Thursday, March 7, 2024

"Health care" Corporations are Evil. Most of the people who work for them are not. Fight back!

Usually, when I write a blog post, I start with something that has happened or is happening, try to develop it and point out the relationships between it and other things that are happening. Toward the end I make an effort to form a conclusion, and, perhaps even make suggestions as to how the problem(s) might be addressed. However, today I think I’ll lead with the conclusion, so folks do not have to read too far:

All of the US healthcare industry (not system) is run by corporations that are effectively evil.* They function for only one purpose: to suck as much money, in the form of profits, stock price, and executive salaries (the executives, who are people, are of course evil) from our economy under the false flag of providing health care. They care not one whit about the health of people, society, or community, nor about decency. They include insurance companies, large hospital systems and provider groups (often owned by insurance companies and -- the exemplar of morality-free rapacious profit -- private equity), pharmaceutical companies and device companies, the large pharmacy chains (e.g., Walgreen’s, CVS) and the PBMs (pharmacy benefits managers) that control drug distribution.

*[I do not believe that corporations are people, despite the scandalous Citizens United decision that decided that they were and that money is speech, so are without human characteristics.]

I could end it there, and say “if you have any questions, read my previous blogs, and the references I cite”, but I will go to talk about a few recent events and actions that bolster this case. First, however, I want to talk about people, the people who work in health care, the people who the other people (called “patients”) seeking health care actually run into. Almost uniformly, they are not the problem. From the higher-paid physicians and other clinicians, including nurses, who provide clinical care, to the pharmacists and pharmacy assistants who dispense medications, to those who answer the phones, schedule appointments, take questions to be transmitted to the clinicians, and even collect money, these are overwhelmingly hard-working people trying to do a good job of serving you. They are almost all employed, however; even about 75% of physicians (and growing) are employed by corporations. If your doctors seem rushed and not to have enough time for you, if they are focused on computer screens, if they don’t quickly call you back, this is not their choice, it is the mandate of the corporation that employs them. It is essentially the same as the traditional “speed up” for assembly line workers: to be “more efficient”, a euphemism for “making more money for the corporation”. The same is true for the clerks who may take a lot of time to answer the phone, or who are “unwilling” to cut you some slack on your bill (when really they do not have the power to), or the pharmacist who takes “too long” to fill a prescription or provide you with the information that you need. These are, by and large, good people trapped in a heartless system.

And, yet, because these are the people –physicians, nurses, pharmacists, clerks – whom we, as patients, see and interact with, they are the ones on whom we take out our frustrations when we feel we are not being treated as we should be. When we are denied care when we are late because the bus was delayed, or because we had to get our children off to school but the early appointment was the only one available, or because we don’t get off work until 4:15 but the 3:30 appointment was the last available. Yes, like the rest of us, all these people in healthcare want to work reasonable hours and get home on time, but the rules that they are required to enforce are not made by them. They are made by the corporate executives, those who have sold their souls, the CPAs and MBAs (and occasionally MDs and RNs, but usually those also have MBAs) whose expertise is in making money for the corporation, not in serving you, and who are handsomely rewarded for it. They are the people who are responsible and to whom your anger should be directed, but good luck getting to them. Maybe you can reach the CEO of a small rural hospital (who will almost never be the real CEO, since it is probably owned by a large hospital corporation) but not the heads of the insurance companies and pharmaceutical companies and massive health systems and private equity owners of all of these. More than the highest Mafia dons, they are protected by layers and layers of others who keep them from having to interact with you. But they ARE the evil people (even if, like those Mafia dons, they are nice to their children), creating, maintaining, and expanding an industry designed to extract as much money as possible from the economy and mis-label it “health care”.

The idea that this skates close to the edge of what is legal is disingenuous. It is often illegal; a huge part of the industry regularly acts illegally. We want there to be laws against such abuse, but even when there are they are irregularly, even rarely, enforced largely due to inadequate funding for the regulators. This is on purpose; those huge corporations have the money to buy – I mean donate to – congresspeople and also offer high-paid jobs to former regulators who “behaved” in the revolving door system. And when the rules are enforced, the fines are relatively low, and are just written off as a “cost of doing business”

Examples?

How about “Whistleblower Accuses Aledade, Largest US Independent Primary Care Network, of Medicare Fraud”, KFF Health News (March 5, 2024)? Using a practice known as “upcoding”, the company employs large numbers of people to add additional diagnoses to the one for which the person is being treated, increasing the reimbursement. This practice results in greater fee-for-service payment, but is even better (for the company) in increasing the “capitated payment” that they get for a particular “covered life”, both in general managed care and in Medicare Advantage programs. In this case, and in many hospitals, it is the provider who is fiddling the data to get more money from the insurer (which, in the case of Medicare Advantage, as well as Medicaid and some other programs, is the government – that is, you, the taxpayer).

