Retailers Buying Up Health Care Delivery

Summary: Major general retailers, like Amazon and Walmart, are acquiring large medical care delivery networks. And they’re linking to Medicare Advantage, a huge cash cow for insurers and linked providers. We need single payer to interrupt the corporate takeover.

How major retailers are trying to change how America consumes health care
March 8, 2023
By Tina Reed

Amazon, Walmart, CVS, Dollar General and other big retailers are elbowing their way into health care delivery, pushing a customized consumer experience driven by digital health products.

At its core, these companies are pulling together different tech-enabled services – urgent, primary, more and specialty care, pharmacy, and, in some cases, full integration with an insurer. 

But the retailers’ forays are prompting growing anti-trust and privacy concerns, as well as fears of further erosion of the doctor patient relationship once considered central to coordinated care.

Amazon brought in an on-demand virtual care services platform, more than 125 locations and a piece of the Medicare Advantage business (with the company’s $3.9 billion acquisition of concierge medicine provider One Medical).

Best Buy Health launched a hospital-at-home program with North Carolina-based Atrium Health.

Walmart announced last week that it plans to nearly double the footprint of its in-store clinics. In the fall, Walmart also inked a 10-year Medicare Advantage deal with UnitedHealth Group.

In January, CVS Health announced a plan to buy Oak Street Health, a primary care group focused on Medicare patients. The pharmacy giant already owns insurer Aetna, pharmacy benefit manager CVS-Caremark, home health company Signify Health and health care service brands MinuteClinic and HealthHUB.

Also in January, Walgreen-backed primary care company VillageMD, scooped up more primary, specialty and urgent care investments augmenting plans to open more than 500 full-service doctors’ offices in Walgreens locations.

Other companies like Rite Aid, Albertsons, and Dollar General have launched programs in health care delivery.

Amazon, CVS and Walmart have made some of the most consequential moves by combining their massive retail footprints with assets like primary or urgent care sites, pharmacies, and some sort of relationship with insurers.

“They’re all acquiring every piece of medicine,” Robert Pearl, a Stanford University professor and former CEO of The Permanente Medical Group, told Axios.

In recent months, retailers are investing in end-to-end primary care. “That’s what gets me increasingly excited about their role because there’s only so much you can do as the urgent care provider and much much more you can do when you have that longitudinal relationship between the doctor and a patient over time,” said Jacob Effron, a principal at Redpoint Ventures.

Each of these businesses are also clearly eyeing a clearly lucrative segment of health care: Medicare Advantage.

Comment by: Don McCanne

It appears that the capture of the health care delivery system by private equity is moving along quite smartly. That is coordinated with private insurance, especially Medicare Advantage plans. The result is a massive cash cow, the “money machine” as we’ve discussed often in HJM.

Two significant trends in this regard have been not only the increase in private Medicare Advantage plans but also the rising recognition that single payer Medicare for All may be the answer to the financial burden that has been created by uninsurance, underinsurance, deductibles, copayments, coinsurance, and disallowed services.

The problem is that they seem to be setting the stage for privatized Medicare Advantage for All, combining the worst of the medical industrial complex. This likely will move even more of our health care dollars into the hands of the uber-capitalists, as Bernie Sanders is explaining on his current book tour, but it will leave care for patients and their providers underfunded, making the wealthy wealthier and the rest of us mired in mediocrity, at best.

No. We don’t want the private sector proposals designed to create more wealth for the wealthy. We want reform designed to provide health services for all of us. But we are rapidly heading in the wrong direction. We need to enact and implement a well-designed single payer Medicare for All, and we need to do it IMMEDIATELY! The billionaires are already swarming.


UK National Health Service Woes Due to Privatization & Funding Cuts

Summary: The UK national health service has been a highly regarded and popular model of public financing and ownership of health services. That is, until the British government fostered privatization and, during Conservative rule, imposed austerity budgets. It can still be saved.

You Don’t Have to Be a Doctor to Know How Much Trouble the N.H.S. Is In
The New York Times
March 17, 2023
By Allyson Pollock and Peter Roderick

You don’t have to work in a hospital to know that Britain’s N.H.S. is in the most serious crisis of its history; you just have to be injured, or ill. And hundreds of thousands of people have had a doctor’s referral for outpatient care at a hospital rejected because there are no available appointments — they are simply bounced back to the doctor to begin the process again.

That the flagship health care service of one of the wealthiest countries in the world is in such a state is shocking, but not without explanation. Decades of marketization, 10 years of Conservative austerity and a pandemic have hollowed out the N.H.S. so much that people who can afford to, and increasingly those who can’t, are having to pay for health care.

A two-tier system with more and more in common with American health care is taking shape. It’s not working, and we’ll soon be at the point where it’s too late to do anything about it.

