DIR Return Create A Forum - Home
---------------------------------------------------------
Sober Thinking
HTML https://soberthinking.createaforum.com
---------------------------------------------------------
*****************************************************
DIR Return to: Advances in Health Care
*****************************************************
#Post#: 557--------------------------------------------------
Medicare Advantage is Capitalist CORRUPTION of Medicare for
Greedball "Health" Insurance Corporations
DIR By: AGelbert
Date: October 3, 2022, 2:10 pm
---------------------------------------------------------
[center]
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-120422130903-68837.png[/center]
[center]Laura Waters: My
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-050422182057.gif<br
/>experience with Medicare Advantage[/center]
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.
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-050422145533-5671050.gif
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.
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-080422121157.gif
HTML https://vtdigger.org/2022/10/02/laura-waters-my-experience-with-medicare-advantage/
#Post#: 590--------------------------------------------------
Health Insurance Whistleblower: Medicare Advantage Is
"Heist" by Private Firms to Defraud the Public
DIR By: AGelbert
Date: October 12, 2022, 10:05 pm
---------------------------------------------------------
Oct 12, 2022
[center]Health Insurance Whistleblower: Medicare
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-040622210450-1415528.gif<br
/>Advantage Is "Heist" by Private Firms to
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-110422205132-6451602.gifDefraud<br
/>the Public[/center]
[center]
HTML https://youtu.be/YEgNxlrfygI[/center]
Democracy Now! 1.17M subscribers
Many of the nation's largest health insurance companies have
made billions of dollars in profits by overbilling the U.S.
government's Medicare Advantage program. A New York Times
investigation has revealed that under the Advantage program,
health insurance companies are incentivized to make patients
appear more ill than they actually are. Some estimates find it
has cost the government between $12 billion and $25 billion in
2020 alone. We speak with former healthcare insurance executive
Wendell Potter, now president ​​of the Center for
Health and Democracy, who says Medicare Advantage will be
recognized in years to come as the "biggest transfer of wealth"
from taxpayers to corporate shareholders, and blames the lack of
regulation over the program on the "revolving door between
private industry and government."
Democracy Now! is an independent global news hour that airs on
over 1,500 TV and radio stations Monday through Friday. Watch
our livestream at
HTML https://democracynow.org
Mondays to Fridays
8-9 a.m. ET.
Support independent media:
HTML https://democracynow.org/donate
Subscribe to our Daily Email Digest:
HTML https://democracynow.org/subscribe
#DemocracyNow
Paul Mezhir
No surprises here. I worked as a sales rep for a company that
operated New York State's first Medicare Advantage program. When
the plans were first introduced, the programs were far more
regulated and could only be operated as a not-for-profit
organization. The beginning of the end for Medicare Advantage
programs was in 2006, with the passage of the "Medicare
Modernization Act," which opened the field to for-profit
insurers like Cigna, Humana, Aetna and United Healthcare. The
Part D drug program was a massive giveaway to for-profit
Insurance companies and the Pharmaceutical and Pharmacy
industries. These companies have become fully integrated, owning
not only the insurance plans but also pharmacy benefits
management, pharmacies and even hospital ownership. It's pure
collusion and it does nothing but harm to Medicare-eligible
enrollees who are restricted by burdensome rules such as the
referral system to see acspecialist, denial of expensive
diagnostic imaging services, denial of care necessitated by
one's own doctor's orders. In some cases, the benefit is worse
even than what one would have if one had Medicare only.
And dont even get me started on the obscene amounts of profit
and/or extravagant salaries for those executives fortunate
enough to really rake in compensation that is easly higher than
doctors and even hospital administrators.
We already have a multi-tier system of death panels in this
barbaric country we live in.
#Post#: 653--------------------------------------------------
Re: Medicare Advantage is Capitalist CORRUPTION of Medicare for
Greedball "Health" Insurance Corporations
DIR By: AGelbert
Date: November 10, 2022, 11:00 pm
---------------------------------------------------------
Real Progressives
October 13, 2022 Economic Justice, Health and Well-being
BY CORY DOCTOROW
[center]
HTML https://realprogressives.org/wp-content/uploads/2022/10/radicalized-book-cover-image-cory-doctorow.jpg[/center]
[center]Radicalized Book cover[/center]
[center]US health insurers get more and more federal funding,
deliver less and less care
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-080422121435.png[/center]
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%
HTML 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. [b]Medicare Advantage[/b] 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:
HTML https://www.nytimes.com/2022/04/28/health/medicare-advantage-plans-report.html
The insurers aren’t done. They raised their prices by 24%
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-110422162337.gif<br
/>in a single year:
HTML 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:
HTML 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:
HTML 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:
HTML 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”:
HTML 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.”
