Monday, October 25, 2021

Medicare Advantage, Direct Contracting Entities, and other scams to transfer your money to insurance companies

In my post DTC Advertising on TV illustrates the corruption and inequity of the US medical care system (March 6, 2021) I talked a little about advertisements for Medicare Advantage (MA), an alternative to traditional Medicare (TM, not ™) that involves an insurance company taking over your Medicare and you maybe paying additional money to, essentially, be enrolled in their HMO or PPO, with its concomitant advantages and disadvantages to you personally. Advantages include a variety of additional services that are not currently included in TM (they should be, but this is a different issue), such as vision care (or at least glasses), hearing aids, and sometimes dental care. This can save you money. The disadvantages are, essentially, the same as those for any HMO or PPO – a limited “network” of physicians and hospitals (and big charges for which you are liable if you go out of network) and, related to that, a limited geographic area in which your network applies. This is not generally a big issue for the occasional traveler (emergencies are usually covered) but can be a big problem for those who split their time between two or more areas. Plus, it doesn’t protect you from “surprise medical bills”, as they are called in Congress (which discusses them but has yet to enact anything to protect you from them). These occur when, while both your doctor and hospital are “in network”, someone else --  the ambulance company, some doctors caring for you (say, the group that staffs the Emergency Department, or the surgeon assisting your surgeon) are not. They can – and do – then send you big bills. This should be a caution.

Why I am bringing this up again now is that the pace and frequency of solicitations for people to abandon TM and enroll in MA have greatly accelerated because we have entered the “open enrollment” period, when people with Medicare can change their insurer or plan type, and the MA plans, mostly owned by insurance companies, really want you*. This is why in addition to adding more former NFL quarterbacks to their ads (Joe Theismann, who is only my age, joins the 78-year-old Joe Namath), you have (if you are of Medicare age) been getting dozens of information packets in your mail for the plans available in your area – almost all of which pick names and design their envelopes and otherwise do their best to make it look as if they are official and from Medicare (I was going to share the link to one with a name that prominently features “Medicare”, but I figured why advertise them?)  They’re not. And they’re being successful. As documented by the Kaiser Family Foundation, MA plans had an 8% increase from 2018 to 2019 and a 15% increase from 2019 to 2020. Advertising really pays off! And, boy, does it pay! Thanks to your generosity (well, Congress’ generosity, on your behalf, or at least using your money) MA plans (and, by the way, “Medicare Advantage” is the official term specified in the legislation, in case you had any doubts about the influence of insurance companies over Congress) get paid a lot more than the government pays on your behalf to TM. For starters, their administrative overhead – comparable to that of most private insurers – is about 13.2%. Is that a lot? Well, the overhead for TM is about 1.8%! Some sources have cited the overhead for “Medicare” as about 3% -- still a lot better – but that is because it is combining the two. And, of course, as MA increases as a share of Medicare that figure will continue to rise.

MEDPAC, the Medicare Payment Advisory Commission, an independent agency created by the federal government to monitor and recommend on issues related to Medicare, notes that MA plans receive more money from Medicare but spend less on providing patient care to their members, costing Medicare an additional $8B. So it is definitely worth pursuing your business! Unless, of course, and this was the reason for the asterisk (*) above following really want you, you are sick. Then you would cost them money, and they would rather that you switch to regular TM. Which would be better for you, of course, but it would have been better for you to have never been in MA. This is a core part of their business strategy: attracting healthy seniors who will not cost them much money with the lure of cheap glasses and hearing aids and such (“cherry picking”) and then getting rid of those beneficiaries who really get sick and would cost them a lot of money (“lemon dropping”). All this is an effort to improve their “Medical Loss Ratio”, which is to say decrease the % of the money that they collect which they have to spend on actually taking care of you. If it sounds weird or offensive (and it is both) that their spending money on what they are supposed to be in the business of doing is called “loss”, it is a term that comes from the overall insurance industry. The % of homeowner’s premiums that have to be paid out to clients because their homes burn down, or auto insurance premiums that have to be paid if you are in a car wreck, is called the loss ratio. Of course, you don’t expect (and certainly don’t hope) to be in a car wreck or have your house burn down, but you do (or should) expect to receive medical care. Indeed, a more apt comparison to your house burning down might be made to “major medical” – coverage for costly hospitalizations – but in fact most people will need those if they live long enough. Much more about the cost of MA and the reasons for it can be found in the Health Affairs Blog posts of September 29 (Medicare Advantage, Direct Contracting, And The Medicare ‘Money Machine,’ Part 1: The Risk-Score Game), and 30 (Medicare Advantage, Direct Contracting, And The Medicare ‘Money Machine,’ Part 2: Building On The ACO Model) by Rick Gilfilan and former CMS administrator Donald Berwick. Another article on MA can be found in Consumer Reports.

