PNHP

Why Antitrust Enforcement Can Only Go So Far in Health Care

Why Antitrust Enforcement Can Only Go So Far in Health Care

Executive Order on Promoting Competition in the American Economy, The White House, July 9, 2021

Stop Playing Health Care Antitrust Whack-A-Mole, Bill of Health, May 17, 2021, by Jaime S. King

The Sleeper Health Cost Policy, KFF, July 22, 2021, by Drew Altman

Comment:

By Allison K. Hoffman, J.D. and Hannah Leibson

In early July, the Biden Administration issued this high-level executive order focused on promoting competition in the American economy. The order urged the FTC and DOJ to significantly ramp up antitrust enforcement to prohibit future mergers and divest existing anti-competitive arrangements.

The order states in part, “whereas decades of industry consolidation have often led to excessive market concentration, this order reaffirms that the United States retains the authority to challenge transactions” in violation of the antitrust laws.

The problem is that it’s likely too little too late for health care.  For the past few decades, health care consolidation has been on the rise.

Jaime S. King points out that the rate of consolidation has increased so dramatically that up to 95 percent of metropolitan areas have highly concentrated hospital markets. Private equity investment has driven much of this trend.

As Drew Altman explains, consolidation is negatively impacting quality of care and significantly driving up health care costs for consumers—as much as 50 percent in some hospital systems. When one or two large hospital systems are running the show in a city or region, insurers don’t have any leverage to negotiate lower prices. Consumers have no choice but to pay the higher prices or travel far distances to seek care.

Things like choices of insurance plans or transparency, both mentioned in the Biden Executive Order, will not solve these structural problems on their own. In the months ahead, the impact of COVID-19 will likely accelerate consolidation in many economically disadvantaged regions where hospitals are already deep in the red.

Amped up antitrust enforcement will only go so far in health care, especially considering thin government resources. It could prevent further consolidation. More aggressively, the administration could review merged entities and unravel those that have proven anticompetitive.

All of these measures could be beneficial, but ultimately, comprehensive price regulation is the only way to control the rising health care costs associated with provider consolidation. As Altman highlights, drugs comprise just 10% of health care spending while hospitals represent a whopping 34%. More and more, physician groups are also merging or are affiliating with hospitals and will benefit from their hefty negotiating power to command higher prices.

One option is a federal all-payer system to set price caps or limits on total hospital spending. It could eliminate the large gap between Medicare rates and those commercial insurers are forced to accept in highly consolidated hospital markets. Medicare for All is another means to set rates federally, in one fell swoop, and it would also eliminate the administrative costs associated with having many different payors.

Another option is rate setting at the state level, but this approach would be more difficult to enact and less coordinated. The state of Maryland already has such a model in place, and has seen positive outcomes since it was launched by CMS as a pilot program in 2014. From 2014 to 2019, Medicare spending in Maryland fell 2.8 percent and the state has seen a 4.1 percent decrease in total health care costs. Alongside these cost savings, quality benchmarks across several dimensions have surpassed expectations. This model could inform policy design at the federal level, just as Massachusetts’s reform informed the design of the Affordable Care Act.

Antitrust enforcement is but one piece of the puzzle of controlling health care price inflation, and, unless the FTC and DOJ aggressively unwind the consolidation of the past decades, it is only a very small piece.

http://healthjusticemonitor.org…

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If the policy is right & the politics are wrong, change the politics!

Newsletter Opinion, The New York Times, August 3, 2021, by Paul Krugman

When you’re a wonk trying to be a pundit — or for that matter any kind of technocrat who wants to have real-world influence — it’s usually not helpful to push for policies that you believe would be right in principle but have no political chance of becoming reality.

The prime example for me has been health insurance. If our goal is to make sure that everyone has adequate, affordable health care, why not just pay for everyone’s care? On policy grounds, I’ve never disagreed with the proposition that we should have Medicare for all; there’s even a pretty good case for direct provision of medical care along the lines of Britain’s National Health Service. Why bother with a Rube Goldberg device like Obamacare, which uses regulations and subsidies to nudge private insurers into covering most people?