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-080422121109.gif
[react]
HTML https://www.levernews.com/health-insurers-get-government-cash-then-jack-up-prices/[/react]
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:
HTML 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:
--- Quote ---
> 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.
--- End Quote ---
HTML 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.
HTML 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.
HTML 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.
HTML https://realprogressives.org/us-health-insurers-get-more-and-more-federal-funding-deliver-less-and-less-care/
#Post#: 753--------------------------------------------------
Medicare Advantage is Capitalist CORRUPTION of Medicare for
Greedball "Health" Insurance Corporations
DIR By: AGelbert
Date: January 1, 2023, 4:40 pm
---------------------------------------------------------
COUNTERPUNCH
DECEMBER 30, 2022 BY SANDRA M. FOX
HTML http://www.createaforum.com/gallery/renewablerevolution/3-080515182559.png
[center]
HTML http://renewablerevolution.createaforum.com/gallery/renewablerevolution/3-130418203402.gif<br
/>Architects of Medicare
HTML http://renewablerevolution.createaforum.com/gallery/renewablerevolution/3-040718162656-14241872.gif<br
/>Privatization: Congress, Biden and the CMS[/center]
SNIPPET:
Advocates for a national single-payer healthcare system in this
country, often referred to as Improved Medicare for All,
acknowledge the weaknesses in the current version of traditional
Medicare. While the federal government has allowed for perks to
beneficiaries in Medicare Advantage plans, including free gym
memberships and some (limited) dental and vision care, these
benefits are not available to those choosing traditional
Medicare. Why not? They are a clever way for private companies
to increase enrollment in their plans, in addition to lowering
their premiums, made possible through excessive payments
received from the Medicare Trust Fund to private insurers. So
far, Congress has not expanded those benefits to beneficiaries
in traditional Medicare, thus favoring for-profit companies.
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-080422121331.gif
The money is there to improve traditional Medicare and expand it
to cover all residents of the United States, as substantiated by
the Congressional Budget Office. But many elected officials on
both sides of the aisle will say otherwise and are compensated
by private health insurers with handsome campaign contributions.
Meanwhile, the Center for 🐍 Medicare and Medicaid
Innovation (CMMI), under the Center for Medicare and Medicaid
Services (CMS) within the Department of Health and Human
Services (HHS), was established as part of the 2010 Affordable
Care Act (ACA). According to its website,
“the CMS Innovation Center, through its models, initiatives and
Congressionally-mandated demonstrations, has accelerated the
shift from a health care system that pays for volume to one that
pays for value.”
The ACA also allowed CMMI to make changes without Congressional
oversight. And CMMI is determined to reframe privatization as
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-040622153114-13822364.jpeg<br
/>
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-040622202527-13931485.png<br
/>value-based care.
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-080422121109.gif
🐍 CMMI has been
HTML http://renewablerevolution.createaforum.com/gallery/renewablerevolution/3-250817135149.gif<br
/>quietly contracting with for-profit companies to engage in
“pilot programs” that insert middlemen into traditional Medicare
without the beneficiary’s consent and often without their
knowledge. The Trump Administration, which launched the
program, contracted with 53 for-profit middlemen called Direct
Contracting Entities (DCEs). The Biden Administration
re-branded the program ACO-REACH (Accountable Care Organizations
Realizing Equity, Access, and Community Health) and increased
the number of corporate participants to 99.
These participants include private health insurance companies as
well as private equity/venture capital firms, which can keep up
to 40% of Medicare dollars in administrative costs and profits
by “managing” patients’ healthcare. The supposed goal is to
lower costs through “value-based care.” We already know that
lowering costs in Medicare Advantage means delaying and denying
care by requiring prior authorizations, as well as restricting
provider networks. Furthermore, an excellent analysis by
healthcare policy experts Kip Sullivan, J.D. and James G. Khan,
M.D., refutes the premise of CMS that Accountable Care
Organizations will save money, given evidence of past
performance.