The damage to the N.H.S. was inflicted in three main waves.

In the late 1980s and early ’90s, a Conservative government introduced the internal market and closed long-stay hospitals — where care was free — under the euphemistic banner of “care in the community.” Private nursing homes backed by equity investors took over provision for older people, and care became chargeable and means-tested.

In the late 1990s and early 2000s, Labour, under Tony Blair, built dozens of new hospitals with money from partnerships with private investors.

In 2010, the Conservatives, back in power — alongside the Liberal Democrats until 2015 — embarked on a decade of austerity.

The cumulative effect was devastating.

But people are also tired of waiting — or not able to wait — and more and more are paying for private treatment.

People are reportedly taking out loans to pay for operations and, in a development that will be familiar to Americans but is something quite new in Britain, more and more people are turning to GoFundMe to raise money for medical treatment.

The government has done plenty to encourage this shift: In 2012, the Conservatives increased the cap on what percentage of an N.H.S. hospital’s income could come from treating private patients to 49 percent.

What we do know is Britons who want to use the N.H.S. are finding it increasingly hard to do so.

The N.H.S. as Britons have known it — accessible, free at the point of use, cherished — is becoming something else. But as long as there are still people willing to fight for it, it’s not too late to save it.

Allyson Pollock in 2014 video raising alarm on NHS privatization:

From here.

Comment by: Don McCanne & Jim Kahn

For many decades, those of us in the policy community interested in health care justice for all have greatly admired the British National Health Service as it was founded as a cherished health care system, accessible to all, and free at the point of service.

In the meantime, we established a public insurance program for seniors – Medicare – and many of us have supported policies to improve that program and expand it to include everyone. Instead, we are well on the path to total privatization of the Medicare program as it has deteriorated. Uninsurance and underinsurance permeate our system, costs have gone up, medical debt and personal bankruptcy are increasing, many are left without the health care they should have, and the increased spending of our health care dollars has been moving into the coffers of the billionaires. The government has not been listening to us in the policy community who can provide the solutions to our health care injustices.

Today’s article tells a really sad story because we should have been learning from the British model and applying it to our system. The British, of course, had demonstrated how much more effective the government was than the private sector, whereas we increased the role of the private sector resulting in the higher costs and deterioration of our system.

A co-author of today’s article, Allyson Pollock, has been a leader in the British policy community, and has issued warnings that they should not follow privatization schemes such as we have in America. Their political leaders did not listen either. As seen in the figure above, the needed growth in health spending as % of GDP was reversed starting in 2009, starving the system. Just as in the United States, it was not just the conservatives, but it was the neoliberals as well, as they followed a path more like ours instead of us following theirs. This brief report shows what a disaster it has been.



How Medicare Advantage Distorts Clinical Outcome Data

Summary: Two studies reveal how Medicare Advantage plans distort comparisons with Traditional Medicare on inpatient and emergency visit rates, which represent clinical deterioration. A study done by MA employees is biased by massive diagnostic upcoding of MA enrollees. A study by university researchers reveals how inpatient admissions fall while emergency visits rise even more. Properly examined, MA has worse outcomes.

Comparison of Care Quality Metrics in 2-Sided Risk Medicare Advantage vs Fee-for-Service Medicare Programs
JAMA Network Open
December 12, 2022
By Kenneth Cohen et al

Findings In this cohort study of 316 312 individuals, physicians in a 2-sided risk Medicare Advantage model provided care of higher quality and efficiency compared with those practicing in a fee-for-service Medicare program in all 8 metrics measured. [NB – HJM doesn’t believe these findings … see comment]

Evaluation of Potentially Avoidable Acute Care Utilization Among Patients Insured by Medicare Advantage vs Traditional Medicare
JAMA Health Forum
February 24, 2023
By Adam L. Beckman et al

Importance Medicare Advantage plans have strong incentives to reduce potentially wasteful health care, including costly acute care visits for ambulatory care−sensitive conditions (ACSCs). However, it remains unknown whether Medicare Advantage plans lower acute care use compared with traditional Medicare, or if it shifts patients from hospitalization to observation stays and emergency department (ED) direct discharges.

Objective To determine whether Medicare Advantage is associated with differential utilization of hospitalizations, observations, and ED direct discharges for ACSCs compared with traditional Medicare.

Results Medicare Advantage patients had lower risk of hospitalization for ACSCs compared with traditional Medicare patients (relative risk [RR], 0.94), primarily owing to fewer hospitalizations for acute conditions (eg, pneumonia). Medicare Advantage patients had a higher risk of ED direct discharges (RR, 1.44) and observation stays (RR, 2.38) for ACSCs vs traditional Medicare patients. Overall, Medicare Advantage patients were at higher risk of needing care for an ACSC (hospitalization, ED direct discharge, or observation stay) than traditional Medicare patients (RR, 1.30).

