworthy, volatile patients, many doctors don’t want the responsibility. But for Alford, prescribing buprenorphine is one of his most rewarding experiences as a doctor. “People with opioid use disorder who you start on buprenorphine, oh my God,” he said. “They’re no longer in withdrawal, they’re able to focus on other things, I mean, it’s just remarkable.”

Unfortunately, access to buprenorphine is often segregated along racial lines. Studies have shown that Black and Latinx communities have more facilities that provide methadone per capita, while white communities have more access to buprenorphine, the newer and less disruptive medication treatment option. “The same disparities that you see in the health care system are prevalent when we’re talking about people with substance use disorder,” said Perez.

In addition to medication-assisted drug treatment, the widespread use of naloxone, the overdose-reversing drug, is key to ending opioid overdoses. But as demand for naloxone has skyrocketed, so has price gouging from pharmaceutical companies. While you used to be able to get a dose of Narcan for $2.50, it can now cost up to $75 or more. And while Purdue got a slap on the wrist for its role in starting the opioid crisis, its malfeasance has continued: Beyond price gouging naloxone, it also marketed fentanyl in the parts of the country hardest hit by the crisis.

“The pharmaceutical industry has total control,” said Trigg, who is also a board member with the Physicians for a National Health Program. “As a result, we either have to give out less naloxone, or health departments and public agencies that pay for it have to cut back on other things.”

The rampant profiteering and fragmentation of care isn’t limited to drug treatment. The lack of comprehensive, affordable, and quality mental and physical health services has also spurred addiction, especially among groups who are most at risk of developing an opioid use disorder—uninsured people, those with mental health conditions and/or past trauma, and people suffering from chronic pain.

Research has shown that mental health conditions and substance use disorders are often comorbid: Up to half of those who have a mental illness in their lives will also experience an addiction, according to the National Institute on Drug Abuse. Despite the law that mental health and drug treatment must be covered by insurance, networks are limited, and behavioral health specialists, especially those who are able to prescribe medication, are often not taking new patients.

A 2019 study by the National Alliance for Mental Health showed that behavioral health visits are five times more likely to be out of network than an appointment with a primary care provider. These inadequate networks “effectively discriminate” against people needing this care, concluded the report.

Trigg said that he’s had so much trouble finding a psychiatrist for his patients, even though they all have Medicare, that he’s resorted to prescribing them antidepressants himself, even though it’s outside his specialty. Many of his patients have also had bad experiences with mental health professionals who treat them with scorn and mistrust.

The role of trauma in fueling addiction is another reason why access to affordable behavioral health care is so important. As addiction researcher Gabor Maté put it in a recent article in Yes! magazine: “We have a social structure that induces trauma in a lot of people. Therefore, it induces escapist, addictive behaviors.” And when accessing health care adds to that trauma rather than addressing it, it makes people less likely to pursue it in the future.

The lack of coordination between mental and physical health care and the fragmentation of our system contribute to the cycle of self-medication. As Trigg posited: “How many people have a primary care provider who they can talk to, who asks about depression and substance use?”

Among those who do have a doctor, few feel comfortable talking about their drug use. Alford said that some doctors he’s worked with to train them on appropriate prescribing practices for opioids have gone so far as to “fire” their patients when they’ve tested positive for drugs. This, of course, is a time when those patients need care more than ever.

“Many people may not feel comfortable going to a medical provider because they might face criminal repercussions or discrimination, and we know that that typically happens to Black and brown people,” said Perez.

Alford led a 2016 study that found that a whopping 87 percent who tested positive for drugs or heavy alcohol use had chronic pain. And 81 percent of those who misused a prescription drug did so to self-medicate. The 2019 National Survey on Drug Use and Health reported that two-thirds of people who last abused a prescription were also trying to relieve pain. The majority got the drugs from a family member or friend—just 7 percent bought them off the street.