The intended goal is the complete privatization of Medicare by
2030, as posted on the
HTML http://renewablerevolution.createaforum.com/gallery/renewablerevolution/3-130418203402.gif<br
/>CMS website: “All Medicare fee-for-service beneficiaries will
be in a
HTML http://renewablerevolution.createaforum.com/gallery/renewablerevolution/3-251117175700.png<br
/>care relationship with accountability for quality and total
cost
of care by 2030.”
HTML http://renewablerevolution.createaforum.com/gallery/renewablerevolution/1/3-120818185038-1647640.gif<br
/>
HTML http://renewablerevolution.createaforum.com/gallery/renewablerevolution/1/3-210818163124-16681686.gif<br
/>Starting January 2023, the number of ACO-REACH programs
managing
the care of traditional Medicare beneficiaries is slated to
increase dramatically, from
HTML http://renewablerevolution.createaforum.com/gallery/renewablerevolution/1/3-250718205808.gif<br
/>99 to over
HTML http://renewablerevolution.createaforum.com/gallery/renewablerevolution/1/3-250718205137.gif<br
/>200.
HTML http://renewablerevolution.createaforum.com/gallery/renewablerevolution/3-130418193910.gif<br
/>
HTML http://renewablerevolution.createaforum.com/gallery/renewablerevolution/2/3-190119153601.gif
The appointment of
HTML http://renewablerevolution.createaforum.com/gallery/renewablerevolution/3-040718162655-14231561.gif<br
/>💵🎩 Elizabeth Fowler, Director of 🐍
CMMI,
whose past work in the private healthcare sector as Vice
President for Global Health Policy at Johnson & Johnson and as
Vice President of insurer Wellpoint (now Anthem), not only poses
a huge conflict of interest. It reflects the intention of many
within the federal government to privatize healthcare. During
the [b]Obama administration, Fowler assisted in the development
and implementation of the ACA, which created the CMMI, the
office she now 💰😈 directs.[/b]
Full article:
HTML https://media.tenor.com/images/5423e809b1a22096b6925bf9bc3fd1cb/tenor.gif
HTML https://www.counterpunch.org/2022/12/30/architects-of-medicare-privatization-congress-biden-and-the-cms/
[move]
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-080422121435.png<br
/>
HTML http://www.sherv.net/cm/emoticons/sick/barfing-smiley-emoticon.gif[/move]
[center]
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-010123182425.jpeg[/center]
#Post#: 776--------------------------------------------------
"Administrative costs eat up 34% of what we now spend and
half of that is not necessary — pure waste."
DIR By: AGelbert
Date: January 14, 2023, 11:52 am
---------------------------------------------------------
[center]
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-120422130903-68837.png[/center]
January 13, 2023 This commentary is by Dr. Deborah Richter,
M.D., a practicing family physician in Cambridge, Vt. She lives
in Montpelier.
[center]
Dr. Deborah Richter:
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-110422180553-643238.gif<br
/>Yes, we can do something about Vermont’s health care
crisis[/center]
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
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-050422182057.gif<br
/>collected by the state’s health care advocate
HTML https://www.vtmedicaldebt.org/.
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. 🥺
[b]Why do we allow it?[/b] Here are the
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-090822164512.png<br
/>excuses we hear from some of our
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-080822134118-17091258.gif💵🎩<br
/>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
HTML https://www.medscape.com/slideshow/2020-compensation-overview-6012684?src=WNL_physrep_200514_comp2020&uac=317871PZ&impID=2380343&faf=1#19.<br
/>
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.
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-050422133908.gif
mplementing a universal system would save massive amounts — as
much as $1 billion, according to some studies
HTML https://ljfo.vermont.gov/assets/docs/healthcare/1a3342b9a2/FINAL-REPORT-Hsiao-Final-Report-17-February-2011_3.pdf.<br
/>
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
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-110422205132-6451602.gif<br
/>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
💵🎩
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-010922192452.gif<br
/>“stakeholders” who exercise considerable influence over what
legislation gets “moved” in the Legislature.
So why not start with a smaller piece: Universal primary care.
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-050422145344-560693.png
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.