Since not everyone who would be a good health risk is forgoing TM for MA, a new scam (excuse me, option!) has been developed by CMMI, the Centers for Medicare and Medicaid Innovation, a branch of CMS, the Center for Medicare and Medicaid Services, which has been granted authority to implement such changes as they (or the insurance company lobbyists) can come up with without needing further Congressional approval. This one is Direct Contracting Entities (DCEs). A company, particularly a health system or medical group, may send people a complicated letter telling them that (for their benefit!) the group has enrolled them in a DCE. The client has the choice to opt out, but this is disguised in complex legal language, and the benefits(!) are so strongly sold, that many people do not.  Remember, this is not being sent to folks who are in MA, but those who have purposely and specifically chosen TM and NOT MA. Thus, they are not expecting that their providers will try to enroll them, backdoor, in a plan that, while it has benefits(!) – like those of MA – also lets insurance companies (wait, how di I get to an insurance company? I thought I was in TM!) collect a lot more money from CMS – like under MA! What a cool idea! If you resist MA because you are more concerned about your healthcare than insurance company profits, CMMI will find a way to allow you to help the insurance companies anyway! A lot more can be learned from a short (15 minute) youtube presentation by PNHP (Physician’s for a National Health  Plan) member Ana Malinow.

Medicare, along with its parent, Social Security, is the most popular government program in the nation, and for good reason. It actually provides important benefits to the taxpaying American people. Instead of paying out lots of extra money to Wall St. and insurance companies, Congress should expand the benefits available under TM to include all necessary health care, including dental care, vision care, and hearing care. Instead of forbidding Medicare to negotiate drug prices with BigPharma and the Pharmacy Benefits Mangers (PBMs) that control access to drugs, Congress should ENCOURAGE and REQUIRE it. Finally, it should extend all these Medicare benefits to EVERYONE in the country, not just the elderly and disabled.

This would be what the American people need.  But if you want to have this, you are going to need to shout it from the rooftops – and write letters to Congress -- to be heard over the sound of cash flowing from insurance companies into your Congresspeople’s pockets.

Then go to and sign the petition asking Sec. Becerra to close the DCE program!

Friday, October 15, 2021

Public Health, Abortion and Childcare: US far behind other countries

On October 3, I wrote about the viciously restrictive Texas (anti-) abortion law, The Texas Abortion Law is contrary to women, to science, and to human values. Texas is not the only state with such restrictive laws; in my own state, Arizona, a very restrictive abortion law has been passed by the legislature and signed by Republican governor Doug Ducey that makes it a crime for a doctor to perform an abortion on a woman “just” because it has a genetic defect (including those incompatible with life, or worse, yet, compatible with a short life full of suffering). While a US district court judge has enjoined the law, Arizona’s attorney general, Mark Brnovich, has asked the judge to allow him to continue to enforce that law while his appeal is pending. That could mean, of course, felony convictions for physicians. This follows the Supreme Court, in a “shadow docket” ruling, declining to invalidate that law despite a prior US Court of Appeals ruling that did so.