Comment by: Jim Kahn

I’m a huge believer in the value of “health services research”. We need formal quantitative analyses of the effects of insurance status and other factors on measures – like hospitalization – that reflect clinical and financial outcomes. And I’ve seen enough studies over the decades to know that extracting legitimate conclusions from these studies is challenging, due to the complexity of the medical world and due to the risk of shoddy (often biased) research.

Both complexity and bias are in evidence with these two studies that compare hospitalization rates in Medicare Advantage (MA) vs Traditional Medicare (TM). One, done by UnitedHealth Group employees, is profoundly biased. The other, by respected academic researchers, elucidates what’s really happening with hospital and emergency stays.

The industry study (Cohen et al) examines several inpatient and emergency outcomes. Its core problem is huge diagnostic upcoding of the MA beneficiaries. As shown in Table 1, the prevalence of recorded serious diagnoses is twice as high for MA plans as for TM – despite the fact that MA enrollees are known to be healthier than TM enrollees. Why does this matter? Because several of the key statistical analyses are adjusted for the misleading extra diagnoses. If the MA beneficiaries seem sicker than they really are, it makes MA plan outcomes look better. Thus, key results are fallacious, most strikingly for COPD and heart attack / stroke. If the MA population was properly represented as healthier than the TM population, TM would probably have looked better across the board. (The paper is also incompletely and confusingly reported, which challenges sorting out all the details.)

An important quick detour: Rick Gilfillan, Don Berwick, and others analyzed the financial implications of this huge diagnostic upcoding, finding that it would lead to a 34% overpayment to MA as compared with TM. This confirms their prior “money machine” analyses discussed here, buttressing the argument that MA is shifting public funds to private shareholders.

The academic study (Beckman et al) is a model of conceptual clarity, sophisticated statistics, and excellent reporting. It adjusts (in several ways) for diagnostic upcoding. And it finds that an apparent decrease in hospitalization rates in MA is more than offset by increases in emergency department discharges and “observation” visits. In other words, for medical conditions amenable to good ambulatory care, overall MA does worse than TM. Why would these clinical episodes shift from inpatient to emergency department only? An obvious concern is that MA plans are denying authorizations for inpatient admission. Is that inferior clinical care? Impossible to say, but that’s a real concern. In any case, this excellent research clarifies that MA claims of lower hospitalization rates are misleading at best.

When it comes to health services research (perhaps even more than medical research in general), coupled with financial interests, the adage must be, “Buyer beware”. We at HJM strive to be your docent in this world.


Bernie Sanders Takes on Capitalism

Summary: Bernie Sanders is a beacon of clarity for the pursuit of human welfare. In his new book, Bernie highlights how very American it is to confront and change the uber-capitalism that afflicts our nation. Health care is the poster child of this struggle.

It’s OK To Be Angry About Capitalism
Crown Publishing
February 2023
By Bernie Sanders

Capitalism is the problem

Some people think that it’s “un-American” to ask hard questions about where we are as a nation, and where we’re heading. I don’t. To my view, there is nothing more American than questioning the systems that have failed us and demanding the changes we need in order to create the kind of society that we and future generations deserve.

Here is the simple, straightforward reality: The uber-capitalist economic system that has taken hold in the United States in recent years, propelled by uncontrollable greed and contempt for human decency, is not merely unjust. It is grossly immoral.

We need to confront that immorality. Boldly. Bluntly. Without apology. It is only then that we can begin to transform a system that is rigged against a vast majority of Americans and is destroying millions of lives.

Confronting that reality and mobilizing people to bring about the transformational change we need is not easy. That’s why I’ve written this book. We need not only to understand the powerful forces that hold us down today but, equally important, to have a vision as to where we want to be in the future.

Health care is a human right. Period.

I’m not talking about expanding the Affordable Care Act and providing more subsidies. To the insurance companies that maintain – and profit immensely from – an incredibly wasteful, bureaucratic, and cruel system. I’m talking about all Americans being able to walk into a doctor’s office or a hospital and get all of the health care they need with no out-of-pocket costs. I’m talking about replacing a wildly inefficient system in which we spend over $12,000 per person every year, almost twice as much as any other major country, while 85 million Americans are uninsured or underinsured and sixty thousand a year die because they don’t get to a doctor on time.

I’m talking about a Medicare For All system.

The establishment – the corporate world, the politicians, and the media – tells us that this is a “radical” idea. Totally impractical. It just can’t be done. It’s not even worth discussing – not in the halls of Congress, not on radio or TV, not in most medical schools.