These figures “speak to the complexity of managing chronic pain and also the lengths that people will go to relieve that suffering,” said Alford.

For patients without a trusting relationship with a primary care doctor who helps coordinate their care, it can be much easier for a provider to prescribe painkillers than to look comprehensively at the root of preexisting health problems that cause pain. (It’s important to note that opioids do have legitimate medical uses. “There is no question that there are patients who are more functional because they’re able to get this one type of medication, and they’re taking it as prescribed, and they’re doing just fine,” says Alford.)

There are other treatments for pain, pharmacological and otherwise, that can help people manage their symptoms. Many of these—such as cognitive behavioral therapy, massage therapy, acupuncture, lidocaine injections, and nerve blocks—are often not covered by insurance. Moreover, new medications can be exorbitantly expensive; insurance companies often refuse to cover them.

It’s no surprise, then, that many have plunged into medical debt, which only exacerbates the impact of opioid use disorders among the same at-risk groups: low-income individuals, the uninsured, and people with chronic medical conditions, according to the Kaiser Family Foundation.

Doctors can’t help their patients when they’re spending a prodigious amount of time fighting with insurance providers. According to a 2018 doctors’ survey, nearly a third of doctors reported spending 20 hours or more a week on paperwork. It’s well documented that patients who spend more time with their doctors have better health outcomes, but our health care system incentivizes doctors to see as many patients as they can as quickly as possible and then turn to the giant stack of prior authorizations on their desks.

In short, there is no way to address the opioid crisis—both in terms of treating people with opioid use disorder as well as caring for people who could develop it—without massive reforms. A good first step would be the creation of a national formulary for pharmaceuticals, which would enshrine one set of rules that could apply to everyone, freeing doctors and staff from having to comprehend the intricacies of each individual plan’s coverage. Biden recently introduced a prescription drug–pricing framework as part of the Build Back Better bill, which, if passed, would help address big pharma’s profiteering of life-saving medications.

Harm reduction is an important step in the right direction of shifting our drug policy from a criminal justice to a public health lens. But acknowledging that drug users deserve not to die is really only the barest of minimums. We need to go further to meet the scale of the crisis, through a single-payer system that would take profit out of the health care system entirely. Given the scale of the crisis, any harm-reduction policy must prioritize making mental and physical health services, including treatment, accessible to all.

“The pivot to harm reduction in both Congress and the administration is fantastic, but it’s not enough,” said Perez. “We need to use every tool at our disposal, and go big.”

https://newrepublic.com…

COVID Stumble: US Politics, Vaccine Hesitancy, & Mortality

Summary: On Monday we posted on how well Taiwan dealt with COVID; today, one way the US fell sadly short. NPR reports that COVID mortality is 3 times higher in heavily Trump than heavily Biden counties – due to lower vaccination rates, in turn due to misinformation and vaccine hesitancy. Thus political division and distortion of science are deadly.

Pro-Trump counties now have far higher COVID death rates. Misinformation is to blame, NPR Morning Edition, December 5, 2021, Daniel Wood and Geoff Brumfiel

Since May 2021, people living in counties that voted heavily for Donald Trump during the last presidential election have been nearly three times as likely to die from COVID-19 as those who live in areas that went for now-President Biden.

NPR looked at deaths per 100,000 people in roughly 3,000 counties across the U.S. from May 2021, the point at which vaccinations widely became available. People living in counties that went 60% or higher for Trump in November 2020 had 2.73 times the death rates of those that went for Biden.

In October, the reddest tenth of the country saw death rates that were six times higher than the bluest tenth…

The data also reveal a major contributing factor to the death rate difference: The higher the vote share for Trump, the lower the vaccination rate.

Recent polling shows that partisanship is now this single strongest identifying predictor of whether someone is vaccinated. Polling also shows that mistrust in official sources of information and exposure to misinformation, about both COVID-19 and the vaccines, run high among Republicans.