But let’s not cry for the poor insurance companies, although they would like you to think it is the doctors and hospitals who are at fault for milking them. Even when something very bad happens, like the recent cyberattack at the largest health insurer, UnitedHealth, in which they may have paid a $22M ransom, it is the providers who are not getting paid. UnitedHealth is doing just fine, thank you. Not only is $22M not that much for them, but as pointed out by former insurance executive and current whistleblower Wendell Potter in his substack

Keep in mind that while the company is unable to pay thousands of the country’s doctors and hospitals for who knows how long because of the hack, UnitedHealth will be able to hold on to billions of dollars in premium income longer, and that will boost its investment income, which is considerable on any day of the week.

They have the system covered from all angles. UnitedHealth has moved into owning practices directly, through Optum, a very large provider and the source of a big percent of their profit. Along with their Medicare Advantage products.

Indeed, as providers and insurers point the finger at each other, and as pharmacies buy up the PBMs that control utilization, increasing vertical integration, and as private equity companies buy up all of these, there is one thing that you can be sure of: the benefit to the customer, consumer, patient, person, society is the one thing not being considered. We are the collateral damage in the fights among these amoral (at least, really immoral) behemoths.

What can we do? It often seems like there is not much. Our feeble cries are drowned out by the corporate contributions to our congresspeople. But we can let our elected representatives know that we are on to the abuses by those companies, and that we hold them responsible for holding (or not holding) the corporations responsible. We can, for example, demand something specific, that they sign on to the Patients over Profits pledge (initiated by National Nurses United, NNU, and now sponsored by many patient and community groups):

I pledge to put patients over profits and not take contributions over $200 from the executives, lobbyists, and PACs affiliated with the corporate health care industry, including private insurers, pharma corporations, and private hospitals who are organizing to take over our health care system.

They won’t if just a few of us ask. But if LOTS of us do, they just might.

And that’s a start.

Monday, February 12, 2024

Medicare Scams? The whole US health care "system" is a scam!

In ‘Staggering Rise in Catheter Bills Suggests Medicare Scam’, Feb 9, 2024, the NY Times suggests that up to 20% of federal spending on medical supplies may be from 7 “high-volume” suppliers of catheters, including people -- like the woman for whom Medicare paid $12,000 for 2000 catheters -- who don’t need them, don’t want them, did not order them, and didn’t receive them. If true, this is a totally illegal scam, something that we see all too frequently in the US, with criminal parasites preying on our people and on a federal agency hamstrung by budget cuts to their enforcement divisions. Perhaps “nursing homes” is what first comes to the minds of many when inflated billing for shoddy care comes to mind, and that is fair, but our medical supply companies and, of course, pharmaceutical companies are right there with scams.

Unfortunately, the biggest scam is not the obviously-illegal like catheter falsifying, but rather the skirting-the-law routine practice of many (maybe not all) health insurance companies in denying necessary, and sometimes legally-required, care to their clients. The most common method for doing so is requiring “prior authorization” and then repeatedly denying it until the client gets weary of fighting it, or recovers, or, maybe, dies from not having a procedure. And it is not like these denials are wisely made by qualified physicians sagely considering the issue; most of them are routinely denied by staff (sometimes, but not always, nurses) following algorithms. Or, increasingly, by AI.

I and others (e.g., https://wendellpotter.substack.com/p/the-great-medicare-advantage-marketing) have written about Medicare Advantage plans several times, which attract seniors with lower out-of-pocket costs (compared to paying for Medicare Part B + a supplement) and full coverage, including for some services not covered by Medicare (glasses, hearing aids, etc.) My main point has been that this is great if you are willing to use their limited network of doctors and hospitals -- until it isn’t. Until they deny you care. Which can be illegal because they are required by law to cover everything Medicare covers. But, using the “prior authorization” and “repeated denials” techniques, many (maybe not all) often (but not always) do. This is just as illegal as the catheter scam, but penalties have been rarely incurred, and when they are, are low enough to be considered a “cost of doing business”, essentially a slap on the wrist.

But it is not only Medicare Advantage (MA) that uses these techniques (I’ll call them PA&RD) to effectively deny care to the people who are paying their premiums. Indeed, the use of these strategies in MA plans was developed for the insurance companies’ non-Medicare clients, those who have coverage through employer-based plans or ACA. For a long time, the use of PA&RD was common, if not ubiquitous, but possibly legal. Unethical, maybe. Fatal for some, yes. But apparently legal. Some state legislatures stepped in to prevent these abuses, requiring coverage for certain conditions, such as diabetes, emergency care or reconstructive surgery for breast cancer. Indeed, ‘States have passed hundreds of laws to protect people from wrongful insurance denials’, but as documented by ProPublica, ‘Health Insurers Have Been Breaking State Laws for Years’. How do they get away with it? Again, lack of enforcers because of budget cuts and very powerful lobbies for the insurers (they make lots of money and are careful to spend enough of it in the “right” places!) Per ProPublica:

State insurance departments are responsible for enforcing these laws, but many are ill-equipped to do so, researchers, consumer advocates and even some regulators say. These agencies oversee all types of insurance, including plans covering cars, homes and people’s health. Yet they employed less people last year than they did a decade ago. Their first priority is making sure plans remain solvent; protecting consumers from unlawful denials often takes a backseat.

