S.T.

Oct 2 2022 This commentary was written by Laura Waters, a retired environmental consultant living in South Burlington.

I saw the recent article in VTDigger about the state employees union fighting the state's plan to go to Medicare Advantage and felt compelled to respond with our recent experience. There are way too many glib sales pitches for Medicare Advantage that hide the “inconvenient truth” about these plans. A recent Health and Human Services report stated that Medicare Advantage plans deny millions of requests for medical care each year and tens of thousands of those denials are for tests and treatments that should have been approved and paid for and would have been paid for if the insured had been covered by traditional Medicare.

In the VTDigger article, Beth Fastiggi, commissioner of the Vermont Department of Human Resources, stated that “A lot of the negative information regarding Medicare Advantage is not necessarily regarding group MA plans” However, my 93-year-old parents are on United Healthcare Medicare Advantage that was negotiated for Bank of America employees, which was supposed to be better than the UHC Medicare Advantage regular plan.

Well, we just had a horrible experience with UHC Medicare 😈 Advantage denying coverage for my dad after he broke his hip and needed to be in rehab for 4-6 weeks. UHC determined that after 2 weeks he was ready to be discharged to his independent living apartment. This was someone who couldn’t even get out of bed without two aides and a Sara Stedy lift for his sit/stand transfers. I immediately appealed the decision which goes into a black hole with an “independent” organization, Kepro, that has an “independent” doctor review their decision. When you go through the appeal process, they make it as difficult as possible to engage since the appeal goes to Kepro which, of course, has every incentive to find ways to deny coverage. The patient and family have absolutely no way to engage with anyone with Kepro to have a meaningful conversation about the needs of the insured. The mysterious Kepro doctor denied my dad’s coverage and when I asked why, the person who called me told me that they didn’t know. The only recourse I had was to re-appeal the decision.

The denial went into effect on Saturday night, so it was impossible to get any information about why he was denied because Kepro wouldn't (couldn't) email me the doctor's letter. I had to wait until the following Monday to go to the rehab facility to collect the information. To make matters even more anxiety-ridden, I only had until 11:00 on Monday to respond with the “family letter.” If I missed the deadline, they would not accept my attached response detailing our concerns.

As I was trying to navigate this impossible process, I got in touch with Vermont Legal Aid and was told that since it is a Medicare Advantage plan they couldn't help us since it was completely outside of state regulations.

Most of the folks in the state government who are advocating for this change are not old enough to have Medicare and are only parroting the talking points of the for-profit insurance companies. From our experience, Medicare Advantage works until you really need it — and that is what they are telling us at the rehab facility. They told us that we would never have been denied coverage for my dad if he had been in traditional Medicare. Once you are elderly or very ill, needing complicated or expensive tests and treatment, they do everything they can to deny coverage so they don't have to pay.

After many, many hours of battling UHC and Kepro, we did prevail and he was allowed to stay until the end of September. However, I had the time and ability to take on this fight. What the insurers are counting on is that folks will give up and they won’t have to pay. 
https://vtdigger.org/2022/10/02/laura-waters-my-experience-with-medicare-advantage/

Real Progressives

October 13, 2022 Economic Justice, Health and Well-being

BY CORY DOCTOROW



Obamacare was poisoned aborning.

The American healthcare system is the worst of all possible worlds. Unlike every other wealthy country, the US leaves its health insurance to the private sector, where your health and your life are a distant second to shareholder profits. But it’s worse, because the majority of the money those terrible, “private” insurance companies “earn” comes from public subsidies.

In other words, the US has a privately run health care sector that is publicly financed, without any public accountability or duty to the public good. Insurance companies take ever more billions from the federal government and deliver ever less care to their customers.

Cigna-exec-turned-whistleblower Wendell Potter has just published a new report that breaks down share of federal subsidies in the largest US insurers’ bottom lines:

• Humana: 91%
• Molina: 89%
• Centene: 86%
• Aetna: 73%
• Unitedhealth: 72%
• Elevancehealth: 68%
• Cigna: 42%

https://wendellpotter.substack.com/p/the-majority-of-big-insurers-health

See that? The vast majority of US insurers’ income is public funding. That’s because of Medicare Advantage, a privatized Medicare service that 27 million older people have been tricked into signing up for, which consistently delivers worse service with higher out-of-pockets, while billing the US government for billions.