It was not always this way. Earlier in the pandemic, many different groups expressed hesitancy toward getting vaccinated. African Americans, younger Americans and rural Americans all had significant portions of their demographic that resisted vaccination. But over time, the vaccination rates in those demographics have risen, while the rate of Republican vaccination against COVID-19 has flatlined at just 59%, according to the latest numbers from Kaiser. By comparison, 91% of Democrats are vaccinated.

Being unvaccinated increases the risk of death from COVID-19 dramatically, according to the CDC. The vast majority of deaths since May, around 150,000, have occurred among the unvaccinated, says Peter Hotez, dean for the National School of Tropical Medicine at Baylor College of Medicine.

While vaccine hesitancy exists in many different groups, Hotez suspects that the deaths are “overwhelmingly” concentrated in more politically conservative communities. “How does this make sense at any level?” he asks. …

Republicans are far more likely to believe false statements about COVID-19 and vaccines. A full 94% of Republicans think one or more false statements about COVID-19 and vaccines might be true, and 46% believe four or more statements might be true. By contrast, only 14% of Democrats believe four or more false statements about the disease.

Comment:

By Gregg Gonsalves and Robert Heimer

This is an interesting look by NPR at vaccine hesitancy, COVID-19 conspiracy thinking and its impact on pandemic mortality by political affiliation. Similar trends have been noted in the New York Times, by the Kaiser Family Foundation and researchers.

However, many of these stories have put the onus on individuals, neglecting to mention or downplaying the notion that it is elected officials, at the state and local levels, who have downplayed and even legislated against epidemic control measures that promote or require masking, testing, or getting vaccinated. The focus on individuals completely neglects the structural determinants of health.

What would be more informative to see would be an analysis of the statements of local and state officials who, aligning with the anti-science attitudes of President Trump, instituted policies at these levels of jurisdiction, and how these policies led to increased COVID-19 mortality. We would assume—and let’s put it to the test—that these factors might have a stronger relationship with mortality than simply voting patterns in the last election.

However, such a simple analysis is likely to miss one of the key features of the cumulative mortality of the COVID pandemic. In the first months of the pandemic, as we were accumulating knowledge about SARS-CoV-2 transmissibility and severity, especially in specific populations, the first places where the virus spread were hit hardest. These include very blue regions of the country. What is disappointing is that the lessons learned there were dismissed in more red regions, perhaps in part because the lessons came from blue states.

http://healthjusticemonitor.org…

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Medicare for All Explained Podcast: Episode 68

Interview with Scott Desnoyers

December 15, 2021

Single-payer activist Scott Desnoyers tells the story of his son Danny, whose loss of critical medication after a $20 missed premium payment led to his tragic death by suicide.

“I’m on a mission to make our politicians look me in the eye,” says Scott. “They must understand that when they support the for-profit system that we have now, they’re supporting murder.”

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

https://medicareforallexplained.podbean.com

School Approves Health Reform Club After Med Student Sues

By Donavyn Coffey
Medscape, December 14, 2021

A medical school has changed its tune about a controversial student club after being sued for initially rejecting the group. As of this fall, the Eastern Virginia Medical School (EVMS), in Norfolk, Virginia, will host one of the country’s newest chapters of Students for a National Health Program (SNaHP). The club was approved in August, 7 months after being denied by the student government and a day after a medical student sued the institution for viewpoint discrimination.

Just before Christmas break in 2020, Edward Si, a medical student at EVMS, applied to start a SNaHP chapter. He believed the application process was a formality. Registering through the student government would give the new SNaHP chapter access to school facilities, funding, and use of the university’s name. However, the application was denied.

According to the complaint filed in US District Court, the student government rejected the application, stating it did “not want to create clubs based on opinions, political or otherwise, and the mission and goals of [SNaHP] do not describe what we believe to be necessary or sustainable for a club.”

The club, which advocates for a single-payer healthcare system, had to fight for its newfound legitimacy on campus for 7 months before being approved.