Really? If this is such an impractical idea then why, in one form or another, has every other major country on earth already accomplished the goal of providing health care for all – and at a fraction of the cost that we’re paying? On a recent trip to London, I chatted with a Conservative member of Parliament who told me how proud she was of the free health care the government provided. That’s a Conservative speaking!

Will Medicare For All solve all our health care problems? Of course not. But think about the profound impact it will have when the burden of devastating health care expenses is lifted from the shoulders of working families. Think of what it will mean when no American hesitates to walk into a doctor’s office because of the cost. Think about what it will mean when no one goes bankrupt because they have a serious illness.


Real Politics Starts with Organizing

One of the important lessons I have learned from history is that real change never takes place from the top down. It always comes from the bottom up. Fundamental change is not going to happen because of fundraisers at wealthy people’s homes. It’s not going to happen because of clever TV ads or the scheming of inside-the-Beltway political consultants and pollsters. It’s going to happen when millions stand up and demand that change.

Real politics is about rejecting the establishment’s determination as to what is “possible,” “achievable,” and “acceptable.” It is about declaring, unapologetically, that we will not allow American oligarchs and their legions of publicists to shape our vision as to the kind of world we want to live in. That’s our decision.

Bernie Sanders Discusses “It’s OK To Be Angry About Capitalism”
Face the Nation (26 m)
Southbank Center (for British audience; 1 h 45 m)

Comment by: Don McCanne & Jim Kahn

Who should not have access to health care? Many of us believe, like Bernie, everyone should be included.

In this important new book, Bernie updates and elaborates on his vision for a just and generous America, one in which we prioritize fundamental human needs – like health – over capitalist profiteering. All other wealthy countries provide comprehensive health care, spending far less than we do with our expensively convoluted system.

Let’s ask the corporate and government oligarchs who are responsible for the policies that create the barriers to care whom they believe should be left out of the system, even though we could very easily afford to cover everyone. Indeed, let’s turn the tables: invite them to negotiate the portion corporations and shareholders get in a single payer Medicare for All program. (Hint: not much!)


Large Insurer Exiting Workplace Health Insurance Market

Summary: Humana announced a pivotal business strategy change that suggests the looming culmination of a massive shift in US health insurance. Job-based insurance started in WWII, and dominated the health insurance business … until insurers convinced government to let them manage large parts of Medicare & Medicaid, while also buying up prescription benefit managers and providers. The privatization train must be stopped, with single payer.

Humana lays out exit from employer-sponsored coverage
ABC News
February 23, 2023
By Tom Murphy

The health insurer Humana will stop providing employer-sponsored coverage as it focuses on bigger parts of its business, like Medicare Advantage.

The insurer said Thursday it will leave the employer-sponsored business over the next 18 to 24 months. That includes coverage provided through private companies and for federal government employees.

Employer-sponsored health insurance is one of the most common ways for Americans to get coverage, but it amounts to a small part of Humana’s enrollment. That is centered largely on Medicare Advantage, the privately run version of the federal government’s Medicare program for people age 65 and older.

Humana also will continue to provide coverage to nearly 6 million military service members and their families.

Humana also runs Medicaid coverage for states and provides stand-alone Medicare prescription drug coverage. The insurer covered about 13.5 million people last year, not counting the stand-alone prescription drug plans.

Employer-sponsored coverage made up around 7% of that total.

Humana CEO Bruce Broussard said in a prepared statement that the exit from employer-sponsored coverage lets Humana focus its “greatest opportunities for growth.”

The company also said its employer-sponsored business “was no longer positioned to sustainably meet the needs of commercial members over the long term or support the company’s long-term strategic plans.”

Enrollment growth in employer-sponsored insurance has stagnated for many years for insurers, including market leaders like UnitedHealthcare. Insurers have turned more to government-backed coverage like Medicare Advantage or managing state Medicaid coverage for enrollment growth.

They also have pushed deeper into managing prescription drug plans and buying care providers in order [they say] to control health care costs.

Shares of Humana Inc., based in Louisville, Kentucky, climbed about $1 to $504.60 Thursday.

Comment by: Don McCanne & Jim Kahn

The key paragraph is: “Enrollment growth in employer-sponsored insurance has stagnated for many years for insurers, including market leaders like UnitedHealthcare. Insurers have turned more to government-backed coverage like Medicare Advantage or managing state Medicaid coverage for enrollment growth.” And they’re expanding their role and power: ”They have pushed deeper into managing prescription drug plans and buying care providers …”

Private insurers are taking over public health insurance programs, reaping profits from each step in medical care funding and delivery. They recognize government largesse when they see it, and reel it in. They exercise massive market and lobbying power to create rules that help them gobble up our public health insurance resources, fueling record profits.