What are the results? One is that people stay sick, get worse, and sometimes die from lack of health care. I hope we can agree that is a bad thing. Another is that people are going broke more and more often from trying to pay the bills that their insurance companies don’t (yes, those insurance companies that they and/or their employers have been paying premiums to). The recent study by KFF Health News and NPR, reported in the Guardian and the Health Justice Monitor and discussed by me recently (ER backups and poor-quality but expensive insurance: The American Way!, Jan 24, 2024), but worth repeating, found that more than 100 million Americans have medical debt. More shockingly, (as reported by Kodiak Solutions, a billing and accounting firm that covers 1800, nearly 1/3 of US hospitals) in just 4 short years the proportion of that debt owed by insured people has risen from 11% to 58%! Think about that – way back in 2018 most “bad debt” was owed by uninsured people (almost all of whom were too low-income to be able to afford it) but by 2022 it was by insured people – meaning insurance companies were not doing what they were contracted to do – paying people’s medical bills – even when required to by state law.

When the bad actions of health insurance companies are combined with the bad actions of health care providers, now often owned by private equity companies seeking only profit (see example of Steward Health Care, or overcrowded ERs in Massachusetts, as well as Arizona) it is obvious that get real pain being is being suffered by – really, inflicted upon -- the American people. On the other hand, insurers like UnitedHealth (which also operates the largest chain of physician practices, Optum), and private equity companies like that which owns Steward Health Care, are doing just fine, thank you, making record profits.  And the drug companies finding all the loopholes in laws to charge more and telling Sen. Sanders and the health committee that sure they charge American consumers more for drugs, but, hey, why the heck not, since we’re allowed to here – and, by the way, don’t change that – are continuing, as they always have, to make out like, well, bandits, which they have always been. They argued to the Senate that Americans get access to new drugs first as part of paying more, but Sen. Sanders appropriately responded that this was of no help to people who were unable to get the drugs because of their cost! Duh!

There are those who think that the money we pay – in premiums, taxes, co-pays, etc. – should be spent on delivering health care, not corporate profits. But so far enough politicians have been willfully deaf and blind on the issue to prevent really significant change to the system so that (as in most countries) it does the latter.

They need to hear from you to tell them that’s what matters.

Thursday, January 25, 2024

ER backups and poor-quality but expensive insurance: The American Way!

The January 22 edition of the Arizona Star (Tucson) reprinted a piece from the Arizona Republic (Phoenix) titled “'I've never seen it this busy': Here's why Arizona emergency departments are jammed”. The article is paywalled, but you don’t really need to read it since that headline basically is the story: all over the state, including its two biggest cities, waits for non-emergencies (and sometimes emergencies) in ERs is many hours to, sometimes, days! The article discusses some reasons, including the increase this winter in respiratory diseases like flu, RSV, and, yes COVID (despite everyone pretending it has gone away; see NY TimesCalifornia and Oregon Ease Covid Isolation Rules, Breaking With C.D.C.”). In fact, there has been a lot of respiratory disease this winter, and as reported by “Your Local Epidemiologist”, Katelyn Jetelina, and while it seems to be declining, there could well be more peaks.

The colder weather makes the most vulnerable, those without housing, even more vulnerable. Also contributing to the ER backup in Arizona is the increase in the number of “winter visitors” (also known as “snowbirds”) who are coming back “after” the pandemic, who are often older and do not have a regular source of care here. And, yes, also that too many of us who live here year round do not have a regular source of care because, as in most places, there are not enough primary care clinicians (see “Primary Care, Private Equity, and Profit: How to ensure poor quality care for the American people”, Sept 28, 2023 and “We need more primary care to serve our people: Why do the medical schools lie?”, Dec 12, 2023). So people go to the emergency room, or to an urgent care center where they are told to go to the emergency room “if it gets worse” or, when it is serious enough, right away.