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-090422150144.png
HTML https://vtdigger.org/2023/01/13/dr-deborah-richter-yes-we-can-do-something-about-vermonts-health-care-crisis/
#Post#: 1491--------------------------------------------------
RE: Medicare Advantage is Capitalist CORRUPTION of Medicare for
Greedball "Health" Insurance Corporations
DIR By: AGelbert
Date: November 28, 2023, 2:35 pm
---------------------------------------------------------
[center]
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-040623141651.png[/center]
November 27, 2023 by Cheryl Kunis, MD, MS
🗽🕊️
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-110422180553-643238.gif<br
/>
[center]'Medicarelessness' Revisited After 50 Years[/center]
[move]🎩 Privatization of the public program has simply
bolstered 😈
corporate
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-110422205132-6451602.gifhttps://soberthinking.createaforum.com/gallery/soberthinking/1-010922192452.gifprofits<br
/>
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-050422135315.png[/move]
SNIPPETS:
Medicare has expanded dramatically since its inception in 1965.
Supposedly to improve its efficiency, Congress eventually
created [glow=red,2,300]Medicare Advantage[/glow]
([glow=red,2,300]MA[/glow]) in 2003. This new program, which is
publicly funded but privately administered, ushered in a new era
of Medicare privatization.
With the advent of [glow=red,2,300]MA[/glow], the insurance
industry has pioneered new and evolving strategies to maximize
profits that have led to widespread accusations of profiteering
and fraud. In 1973, "Medicarelessness" referred to "reckless"
government spending on what became life-saving treatment; today,
I believe it's more appropriate to assign this label to reckless
spending used to bolster corporate profits.
In a just society, healthcare is an essential service that
benefits all. The U.S. stands apart from other industrialized
nations in that healthcare is not guaranteed. Medicare
represents an attempt by our country to partially remedy this
injustice. It not only provides care to some of the most
marginalized members of society (the elderly and disabled), it
also helped to desegregate the healthcare system, promoting
racial equity. ... ...
🎩😈 Proponents of [glow=red,2,300]MA[/glow] claim
that
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-040622202527-13931485.png<br
/>[glow=maroon,2,300]privatization promotes innovation and
efficiency[/glow], but its [glow=red,2,300]role[/glow] in
healthcare appears questionable at best. The reality is that no
matter what, [glow=red,2,300]profit-driven corporations[/glow]
will likely never put the interests of the public above those of
their shareholders. Privatization allows the government to
[glow=red,2,300]shirk fiscal and moral responsibilities[/glow]
at the expense of those it claims to serve. It is a myopic
strategy that benefits
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-040922144518.gif<br
/>corporations, yet keeps costs largely public. In short, the
privatization of Medicare is "Medicareless."
"Medicarelessness" poses a much greater threat in 2023 than it
did in 1973. We are thoughtlessly subsidizing the private
insurance industry at an extravagant cost to the American
taxpayer, and dismantling a vital and beloved public program. We
must accept that life-sustaining services should remain in
public hands to safeguard citizens from the
[glow=maroon,2,300]gravest injustices[/glow]. Medicare remains a
potent symbol of our most sacred democratic principles:
equality, dignity, and self-determination. We can no longer
afford to be "Medicareless," both ethically and financially. We
must say no to privatization.
Full EXCELLENT article:
HTML https://www.medpagetoday.com/opinion/second-opinions/107537<br
/>
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-040422164615-5351419.gif
#Post#: 2326--------------------------------------------------
RE: Medicare Advantage is Capitalist CORRUPTION of Medicare for
Greedball "Health" Insurance Corporations
DIR By: AGelbert
Date: September 4, 2024, 1:50 pm
---------------------------------------------------------
👉 Graphics and emojies by AGelbert. 👈
[center]
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-040623141651.png[/center]
September 2, 2024 by Fred Schulte, KFF Health News
[center]
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-110822203938-17581013.png<br
/>[glow=red,2,300]Feds[/glow] Killed Plan to Curb Medicare
Advantage
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-110422205132-6451602.gifhttps://soberthinking.createaforum.com/gallery/soberthinking/1-010922192452.gif😈<br
/>Overbilling After 😈🎩 Industry Opposition —
"🙊🙉🙈😉😈 CMS made a
complete boondoggle out of this," one expert said[/center]
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
HTML http://media.tumblr.com/c6492e4b47cfdbd50e74d285fde3c53e/tumblr_inline_mm3g4yCaZc1qz4rgp.gif<br
/>amid an
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-090822164555.png<br
/>"uproar" from the 🐷🎩 industry, newly released
court filings showed.