You should not sign up for Medicare Advantage, nor let anyone you love do so. Medicare Advantage will deny you care you are entitled to and leave you to sicken and die, while draining the last of your savings in co-pays:

https://www.nytimes.com/2022/04/28/health/medicare-advantage-plans-report.html

The insurers aren’t done. They raised their prices by 24% in a single year:

https://wendellpotter.substack.com/p/the-price-of-health-insurance-has

Despite these massive profits, spiraling fees, and mounting premiums, the Biden admin is on track to let the insurers raise their prices again, though not by as much as originally announced:

https://www.cnn.com/2022/09/27/politics/medicare-premiums-biden/index.html

You don’t have to be on Medicare to be part of the health insurance scam. If you’ve got an Obamacare subsidy, you are helping to transfer billions in public money to insurers, even as these ACA plans grow steadily worse. ACA plans deny one in five claims:

https://www.kff.org/private-insurance/issue-brief/claims-denials-and-appeals-in-aca-marketplace-plans/

Meanwhile, the out-of-pocket expenses your ACA insurer can rook you for just went up to $14,700/year:

https://www.healthcare.gov/glossary/out-of-pocket-maximum-limit/#:~:text=For%20the%202022%20plan%20year,and%20%2417%2C400%20for%20a%20family.

ACA coverage is so poor that many of the people paying for it are best understood as “functionally uninsured”:

https://www.forbes.com/sites/forbesbusinessdevelopmentcouncil/2022/07/27/functionally-uninsured-the-fiction-of-healthcare-coverage/?sh=5e6547a2680b

ACA was sold as a brokered compromise between public healthcare advocates and private healthcare cultists. It created a situation where private insurers could grow larger, more powerful, more profitable, and less accountable to government, patients or doctors, so that care would steadily erode and prices mount.

ACA set the stage for Medicare privatization through Medicare Advantage. It was the template for the public-private-partnership from hell, teeing up a future where we finally get the wildly popular Medicare For All, but delivered by the same murdering profiteers who run the private system it was supposed to replace: Medicare Advantage For All.

As David Sirota writes in The Lever, Biden’s 2020 campaign recognized this, and promised us a public option where “premiums could be substantially lower than those of private plans,” but “Biden hasn’t once mentioned a public option since becoming president.”

https://www.levernews.com/health-insurers-get-government-cash-then-jack-up-prices/

When Congress votes to give billions in public money to the health insurance industry, it also votes to give millions to itself — our legislature is awash in health insurance company dark money, and Democrats — including members of the Progressive Caucus — are carrying its water:

https://bettermedicarealliance.org/wp-content/uploads/2022/01/final_2022_house_ma_letter_.pdf

Giving for-profit insurance companies more public money will not translate into better care. The CEOs of every one of those publicly subsidized insurance companies took home more than $20 million in pay last year. 86% of Centene revenues came from the public coffers. Its (recently deceased) CEO Michael Neidorff paid himself $20.6 million.

It doesn’t have to be this way. We know how to fix this. Biden laid it out in 2020:

Giving Americans a new choice, a public health insurance option like Medicare. If your insurance company isn’t doing right by you, you should have another, better choice. Whether you’re covered through your employer, buying your insurance on your own, or going without coverage altogether, Biden will give you the choice to purchase a public health insurance option like Medicare. As in Medicare, the Biden public option will reduce costs for patients by negotiating lower prices from hospitals and other health care providers. It also will better coordinate among all of a patient’s doctors to improve the efficacy and quality of their care, and cover primary care without any co-payments. And it will bring relief to small businesses struggling to afford coverage for their employees.

https://joebiden.com/healthcare/

People are angry at their insurers, and justifiably so. Cigna isn’t just raising prices and co-pays, it’s committing mass-scale fraud: “exaggerat[ing] the illnesses of its Medicare members to obtain higher payments from the federal government.” Also credibly accused of Medicare fraud: Unitedhealth and Elevance.

https://www.modernhealthcare.com/insurance/doj-joins-cigna-medicare-advantage-fraud-case

In 2019, I published Radicalized, a collection of four novellas subtitled “four tales of our present moment.” The title story, “Radicalized,” was frightening and upsetting to write, but I couldn’t stop myself. It’s a story about angry men who watch the people they love the most slowly and agonizingly murdered by care-denying insurance companies, who meet on message boards where they plot to murder health-care executives.

https://us.macmillan.com/books/9781250228598/radicalized

Having grown up in Canada and then spent more than a decade in the UK — and now become a US citizen — it’s incredible to me that Americans tolerate this ghastly, worsening system. Not that I want to see terrorist violence! The very idea is sickening and terrifying.