But there is something else going on here. That is the breakdown of the American health care system, particularly the insurance system and the ways people are covered (or not) for health care costs. It is breaking down at all levels: there are not enough doctors, especially in primary care (see the blog posts cited above), insurance companies and employers are covering less and less of the cost of health care and requiring those who have insurance to pay more and more, and private equity (see the referenced blog above) has taken over many practices and is squeezing them for maximum profit without regard to what it does to the quality of the “product”, which is our health care. Private equity in the healthcare sector follows the same playbook it follows everywhere: squeeze profit out, diminish services, and if it bankrupts the company too bad; they already have theirs. And when it is insurance companies that take over the practices (such as United Health Care owning Optum) the result is about the same. No one is minding the people-serving part of the store.

Yes, there are plenty of uninsured people, including the homeless, and those who are “too rich” (hah!) to get Medicaid, which in most states requires an income far below (often way less than half) the poverty level (which is about $31,000 for a family of 4), and anyway is also, in most states, pretty much limited to women with small children and virtually never covers single adults. But there are also the under-insured, those with terrible insurance coverage because it is all they can afford, as employers cut back on their contributions and insurance companies raise their rates and the financial burden on the insured including through copays, deductibles, and denied care (kind of like both raising the price and shrinking the size of a candy bar, except with much more serious outcomes). In addition, the expenditures by employers on health insurance (even when it is inadequate) is money that is not spent on wages, thereby increasing income inequality, as documented recently by Hager, Emanuel, and Mozaffarian in JAMA Open Network. And, since health insurance premiums are tax deductible for employers (although not for employees!) they prefer it to paying higher wages. What is the result of having insurance that doesn’t pay for what you hoped and expected it would when you or a family member is seriously ill? You go into debt. So the proportion of medical debt held by insured people as opposed to “self-pay” (uninsured, virtually all poor) people, has risen from 11.1% to 57.6% in 4 short years, from 2018 to 2022. Quintupled. The system, to the extent that it can be called a system at all, is broken.

But why? How? While there are still undoubtedly those, including politicians, pundits, and health administrators (all of them WELL-insured, you can be sure!) who blame it on some kind of “overuse” by patients (the medical word for “people”), there are actually 2 real causes:

  1. Abuse, corruption, and illegal behavior by insurance companies in pursuit of ever-more profit, and
  2. The failure of government entities to prevent them from doing so, or to prosecute them when they do.

Really? Really. Not only are insurance companies inadequately regulated, and able to effectively abstain from paying for care by repeatedly denying it and creating other obstacles, they frequently simply break the law, as documented in a study by ProPublica and reported by the Nonprofit Quarterly:

‘The findings point not just to bad behavior on the part of health insurance companies but also to a failure of the state regulatory apparatuses that oversee health insurance coverage to enforce laws already on the books: … If explicit laws on the books, spelling out mandatory coverage requirements, aren’t enough to prevent insurers from denying coverage, how are ordinary people to push back?

The answer, ProPublica’s Cheryl Clark found, is that those fighting for their own coverage are forced to navigate a “mind-boggling labyrinth” of bureaucracies set up by insurers and often barely regulated.”

It’s pretty bad, and it’s getting worse. Poor and uninsured people suffer the most, but employed and insured people are right behind them. Their medical debt increases in part because they think they have insurance and actually seek care, rather than avoiding it, as uninsured people often do. Which is, of course, terrible – how can there possibly be any justification at all for a “system” that encourages people to not seek care when they are sick, that provides too few primary care doctors or other clinicians to care for them, that makes them wait hours or days in ERs to be seen, and then saddles them with unpayable – but of course credit-destroying -- medical debt when they do get care?

Who are the worse criminals? The insurance companies and private equity firms who directly cause these problems by pursuing only maximum profit? Or the politicians who allow it to happen, who at best tinker around the edges, trying to limit (only occasionally with any success) the worst abuses? Should we run our fire departments like that? Police? The answer is in part tight regulation, prosecution of abuses and illegal activities including putting senior executives in prison, and really, finally, creating a universal coverage system in which each person has good coverage, can get good care, and be treated as a human being.

Like the executives, politicians and pundits expect for themselves.

Saturday, January 6, 2024

Guns good? Depends on what you believe. Guns dangerous? No question.

People like guns.

People hate guns.

People are scared of guns.

Guns are good for sport, like hunting animals.

Guns are good for war.

Guns are good for self-protection, in case “they” come for you.

Guns are good for going out and killing other people because:

·        They might otherwise come for you.

·        They are bad people because they are:

o   The wrong religion.

o   The wrong race or ethnicity.

o   Believe in abortion.

o   Are liberals.

o   Support restrictions on guns.

Guns are bad because they can be and are used for all of the reasons above.

Whether guns or good or bad or dangerous or not is irrelevant because “Second Amendment”.

If you like, substitute “automatic rifles” for guns in all or any of the above.

All the above are true.

There are definitely people who are terrified that “they” will be coming for them.  “They” could be the government (except when the government is on their side), or they could be, you know, “them”, the other.