But the politics are impossible, and not just because of special interests: You’d have to persuade the 170 million Americans with private insurance to accept something completely different. Even though most of them would probably be better off, that’s too heavy a lift. So incremental reform, possibly evolving over time into single-payer, is how it’s going to have to be.

Virchow at 200 and Lown at 100 — Physicians as Activists, New England Journal of Medicine, July 22, 2021, by Salvatore Mangione, M.D., and Mark L. Tykocinski, M.D.

Current Surgeon General Vivek Murthy wrote in 2019 about the need for physicians to be guardians of integrity: “People will accuse us of being political, but if people accuse you of being political because you’re standing up for people who can’t stand up for themselves, then you should do it anyway, because that is at the heart of our profession.”

Comment:

By Don McCanne, M.D.

Anyone who has studied the subject realizes that a well-designed single payer system would provide equitable, high quality health care for everyone at a price that each of us could afford, paid for with progressive taxes. In principle, the concept is the moral imperative, but it does not mesh with the politics.

So what do we do? Like Paul Krugman, who represents the intellectuals who do understand, do we say that it is too heavy a lift? And then do we move on to insufficient and unsatisfactory tinkering? No, that is not right. The only right course is the one that accomplishes our goal of health care justice for all.

If the policy is right and the politics are wrong, you change the politics, not the policy. That would move us into the realm of politics, but, as Vivek Murthy said, since we’ll be standing up for people who can’t stand up for themselves, we should do it anyway. It’s simply the right thing to do.

http://healthjusticemonitor.org…

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Health care is a human right

By Judith L. Albert, M.D.
Pittsburgh Post-Gazette, Letters, August 4, 2021

I read with interest your recent opinion piece (July 11, “Unhealthy and unequal”). The author profiled in your piece, Brian Alexander, captured the essence of the failed health care “system” by describing health care as “first of all, not a system, but a haphazard labyrinth of chance.” I am in complete agreement that what we have is not a system, but not due to chance.

Actually, our health care insurance is working exactly as planned: private, for-profit health insurance companies collect premiums and make a profit by denying care to their subscribers. Americans bought the lie that health care could be governed by the market, but marketplaces are designed to ration goods, in this case medical care, based on the ability to pay. Nonprofit hospitals are constrained by these market forces: If their patients have comprehensive insurance coverage to pay for care, then the hospital does well.

Hospitals can invest their “excess revenue” in fancy buildings and equipment to attract more wealthy patients. If jobs, and therefore health insurance, leave a community, as in so many rural and rust belt areas, then community hospitals must provide care for free or for the lower reimbursement rates paid by Medicare and Medicaid, an unsustainable proposition that leads to insolvency.

Enough of the “stop-gap” reforms! What we need to establish is Medicare for All, a publicly funded, privately delivered actual health care system, as is proposed in the current House Bill 1976. Because health care is a human right.

https://www.post-gazette.com…

Dental Care Access for the Elderly: A Gaping Shortfall

Medicare and Dental Coverage, KFF, July 28, 2021, by Meredith Freed, et al.

Key Findings:

  • Nearly half of Medicare beneficiaries (47%), or 24 million people, do not have dental coverage, as of 2019.
  •  Almost half of all Medicare beneficiaries did not have a dental visit within the past year (47%), with higher rates among those who are Black (68%) or Hispanic (61%), have low incomes (73%), or who are in fair or poor health (63%), as of 2018.
  • Average out-of-pocket spending on dental services among Medicare beneficiaries who had any dental service was $874 in 2018. One in five Medicare beneficiaries (20%) who used dental services spent more than $1,000 out-of-pocket on dental care.

Comment:

By Isabel Ostrer, M.D.

The Medicare website explicitly reads, “Medicare doesn’t cover most dental care, dental procedures, or supplies, like cleanings, fillings, tooth extractions, dentures, dental plates, or other dental devices,” so it’s no wonder that a recent analysis by the Kaiser Family Foundation (KFF) found that 24 million Medicare beneficiaries lacked dental coverage in 2019. These disparities in access to dental care are even greater for non-white and low-income Medicare beneficiaries.

