Month: February 2023

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?

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. 

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.

– JGK

Fact sheet on this announcement is here.

Comment submission instructions:

Comments are due by Friday, March 3, 2023.

Go to www.regulations.gov, 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,

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!

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.

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
Gallup
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. 
https://news.gallup.com/poll/468401/majority-say-gov-ensure-healthcare.aspx 

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

Summary: A new study quantifies huge anticipated gains over 10 years – $2.5 trillion in financial savings alongside added resources for clinical care – by shifting hospital financing from today’s service-based payment and profit generation to global budgeting.

Hospital Expenditures Under Global Budgeting and Single-Payer Financing: An Economic Analysis, 2021–2030
International Journal of Social Determinants of Health and Health Services
February 2023
By Adam W. Gaffney, David U. Himmelstein, Steffie Woolhandler, & James G. Kahn

Abstract

U.S. hospitals provide large amounts of low-value care and devote inordinate resources to administration, while some hospitals leverage market power to realize large profits. Meanwhile, many rural and safety net hospitals are financially distressed. The coexistence of waste and want suggests that U.S. hospital financing is neither efficient nor equitable.

We model the economic consequences of adopting the mode of hospital payment used in Canada and the U.S. Veterans Health Administration and proposed in the leading congressional single-payer Medicare-for-All bill: global budgeting. Our models assume increased utilization due to expanded and upgraded coverage; gradual reductions in administrative costs from simplified payment; and the elimination of hospital profits, with hospital capital expenditures funded by explicit grants rather than from profits or borrowing.

We estimate that non-federal hospital operating budgets will total $17.2 trillion between 2021 and 2030 under current law versus $14.7 trillion [14.5% lower] under single-payer with global budgeting. This difference of $2.5 trillion reflects $520 billion in foregone profits and $1,984 billion in reduced expenditures on hospital administration. Expenditures on clinical operating budgets, however, would be higher than under current law, funded out of profits.

Comment by: Jim Kahn

This economic analysis (full disclosure: HJM authors, including myself) quantifies the anticipated changes in hospital costs over 10 years with a shift to global budgeting. The cumulative savings are estimated at $2.5 trillion, nearly 15% of the total.

The chart conveys the key findings: Savings accrue most of all by simplifying administration, but also by eliminating profit and slowing the rate of growth. At year 10, when current law spending is projected at $2.2 trillion, single payer is $1.8 trillion. These analyses include an allowance for increased care and quality improvement. Global budgets would assure financial stability, protecting hospitals for rural areas and when medical care needs shift.

This funding mechanism echoes the approach used successfully in most other wealthy countries. And the hospital analysis illustrates the kinds of savings that single payer would offer across the health system.

Global budgeting of hospitals (and of the entire health system) would require a complete shift in how we pay for medical care. That’s what’s needed. Single payer, putting patients above profits.

Summary: A physician-anthropologist highlights the conflict plaguing today’s medical profession: the contradiction of medical values and a profit-focused health care system. He advocates collective action for universal health care following the single payer model.

Doctors Aren’t Burned Out From Overwork. We’re Demoralized by Our Health System.
New York Times
Feb. 5, 2023
By Eric Reinhart (Political anthropologist and physician, Northwestern University.)

The United States is the only large high-income nation that doesn’t provide universal health care to its citizens. Instead, it maintains a lucrative system of for-profit medicine. For decades, at least tens of thousands of preventable deaths have occurred each year because health care here is so expensive.

What’s burning out health care workers is less the grueling conditions we practice under, and more our dwindling faith in the systems for which we work. What has been identified as occupational burnout is a symptom of a deeper collapse. We are witnessing the slow death of American medical ideology.

During the pandemic, physicians have witnessed our hospitals nearly fall apart as a result of underinvestment in public health systems and uneven distribution of medical infrastructure. Long-ignored inequalities in the standard of care available to rich and poor Americans became front-page news.

According to an investigation in The New York Times, ostensibly nonprofit charity hospitals have illegally saddled poor patients with debt for receiving care to which they were entitled without cost and have exploited tax incentives meant to promote care for poor communities to turn large profits. Hospitals are deliberately understaffing themselves and undercutting patient care while sitting on billions of dollars in cash reserves. Little of this is new, but doctors’ sense of our complicity in putting profits over people has ‌grown more difficult to ignore.

From at least the 1930s through today, doctors have organized efforts to ward off the specter of “socialized medicine.” We have repeatedly defended health care as a business venture against the threat that it might become a public institution oriented around rights rather than revenue.

This is in part because doctors were told that if health care were made a public service, we would lose our professional autonomy and make less money. For a profession that had fought for more than a century to achieve elite status, this resonated.

For example, a system of billing codes invented by the American Medical Association as part of a political strategy to protect its vision of for-profit health care now dictates nearly every aspect of medical practice, producing not just endless administrative work, but also subtly shaping treatment choices.

Addressing the failures of the health care system will require uncomfortable reflection and bold action. Any illusion that medicine and politics are, or should be, separate spheres has been crushed under the weight of over 1.1 million Americans killed by a pandemic that was in many ways a preventable disaster. And many physicians are now finding it difficult to quash the suspicion that our institutions, and much of our work inside them, primarily serve a moneymaking machine.