Probably not for deer hunting; 30 or 40 rounds of high-power automatic rifle fire can really tear up the meat.

It could be post-apocalyptic, where they are, like Mad Max, fighting for survival. They believe that they need thousands of rounds of ammunition for all their guns (after all, ammo stores might not be open after the apocalypse) and high-capacity, high-speed automatic weapons are going to be more effective in protecting themselves and their families from, well, whatever.

Zombies. Or “them”.

If you believe this stuff, and your social circle and the sites that you frequent on the Internet completely reinforce these beliefs, there is no reason to doubt that it is true. Even if you used to not believe them. (Remember, perfectly rational people from the Midwest have moved to California and, after some time being among only Californians, have come to think that it is normative to believe in the healing power of crystals.)

If you do not believe this stuff, and your social circle and the sites that you frequent on the Internet completely reinforce your non-belief, you become convinced that the folks that do are both crazy and deluded. Which they may be.

If you think that these people watch too many movies and zombie TV shows, you’re right; the most important FACT is that there will be a much more limited number of people who are alive to duke it out after a nuclear war; let’s see, after nuclear winter, roughly ZERO!

If you think that there is a certain cognitive dissonance in thinking that people on the left are pansy snowflakes and also fearing that they’ll be coming after the heavily armed folks with the fears, you’re right, but so what?

Total logical contradictions have never been a problem for them in the past (see, e.g., “Donald Trump – Christian”).

There are a lot of folks in the “I need more guns and ammo” camp who are strongly opposed to mass murder, although there are pretty many (including in Congress) who are able to make arguments (sure, weird syllogisms, but hey…) defending folks who go to peaceful demonstrations with loaded weapons looking for other people to shoot. Charlottesville? Kenosha?

It is a “prevent defense”, I guess. There are even more who are opposed to slaughtering children in school (hardly anyone comes out specifically in favor of that), but are 100% against any proposal that might make it more unlikely.

Because, you know, if you make psychotic minors unable to purchase an AR-15 without a waiting period, the next thing will be government agents confiscating your deer rifle. Or Uzi.

No one is in favor of school shootings, but we have them almost every day. In every state. We look at the news, open the paper, hear our phones ding, and we see the newest one. And our Congress, and our state legislatures, all of whom are against school shootings, can’t seem to do anything to prevent them. Even though we – and they – know exactly what would do it.

Make guns very hard to get. Especially for young people. The brain does not fully mature until at least the mid-20s and the last part to develop is the frontal cortex where executive function and judgement reside.

Especially for automatic weapons.  Especially with those with histories of violence. Yes, crazies but mainly not them. Mostly those who have or have threatened to use violence. You see, shooting people, especially lots of people, that may or may not be crazy, but it is for sure violence. Any abuser of any kind, any barroom brawler, anyone who threatens violence.

But of course they won’t. Maybe because it would lose them votes, or maybe they just believe the same things. Maybe they believe their own stories.

But, you know, you can kill people with a knife. Or a baseball bat. Or a garotte. Of course, it is not easy to kill a whole lot of people from 100 feet away with any of those.

I would be remiss to not mention suicide. They constitute the majority of gun deaths. Yes, suicide is an individual’s choice, but it is not necessarily an unchangeable choice. The “successful” suicide rate among teens and young adult males 16-24 is TEN TIMES higher in the states with the loosest gun laws as in those with the most restrictive. Are young men in, say, Montana more depressed than those in, say, Connecticut? I don’t know, but suicide attempts, especially in young people, are very often impulsive, and the easy availability of a gun makes that impulse easier to follow. And attempts at suicide by gun are much more likely to be “successful” (called lethality) than those by poison, or gas, or hitting yourself on the head with  brick

In the US it is often people in poor and minority communities who suffer the most random death. But it is older white men who commit suicide most. Often with guns that they had right there.

If you think we should make guns, especially automatic weapons, less easily available, especially to those most likely to use them for killing people, great. But lots of others do not agree. Of course, they include those most likely to use them for killing people.


 

The rest of the wealthy world could provide an example of what to do, but you know what? They are not Americans. A number of countries have higher gun-death rates than the US, mostly those at war (e.g., Ukraine) or in the midst of narco terrorism. We are not.

But we have a lot of guns, and that helps us make up the difference.