But it is baffling to me that there are Americans who shoot each other over road-rage and yet as far as I know, the $20m/year vampire CEOs of profiteering, fraud-addicted insurance companies are living in comfort and safety.

It’s one of the great paradoxes of the American psyche: all of that macho, don’t-tread-on-me posturing turns to vapor when the person who’s literally condemning your family to die is a distant corporate executive.

All that anger has to be out there, somewhere, channeled by cynical operators into scapegoating and nihilism. It’s a ticking time-bomb. Imagine the political win that would accrue to the party that made saving your life and the lives of the people you love its political centerpiece. A party that met astroturf with naming names, hauling insurance execs into Congress to confront grieving mothers, fathers, children and spouses. A party that refused to let Lucy yank the football again with a “compromise” that gives us a privately managed, publicly funded service that only serves shareholders and executives.

Originally published on the author’s Medium blog.
https://realprogressives.org/us-health-insurers-get-more-and-more-federal-funding-deliver-less-and-less-care/

January 13, 2023 This commentary is by Dr. Deborah Richter, M.D., a practicing family physician in Cambridge, Vt. She lives in Montpelier.


Legislative leaders have already laid out their agenda for this session. Despite the dire state of health care for the almost half of Vermonters under age 65 who are “underinsured,” it is clear that they have no intention of doing anything meaningful to address the state’s health care crisis.

Underinsured is an abstract idea that is easy to dismiss, but it has serious, potentially deadly real-life consequences. The underinsured 😞 have two alternatives when they are sick:

► Delay care and risk their health.
► Pay for care and risk falling into debt, getting evicted, etc.

Delaying care can cost them 🥵 dearly. Two examples:

► A diabetic with a huge deductible fails to get routine checkups and ends up needing a foot amputation.
► A person with a high fever and shortness of breath waits days to seek care and dies of bacterial pneumonia.

The other alternative, paying for care you can’t afford, also costs them dearly. That’s how “around 30,000 Vermonters” ended up with medical debt turned over to collection agencies, while “tens of thousands more … are paying down medical bills” that have yet to be turned over to collections.

If you want to see what medical debt does to your life, read over some of the stories collected by the state’s health care advocate. Medical debt has dramatic effects on these people’s lives, from ruined credit to skimping on food to postponing retirement. It goes without saying that these people avoid getting future medical treatment for fear of running up even more debt.

This kind of deciding between a rock and a hard place goes on every day in Vermont. It amounts to the worst, most unfair kind of health care rationing. 🥺

Why do we allow it? Here are the excuses we hear from some of our 💵🎩 legislators:

Excuse 1: Because Medicare and Medicaid are federally directed, we can’t change the rules they have in place.

This is simply not true. Waivers of federal rules are very common in Vermont and other states. In Vermont, VHAP, Dr. Dynasaur, and the all-payer model and the accountable care organization running it all operate under waivers of federal rules. And anyone watching the recent circus in Washington knows that we cannot expect a national universal health care system anytime soon.

Excuse 2: We don’t have enough primary care clinicians and expanding coverage would just make this worse.

Again, not true. Implementing universal primary care would be a magnet drawing primary care clinicians to this state. Including all patients in one program, with one set of rules and regulations rather than hundreds they now face, would vastly reduce the amount of time and effort they are forced to spend on administrative tasks.

Few people outside the medical profession appreciate how heavy that burden is now: 15.9 hours a week for family medicine doctors, according to a 2020 survey.

Excuse 3: It is too expensive to expand coverage to everyone.

In fact, we already spend more than enough to provide comprehensive care to all Vermonters. That has been shown in study after study.

mplementing a universal system would save massive amounts — as much as $1 billion, according to some studies.

Excuse 4: We need to address cost of care before expanding access.

The truth is that we will never be able to make health care affordable until we implement a universal access system. First, keeping people out of the current system is administratively very costly, as discussed above. Second, our current system encourages delayed care, which ends up costing more because people get 🤧🤒🤮🤢🤕 sicker during the delay.

​Note that these arguments against needed reforms are generalities while avoiding real reform inflicts very specific and extensive damage on a large portion of Vermonters.

Everyone agrees that health care needs to be fixed. Admittedly it is a gargantuan task to try to fix the whole system at once. After all, health care is nearly 20% of the Vermont economy with big, entrenched 💵🎩 “stakeholders” who exercise considerable influence over what legislation gets “moved” in the Legislature.

So why not start with a smaller piece: Universal primary care.

That makes primary care — including mental health and substance use disorder services — a public good, like police protection and firefighting. Commercial insurers would no longer have to pay the cost of primary care, and premiums would be reduced accordingly.