EVMS did not respond to Medscape’s interview requests.

The EVMS roster of clubs raised questions about the university’s reason for denying his proposed group, according to Si. For example, Medical Students for Choice, LGBT-focused Alliance Group, and the Christian Medical and Dental Association, to name a few approved clubs, are all officially registered with the school, though they elevate specific viewpoints and take political stances on certain issues. To Si, it appeared the student government found some opinions more palatable than others.

Believing that his constitutional rights were being undermined, Si sought legal counsel and sued the school for viewpoint discrimination in August. The day after the suit was filed, EVMS approved the club.

Now, almost a year later, the club is actively advocating for a single-payer healthcare system on campus. But Si’s legal counsel says they’re continuing the suit until the school changes the policies that allowed for discrimination in the first place.

Organizers at SNaHP headquarters in Illinois say a student chapter has only been denied on one other occasion.

“This was really unusual for a university to deny a group of medical students the chance to develop an organization promoting health policy,” Clare Fauke, communications specialist for the organization, said.

First started in 2010, SNaHP now has more than 100 chapters across the country hosting educational activities, speakers, and seminars. They organize phone banks to call congressional leaders and lead street medic efforts, Fauke said. Many of these students go on to be members and leaders in SNaHP’s parent organization, Physicians for a National Health Program.

Long-time member and current president of Physicians for a National Health Program, Susan Rogers, MD, said, “I don’t know why they had to go to these lengths to get their org approved. I can only say that the political climate in this country has gotten so polarized that it would be remiss to think it didn’t trickle into universities.”

When he received the rejection letter from the student government in early January 2021, Si was initially disheartened. But then he read the email several times.

Si said he believed he might have been discriminated against or had his rights violated.

“That was more shocking than getting rejected in the first place,” he said.

EVMS doesn’t have a way to appeal a decision made by the student government, so Si texted a member of the student government about his concerns. They called Si to explain, but Si found their explanation insufficient. He would have to go above the student government to the administration. But before he could do that, he felt he needed protection and a legal expert who could explain the law.

Si reached out to FIRE, the Foundation for Individual Rights in Education. Attorneys at FIRE sent a letter to EVMS in February detailing their opinion on the student government’s alleged viewpoint discrimination.

“The first amendment protects the right to an opinion and the right to associate with others,” Jeff Zemen, one of the attorneys on Si’s case, explains in this video. “So EVMS can’t prevent the club because of its opinions.”

These kinds of First Amendment infringements are “often resolved before the need of a lawsuit,” Zemen later told Medscape. However, in response to FIRE’s letter, EVMS invited SNaPH to reapply, claiming they hadn’t submitted a constitution, a document establishing the club’s operating principles, the first go-round. Si and Zemen both say that was untrue, that Si did submit a constitution on December 20, 2020, and the initial rejection from student government didn’t mention any insufficiencies in SNaHP’s application.

Si emailed the vice president and general counsel on March 1, 2021, according to court documents, concerned that the administration had been misinformed to think SNaPH was denied based on an unfinished application. Si did reapply on March 8, 2021. The following week. FIRE sent a second letter notifying EVMS about the reapplication, but EVMS never responded, according to the complaint. In late March, the SGA vice president said SNaHP’s application wouldn’t be reviewed until the fall.

Born out of a grassroots movement and unattached to an undergraduate institution, EVMS has developed a reputation for going its own way. The school is known for eccentric traditions, like themed costumes for Match Day and the POETS (Piss On Everything, Tomorrow’s Saturday) student program, which hosts regular student-faculty Friday celebrations.

“They take pride in the fact that they are the most diverse school in Virginia,” Si said. “You must understand, I would have thought that a club like mine would have been accepted. In our curriculum, we talk about healthcare disparity. I would have imagined that we would have been encouraged.”

Rogers said, “I can only [imagine] that they think getting students together to advance single payer is threatening, but I don’t know why.”