Tuesday, December 12, 2023

We need more primary care to serve our people: Why do the medical schools lie? (reposted from April 5, 2021)

I recently re-read this blog post from 2-1/2 years ago, and decided that it was still important as well as relevant and accurate. So, in a "first" I am reposting it, since some folks may have missed it:


Every year the nation’s medical schools graduate thousands of people with MD and DO degrees. But this is just the start of becoming a practicing physician; they now need to complete residency programs in a specialty area, ranging from 3 to as many as 8 years, to become family physicians, surgeons, radiologists, dermatologists, orthopedists, etc. Indeed, for many physicians this “postgraduate” training (meaning post-medical school, since medical school itself is post-graduate, requiring a bachelor’s degree for entrance) can have two components as well. First there is the primary residency program, say an internal medicine residency of 3 years, and then there is subspecialty training, usually called “fellowship”, where that internist becomes a cardiologist, or endocrinologist, or pulmonary medicine physician. While the internist who completes 3-year residency may practice general internal medicine and thus become a primary care physician for adults, those subspecialists do not. A similar process exists for pediatrics. Family physicians completing their 3 year residencies can also do fellowships in a limited number of areas, and some limit their practices to sports medicine or geriatrics or adolescent medicine, but most add these skills to their primary care practice. And, of course, geriatrics and adolescent medicine are, like general internal medicine or general pediatrics, primary care for a particular population.

This is important. Primary care doctors provide care for their patients that is comprehensive and unrestricted, other than by age for pediatrics, internal medicine, and geriatrics. They meet the World Health Organization (WHO) criteria for primary care, providing continuous, comprehensive, community-and-family-centered care. Distilled down, this means that primary care physicians see their patients for everything, whatever concerns them, referring when needed. They are the doctors for their people, not for a particular disease or set of diseases. The lack of sufficient numbers of primary care doctors has significant negative impact on the health of our people. Of course, it falls hardest on those who are always most disadvantaged – the poor, members of minority groups, and rural residents. But it also has negative impact upon the health of privileged people who see lots of subspecialists, in two ways. One is that the specialist may be expert in their field, but miss appropriate treatments, and especially preventive measures, outside it. The other is that many specialties and subspecialties rely on and extensively use care that is very high-tech and expensive, which can lead to people getting tests and treatments that are not only costly but may not be of any benefit, and indeed may lead to harm.

 So, when a medical school claims that it is good at producing primary care physicians, this is serious, and should be accurate. But it usually is not, because schools want to look as good as possible so establish criteria that make them look good, counting a wide variety of specialties that their graduates might enter as “primary care”. The biggest “offender” in this regard is counting all graduates entering internal medicine residency programs as entering primary care. As described above, some of these end up doing fellowships to become subspecialists and do not practice primary care; indeed, “some” is an understatement as it is about 80%. In addition, about half the rest end up practicing as “hospitalists”, taking care of hospitalized patients only, rather than practicing primary care. So an approximation would be to assume about 10% of those entering internal medicine residencies will practice primary care. In pediatrics, continuing as a general pediatrician is much more common; the appropriate multiplier is probably 60%, and for family medicine as much as 95%. There are also residency programs in a combination of medicine and pediatrics (Med/Peds) which can produce primary care doctors, and whose graduates are less likely to pursue subspecialty training; however, they are very likely to choose only one of those areas (adult medicine or pediatrics) and also to become hospitalists.

In addition, some (or many) schools include in the primary care numbers specialties that are simply not primary care at all. Most commonly, they include emergency medicine and obstetrics/gynecology. Emergency medicine does indeed provide first-contact care, but it does not provide continuity. Obstetrics/gynecology can provide some aspects of primary care (and indeed OBGyns may be the only doctors some young women see) but it is limited in that it is not comprehensive; women are more than their reproductive tracts, and they can have a variety of conditions OBGYN does not care for (diabetes, hypertension, heart disease, depression, arthritis, asthma and other lung problems, substance abuse, etc., to name a few). Perhaps the most egregious abuse is counting all students who enter internal medicine “transitional” or “preliminary” years. Such one-year programs, which have replaced the old “rotating internships”, are required for many specialties such as neurology, anesthesiology, radiology, ophthalmology, dermatology, and others, whose practitioners do not do primary care at all.

If we want to know how well a school is doing in graduating students who actually practice primary care at the end of their residency and fellowship training, these inflated numbers do not inform us. Fortunately, one of the most popular sources of information on medical (and other) schools, US News, has worked with the Robert Graham Center, the policy center of the American Academy of Family Physicians (AAFP) to develop and publish a metric that does show which schools actually produce primary care physicians, available at https://www.usnews.com/best-graduate-schools/top-medical-schools/graduates-practicing-primary-care-rankings. The top of this list is dominated by schools of osteopathic medicine, which consistently graduate higher numbers of primary care physicians, and, among the allopathic schools, the mainly public schools who have been doing well in this area for a long time. The private, largely northeastern, schools that usually top rank lists are nowhere to be found.