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-050422145533-5671050.gif
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
[b]identify overpayments by CMS and refund them to the
government.[/b]
But in May 2014, CMS
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-080822134118-17091258.gif🐷🎩<br
/>dropped the idea
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-040622202650-14041402.gifhttp://www.createaforum.com/gallery/renewablerevolution/3-280515145049.png<br
/>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 🐷🎩
[glow=red,2,300]UnitedHealth Group[/glow] 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
HTML http://renewablerevolution.createaforum.com/gallery/renewablerevolution/3-030817202100.gif<br
/>
HTML http://www.createaforum.com/gallery/renewablerevolution/3-280515145049.png<br
/>press office declined to make Rice available for an interview.
Hornsby, who has since left the agency, declined to :-X
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."
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-080422121109.gif<br
/>
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-040622153109-13672051.gif
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 🐷🎩 [glow=red,2,300]UnitedHealth Group
executive[/glow]s on the call said in depositions that CMS
staffers told them the company had
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-110422205132-6451602.gif<br
/>no obligation at the time to uncover
😉😈💰
erroneous codes. One of the executives,
[glow=red,2,300]🐽 Steve Nelson[/glow], called it a "very
clear answer" to the question.
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-080422121331.gif<br
/>Nelson has since left the company.
For their part, four of the five CMS staffers on the call said
in depositions that they
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-040622202527-13931485.png<br
/>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
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-040622202551-13971996.gif<br
/>to bill only for verified codes -- or face possible penalties
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-090822140006.gif<br
/>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
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-040622202527-13931485.png<br
/>support patients, identify chronic conditions, and
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-040622153114-13822364.jpegprevent<br
/>those conditions from becoming more serious," said Chris
Bond,
a 🐍 spokesperson for [glow=red,2,300]AHIP, a
🐷🎩 health insurance [/glow]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
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-040422164718-5381960.png<br
/>
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-080822141004-17211668.gif<br
/>something, because the whole system is going to collapse
😟. [glow=red,2,300]Advantage 😈🐷🎩
plans [/glow]do not provide healthcare, they play games that
hold off doctor time and as much care as they can, Patients to
😈 [glow=red,2,300]them[/glow] are just pockets of gold.
Read more COMMENTS:
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-040422164555-532108.png
HTML https://www.medpagetoday.com/publichealthpolicy/medicare/111723
#Post#: 2482--------------------------------------------------
"... recent analyses indicate that Medicare Advantage is
more expensive than traditional Medicare, the report continued
DIR By: AGelbert
Date: October 18, 2024, 12:33 pm
---------------------------------------------------------
👉 Emojies by AGelbert. 👈
October 18, 2024
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-090422150144.png<br
/>AGelbert NOTE: Reality based comments on the reality based
article posted here after the comments:
Charles_Beauchamp 11 hours ago edited
If the current trend of an upswing in denied prior
authorizations coupled with rural - metropolitan disparities in
application of rules, regulations & reimbursements continues,
there will be an implosion of rural primary care independent of
the hospital.
BeckyR 12 hours ago
And yet most Republicans say they want all seniors to transition
to this type of care that only ensures profits for the insurance
companies while putting people's health and safety at risk!!
Lou_L > BeckyR 2 hours ago
Over the years of making Hill visits to advocate for Long Term
Care Hospitals, I’ve seen a remarkable change in the tone from
the Republican offices. It used to be they didn’t want to hear
any criticism of Medicare Advantage. During the past two years
they’ve become increasingly aware of MA plans abusing prior auth
to deny care. This report will really help hammer home the
message.
Steven_B_MD 15 hours ago
Is anyone surprised that Medicare Advantage plans appear to be
more interested in profits than patients?
Brant_S_Mittler_MD_JD a day ago
Thanks for Joyce Frieden's usual excellent reporting. But the
last paragraph from the managed care lobby should be read with
full understanding that Medicare HMO data is largely
proprietary. The HMOs use it to their advantage when they want
to. They use researchers who they know will produce results they
want. if you look at their data sharing arrangements you will
see that you can't get the data or have to pay $millions to get
it if they would even sell it to you. These data reflect care
produced with taxpayer dollars yet taxpayer institutions can't
use them for objective outside reviews. Virtually all the
quality data on Medicare comes from Fee for Service (FFS)
Medicare. Those data are produced by non-HMO medical practices
i.e. individual doctors, NPs, PAs, nurses laboring late into the
day and night producing the data that Medicare beneficiaries get
to use to look at quality, diagnosis + prognosis, test ordering
and outcomes. The HMO part of Medicare is largely opaque and
contributes NOTHING to transparency and quality analyses while
making outrageous profits for its overpaid executives and armies
of prior authorization clerks. It's a national disgrace that is
impossible to change due to the power of the HMO lobby in DC and
state legislatures. "Plea for service" runs U.S. health care.