According to Zemen and the complaint, the decision to block the SNaHP chapter came from the student government association ― a body of medical students who are supervised by EVMS Board of Visitors. As a result of their decision, Si and his cofounders “were unable to avail themselves of resources made available to other groups: funding, school facilities, use of school names,” Zemen said.

Despite Si’s attempts to counter the rejection, the decision held for months. Then, FIRE filed the lawsuit against the EVMS president and other officials on Tuesday, August 17. Si’s club was approved on Wednesday.

“It felt good finally being vindicated,” Si said. “I felt like it was over and I can continue what I want to do, what I feel is necessary…. That’s what I’ve been doing right now.” The club is scheduling meetings, inviting speakers, and hopefully organizing advocacy events soon.

It’s a victory, but there are still some institutional changes that need to be made, Zemen said. There are bylaws in place within EVMS’s student government that allow for this type of decision making, he said. Beyond Si’s chapter of SNaHP, FIRE “want[s] to make sure that measures are in place that no longer allows student government to deny students based on viewpoint discrimination.”

FIRE said it plans to continue the lawsuit until “unconstitutional policies” are overturned, and they have remedied the 258 days Si went “without his constitutional rights.”

https://www.medscape.com…

Medicare Privatization Scheme Faced Legal Questions About Profiteering

Government attorneys expressed concerns that the Medicare direct contracting model — begun by Trump, and continued under Biden — was geared to benefit specific companies.

By Ryan Grim and Austin Ahlman
The Intercept, December 14 2021

In the final stretch of the Trump administration, government attorneys expressed ethics concerns about a Medicare privatization scheme being set up by Adam Boehler, a former dorm-mate of Jared Kushner’s who was made director of the Center for Medicare and Medicaid Innovation, also known as CMMI or the Innovation Center.

In January 2019, ahead of the launch of a new direct contracting model, the Office of the General Counsel for the Health and Human Services Department warned, in comments on a draft of the proposal, that it appeared as if the new project was being set up to benefit specific companies.

“We are concerned based on [Centers for Medicare and Medicaid Services]’s regular references to organizations like Chen Med, Oak Street Health, and Verily in the comments and otherwise, that this model has been designed with specific private sector entities in mind. If accurate, this could create ethics concerns, as the creation of this model would give those entities a leg up in the market,” read the guidance, a copy of which was obtained by The Intercept.

The direct contracting model was announced publicly in April 2019 and began its implementation phase in October 2020. The project pays private companies a predetermined but individualized amount per year, per patient, regardless of what the company spends on care, and has persisted and grown under the Biden administration.

Boehler, prior to working in the Trump administration, ran a startup called Landmark Health, which was backed by venture capital money, including the firm Oxeon. Multiple Oxeon-funded health companies, such as Oak Street Health, were directly referenced in the documents setting up the new project, which drew scrutiny from the Office of the General Counsel. Under Boehler, CMMI contracted with Oxeon to recruit the noncareer staff for CMMI, who then went on to design the program. Once the project was set up, Landmark Health announced it would be contracting with CMMI to become a direct contracting entity — meaning Boehler’s model was shoveling money to the firm he had left. Boehler is now CEO of Rubicon Founders, a venture capital and private equity firm operating in the health care industry. (Before taking his position in the administration, he had divested from any Landmark, along with other healthcare-related investments.)

In May 2019, a calendar alert went out to staff reading “discussion with Landmark on the direct contracting model.” Career staff were appalled. “This shit is so fucking gross,” wrote one in a group text with other aides which was shared with The Intercept. “Ugh. What the fuck,” replied another, with a third sending a link to the Office of the Inspector General, suggesting it be reported. (It does not appear to have been reported.)

The payment model is designed to be lucrative for firms contracting with the government: The government pays a set amount of money annually per patient based on a risk score that is easily gamed by the health care company, and there is no requirement that a minimum percentage of the money be spent on care, a requirement known as a “medical loss ratio” that is typically used to constrain insurance firms or providers from eating the bulk of the funding.