It is important to look at this list, not the list of “Top Primary Care Schools”, to get accurate data on production of primary care physicians. The metric on percent of students going into primary care has also been fixed in the “Top Primary Care” rankings, so it is better, but it still only accounts for 40% of that ranking. “Peer Assessment” (subjective rankings) account for 30%, half from medical school deans and other leaders, and half from residency directors. The other 30% is half “faculty resources” (largely faculty ratio) which may be skewed to the advantage of research-intensive schools, because it includes faculty who are mostly in laboratories and not teaching, and half “student selectivity” (based on student grades and MCAT scores), which is actually negatively associated with entry into primary care. This doesn’t mean the students that enter primary care are not as smart; it means that the cachet of attending a research-intensive school makes the competition greater. Unsurprisingly, adding these other criteria does affect the rankings; Harvard, for example, is now #8 in “best primary care schools”, although it ranks #141 of 159 schools in percent of graduates practicing primary care. (In contrast, the University of Kansas, which ranks #9 in primary care, below Harvard, ranks #17 in graduates practicing primary care, at 37.8%). Reputation affects peer assessments in at least 3 ways. One is spillover effect -- well, it’s Harvard, and good in everything so it must be good in primary care. A second is the ignorance of non-primary care deans and residency directors about what kinds of doctors the school produces. Finally, the fact that “good in primary care” can mean things other than what specialties the graduates enter can have an effect; there are schools in which the family medicine and other primary care faculty are well-known for their research and leadership in national organizations, but which do not graduate very many students into primary care disciplines.

The fact remains, though, that the US very short of the primary care doctors it needs to provide quality health care to the American people. The way to begin to change that is to stop deceiving ourselves. Then we can start the process of producing a higher percentage, in every school.

Friday, December 1, 2023

The insurance company mafia and Medicare Advantage: Taking your money and denying you care

If the government were considering ways of making small businesses function more effectively to meet the needs of their customers and make a reasonable living for their owners, they would consider the stakeholders. Those might reasonably be the owners, the customers, and perhaps the suppliers. And, of course the gangsters who supplied “protection" to the owners – that is, protecting them from damage that might occur if the owners didn’t pay up.

Oh. You don’t think so? Why would we include the gangsters who just prey upon these businesses, drive up costs and thus probably prices, and threaten bodily harm to innocent people? Well, why not? After all, they have a stake in those businesses as well. If this seems like a ridiculous idea, consider the fact that we do it whenever we consider changes to our healthcare system in the United States. Except, in that case, it is the health insurance, a huge parasitic industry that preys on the health of the American people by sucking out billions in profit from funds intended to pay for our actual health care. We not only allow it, we encourage it!

The patchwork nature of health insurance coverage in the US is incredible. Many folks are coverage by policies held by their employers, or the employers of family members, but the employer contribution has been decreasing with increases in what employees have to pay in premiums, co-pays, and co-insurance. Others are covered by government programs – indeed, when considering all of these including Medicare, Medicaid, military families and retirees, employees and families of federal, state, and local government – public funds are more than half our health expenditures, rising to about 60% if the taxes foregone by the government because (unlike wages) employer contributions but not employee contributions) to health insurance are tax free. And still others have insurance through the ACA (Obamacare) or actually pay their whole cost. And, of course, lots and lots of people are uninsured.

And the coverage for those who are insured varies tremendously, from plan to plan, insurer to insurer, employer to employer. Many policies are so bad that those who have them are almost as bad off as the uninsured – but they are paying for it. People get low-cost policies because this is what they can afford,  but pay the price when they find out they are sick. It is bad, bad, bad, inefficient, incredibly expensive, and, like all “protection” plans, beneficial only to the insurance company mafia. But it is even, in a way, more egregious when we consider how it has cannibalized Medicare, the federal program that is supposed to cover the aged, blind, and disabled. Not that it is ok to screw the younger, non-blind or disabled portion of our population, but Medicare, passed in 1965, was supposed to ensure health care for the elderly, who are, in fact, more likely to be sick.

But then we get “Medicare Advantage” (also known as Medicare Part C), pushed by successive Republican administrations and assented to by the Democrats who seem to believe the hype. Let’s be clear about what MA is and is not. It is NOT Medicare, the program funded by your Medicare taxes from your paycheck (Part A) or general revenue + you (Part B). It is private health insurance being paid for with Medicare dollars (and the MA insurers get more, per capita than Medicare itself). It is usually a PPO or HMO plan, which can (and does, its essential character) restrict the health care providers (doctors, hospitals, etc.) you can use, and can and does make it more difficult to get care by denying payment (illegal as such; it is supposed to cover, by law, everything Medicare does, but it can delay and delay by repeated denials) or requiring prior authorization for – everything. Sometimes until it is too late and you die. We’ll look at some examples.