As Dr. Sanjeev Sriram said during a rally on July 30th marking the 56th anniversary of the Medicare program, “Your eyes, your ears, and your teeth are connected to your body… These things are not luxury items. Your teeth are not luxury items.” Why, then, in the richest country in the world, do we separate dental care from health care?

The simple answer boils down to an historical anomaly: dentistry has its roots in the barber profession – until the 1800s barbers routinely pulled painful teeth after they finished trimming a patron’s hair – and was consequently shunned by the medical profession. When the first medical schools were created dentistry was not recognized. Subsequently, when Medicare was enacted in 1965 dental services were not covered.

This history ignores that oral health is intimately tied to overall health and well-being. Dental pain is a leading reason for emergency department visits. Poor oral health is associated with numerous medical conditions, including cardiovascular disease and rheumatoid arthritis.

As Congress works towards passing a trillion dollar infrastructure bill that includes Medicare reform, adding vision, hearing, and dental benefits should be a top priority. But while we’re at it, we should push for sweeping health reform. Medicare for All would ensure that all Americans – not just seniors – have access to comprehensive benefits including dental coverage.

http://healthjusticemonitor.org…

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Physicians are unsuited as bill collectors

The Increasing Role of Physician Practices as Bill Collectors Destined for Failure, JAMA, July 30, 2021, by A. Jay Holmgren, et al.

Through increasing deductibles, coinsurance, and co-payments, the privately insured population in the US is responsible for a larger share of health care out-of-pocket costs. Although many studies have examined the effects on patients, the implications for physicians have received less attention. The increase in cost sharing is forcing many physicians and health systems to take on the role of bill collectors. It is a task for which physician practices are unsuited. The result is a system with substantial administrative burden, frustrated patients struggling with confusing bills, and physicians receiving less compensation.

Moving away from deductibles and toward fixed-dollar co-payments as a cost-sharing mechanism could simplify the billing experience for patients and the collection process for physicians while retaining the ability of payers to steer patients to lower-cost care with financial incentives.

Conclusion: The growth of cost sharing and HDHPs has resulted in patients’ taking on more of the cost of their own care and in physicians’ holding the risk and responsibility of collecting large dollar amounts. Physician offices are poorly suited to the task, exacerbating a complex and confusing system for patients and clinicians alike. New private firms have developed products to simplify, consolidate, and improve billing. However, these private-sector solutions may help ameliorate the problem but will not solve it. Only larger shifts in how out-of-pocket costs are envisioned will meaningfully address the burden of high out-of-pocket spending on both patients and physicians.

Comment:

By Don McCanne, M.D.

This JAMA Viewpoint article explains the burden of out-of-pocket cost sharing on both the patient and the physician – financial barriers for the patient, and a costly administrative burden for the physician.

Cost sharing can interfere with the delivery of care. High cost sharing may cause individuals to forgo beneficial health care. Even modest cost sharing can cause individuals with limited resources to forgo essential care. Also cost sharing has been a significant contributor to the expansion of medical debt with its associated bankruptcies. Cost sharing is detrimental to the goal of health care justice for all.

The purported reason is that the financial disincentives of cost sharing steer patients to lower-cost care. But do patients really shop cost-sharing prices? And would any modest differences have a significant impact on the total cost of care?

If we are trying to control health care spending, wouldn’t it be much more effective and efficient to institute administered pricing with a public plan? We should be able to get pricing right when the public administrators take into consideration both the legitimate costs and fair compensation for physicians, and the interests of the potential patients subjected to progressive taxes.