These actions by Republican-controlled states are all predicated on the assumption that the Supreme Court will soon invalidate Roe v. Wade and take away any Constitutional protection for women seeking, or doctors or others providing, abortions. This may well happen with a case on the agenda for this year challenging Mississippi’s draconian law virtually outlawing abortion. That this is a distinct possibility is because of the success of the Republican party and Sen. Mitch McConnell in ensuring that The Former Guy, Donald Trump, was able to appoint 3 justices to the Court, first by preventing President Obama’s nomination of Merrick Garland (the current US Attorney General) on the specious grounds that it was the last year of his term (while there were over 9 months left), and then going ahead and then entirely hypocritically approving the nomination of Amy Coney Barrett just a week before the election, which Trump lost. Thus we have a Supreme Court with 6 Republican justices of which Chief Justice John Roberts, Jr., is the least reactionary – but no longer a swing vote. Many, including Coney Barrett (referred to by NY Times columnist Maureen Dowd in her recent piece “The Supreme Court v. Reality” (Oct 9, 2021) as “Lady Handmaid’s Tale” for her advocacy for some of the repugnant and misogynistic practices described in Margaret Atwood’s book and the later TV series, strongly opposed to abortion. It is, of course, worth remembering that large majorities of the American people favor retaining the rights in Roe v. Wade, and that in some circumstances (such as rape and incest and a threat to the life of the mother) that support is overwhelming. Not, however, on GOP legislatures or on the Supreme Court.

Much of the support that exists in the US for overturning Roe v. Wade, and in general opposition to abortion, justifies itself by claiming abortion is murder, that they are only advocates for helpless fetuses, whom they call “babies”. There are undoubtedly many in their ranks who are consistent in their opposition to killing, opposing the death penalty and war (the late Joseph Cardinal Bernardin of Chicago comes to mind, and perhaps the current Pope Francis), but the vast majority of them, including all these legislators and SCOTUS justices, are not. And, indeed, their concern for babies and children only extends back from birth to conception, not forward from birth. We got you to there, they effectively say, but then you’re on your own. Or your parents are. This country is the meanest, using the word in both its senses, unkind and stingy, of all wealthy countries in providing support for infants, children and their parents. No box of baby necessities as in Finland (available for sale in the US, but provided by the government in Finland) . No requirement for parental leave. No guarantee of health insurance coverage, not to mention adequate coverage. No support for childcare. This one is the subject of a dramatic graphic included in the NY Times demonstrating how much countries in the Organization for Economic Cooperation and Development spend per child on early childhood care. The mean is $14,436. The second-lowest, Israel, is $3,327. Hungary spends twice that, Lithuania is over $8,000 and Slovenia over $11,000. The “poor” US comes in, as in virtually all measures of caring for its people, last, at $500. Well, you know, it costs a lot to provide care for its least needy; for the billionaires who need tax cuts.

This, of course, does not bother the majority of the Supreme Court. They are not looking for consistency. They are looking for two things: 1) to enact their political agendas, and those of the Presidents who appointed them, and 2) to have people ignore #1 and lash out at people who point it out, painting themselves as victims.

Meanwhile, thing as better on the health front in the small Central American nation of Costa Rica, as described by surgeon and health care pundit Atual Gawande in the New Yorker (‘Costa Ricans Live Longer Than We Do. What’s the Secret?’, August 23, 2021). In a country with a “per-capita income is a sixth that of the United States—and its per-capita health-care costs are a fraction of ours—life expectancy there is approaching eighty-one years. In the United States, life expectancy peaked at just under seventy-nine years, in 2014, and has declined since.” This latter fact has been described in great detail in recent years, particularly in the work of Anne Case and Angus Deaton (in the Proceedings of the National Academy of Sciences,Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century”, and discussed by me in Rising white midlife mortality: what are the real causes and solutions?, Nov. 14, 2015). Costa Rica, in 1970, had an infant mortality rate of 7%. By 1980, it was only 2%. “In the course of the decade, maternal deaths fell by eighty per cent. Part of the change is due to improvements in access to medical care, a characteristic of middle-income countries such as Costa Rica as well as most (obviously excepting the US) upper-income countries.” This points to the second big reason, and the focus of Gawande’s article, the emphasis on public health, on the health of communities, on interventions (and spending money) on things that improve the health of all people, in great contradistinction to the US focus on providing medical care for individuals.