What intentions do they have for Medicare For All? Doesn’t this look like a setup for Medicare Advantage for All? A public insurance program under control of the private insurers? With their additional use of private equity to gain ownership of the delivery system?

We know this would waste massive resources while denying needed care. Private insurance-mediated Medicare and Medicaid are more expensive and deny or delay care through prior authorization, narrow networks, and patient cost-sharing obligations.

The battle lines are set! The wealth of the billionaires versus the health of the people. Further inertia on the part of us, the people, will result in their inevitable control.

We have the ultimate move that can tip the balance toward health, if we act soon. That, of course, is to implement an improved, publicly-administered Medicare that covers everyone. What do we want to use the people’s money for? More wealth for the wealthy, or more health for the people?


California Survey on Health Care Access, Debt, & Equity

Summary: The newest survey of California health issues finds access limited by cost, causing clinical harm; pervasive medical debt; and racial differences around provider interactions. These ongoing health system failures highlight the desperate need for real reform.

The 2023 CHCF California Health Policy Survey

February 16, 2023

By Lucy Rabinowitz Bailey et al

Key findings from this year’s survey include:

Health care costs. Like prior years, half of Californians (52%) report skipping or delaying health care due to cost in the past 12 months.  Of those who skipped or delayed care, half of them (50%) say their condition got worse as a result.

Medical debt. More than 1 in 3 (36%) report having medical debt, and of those, 1 in 5 (19%) report owing $5,000 or more. Californians with lower incomes (52%) are more likely than those with higher incomes (30%) to report medical debt. [Rates for Black (48%) and Latino/x (52%) respondents are nearly twice as high as among Whites and Asians.]

Equity. More than half of Californians (54%) experienced at least one negative interaction with a health care provider in the last few years. Black and Latino/x Californians were more likely (69% and 62%, respectively) to report having negative experiences than White and Asian Californians (48% each).

Comment by: Don McCanne

This is California, land of affluence with Blue State politics where we care about each other, or do we? We have the resources to provide health care to everyone, and we have the knowledge of how to distribute those resources equitably to everyone through a single payer system. And yet look at our current health policy survey: Californians skipping care due to cost, half experiencing worsening of their medical condition as a result, over one-third facing medical debt, all while perpetuating racial and ethnic inequities.

We can end this now, not just for California, but for the entire nation. We merely need to enact and implement a well-designed, single payer, health care financing system. We have the right policy; it is long past time to break down the political barriers. 


Support CMS 2024 Medicare Advantage Payment Rules

Summary: Today’s post is a request to comment favorably (by March 3rd) on proposed payment adjustments for Medicare Advantage for 2024.

CMS issued a draft of a plan for 2024 payments to Medicare Advantage plans. Overall it’s a 1% increase, after taking into account various technical factors. While it doesn’t address all serious Medicare Advantage over-charging problems, it does address some. It’s a decent start. A big change from last year when the MA plans got an 8.5% increase. Insurers are asking for a larger increase. We should support CMS on this one.

Write to CMS to endorse this proposed approach. By March 3rd. Below are some bullets to consider for your comment to CMS. Please adapt them into your own words … thanks!

By the way, if you’re an economist or similarly focused academic, contact me to review and I hope sign a technical version of the CMS comment.


Fact sheet on this announcement is here.

Comment submission instructions:

Comments are due by Friday, March 3, 2023.

Go to, enter the docket number “CMS-2023-0010” in the “search” field, and click on “Comment”. You can paste or type your comment, or upload a file.

  • Writing to support — CMS 2024 Advance Notice of Methodological Changes for Medicare Advantage Capitation Rates and Part C and Part D Payment Policies.
  • The changes proposed by CMS are critically important. They begin to correct overpayment of Medicare Advantage plans by tens of billions of dollars per year due to exaggerated diagnostic coding. Further billions in excess payments are created by recruiting healthier patients and shedding sicker ones. These massive excess payments are depleting the Medicare Trust fund in order to feed huge profits for health insurers.
  • Although the proposed payment adjustments do not address all problematic diagnostic coding practices, they correct important flaws in coding rules and risk adjustment that contribute to the magnitude of overcharging.
  • As a [current or prospective] Medicare beneficiary, I count on CMS to provide responsible stewardship of the program. The proposed adjustments are part of this stewardship.
  • As a taxpayer, I expect the same.
  • The proposed net 1% increase in revenue for Medicare Advantage plans will permit continuation of current benefits and ample profits for the plans. Past increases of 8% were a gift to the insurers, at the expense of beneficiaries and taxpayers.
  • Please issue the final procedures as drafted.