The authors acknowledge that physician offices are “poorly suited” to the task of collecting cost sharing payments, but the solution is not more of the same by moving from deductibles to co-payments. The solution is to dispense with patient cost sharing and move to universal, first dollar coverage, which would also eliminate the scourge of medical debt and save lives.

http://healthjusticemonitor.org…

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Medicare for All Explained Podcast: Episode 61

Interview with Miryam Weisberg

August 1, 2021

Tricare enrollee Miryam Weisberg describes the barriers she’s faced trying to access care through the program for members of the military, retirees, and their families. For example, she was told, “even though [Tricare] walks like insurance and quacks like insurance, they say it’s not insurance, so rules that are meant to govern insurance don’t apply to it.”

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

https://medicareforallexplained.podbean.com

For its 56th birthday, let’s improve Medicare

By George Bohmfalk, M.D.
Aspen (Colo.) Daily News, July 31, 2021

On July 30, 1965, President Johnson signed Medicare into law. Less than a year later, the vast majority of Americans over 65 were enrolled. Today Medicare is our most popular and efficient health insurance program.

Medicare has substantially improved older Americans’ health and decreased their rate of poverty, but it has several shortcomings that could be addressed in the huge budget reconciliation bill being formulated in Congress. While a full-on transition to Medicare for All would be the preferred solution, we should incorporate these incremental improvements as soon as possible.

Medicare doesn’t cover vision, hearing or dental care, each of which substantially affects other health issues, like arthritis and heart disease. Many Medicare enrollees who need hearing aids can’t afford them. In a recent year, most who had difficulty eating because their teeth hadn’t seen a dentist, and nearly half with vision problems hadn’t had an eye exam. To improve overall health and quality of life, Medicare should include vision, hearing and dental care.

Traditional Medicare pays only 80% of many charges and has no limit on out-of-pocket expenses. This is a huge economic burden for over half of Medicare enrollees, who live on less than $30,000 a year. With the average enrollee annually spending nearly $6,000 on out-of-pocket costs, medical debt and bankruptcy are ever-constant threats. Congress should place a reasonable cap on annual out-of-pocket costs.

Medicare is now available only to people over 65 and some with disabilities. A recent Stanford University study showed that, of people with cancer, those over 65 did better than patients in their early 60s. One might expect the younger group would fare better, but the factor benefitting the older group was having better access to health care, through Medicare. Lowering the eligibility age to 60 would extend the reliability and better outcomes of Medicare coverage to 23 million more Americans. Given the bipartisan support for doing so, Congress should lower the Medicare eligibility age to 60.

On average, Americans pay over twice as much for medications as do people in other countries. Medicare could save hundreds of billions of dollars by negotiating drug prices, which a previous Congress banned it from doing. As these savings could be used to pay for the other improvements, Congress should allow Medicare to negotiate drug prices.

The above improvements would extend beyond individual beneficiaries. The COVID-19 pandemic has both illuminated and aggravated unconscionable racial and ethnic health care inequities affecting millions of Americans. These improvements to Medicare would not erase any inequities, but they would substantially mitigate many of them. Businesses would also benefit, as they would no longer bear as large a burden of their employees’ health care costs.

Over 150 members of Congress signed a letter to President Biden requesting that the American Families Plan include these improvements to Medicare. If your representative is among them, please thank them. If not, ask them and your senators to support these improvements as a bill is developed.

Happy and healthy 56th birthday, Medicare! Short of expanding Medicare to cover everyone, there is no better way to celebrate it than to enhance the physical, emotional and financial health of older Americans by improving and expanding Medicare coverage.

Dr. Bohmfalk is a retired neurosurgeon in Carbondale and a member of Physicians for a National Health Program.

https://www.aspendailynews.com…

You Want Me to be Blind and Toothless?

Expanding Medicare coverage to hearing, vision and dental would alleviate the suffering of millions including this writer.

By Steven Wishnia
The Indypendent, July 31, 2021

Senator Bernie Sanders has introduced legislation to have Medicare cover dental, vision, and hearing care, along with other additions such as lowering the age of eligibility from 65 to 60. They would be included in a budget reconciliation bill to preclude a filibuster by Senate Republicans, which would be painfully inevitable if it were a standalone measure.