Doctors can no longer be passive witnesses to these harms. We have a responsibility to use our collective power to insist on changes: for universal health care and paid sick leave but also investments in community health worker programs and essential housing and social welfare systems.

Neither major political party is making universal health care a priority right now, but doctors nonetheless hold considerable power to initiate reforms in health policy. If we can build an organizing network, then proposals to demand universal health care through use of collective civil disobedience via physicians’ control over health care documentation and billing, for example, could move from visions to genuinely actionable plans.

Regardless of whether we act through unions or other means, the fact remains that until doctors join together to call for a fundamental reorganization of our medical system, our work won’t do what we promised it would do, nor will it prioritize the people we claim to prioritize. To be able to build the systems we need, we must face an unpleasant truth: Our health care institutions as they exist today are part of the problem rather than the solution.

Comment by: Don McCanne

Eric Reinhart already said what I have to say, “Until doctors join together to call for a fundamental reorganization of our medical system, our work ‌won’t do what ‌we promised it would do, nor will it prioritize the people we claim to prioritize.”

Of course, the model on which we can all work together and which will prioritize all of the people is single payer.

The House of Representatives this month passed a ridiculous resolution condemning “socialism” when it should have passed a resolution supporting public policy while condemning divisive politics. This would have provided a bipartisan pathway to bring us single payer. I tell you, it would have cured my burnout.

Summary: Two KHN stories illustrate how nursing homes and Medicare Advantage health plans share a business rapacity, using no-holds-barred tactics to funnel public health insurance funds to the pockets of shareholders.

Nursing Home Owners Drained Cash During Pandemic While Residents Deteriorated
KHN
By Jordan Rau
February 1, 2023

After the nursing home where Leann Sample worked was bought by private investors, it started falling apart. Literally.

Part of a ceiling collapsed on a nurse, the air conditioning conked out regularly, and a toilet once burst on Sample while she was helping a resident in the bathroom, she recalled in a court deposition.

“It’s a disgusting place,” Sample, a nurse aide, testified in 2021.

The decrepit conditions Sample described weren’t due to a lack of money. Over seven years, The Villages of Orleans Health & Rehabilitation Center, located in western New York near Lake Ontario, paid nearly $16 million in rent to its landlord — a company that was owned by the same investors who owned the nursing home, court records show. From those coffers, the owners paid themselves and family members nearly $10 million, while residents injured themselves falling, developed bedsores, missed medications, and stewed in their urine and feces because of a shortage of aides, New York authorities allege.

At the height of the pandemic, lavish payments flowed into real estate, management, and staffing companies financially linked to nursing home owners throughout New York, which requires facilities to file the nation’s most detailed financial reports. Nearly half the state’s 600-plus nursing homes hired companies run or controlled by their owners, frequently paying them well above the cost of services, a KHN analysis found, while the federal government was giving the facilities hundreds of millions in fiscal relief.

In 2020, these affiliated corporations collectively amassed profits of $269 million, yielding average margins of 27%, while the nursing homes that hired them were strained by staff shortages, harrowing injuries, and mounting covid deaths, state records reveal.

Government Lets Health Plans That Ripped Off Medicare Keep the Money
KHN
By Fred Schulte
January 30, 2023

Medicare Advantage plans for seniors dodged a major financial bullet Monday as government officials gave them a reprieve for returning hundreds of millions of dollars or more in government overpayments — some dating back a decade or more.

The health insurance industry had long feared the Centers for Medicare & Medicaid Services would demand repayment of billions of dollars in overcharges the popular health plans received as far back as 2011.

But in a surprise action, CMS announced it would require next to nothing from insurers for any excess payments they received from 2011 through 2017. CMS will not impose major penalties until audits for payment years 2018 and beyond are conducted, which have yet to be started.

While the decision could cost Medicare plans billions of dollars in the future, it will take years before any penalty comes due. And health plans will be allowed to pocket hundreds of millions of dollars in overcharges and possibly much more for audits before 2018.

Comment by: Jim Kahn

In these two stories, KHN highlights the aggressive tactics employed by recipients of Medicare and Medicaid funding to maximize profits without regard to effects on patients or taxpayers.

Nursing home owners create supplier companies which then charge the nursing homes inflated prices. This depletes the nursing home budgets and results in dangerous under-staffing and patient harm. The supplier companies are highly profitable, so the owners of these linked entities make out like bandits. Shareholders win, patients lose, Medicaid (and private) payers lose.

Meanwhile, Medicare Advantage plans threaten to sue CMS about an eminently fair rule that diagnostic upcoding and overcharges found in intensive audits should be extrapolated to all patients in that plan. After years of rule-making, CMS backs down, foregoing reimbursement of hundreds of millions or billions of dollars in excessive charges. Once again, the legal and political muscle of insurers enables massive larceny from taxpayers.

A health system based on inadequately regulated private for-profit corporations cannot work. See our recent discussion on the corrosive effects of profit in US health care.

Single payer would dump the private insurers and control the providers.