In a piece subtly titled “Deny, deny, deny”, NBC News on Oct 31, 2023 describes how rural hospitals, usually the sole community provider, are losing so much money from MA plans denying their claims that they are either in danger of closing or at least will no longer accept MA. That, of course, creates major problems for their patients covered by MA plans – remember, they are not a problem until you get sick! ‘Rose Stone of Holly Springs, Miss., said she stopped going to her doctor after her Medicare Advantage plan wouldn't pay for the visits. “It was a mess,” Stone told NBC News. “I didn’t go to the doctor because I was going to have to pay out-of-pocket money I didn’t have.”

The Washington Post, on Nov 29, 2023, in Hospitals and doctors are fed up with Medicare Advantage, discusses that they are not only fed up, but they are refusing to accept MA plans because it does not pay them for the services that they provide. Scripps Health in San Diego joined Mayo Clinic and many other facilities in not taking any MA plans. The problem with the article is it can be read to imply that doctors and hospitals are greedy, since ‘Medicare Advantage plans are pretty popular with both lawmakers and ordinary Americans — they now enroll about 31 million people, representing just over half of everyone in Medicare, by KFF’s (Kaiser Family  Foundation) count.’ Popular with lawmakers because, a lot, they are heavily lobbied by insurers and get campaign contributions from them. Popular with ordinary Americans in the same way that a lot of things are popular – they are heavily advertised and cheaper on the front end than having to buy a Medicare Supplement plan because Medicare only pays 80% of the money it approves for covered services. And they provide glasses, and dental, and often drugs without a separate Part D plan, and even gym memberships! Great! Until you really need care…like Ms. Stone.

Or like the woman who was denied coverage by Cigna for a lung transplant and died, as discussed by former insurance executive and current whistleblower Wendell Potter in his substack, “Health Care Un-Covered”, on Nov 27, 2023. Or the reports of massive denials, including those that break the law, identified by ProPublica in partnership with Scripps News and reported by Potter on Nov 30, 2023. These are not isolated stories; they occur all the time.

Potter also testified in favor of retirees from Cortland County,  NY, when the county was trying to push them all into an MA plan run by UnitedHealth. For this year, at least, they were successful, arguing basically about how Prior Authorizations (PAs) required by UnitedHealth would limit their care. At the last minute, under discovery, they obtained a (possibly incomplete) list of services requiring PA…essentially everything (see the list at the end of this post)! And if anyone is worried that these doctors and hospitals wanting to be paid for the work that they actually do for people’s health (remember – insurance companies do ZERO of this!) will bankrupt the MA plans, we can look at their profits. In a piece Potter wrote looking at how Cigna is trying to acquire Humana to get a piece of the MA market he provides the profit made by the largest players in the industry: Cigna $7.28B on revenues of $181B, Humana $4.2B on revenues of $93B, and industry leader UnitedHealth $28.4B on revenues of $324B – nearly 9%! ALL of this is on money that was intended to be spent on providing health care to Medicare recipients! No wonder they can pay for your gym membership! They sure ain’t hurting!

Other countries have much less complex and arcane coverage systems. You’re born, you’re covered. Everyone is in, no one is out. Pretty much everyone is in the same plan. That is what we could have if we had an expanded (to everyone) and improved (covering 100%, not 80%, of ALL necessary services, including mental health, dental, vision, hearing, drugs, long-term care) Medicare for All.

But the insurance company mafia stands in the way. Contact your senators and congresspeople! 


    From Wendell Potter, list of services (possibly incomplete) requiring PA from UnitedHealth:

The list includes:

  • Cardiac rehabilitation services
  • Intensive cardiac rehabilitation services
  • Chiropractic services
  • Outpatient diagnostic colonoscopy
  • Supplies to monitor blood glucose
  • Continuous glucose monitors
  • Therapeutic shoes for people with diabetes
  • Durable medical equipment
  • Diagnostic hearing and balance evaluations
  • Home infusion therapy
  • Inpatient services in a psychiatric hospital
  • Medicare Part B drugs and non-chemotherapy drugs to treat cancer
  • Medicare-covered chemotherapy drugs to treat cancer and the administration of that drug
  • Opioid treatment services
  • Outpatient diagnostic tests and therapeutic services and supplies, including x-rays and other radiation therapies
  • Lab tests and other diagnostic tests
  • Outpatient mental health care
  • Outpatient rehabilitation services
  • Outpatient substance abuse services
  • Outpatient surgery and other medical services at hospital outpatient and ambulatory surgical centers
  • Partial hospitalization services and intensive outpatient services
  • Basic hearing and balance exams
  • Some telehealth services
  • Second opinions prior to surgery
  • Non-routine dental care
  • Monitoring services in a physician’s office or outpatient setting
  • Medically necessary medical and surgical services that are provided at home or nursing home
  • Prosthetic devices
  • Pulmonary rehabilitation services
  • Skilled nursing care
  • Supervised exercise therapy
  • Outpatient services provided by an ophthalmologist or optometrist
  • Eye exams for people with diabetes

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