The legislation is “still a work in progress,” cautions Physicians for a National Health Program President Dr. Susan Rogers. But for me, it can’t come a moment too soon. What are three body parts and functions that almost universally deteriorate in older people? Their eyesight, their teeth, and their hearing. What kind of perversity would withhold care for that?

It’s personal. Medicare does not cover the dental work I need after decades of wear and tear on my adult teeth. That has run well into four figures over the last six months, a serious sum on a freelance writer’s income. I’ve been wearing glasses since I was seven-years-old but haven’t been to an eye doctor in almost three years. The last time I went, they tried to charge me almost $700 for a checkup and refused to negotiate. (My hearing is not too bad, especially considering that I’ve been playing amplified music for 50 years.)

What shocked me most when I turned 65 was how much Medicare cost. Basic coverage for doctors and a minimal private prescription-drug policy comes to about $170 a month. Medicare also covers only 80% of doctor and hospital expenses, and private insurance that would cover most — but not all — of the other 20% would bring the bill up to around $500.

The reason Medicare does not cover vision, dental or health is primarily because it was modeled on benefits provided by private insurance when it was enacted in 1965, says Dr. David Himmelstein, a professor of public health at Hunter College and longtime advocate of single-payer health care. Those benefits, largely provided by employers, were aimed at working-age people, he adds. Vision, dental and hearing care were omitted even though the elderly are more likely to need it, notes Rogers.

The 80/20 split was partially a compromise to defuse opposition from insurance companies, says Rogers, and partially, says Himmelstein, because there was a consensus in the health-policy community that “you needed to have some kind of barrier to keep people from seeking care they didn’t need.” But that 20% copayment, they say, was minimal in the 1960s. Since then, health care costs have inflated so much that it’s unaffordable.

Coverage for prescription drugs, also a relatively small expense in 1965, was not added until 2003.

Private Medicare Advantage plans, which began in 1997, often cover vision, dental, and hearing — but the catch is that they also often have a limited network of providers who accept them and people going outside that network will get billed for the full list price.

The free market simply doesn’t work for health care. The opportunity-cost principle that holds down the price of luxuries and limits most people’s overindulgence in them just doesn’t exist. For example, if I wanted to buy a Fender electric guitar, I’d have choices all along the range from a $220 Indonesian-made budget model to a $3,900 custom-made instrument, and I could save up for it or find a deal on a used one.

But if I break my leg, I can’t wait until Bellevue has a sale on orthopedics. If I get an infection, I’d be unlikely to find legitimate antibiotics on Craigslist.

The current U.S. system has two perverse pricing practices. It forces people to pay the most when they are least able to work to recoup those costs. And list prices are insanely inflated; Medicare and insurance companies negotiate them down dramatically but the person who’s uninsured or under-insured gets stuck owing the full rate.

The market also doesn’t work for selecting health insurance policies. “There’s no transparency in cost because the costs vary so much and you don’t know what you’ll need,” says Rogers. It is far too common that someone schedules a surgery with a hospital and a surgeon that accept their insurance, only to get whacked with a $7,000 bill because the anesthesiologist was out of network.

Insurance companies often argue that high copayments and “narrow networks” are necessary to save costs and discourage unnecessary use. The implication is that people must have “skin in the game” or else they would go to a podiatrist to get their toenails clipped. That hasn’t happened in any country with universal health care, says Rogers, and elderly Americans didn’t “flock to the doctor and overwhelm the system” when Medicare went into effect.

The fundamental choice the market demands is either you pay up or you go without important or essential care. This is both bad for public health and more costly in the long run, because people who go without such care will eventually need it for much more advanced ailments.

The proper metaphor isn’t “skin in the game,” but from The Merchant of Venice: “a pound of flesh.”

“The whole idea that the market can control costs is really erroneous. It hasn’t worked,” says Rogers. Instead, the money is “going to a system that offers profits for not providing health care.”

Medicare for All, in contrast, would have no premiums, no deductibles, and no copayments, says Nancy J. Altman, president of Social Security Works.