Universal primary care is a small but important piece of the answer. It comes with a small price tag for taxpayers — less than 6% of total spending — and that is offset by lower premiums. But it would make a big difference. Everyone needs primary care, even healthy people.

Make no mistake: This legislation is within the power of the Vermont Legislature. Ask your legislators to support universal primary care.
https://vtdigger.org/2023/01/13/dr-deborah-richter-yes-we-can-do-something-about-vermonts-health-care-crisis/

👉 Graphics and emojies by AGelbert. 👈


September 2, 2024 by Fred Schulte, KFF Health News


A decade ago, federal officials drafted a plan to discourage Medicare Advantage health insurers from overcharging the government by billions of dollars -- only to abruptly back off   amid an "uproar" from the 🐷🎩 industry, newly released court filings showed.

The Centers for Medicare & Medicaid Services (CMS) published the draft regulation in January 2014. The rule would have required health plans, when examining patients' medical records, to identify overpayments by CMS and refund them to the government.

But in May 2014, CMS 🐷🎩 dropped the idea without any public explanation. Newly released court depositions show that agency officials repeatedly cited concern about pressure from the industry.

The 2014 decision by CMS, and events related to it, are at the center of a multibillion-dollar Department of Justice (DOJ) civil fraud case against 🐷🎩 UnitedHealth Group pending in federal court in Los Angeles.

The Justice Department alleged the giant health insurer 😈 cheated Medicare out of more than $2 billion by reviewing patients' records to find additional diagnoses, adding revenue while ignoring overcharges that might reduce bills. The company "buried its head in the sand and did nothing but 😈 keep the money," the DOJ said in a court filing.

Medicare pays health plans higher rates for sicker patients but requires that the plans bill only for conditions that are properly documented in a patient's medical records.

In a court filing, UnitedHealth Group denied wrongdoing and argued it shouldn't be penalized for "failing to follow a rule that CMS considered a decade ago but declined to adopt."

This month, the parties in the court case made public thousands of pages of depositions and other records that offer a rare glimpse inside the Medicare agency's long-running struggle to keep the private health plans from taking taxpayers for a multibillion-dollar ride.

"It's easy to dump on Medicare Advantage plans, but CMS made a complete boondoggle out of this," said Richard Lieberman, a Colorado health data analytics expert.

Spokespeople for the Justice Department and CMS declined to comment for this article. In an email, UnitedHealth Group spokesperson Heather Soule said the company's "business practices have always been transparent, lawful, and compliant with CMS regulations."

Missed Diagnoses

Medicare Advantage insurance plans have grown explosively in recent years and now enroll about 33 million members, more than half of people eligible for Medicare. Along the way, the industry has been the target of dozens of whistleblower lawsuits, government audits, and other investigations alleging the health plans often exaggerate how sick patients are to rake in undeserved Medicare payments -- including by doing what are called chart reviews, intended to find allegedly missed diagnosis codes.

By 2013, CMS officials knew some Medicare health plans were hiring medical coding and analytics consultants to aggressively mine patient files -- but they doubted the agency's authority to demand that health plans also look for and delete unsupported diagnoses.

The proposed January 2014 regulation mandated that chart reviews "cannot be designed only to identify diagnoses that would trigger additional payments" to health plans.

CMS officials backed down in May 2014 because of "stakeholder concern and pushback," Cheri Rice, then director of the CMS Medicare Plan Payment Group, testified in a 2022 deposition made public this month. A second CMS official, Anne Hornsby, described the industry's reaction as an "uproar."

Exactly who made the call to withdraw the chart review proposal isn't clear from court filings so far.

"The direction that we received was that the rule, the final rule, needed to include only those provisions that had wide, you know, widespread stakeholder support," Rice testified.

"So we did not move forward then," she said. "Not because we didn't think it was the right thing to do or the right policy, but because it had mixed reactions from stakeholders."

The CMS press office declined to make Rice available for an interview. Hornsby, who has since left the agency, declined to  comment.

But Erin Fuse Brown, JD, MPH, a professor at the Brown University School of Public Health in Providence, Rhode Island, said the decision reflects a pattern of timid CMS 🙊🙉🙈 oversight of the popular health plans for seniors.

"CMS saving money for taxpayers isn't enough of a reason to face the 👿 wrath of very powerful 🐷🎩 health plans," Fuse Brown said. "That is extremely alarming."