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-080422121109.gif
[center]
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-040623141651.png[/center]
October 17, 2024 by Joyce Frieden, Washington Editor, MedPage
Today
[move]Use of 🔨😈 Prior Authorization Up in
[glow=red,2,300]😈🎩 Medicare Advantage
Plans[/glow], Senate Report Finds — Post-acute care services
🔨😈 targeted for [glow=red,2,300]coverage
denials[/glow][/move]
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-080822134118-17091258.gifhttps://soberthinking.createaforum.com/gallery/soberthinking/1-020623123855-24412004.png<br
/>[glow=red,2,300]Medicare Advantage plans[/glow] have increased
their use of prior authorization and appear to be targeting
certain types of care -- such as expensive post-acute hospital
care -- for coverage denials, according to a report issued
Thursday by the Senate Permanent Subcommittee on Investigations.
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-080822134118-17091258.gif💵[glow=red,2,300]🎩<br
/>Insurers [/glow]"are using prior authorization to protect
billions in profits while forcing vulnerable patients into
impossible choices," the subcommittee's report concluded.
"This is particularly troubling when recent analyses indicate
that [glow=red,2,300]Medicare Advantage[/glow] is more expensive
than traditional Medicare," the report continued. "There is a
role for the free market to improve the delivery of healthcare
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-040622202551-13971996.gif<br
/>to America's seniors, but there is nothing inevitable about
the
harms done by the current arrangement. Insurers can and must do
better, for the sake of the American healthcare system and the
patients the government entrusts to them."
Four Years
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-120422122505-6702373.gif<br
/>of Data
The subcommittee sought data about prior authorization requests
and denials between 2019 and 2022 from [glow=red,2,300]three of
the largest Medicare Advantage insurers:
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-040622210450-1415528.gif<br
/>UnitedHealthcare, Humana, and CVS.[/glow] "This date range
aligned with increases in concern from patients and providers
that prior authorization was threatening seniors' well-being and
the viability of medical practices," the report authors noted.
"The time period also overlapped with reporting showing that
Medicare Advantage insurers were expanding their use of AI
[artificial intelligence] and other methods of
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-040922144518.gif<br
/>automating the
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-120422122619-6781750.png<br
/>processing of healthcare claims."
In addition, lawmakers "also collected documents used in
training workers evaluating prior authorization requests, and
explanations of the procedures used to evaluate or measure these
workers and determine their prospects for advancement. The
subcommittee has also obtained documents related to the use of
algorithms, AI, and other predictive technologies, including the
way the companies use these technologies in the context of prior
authorization and other utilization management practices."
The report noted that "[glow=red,2,300]Medicare Advantage
insurers[/glow] are intentionally using prior authorization to
😈 boost 💰 profits by targeting costly yet
critical stays in post-acute care facilities. Insurer
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-110422205132-6451602.gif<br
/>denials at these facilities, which help people recover from
injuries and illnesses, can force 🥵 seniors to make
difficult choices about their health and finances in the
vulnerable days after exiting a hospital."
In particular, the report found:
In 2022, both [glow=red,2,300]UnitedHealthcare[/glow] and
[glow=red,2,300]CVS[/glow] denied prior authorization requests
for post-acute care at rates that were approximately three times
higher than the companies' overall denial rates for prior
authorization requests. In that same year, Humana's prior
authorization denial rate for post-acute care was over 16 times
higher than its overall rate of denial.
CVS's prior authorization denial rate for post-acute care
remained relatively stable during the period reviewed. However,
the number of post-acute care service requests CVS subjected to
prior authorization increased by 57.5%, far higher than the
company's roughly 40% growth in enrollment during that period.
In a May 2019 presentation, CVS determined that it had saved
more than $660 million the previous year by denying prior
authorization requests its Medicare Advantage beneficiaries
submitted for inpatient facilities. A majority of these savings
came from "denied admissions."