Public health in the US is grossly underfunded, as has been apparent since the beginning of the COVID-19 pandemic. Well, it has long been apparent to those who thought about those things. The emphasis in the US is on individual medical care, and this is what is discussed by those who have power and those who fund them, and of course the mass of journalists and pundits.This is a failure of those who should be providing accurate information, but it is also the fault of our people’s willingness to deny a problem until it is right in their face. Many Americans do not even take the preventive measures that are easily available to them (the COVID vaccine, for some reason, comes to mind) and many others are unable to avail themselves of screening and early treatment because of a lack of money or decent health insurance and so end up in extremis and grateful for whatever invasive, expensive, and often unlikely-to-be-successful medical care is available. But, as I have said before, it is less common for people to wake each morning and be thankful that they don’t have cholera because they have clean water.

It is not that the American people are stupid or have the wrong values. If a large majority support Roe v. Wade, and much larger majority believes everyone has the right to health care and that we should have a universal health insurance system. And a huge majority (about 88% including 77% of Republicans) believe that drug costs are too high, that the reason is that drug companies make too much money, and that Medicare should be able to use its clout as the nation’s biggest insurer to negotiate drug prices. Also, while we’re on it, that all children should have an excellent education, and that childcare and parental leave are truly important priorities.

But we don’t have that. We don’t have the “Finnish baby boxes”, and we don’t have universal health insurance, and we don’t have requirements that all health insurance cover everything needed, and we don’t have childcare or parental leave or excellent education for all our children or a decently supported and effective public health system or even the ability of Medicare to negotiate drug prices. Of course the poster child for opposing this latter while her constituents favor it is my senator from Arizona, Kyrsten Sinema, who has gotten a lot of money from the pharmaceutical industry. Do we think that is part of it??

The only solution is to vote them out. Make supporting public health and universal health care and affordable drugs more important to re-election than opposing abortion rights.

Sunday, October 3, 2021

The Texas Abortion Law is contrary to women, to science, and to human values

The new Texas abortion law and the Supreme Court tacit endorsement of it is the latest (as of this writing – there will be more!) assault on science, medicine, and the will of the people, in an almost unbroken string of such actions. Another example of this process is the effort to spread COVID by opposing mandates for masking, vaccination, or social distancing, under the pretense of “individual liberty”, by a variety of jurisdictions, mostly at the state level and mostly in Republican-controlled states.

First, a quick review: the Texas law prohibits abortions after 6 weeks without exceptions for anything, including rape and incest, or ability of the fetus to survive outside the womb. It employs a cute (in the sense that the term “cute” can be applied to, say, a giant, mean, ugly, evil, violent ogre) trick to try to get around potential lawsuits that would be based on fact that the Roe v. Wade decision gives women a Constitutional right to abortion. The law does not mandate that state officials enforce it. Instead, anyone, from any state, is empowered to be a “whistleblower” and turn in anyone enabling the abortion (doctor, nurse, counselor, taxi driver) with the potential reward of $10,000 (from the state, of course) if successful.

Neat, huh? The Supreme Court majority thought so too, and, using another trick (called the “shadow docket”) declined to invalidate it. This method obviates the need for a hearing, presentation of arguments on either side, questions from the justices, and thought-out opinions which present the reasoning of the majority and the dissenters. It thus does not require the identification of those voting in the majority (we only know in this case that it was 5-4 and who the 5 and 4 were because each of the 4 issued their own dissenting statement). It also does not allow the lower courts to know what the reasons and arguments were, resulting in inconsistent interpretation of the decision by those courts. This, of course, was on purpose. Justice Sotomayor (one of the 4) put it succinctly “The court has rewarded the state’s effort to delay federal review of a plainly unconstitutional statute, enacted in disregard of the court’s precedents, through procedural entanglements of the state’s own creation.”

Several of the justices who created this problem have defended their action, and Justice Alito, in a speech at Notre Dame, not only defended the shadow docket but portrayed himself and the other members as the actual victims. This is another neat trick, which has been employed by the right, including former president Trump, and billionaires and corporations who have been criticized for such things as underpaying their workers and not paying taxes. The best defense, it is said, is a good offense.

 Let’s review the science:

1.      a large percentage of pregnant women do not even know that they are pregnant, particularly if they usually have irregular periods, before 6 weeks,

2.      the assertion in the Texas law that the fetus has a heartbeat at 6 weeks, thus why they chose that timeframe, is incorrect. In fact, the embryo is not even a fetus at 6 weeks.

