Medicare (Dis)Advantage - Even Hospitals Don’t Like It.

If the hospitals are smelling a rat, so should Medicare (Dis)Advantage victims (AKA enrollees).

If the hospitals are smelling a rat, so should Medicare (Dis)Advantage victims (AKA enrollees).

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“We hear every day, from our hospitals and health systems across the country, about challenges they experience with Medicare Advantage [MA] plans,” said Michelle Millerick, senior associate director for health insurance and coverage policy at the American Hospital Association, which represents about 5,000 hospitals. The hurdles include prior authorization restrictions, late or low payments, and “inappropriate denials of medically necessary covered services,” she said. (Kaiser Family Foundation (KFF) Health News March 29, 2024)

I have already described in many previous articles the horror show that Medicare (Dis)Advantage has become for those unfortunate enough to have opted for one (see articles in Related Links below). MA eats away at the Medicare Trust Fund at the rate of $80-$140 BILLION a year, money that could have gone directly for the care of the Medicare insureds but that is re-routed into the coffers of hedge funds and insurance companies. It is unarmed robbery, but robbery nonetheless. This video, prepared by Students for a National Health Plan (SNaHP) recaps in 30 minutes the present situation with MA.  

I am not, however, crying crocodile tears for hospitals who take advantage of the system even as some complain about prior authorization, late payments, or denial of service. The hospital won't die because of shitty insurance. People do. Some hospitals grab onto the MA gravy train with eager abandon by entering into programs such as ACOReach, a form of the scheme previously known as Direct Contracting Entities. Our own monopolizing PeaceHealth (PH) hospital behemoth moved thousands of it clients with primary care doctors at PH, without their consent or knowledge, from Traditional Medicare (TM) to its “special money extraction unit” (ACOReach) that they blandly call Cascadia Community Care Alliance, which has little to do with community or care but much to do with sucking dollars from the teat of the Medicare Trust Fund. No doubt you will soon see comments below from their corporate office trying to defend the indefensible, their very own ACOReach, as they did with one of my previous articles, “Growth of Medicare’s ACO Reach Scam Halted”.  

What then to do?

I recently received an email from Physicians for a National Heatlh Plan (PNHP) reporting that 60 members of the U.S. House of Representatives sent a letter to Medicare administrators indicating the ways MA harms those enrolled in Medicare. The letter can be read in its entirety here. Meanwhile, let me direct you to this part: 

Supporters of MA claim the program reduces costs. Unfortunately, the MA program has never saved the government money.

1. In fact, spending per beneficiary is growing faster in MA than in TM, and the Medicare Payment Advisory Commission (MedPAC) estimates that CMS pays MA plans 6 percent more per enrollee than what it would cost to cover the same enrollee in TM.

2. Despite these higher costs, the data demonstrates that MA often provides worse coverage than TM. For example, a recent study found that people in MA are significantly more likely to die in the month following surgery for stomach, pancreatic, or liver cancer compared to people in TM.

3. Other recent data has shown that the bottom 5 percent of MA plans are responsible for 10,000 preventable deaths every year.

The letter goes on to say that to improve patient health, reforms are needed to:

1. Ensure that insurance companies do not prevent older adults and people with disabilities from getting care by putting up obstacles, including onerous prior authorizations, Artificial Intelligence (AI) algorithms [sets of computer procedures], or limited networks;

2. Strengthen provider encounter and patient data collection and transparency to improve public understanding of the effects of insurer-run MA plans on patients and the Medicare program;

3. Rein in overpayments to insurers in MA by adjusting benchmarks to compensate for favorable selection and cracking down on deceptive tactics by private insurance companies, including upcoding; and

4. Strengthen Medicare for everyone through administrative action, such as by lowering Medicare premiums, and support legislative efforts to expand Medicare benefits, cap out-of-pocket (OOP) costs in TM, and adjust the physician fee schedule to account for increases in provider costs.

Locally, the Whatcom Democrats have gone further and unanimously passed (70-0) a resolution* asking the Biden administration to:

1.Phase out all MA programs and return all Medicare insureds to Traditional through a
detailed transition process.

2.Move to a single payer national health plan: Medicare (TM) for All.

3.Add vision, hearing, and dental coverage to Medicare for All.

4.Eliminate the 20% co-pay
 

The Whatcom Democrat's platform now contains these planks. 

1.Federal Government: Terminate efforts to privatize original Medicare (Medicare “Advantage” is already privatized) through Direct Contracting Entities (DCE) or anything similar, and prohibit the practice of assigning original Medicare recipients to these entities without their prior consent.

2.PeaceHealth: Cancel the Medicare DCE contract. [AKA Cascadia Community Care Alliance]

3.Federal Government: Phase out so-called Medicare Advantage, which, despite its misleading name, is privatized, and costs the government more per person than traditional Medicare. That difference could fund vision, dental, and hearing benefits.

4.Congress: Expand Medicare to include vision, dental, and hearing benefits.

5.Congress: Pass a single-payer health care system such as Medicare for All.

In short, we should immediately stop the bleed caused by MA and ACOReach, while moving quickly to a nation-wide single payer system for delivery of healthcare. All else is lipstick on the pig and polishing the proverbial turd.

*Full Disclosure - I drafted the original version of this resolution.

 

 

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About Dick Conoboy

Citizen Journalist and Editor • Member since Jan 26, 2008

Dick Conoboy is a recovering civilian federal worker and military officer who was offered and accepted an all-expense paid, one year trip to Vietnam in 1968. He is a former Army [...]

Comments by Readers

M. Lynda Hanscome

Mar 31, 2024

BRAVO to Dick Conoboy!!!!

I am one of the 2.1 million TM beneficiaries who was dumped in an ACO-REACH for-profit Medicare Scam WITHOUT MY KNOWLEDGE OR CONSENT—PeaceHealth, I’m lookin’ at you….   It is ALL about Upcoding on the front-end by exaggerating medical prognosis and once the for-profit gets the money-in-pocket to “manage” the paitent, they subsequently delay or deny necessary treatment.  Don’t get me started about PeaceHealth, medical crooks of Bellingham.  I am in the process of cutting off PeaceHealth from ever receiving any future Medicare information about me; I have begun travelling outside of Bellingham for my minimal medical needs.

These Medicare Scams will ONLY stop when ALL beneficiaries (including future beneficiaries) stand up and demand the raiding of the Medicare Trust Funds stop.

Thank you, Dick, for your outstanding coverage of this issue.

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