Brad Smith, a recruit of Boehler’s who briefly served as director of CMMI after Boehler was appointed to an unrelated position by President Donald Trump, wrote an article for the New England Journal of Medicine in February of this year that was highly critical of similar payment models the organization was rolling out, noting with unusual frankness that “the vast majority of the Center’s models have not saved money, with several on pace to lose billions of dollars. Similarly, the majority of models do not show significant improvements in quality.” Smith identified “inflated benchmarks” — in which providers wildly overestimate what they expect a patient will cost — and providers’ ability to “game” the payment models as key drivers of losses for the government. Smith expressed hope for direct contracting as a fix, though the project’s critics note it has the same elements.

Smith, able to spot a good business opportunity, launched a health care company, Russell Street Ventures, in June. That company is now directly contracting with Medicare. Smith did not respond to a request for comment. In October 2020, when the direct contracting program was in its early implementation phase, Smith indicated on a panel with Boehler and another former CMMI head, Patrick Conway, that in the program’s early stages the firms that had “come into that space that [were] running the program” were mostly “new and mid-stage companies” — like his firm and those founded by Boehler. Conway noted that he had recruited Boehler to the job, just as Boehler had recruited Smith. As Boehler added during the panel, the trend is bipartisan. Andy Slavitt, Obama’s head of CMS and an outspoken resistance Democrat, has now linked up with Oxeon – the same VC firm that was funding Boehler – for his own direct contracting enterprise.

The latest privatization scheme echoes the Medicare Advantage system, the private-insurer-run version of Medicare currently used by over 40 percent of enrollees.

Direct contracting uses a model that, in theory, pays firms for maintaining the overall health of a patient rather than billing Medicare for individual medical services. Critics argue that the latter model, which is currently used for standard Medicare enrollees, incentivizes unnecessary hospital visits and treatments. But the former model, which is referred to as value-based contracting, requires complex bureaucratic oversight to ensure that providers are not juking the system by unreasonably inflating the cost and difficulty of caring for a patient.

Medicare Advantage also currently uses a version of the value-based contracting model, but the design failures of the program have led to significantly higher costs than under the traditional Medicare fee-for-service model — with little evidence to support the claim that patients are receiving better care. This is because of the insurer payment formula for Medicare Advantage, which largely depends on the number of diagnoses each patient has received, or their “risk score.”

An entire cottage industry has popped up to help insurers and providers increase a patient’s risk score by scouring for potential diagnoses before patients enroll in Medicare Advantage plans. By finding more diagnoses, whether treatable or not, the annual reimbursement rate under the value-based contracting model increases. Experts have estimated that the resulting overpayments will lead to hundreds of billions of dollars in cost overruns over the next several years. While technocratic fixes to the formula could fix many of the problems plaguing the Medicare Advantage program, Congress and executive branch appointees have so far been unwilling to stomach the political risks posed by large-scale interruptions to the care of Medicare enrollees that would be necessary to combat the wasteful spending generated by privatization.

In a paper published in September, Richard Gilfillan, the head of CMMI from 2010 to 2013, and Donald Berwick, a former head of Centers for Medicare and Medicaid Services, or CMS, during the Obama administration, warned that many of the waste-generating elements of Medicare Advantage programs would carry over to direct contracting. While the direct contracting pilot adjusts the formula for payments to blunt the impact of risk-score gaming, it is unclear whether these adjustments are sufficient to end the practice. Adjusting each firm’s scoring downward by an equal amount punishes firms behaving honestly, they argued, and rewards the firms who hire consultants to game the coding exercise. That puts the government’s thumb on the scale of the most aggressive coders.