Invalid Codes

The fraud case against UnitedHealth Group, which runs the nation's largest Medicare Advantage plan, was filed in 2011 by a former company employee. The DOJ took over the whistleblower suit in 2017.

DOJ alleges Medicare paid the insurer more than $7.2 billion from 2009 through 2016 solely based on chart reviews; the company would have received $2.1 billion less if it had deleted unsupported billing codes, the government said.

The government argued that UnitedHealth Group knew that many conditions it had billed for were not supported by medical records but chose to pocket the overpayments. For instance, the insurer billed Medicare nearly $28,000 in 2011 to treat a patient for cancer, congestive heart failure, and other serious health problems that weren't recorded in the person's medical record, DOJ alleged in a 2017 filing.

In all, DOJ contends that UnitedHealth Group should have deleted more than 2 million invalid codes.

Instead, company executives signed annual statements attesting that the billing data submitted to CMS were "accurate, complete, and truthful." Those actions violated the False Claims Act, a federal law that makes it illegal to submit bogus bills to the government, DOJ alleged.

The complex case has featured years of legal jockeying, even pitting the recollections of key CMS staff members -- including several who have since departed government for jobs in the industry -- against those of UnitedHealthcare executives.

'Red Herring'

Court filings described a 45-minute video conference arranged by then-CMS Administrator Marilyn Tavenner on April 29, 2014. Tavenner testified she set up the meeting between UnitedHealth and CMS staff at the request of Larry Renfro, a senior UnitedHealth Group executive, to discuss implications of the draft rule. Neither Tavenner nor Renfro attended.

Two 🐷🎩 UnitedHealth Group executives on the call said in depositions that CMS staffers told them the company had no obligation at the time to uncover 😉😈💰 erroneous codes. One of the executives, 🐽 Steve Nelson, called it a "very clear answer" to the question. Nelson has since left the company.

For their part, four of the five CMS staffers on the call said in depositions that they didn't remember what was said. Unlike the company's team, none of the 🙊🙉🙈 government officials took detailed notes.

"All I can tell you is I remember feeling very uncomfortable in the meeting," Rice said in her 2022 deposition.

Yet Rice and one other CMS staffer said they did recall reminding the executives that even without the chart review rule, the company was obligated to make a good-faith effort to bill only for verified codes -- or face possible penalties under the 😇😉 False Claims Act. And CMS officials reinforced that view in follow-up emails, according to court filings.

DOJ called the flap over the ill-fated regulation a "red herring" in a court filing and alleged that when UnitedHealth asked for the April 2014 meeting, it knew its chart reviews had been under investigation for 2 years. In addition, the company was "grappling with a projected $500 million budget deficit," according to DOJ.

Data Miners

Medicare Advantage plans defend chart reviews against criticism that they do little but artificially inflate the government's costs.

"Chart reviews are one of many 😈 tools Medicare Advantage plans use to support patients, identify chronic conditions, and prevent those conditions from becoming more serious," said  Chris Bond, a 🐍 spokesperson for AHIP, a 🐷🎩 health insurance trade group.

Whistleblowers have argued that the cottage industry of analytics firms and coders that sprang up to conduct these reviews pitched their services as a huge moneymaking exercise for health plans -- and little else.

"It was never legitimate," said William Hanagami, a California attorney who represented whistleblower James Swoben in a 2009 case that alleged chart reviews improperly inflated Medicare payments. In a 2016 decision, the 9th Circuit Court of Appeals wrote that health plans must exercise "due diligence" to ensure they submit accurate data.

Since then, other insurers have settled DOJ allegations that they billed Medicare for unconfirmed diagnoses stemming from chart reviews. In July 2023, Martin's Point Health Plan, a Portland, Maine, insurer, paid $22,485,000 to settle whistleblower allegations that it improperly billed for conditions ranging from diabetes with complications to morbid obesity. The plan denied any liability.

A December 2019 report by the HHS Inspector General found that 99% of chart reviews added new medical diagnoses at a cost to Medicare of an estimated $6.7 billion for 2017 alone.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF -- an independent source of health policy research, polling, and journalism.

SGA_MD September 2, 2024
Health care dollars going to executives and shareholders instead of patients or health care professionals. This is the flawed American system of haves and have nots and nobody will do anything about it.

EwMPH > SGA_MD September 2, 2024
Then they better do something, because the whole system is going to collapse 😟. Advantage 😈🐷🎩 plans do not provide healthcare, they play games that hold off doctor time and as much care as they can, Patients to 😈 them are just pockets of gold.

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https://www.medpagetoday.com/publichealthpolicy/medicare/111723