Respectfully submitted,


Needed: Political Will to End the Violence in Ukraine & in our Health System

Summary: A Russian opponent of the war in Ukraine calls for the cease-fire that will stop the killing and permit finding a solution. We need the political will to end the ongoing deaths of untold thousands, and implement an enduring solution. Just like we need to reach single payer.

Stop the Killing
The Nation
February 9, 2023
By Gregory Yavlinsky

The war in Ukraine has been going on for almost a year. During this time, thousands of people have died on both sides, entire cities have been destroyed, and millions of people have become refugees.

But now, before our eyes, preparations for even larger-scale military action are in full swing. And all the key players—Moscow, Kiev, Washington, Brussels, NATO, and along with them the crowds of militaristic fans sitting in cafés and restaurants, hotels and cozy apartments, as well as numerous Internet media outlets—are all demanding the continuation of hostilities, fantasizing about victories, takeovers, and breakthroughs, agitating for new offensives.

Almost no one understands—or is afraid to say out loud—that the dangers are growing very seriously and the continuation of military action has no positive outlook. There is none!

Many territorial conflicts are known to have no end. There is only one successful example of territorial peace: the European Union. The idea accepted by all members of the European Union that human life, human dignity and human rights are valued higher than any national boundaries has become the guarantee of peace in Europe.

Sooner or later, this is what Russia, Ukraine and Belarus will come to—peaceful coexistence with each other and with other European countries. There is no alternative way to peace. But this way is complex and long.

What should be done now? Stop it! Everything else is a stupid and very dangerous illusion.

Declare a cease-fire. Stop killing people!

A cease fire is a political demand, the realization of which depends entirely on the willingness and understanding of the people making the decisions. In practice, it can only be implemented if at least Putin, Zelensky, Biden, and the EU and NATO leadership are willing to do so. But the problem is that none of them is willing right now. To date, all sides are intent on continuing large-scale hostilities, mistakenly counting on a military victory that is beyond anyone’s reach in the current climate. We must therefore insist: A cease-fire is necessary! If this does not happen, the consequences will be catastrophic and most likely, as already mentioned, irreversibly destructive.

And the main thing is that we will never get back people who are dying hourly in this catastrophe: not 18-month-old Makar and 15-year-old Anya from Dnipro, not 5-year-old Milana from Donetsk, not 9-year-old Ivan and 8-year-old Nina from Yeisk.

It is perfectly clear that all this has to stop. Everyone. And only after that should we try to talk. The main thing is that during this time people won’t be killed.

This is the only way to discuss territorial issues, borders, and movement of troops. Then diplomacy will also be needed—tough, difficult, with failures and limitations. We are in a situation where we are left with either bad options or even worse ones. The good options are gone now.

But there is still an option that can be avoided without further colossal casualties—that is, an immediate cessation of hostilities. And the demand to use this option must now be made by everyone who does not want to kill innocent people and does not want this to be done on their behalf. To make their position known by all available means.

Shout on every corner: Come to your senses! Stop!

Grigory Yavlinsky is the founder and leader of the Yabloko Party, the only party in Russia to protest the war and call for peace.

Comment by: Don McCanne

Why can’t we seem to get our policy and our politics in order? Policy-wise, we have demonstrated that a well-designed single payer system, an improved Medicare For All, could provide high quality care for everyone in the nation while reducing our health care costs. Yet our politics are screwed up enough such that the chairman of our Senate HELP Committee, Bernie Sanders, lacks the support of all Republicans and a significant proportion of Democrats for single payer and is having to resort to much more modest incremental reform proposals.

Where do we stand as far as politics and policy on the Russian military invasion of Ukraine? It seems that our policy should be to end the killing: the tragic killing of both the young Ukrainian and Russian soldiers and the tragic killing of the Ukrainian citizens, young and old alike, not to mention the extensive property destruction. But what is our politics? We are sending them more tanks to increase the killing? Shouldn’t the politics be directed to all efforts to end the killing? Shouldn’t the politics be more narrowly directed to obtaining a humane response from Vladimir Putin and his political gaggle?

Where should that political power come from? Us, the people. We need to let our president know that we want the killing in Ukraine to stop! Sending killing machines is not the way to stop killing. Providing political support to those who should have support and political opposition to those who should be opposed should help provide long range solutions, but we do need that immediate cease fire that Yavlinsky is calling for! No more killing!

But then, as we have been saying over and over again, we need to get our own politics right. We have the policy we need in the form of the single payer Medicare For All model, but we still need to be sure that the public at large has an excellent understanding of the clear benefits of the policies of the single payer model so that they will create the unmistakable political demand that Congress and the Administration cannot ignore: a health care system that is universal, comprehensive, affordable, equitable, efficient, with improved health outcomes for all.

On either front, national health or war, we should not be having people dying needlessly when the problem is merely a failure of national political application of appropriate national policies. Let’s get our politics right; it’s a matter of life and death!