Having the Medicare program cover people 65 and older, she explains, was President Lyndon Johnson’s “fallback” to provide health care for the elderly after the national universal health care plan envisioned as the next step after Social Security proved politically impossible. President Harry Truman’s plan was blocked in the late 1940s, when the medical industry denounced it as “socialized medicine” and powerful Southern members of Congress feared it would force the desegregation of hospitals.

Adding vision, dental and hearing coverage, Altman says, “would be an excellent next step toward ensuring that health care is a right and not a privilege.”

It would also be an excellent political move, says Himmelstein: Obviously, the concept of expanding Medicare benefits for people who already have them “has a huge constituency” behind it.

Rogers, however, worries that coverage could be sanded down to inadequacy, such as paying only for routine dental care like cleaning, and not the more complex care older people need, such as partial bridges and crowns.

Medicare, “even though it was a legislative act, it required social movements to make it work. I think we have to remember that,” she says. If Medicare is expanded or Medicare for All enacted, she adds, “we’ll still need to continue social activism to make sure it works.”

And the alternative — as I’d ask anyone opposing adding vision and dental coverage: “You want me to be blind and toothless?”

https://indypendent.org…

Medical Debts Now Surpass All Others, and Likely Shorten Lives

Medical Debt in the US, 2009-2020, JAMA, July 20, 2021, by Raymond Kluender et al.

Data … were obtained from a nationally representative 10% panel of consumer credit reports between January 2009 and June 2020 (reflecting care provided prior to the COVID-19 pandemic)…

An estimated 17.8% of individuals had medical debt (13.0% accrued during the prior year), and the mean amount was $429 ($311 accrued during the prior year). The mean medical debt was highest in the South and lowest in the Northeast ($616 vs $167; difference, $448) and higher in poor than in rich zip codes ($677 vs $126). Between 2013 and 2020, states that expanded Medicaid in 2014 experienced a decline in the mean medical debt that was 34.0 percentage points greater (from $330 to $175) than the states that did not expand Medicaid (from $613 to $550).

Association of Wealth With Longevity in US Adults at Midlife, JAMA Health Forum, July 23, 2021, by Eric D. Finegood et al.

Higher net worth was associated with lower mortality risk (hazard ratio, 0.95). Among siblings and twin pairs specifically, a similar within-family association was observed between higher net worth and lower mortality (HR, 0.94), suggesting that the sibling or twin with more wealth tended to live longer than their co-sibling or co-twin with less wealth.

Comment:

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

In a series of studies dating back 16 years (see: here, here and here), we and our colleagues found that illness and medical bills are a leading cause of bankruptcy. Those findings, based on court records and surveys of debtors, have been derided by scholars funded by the health insurance industry (see our response to them here), and by leading health economists. Those critics have claimed that debtors can’t accurately identify the causes of their financial ruin, and have turned instead to statistical analyses that rest on unwarranted assumptions about who incurs medical debts and when those debts begin to accrue.

Kluender et al document the extraordinary frequency and size of medical debts. Even prior to the COVID-19 pandemic, more than one out of six Americans with a credit record had a medical bill in collection, with medical debts totaling about $140 billion – more than the total amount of all other debts in collection. As the authors acknowledge, that figure surely understates the magnitude of medical debts, e.g. it excludes medical bills charged to credit cards.

Kluender et al find that states that implemented the ACA’s Medicaid expansion reduced medical debts relative to non-expansion states. Yet even in expansion states Medical debts accounted for the majority of all debts in collection.

Finegood et al’s study suggests that debts have health as well as financial consequences. Even among genetically identical twins, lower net worth (assets minus debts) is a predictor of earlier death.

When journalist TR Reid asked policy leaders in other developed nations about the frequency of medical bankruptcy in their country he was generally met by blank stares; medical bankruptcy was virtually unknown. It’s high time that the US join the civilized world and abolish medical debt by implementing universal, first dollar health coverage.

http://healthjusticemonitor.org…

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Firefighters’ plight is another example of need for single payer health insurance

Local fight shows need for health care reform

By Jay Brock, M.D.
The (Fredericksburg, Va.) Free Lance-Star, Letters, July 29, 2021

There may be better examples of how dysfunctional our health insurance system is, but the difficulties of 15,000 Fredericksburg-area patients covered by health insurance giant Cigna who are in the unenviable position of having to change providers due to a contract dispute between Cigna and Mary Washington Healthcare [“Firefighters rally to get health care access back,” July 17] is certainly an apt one.