While the use of prior authorization has expanded significantly
for all types of insurance since the 1980s, its use in Medicare
Advantage plans has particularly increased in the last 5 years.
The American Journal of Managed Care found that the share of
Medicare Advantage enrollees in a plan requiring prior
authorization for at least one category of healthcare services
was 72.6% in 2019, which was similar to the rate it had been in
2009. But by 2023, KFF reported that 99% of Medicare Advantage
enrollees were in a plan requiring prior authorization for some
services.
"Although post-acute care facilities represent a significant
share of all prior authorization denials, they represent only a
portion of all prior authorization requests, meaning that an
insurer's denial rate for post-acute care could increase
significantly from one year to the next even as the insurer's
overall denial rate, which is publicly available, appears
relatively unchanged," the report found. "At the facility level,
these changes can be striking. For example, between 2019 and
2022, UnitedHealthcare's denial rate for skilled nursing
facilities increased by a factor of nine."
Use of 🤖 AI Examined
In its investigation of the plans' use of artificial
intelligence to consider prior authorization requests, the
subcommittee found that:
Facing pressure to cut costs in the Medicare Advantage division,
in April 2021 CVS deployed "Post-Acute Analytics," which used AI
to reduce the amount of money spent on skilled nursing
facilities. CVS initially expected that it would save
approximately $4 million per year, but within 7 months, the
company projected that an expanded version of the initiative
would save the company more than $77 million over the next 3
years.
In April 2021, an[glow=red,2,300] internal UnitedHealthcare
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-010922192452.gif<br
/>committee[/glow] voted to approve the use of 🤖
"Machine
😉 Assisted Prior Authorization" in the company's
utilization management efforts. They were told that the doctor
or nurse reviewing the case still had to "verif[y] that the
primary evidence is acceptable," but also that testing of the
technology had reduced the average time needed to review a
request by 6 to 10 minutes.
In early 2021, UnitedHealthcare tested a "HCE [Healthcare
Economics] Auto Authorization Model." Minutes from a meeting of
an internal committee reviewing the model noted that initial
testing had produced "faster handle times" for cases as well as
"an increase in adverse determination rate," which the meeting
minutes attributed to "finding contraindicated evidence missed
in the original review." The committee voted to tentatively
approve the model at a meeting the following month.
Recommendations for CMS
The subcommittee recommended several actions for the Centers for
Medicare & Medicaid Services (CMS) to take to address some of
the issues raised in the report, including requiring that prior
authorization information be broken down by category, conducting
targeted audits under certain circumstances, and implementing
regulations to ensure that predictive technologies do not have
"undue influence" on human reviewers.
In particular, regarding the plans' use of AI to evaluate prior
authorization requests, "CMS has not provided sufficiently
specific guidance on separating the use of predictive
technologies from patient determinations regarding post-acute
care," the authors concluded, adding that in a February 2024
memo, the agency said AI could be used to "assist" in predicting
a patient's length of stay, but that medical necessity
determinations had to be based on "the individual patient's
circumstances." However, the agency provided no further guidance
on ensuring that the AI prediction didn't have undue influence
on the length-of-stay authorization, they said.
Asked to comment on the report, [glow=red,2,300]a spokesperson
for America's Health Insurance Plans -- a trade group for health
insurers [/glow]-- said in an email that "More than 33 million
seniors and people with disabilities choose Medicare Advantage
for their health coverage because it provides them better care
at a lower cost
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-110822211037-18321080.jpeg<br
/>than fee-for-service. Studies show that MA [Medicare
Advantage]
outperforms fee-for-service
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-260322170319.png<br
/>in nine out of 10 quality measures focused on prevention and
chronic care, and 95% of MA beneficiaries say they are satisfied
with their coverage and care."
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-040622202533-1394275.gif
[glow=red,2,300]A
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-090822164555.png<br
/>spokesperson for Humana[/glow] told MedPage Today in an email
that
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-100323192446-23162278.png<br
/>
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-040622202527-13931485.png<br
/>"This is a partisan report laden with errors and misleading
claims. In fact, Senator [Richard] Blumenthal's team declined to
correct those errors and mischaracterizations that Humana
identified after reviewing certain heavily redacted excerpts
prior to the report's release."
HTML https://soberthinking.createaforum.com/gallery/soberthinking/1-090822140006.gif
HTML https://www.medpagetoday.com/publichealthpolicy/medicare/112434
*****************************************************
Page 1 of 1