Prior Authorization Scrutinized

Summary: Managed care advocates argue that prior authorization saves money and improves quality of care. But the evidence is unclear. Mainly, it’s an irritant for doctors and patients. An anonymous prior auth practitioner describes how it looks from the inside. Bottom line: another money-making scheme in our profit-driven health care system.

LIFE AND DOLLARS: a health care insider’s account of how prior authorization really works.
Health Care Un-Covered, Editor Wendell Potter
Feb 7, 2023
By Anonymous

Requiring patients to get prior authorization from an insurance company for medical procedures and drugs was supposed to lower medical costs. The theory was that it would prevent doctors from charging for unnecessary care.

The process frustrates patients and burdens health-care providers. And, the numbers show, it doesn’t really work.

I worked at one of the largest prior-authorization companies, running a team that supported the non-clinical side of our business. Most of our business was in radiology and cardiology medical-benefit management.

It may surprise people to know that many of the biggest health-insurance companies outsource their prior authorization programs. In fact, it would probably shock most people to understand just how much middle management exists between their doctor’s decisions and their ability to receive care. The commercial health insurance industry is overrun with opportunistic companies who profit off our complicated health care system, adding costs that lead to higher premiums and cost of care.

While working in the industry, it often seemed to me as if [T[he real value in prior authorizations isn’t in savings from clinically inappropriate procedures, and instead is a function of helping commercial insurers and third parties keep as much money as possible in the health-care system shell game. There is a large layer of middle management and profiteering that exists between the patient, the provider, and the insurance company. I know dozens of people who have made dopey amounts of money by rinsing-and-repeating the process, building small, ancillary companies that nibble on the edge of our high health-care costs. It all just gets baked into the cost of the premiums.

Examining Prior Authorization in Health Insurance
KFF Health Reform
May 20, 2022
By Kaye Pestaina and Karen Pollitz

Long used as a tool to control spending and to promote cost-effective care, prior authorization in health insurance is in the spotlight as advocates and policymakers call for closer scrutiny about its use across all forms of health coverage.

What is Prior Authorization?

Prior authorization (also called “preauthorization” and “precertification”) refers to a requirement by health plans for patients to obtain approval of a health care service or medication before the care is provided. This allows the plan to evaluate whether care is medically necessary and otherwise covered. Standards for this review are often developed by the plans themselves, based on medical guidelines, cost, utilization, and other information.

The process for obtaining prior authorization also varies by insurer but involves submission of administrative and clinical information by the treating physician, and sometimes the patient. In a 2021 American Medical Association Survey, most physicians (88%) characterized administrative burdens from this process as high or extremely high. Doctors also indicated that prior authorization often delays care patients receive and results in negative clinical outcomes.  Another independent 2019 study concluded that research to date has not provided enough evidence to make any conclusions about the health impacts nor the net economic impact of prior authorization generally.

Comment by: Jim Kahn

The insider story is compelling – give it a full read.

I have my own extended patient experience with PA. Multiple rounds of PA for one drug, with two insurers. Poorly documented requests by my ophthalmologist’s office. Denials, then appeals and approvals. Repeat with next insurer. All for a medicine that is clearly indicated, needed, and valuable. Most recently, some PA professional, or some AI program, seems to have decided that this medicine should just be routinely approved. No more PA battles. Phew. Fingers crossed.

Here’s my analysis of the state of prior authorization:

Prior authorization (PA) is supposed to lower medical costs and avoid unproven and dangerous care by confirming medical indications. Indeed, there’s plenty of inappropriate care in medicine, perhaps 20%, according to the National Academy of Medicine. With complete data and lots of time, we could reduce that. But there’s no good evidence that PA works in the real world (see the KFF excerpt above). Sophisticated review is too costly and burdensome, and the needed clinical data aren’t available to reviewers. So, as PA is actually practiced, it’s very hard to distinguish between unjustified services and typing errors or oversights. The process confuses & frustrates patients. It causes delays and may deny valuable care. It hugely burdens providers mentally and financially, and thus is contributes substantially to burnout.

Like so much of the business activity layered onto traditional health insurance activities (think: Pharmacy Benefit Managers), PA is driven by economic considerations. It’s much more a financial game than pursuit of quality care. Its real purpose is to save money. But that’s elusive, because practice is imperfect. Doctors learn to provide the right answers. So, as noted, evidence for overall savings is equivocal. Delay is part of the game – an expensive service is “kicked down the road”, perhaps to the next insurer.