The problem? Our health insurance system is based on our for-profit health insurance industry, which is an exceptionally expensive—and entirely unnecessary—middleman that provides no care to anyone, but whose financial health, given our twisted system, must be protected at all costs. Even at the expense of the health of those 15,000 “covered lives.”

The solution? An entirely new health insurance system, one where the health of the patient, not the financial health of an insurance company, is paramount. American healthcare experts have for decades recommended switching to single payer Medicare for All health insurance to replace the current dysfunctional system that is directly responsible for the healthcare chaos now affecting those 15,000 folks.

But don’t look to our legislators in Congress to change much. Pleas to Representatives Wittman and Spanberger and Senators Kaine and Warner to prevent health insurance dilemmas like this one by supporting such a new system—one that puts patients first—have fallen on deaf ears: these four have so far failed to support any real health insurance reform, preferring instead to perpetuate the current system.

We can and must do better than that.

https://fredericksburg.com…

Medicare Advantage Skips Out on Paying for End-of-Life Care

Medicare Advantage: Beneficiary Disenrollments to Fee-for-Service in Last Year of Life Increase Medicare Spending, U.S. Government Accountability Office (GAO), June 28, 2021

Medicare Advantage (MA) beneficiaries in the last year of life disenrolled to join Medicare fee-for-service (FFS) at more than twice the rate of all other MA beneficiaries, GAO’s analysis found. MA plans are prohibited from limiting coverage based on beneficiary health status, and disproportionate disenrollment by MA beneficiaries in the last year of life may indicate potential issues with their care. Stakeholders told GAO that, among other reasons, beneficiaries in the last year of life may disenroll because of potential limitations accessing specialized care under MA.

Beneficiaries in the last year of life who disenrolled from MA to join FFS increased Medicare costs as they moved from MA’s fixed payment arrangement to FFS, where payments are based on the amount and cost of services provided. GAO’s analysis shows that FFS payments for such beneficiaries who disenrolled in 2016 were $422 million higher than their estimated MA payments had they remained in MA, and were $490 million higher for those that disenrolled in 2017.

Prior GAO and other studies have shown that beneficiaries in poorer health are more likely to disenroll from MA to join FFS, which may indicate that they encountered issues with their care under MA. Beneficiaries in the last year of life are generally in poorer health and often require high-cost care.

Comment:

By Eagan Kemp

This report is a bombshell — even when delivered in GAO’s typically understated style. Having been a senior analyst at GAO for more than a decade before coming to Public Citizen, I can tell you that it takes an overwhelming amount of substantiated evidence to state things as strongly as they do in this report.

The implications couldn’t be more clear and the profit motive more transparent. Medicare Advantage plans — as they also do with other high-cost patients in poor health — are finding ways to avoid paying the high costs of end-of-life care. They often do this through limiting access to specialized care through narrow networks or other unscrupulous means.

These vulture Medicare Advantage companies will stop at nothing to keep their profits high — including forcing beneficiaries and their families to jump through numerous hoops to disenroll from predatory Medicare Advantage plans and enroll back into traditional Medicare at the worst possible time. And all so that traditional Medicare is left to pay the bills instead of Medicare Advantage plans. I am not sure how these people sleep at night.

It should be no surprise that insurers do everything in their power to evade the one thing they are supposed to do: pay for the care their enrollees need. It is exactly why insurers were insanely profitable during the COVID-19 pandemic — by NOT paying for care.

If it wasn’t already clear by now, these findings drive home the point that insurers add nothing but misery and administrative hurdles for patients while raising the overall cost of the health care in America through massive waste, fraud, and abuse.

It is time to end their ability to hurt patients and reap insane profits. It is time for 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.