There is in fact a lot more relevant science, but let’s move on, since the science is only an issue for those of us who believe in it.

The reason for the restrictive abortion law in Texas (and all the other states’) is not in the least because they have any respect for science or medicine. For different individuals, of course, there are different reasons. For some it is because of their religious beliefs, Catholic or otherwise, that all life is sacred and thus abortion is murder. That this may result in the death of the mother, or that it should then require the same level of commitment to helping the parents ensure that children have a reasonable chance at life (housing, food, clothing, education) may be positions supported by some Catholics, including the current Pope, but is not a corollary of opposition to abortion for most of these people. This is important, because in the case of taking a human life by say, murdering them with a gun, the public is not empowered to sue anyone who might have enabled them, like the gun dealers or manufacturers.

For others, the abortion restrictions are, explicitly or not, about restricting the rights of women and relegating them to their place. This is so essentially the results of such laws and policies that denial of it is virtually always disingenuous. Even those who take the “life is life” Catholic anti-abortion position find themselves in this situation (arguably, this position on women is part of the justification by an entirely male-run church). None of these laws or policies create any penalty or responsibility for the male whose role in creating the pregnancy was central. And 100% of unintended pregnancies are directly caused by men.

Finally, the reason for these laws is political. They garner support for a generally right-wing, pro-corporate political agenda from those who would not support it as such. This trend has always been part of US politics, but more explicitly so since Richard Nixon. Ultimately, of course, whatever the ostensible position of any individual is, the issue is essentially about politics. You put together a coalition, and then you implement the laws you want to. Make no mistake, this is what it is about. Nationally, a large majority of Americans oppose overturning Roe v. Wade (about 60%). In individual states, it may differ. A good history of the right-wing of the GOP looking for an issue that would mobilize the evangelical community in support of them, and their segregationist, pro-corporate agenda, is found in a recent issue of Politico. Abortion turned out to work after other issues didn’t, despite evangelical ambivalence on the issue at the time.

For nearly two decades, [right-wing activist and segregationist Paul] Weyrich, by his own account, had been trying out different issues, hoping one might pique evangelical interest: pornography, prayer in schools, the proposed Equal Rights Amendment to the Constitution, even abortion. “I was trying to get these people interested in those issues and I utterly failed.”

To the extent that the Texas anti-abortion law is about a rejection of science to achieve a political or religious or misogynist agenda, it is not entirely a separate issue from COVID and opposition to mask or vaccination or distancing mandates. The politicians want what they want – mainly power – and are willing to pander to whoever to get it, even fomenting anti-science agendas. Truth no longer matters, and it has gotten beyond an abstract concept to the point where people are dying, and yet others are still unwilling to believe in the cause-and-effect. A recent article in Rolling Stone notes that in parts of Oklahoma, hospitals are not only full of people with COVID and its complications but with people who are overdosing on ivermectin, an anti-parasitic drug that has widely -- and falsely – been promoted as a treatment for COVID. Since ivermectin requires a prescription for people (and it is indicated for certain kinds of worm infestations and actually does work to treat scabies), people are buying it at feed stores where it is sold for deworming horses! If the RS article is correct, many of these hospitals are even too full for gunshot victims!

COVID is a virus, and one that mutates and evolves (whether you believe in evolution or not) and can create more dangerous strains like the Delta variant. It is infectious. Immunization offers great, if not perfect protection; while it is possible to get infected after being immunized, it is less likely and, more important, it is much less likely that you will be hospitalized, ventilated, and die. This is  a fate reserved almost exclusively for the unvaccinated. Masks do help, although they are better at protecting others from being infected by you than protecting you from others – this is why OTHER people wearing masks makes a difference. This is science. On abortion – a “6 week” pregnancy is measured since the last menstrual period, which could easily mean 4 weeks since ovulation, 2-3 weeks since fertilization, and less since implantation, not to mention a positive pregnancy test. A very high percent of women don’t yet know that they are pregnant.

Scientific answers are arrived at through experimentation and re-experimentation; “truth” changes as more information becomes available. It is messy, not simple and easy to understand like a “belief”, or something you read on the internet. If it is one-dimensional and simple it is probably wrong.

But more important, it is usually out there to accomplish another agenda.

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