So, if it doesn’t work, and it’s annoying, why does it persist? Ultimately, PA thrives because it creates business sectors. PA reviewers get paid to review, and consultants get paid to advise providers on how to succeed with reviews. It’s an arms race, profitable to all involved. The end result is that ancillary companies nibble at the edge of our costly healthcare, making “dopey amounts of money”, and it all “gets baked into premium costs”, as the PA insider so eloquently wrote. We all pay.

By the way, PA is only part of the story. A bigger issue is denials of submitted claims, which are estimated at 17% in-network for ACA exchange plans, 13% in private managed care, 7% in traditional Medicare, 8% in Medicare Advantage, and 13-21% in Medicaid. This largely reflects complexity of coverage rules and procedures.

Under single payer, quality and cost control would rely on methods other than PA. For starters, we’d have complete data on clinical diagnoses and services, thus much better information to use to identify and reduce medically inappropriate care. Denial rates would be lowered by broader and simplified benefits (identical for everyone) and thus less confusion. And by removing the profit motive that drives so many decisions today. More on this another day.


Public Education Needed on the Advantages of Public Insurance

Summary: US adults are fed up with health insurance costs and coverage, eager for real reform. Most favor a government guarantee of coverage, and a plurality (38%) support single payer. Yet 53% prefer a system of private insurance, despite its failings. We need to further educate the public.

The Challenge of Healthcare Reform
January 27, 2023
By Frank Newport

Gallup data show that Americans’ current ratings of their personal healthcare situations are on the positive side of the majority line, including a 72% excellent or good rating for personal healthcare quality, a 66% excellent or good rating for personal healthcare coverage, and 56% who are satisfied with personal healthcare costs.

Americans are clearly more negative when asked about healthcare “out there” across the country. For example, 76% of Americans are dissatisfied with the cost of healthcare in the U.S.; only 32% rate healthcare coverage in the U.S. as excellent or good; and the new low of 48% of Americans rate the quality of healthcare in the country positively.

One seemingly simple solution for healthcare problems is the single-payer, “Medicare for All” program advanced by such leaders as Sen. Bernie Sanders. We don’t find strong support for this remedy from the public, although the public’s attitudes are complex (and interesting to study).

A 57% majority of U.S. adults believe that the federal government should ensure all Americans have healthcare coverage. Yet nearly as many, 53%, prefer that the U.S. healthcare system be based on private insurance rather than run by the government.

Putting responses to these two questions together, we find that only 38% of Americans adopt the position Sanders espouses — that the government’s role is to ensure that everyone has healthcare coverage and that the government should run the system. Another 35% of Americans adopt the opposite views, believing both that the nation should use a private insurance system and that it is not the government’s role to ensure healthcare for all to begin with. And 18% of Americans believe that the government should ensure that everyone has insurance, but that this should be accomplished through private insurance, not a government-run system.

The takeaway here: The majority of Americans recognize that government has a role in expanding health insurance coverage, but many are ambivalent about fulfilling that role with a government-run system.

Comment by: Don McCanne

The Gallup data confirms that Americans are increasingly concerned with cost and coverage of healthcare in the nation, though they rate their own personal situation more positively than they do for the nation generally. This lack of pressing personal concern combined with everyone’s concern about taxes likely explains why many are reluctant to support comprehensive healthcare reform at this time.

Another important finding confirmed here is that there is a clear preference for the insurance system to be run by the private sector rather than by the government. This probably represents a relative satisfaction with employer-sponsored plans, contrasted with problems with Medicaid and some other safety net health programs, as well as other experiences with government bureaucracies. This is heavily reinforced with positive marketing campaigns from the private industry and negative propaganda campaigns from right-wing advocacy organizations.

This preference for private plans would be very unlikely if the public at large truly understood the clear advantages of a well-designed single payer system over a market of private plans: universal, comprehensive, accessible, affordable, equitable, high quality health care for everyone. Indeed poll questions that describe single payer’s universal comprehensive coverage with lower costs often yield 2/3 support.

We’ve long said that we need to educate the public on these advantages. We’ve also been trying to educate them on the deficiencies of the private plans (medical debt and bankruptcies are now growing rapidly amongst the privately insured!). Even our President doesn’t get the message. Frank Newport writes, “The Joe Biden administration certainly feels the ACA has been a success,” when we have the most expensive system that barely qualifies as being mediocre.

There is a message here. We have to become much more effective at delivering it.

Response from Kip Sullivan:

I want to call attention to bias in the question Gallup asked. Pollsters frequently confuse respondents by asking how they feel about “government-run health care” or similar, rather than a more accurate phrase such as “government insurance like Medicare.” I tried to download the questions Gallup asked and was allowed to see only one. Here it is:

Which of the following approaches for providing healthcare in the United States would you prefer? * Government-run health systems * System based mostly on private insurance. 

Single-payer bills would not, as we all know, require the “government to provide health care.”