“In Direct Contracting, CMS established a stated aim of bringing ‘organizations that currently operate exclusively in Medicare Advantage’ into traditional Medicare, targeting the very MA insurers and investor-controlled provider firms that are driving the MA overpayments,” Gilfillan and Berwick noted, specifically mentioning Oak Street Health and Landmark Health, which Boehler previously ran, as examples of investor-controlled provider firms. (Gilfillan himself is CEO of Trinity Health, a major player in the healthcare industry.)

Diane Archer, founder of Just Care and a health policy expert, described a similar scenario in an email to The Intercept. “The way they make money is by spending as little as possible on patient care, while ensuring as best they can that they have all diagnoses possible for their enrollees in order to maximize government payments. The more diagnoses, the higher the government payments. Government payments are set upfront and unrelated to the cost or number of services people receive.”

“And, yes, the incentive is to deny as much care as possible,” she continued, “it’s also to delay as much care as possible and to create administrative and financial barriers that make it hard for enrollees to get care, even if the DCE does not delay or deny care,” she said, referring to direct contracting entities approved to participate in the program.

Aside from the looting of public funds and the depreciation of care, the shift toward privatization has profound implications for the political economy of health care. Every new private equity or venture capital-backed firm that grabs a bigger piece of the health care market becomes an incumbent corporate stakeholder and a well-funded obstacle to public-minded reform efforts.

Throughout the medical industry, physician practices, hospitals, and groups of specialists are being bought up by investors and consolidated. In the direct contracting space, much of the funding is coming from venture capitalists, but private equity has gotten involved as well.

CanoHealth, a private-equity backed firm, told investors in a presentation that as of April 2021 it had added direct contracting to its existing Medicare Advantage business model. More than half of Medicare recipients have declined to opt in to the privatized Medicare Advantage model, and CanoHealth noted that becoming a direct contracting entity massively expands the company’s potential pool of customers, saying it “triples the addressable market opportunity.” (More recent estimates put the number of Medicare Advantage enrollees higher, at 42 percent.)

The entrance of big private money can be damaging to patient health. A recent study of private equity influence in nursing homes found that residents under the care of a private equity-owned facility were a startling 10 percent more likely to die.

At the center of this privatization project now that Joe Biden is in the White House is Liz Fowler, who was previously the lead health care staffer for former Sen. Max Baucus, D-Mont., who drafted massive chunks of the Affordable Care Act. Fowler was in the trenches battling progressives over the shape and construction of Obamacare, and before that, she had been a top lobbyist for the insurance company WellPoint. After that, she went on to work for Johnson & Johnson. Now she’s back in government, as the deputy administrator and director of CMMI, the innovation agency created by the law she helped write, and people involved in the fight over this project say she’s a strong backer of direct contracting. Fowler did not respond to a request for comment.

In May, four Democrats in Congress — Reps. Bill Pascrell, Mark Pocan, Katie Porter, and Lloyd Doggett — sent a letter to CMMI and to Health and Human Services Secretary Xavier Becerra, who is himself a supporter of Medicare for All, asking for the program to be frozen due to concerns that “funneling people into Medicare Advantage-like plans not only eliminates beneficiary choice, but also erects more barriers and provides fewer consumer protections for beneficiaries.”

In a sign of how big direct contracting has gotten, it has its own lobby now. The Direct Contracting Coalition, which operates as part of America’s Physician Groups, sent a letter in response, arguing that the critics don’t understand how much it can help beneficiaries and cut costs for the government.

The Biden administration paused implementation of two of the three models for direct contracting earlier this year, but there is no indication the administration intends to halt the program altogether. Archer, the health policy expert, said that the path toward a full privatization of Medicare is now apparent if the Biden administration doesn’t change course. “The private equity takeover is short term,” she predicted. “PE will sell their DCEs to insurers. We’ll get fully privatized Medicare, unaccountable and far less cost-effective. Traditional Medicare will wither on the vine.”

https://theintercept.com…

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2021 – Revelations, Resolve, Resistance

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