It is a given, Trump’s new executive order is calling for “market-based” pricing or whatever the market will bear pricing to replace Medicare set pricing. Trump sees a conflict between Medicare and the market. Well he is right; but, his solution ll only aggravate the problem of costs. It will drive up costs for everyone in Medicare, destroy traditional Medicare as healthcare for the elderly, steer more people into costly commercial healthcare, reduce Medicare funds at a faster pace, and allow the already profitable healthcare industry to increase profits well beyond what it is today.
But, but are Medicare Advantage Plans ripping people and Medicare off? “Yes they are” a for-profit industry is profiteering by taking advantage of a system of healthcare for which they wanted to be a part. As Trump signed the EO, it is stunning to watch a bunch of seniors up on the stage clapping as el jefe was showing off his executive order allowing commercial healthcare to further pickpocket them, exploit healthcare, and destroy Medicare. All smiles there . . .
Medicare Advantage programs are managed differently than Fee for Service traditional Medicare. Besides providing a series of services not found in regular Medicare, the MA plans instituted a different form of physician/hospital payment called Capitation. Capitation Payments are theoretically used by managed care organizations to control health care costs. The VA is a good example of this type of managing costs. A capitation payment model controls the use of health care resources by putting the physician at a financial risk if too many services are provided to patients or if quality decreases as witnessed by return patients for the same disorder or illness. To ensure patients do not receive suboptimal care through under-utilization of health care services, MAOs measure the rates of resource utilization in physician practices. These utilization reports are then made available to CMS to measure health care quality, utilization, costs, etc.. They are also linked to financial rewards such as withheld fees and bonuses.
Past the leap, I explain how the capitation model can be gamed by Advantage plans.
As I mentioned, the capitation payment model used by MAOs has economic considerations to consider in providing healthcare. The organizations know money can be saved by withholding care or by providing less expensive care (for example, substituting a generic drug for a name-brand pharmaceutical) potentially creating a conflict of interest. For each member of an Advantage Plan, CMS/Medicare pays a monthly fee (minus a percentage) whether a member uses the organization’s healthcare facility or not. In treating both regular Medicare and Medicaid Advantage patients in the same facility, there are possibilities in which regular Fee for Service Medicare could be used to subsidize Medicare Advantage payments if an organization was exceeding its cost goals for MA. More services can be given under traditional Medicare.
As I said, the fee schedules are established for Medicare Advantage programs from which a portion of the monthly payment is withheld until the end of an agreed contract period. If the organization is meeting the goals, it will be paid the balance of the payment withheld and any bonuses for reaching its goals. The idea is to create an environment where excess treatment and medicine is nonexistent, a problem in traditional Medicare which Dr. Donald Berwick detailed as he was leaving the CMS. MAOs are supposed to supply complete and accurate claims data to CMS which is used to ascertain whether the plans are providing the needed care to seniors.
It may be, doubtful, but there is a chance the Centers for Medicare and Medicaid Services (CMS) may not have told Trump about the issues discovered by government audits which revealed many Medicare Advantage plans lack of care poses a threat to the health of their enrollees” besides the overcharge of taxpayers of an approximate $10 billion a year. UnitedHealth, Aetna, Cigna, etc. have failed to turn over the data as required by law making it impossible for CMS to know whether they are covering the health care services they state are required and paid to provide or oversee.
MA organizations submitting insufficient medical record documentation to CMS did not support the diagnoses those organizations had previously submitted to CMS to determine risk adjustment payments. Arguing back, the MA organizations are claiming (afterwards) their enrolled members were found to be in worst shape than previously thought and required more treatment which eased costs.
The lack of medical record documentation or the inaccuracy of the documentation makes it difficult to monitor the service provided. Furthermore, MA Organizations have denied coverage or delayed payments. Some MA Organizations do not have the broadness of doctors and healthcare initially sold to their customers initially.
In a detailed letter to CMS Director Seema Verna Senators Sherrod Brown, Amy Klobuchar, Chris Murphy, Richard Blumenthal, Bernie Sanders and Debbie Stabenow have revealed the serious issues with the Medicare insurers UnitedHealth Group, Aetna, Cigna and Humana. As follows:
- The government has experienced Tens of $billions in overcharges over the years. Medicare Advantage plans have been overcharging the government for the services provided for many years and are now claiming their members were in worse health than thought, higher costs were experienced as a result, and they had to increase payments. When challenged, they refused to pay back the tens of $billions in overpayments by the federal government. United Health Care (UHC) successfully fought to keep the government from collecting this money even though the case was initiated by an internal whistleblower.
Me: The issue here is UHC signed on for a Capitation Payment plan which does not allow for chargeable additional services whereas a Fee for Service healthcare plans does. United Healthcare’s argument for not paying back the over charges being regular Medicare charges for additional treatments; thereby UHC should be allowed to do so also.
- Medicare Advantage plans are not covering or are slow to cover the care for which their members need and to which they are entitled. Government audits show Medicare Advantage plans are purposely delaying and denying care and coverage to hundreds of thousands of their members. In the end people are late in paying, end up paying out-of-pocket for care the plans should have covered, or they forego needed care. The Health and Human Services IG had this to say in its findings;
“When beneficiaries and providers appealed preauthorization and payment denials, Medicare Advantage Organizations (MAOs) overturned 75 percent of the denials during 2014–16, or an approximate 216,000 denials each year.”
- CMS has failed to name or flag these MA health plans on its Medicare website or notify people in any other way of plans with serious violations. This was something CMS agreed to do at the recommendation of the Office of the Inspector General. Upon enrollment in MA plans people are unaware the government has found some plans are jeopardizing the health and safety of its members. Instead, CMS continues to give four – and five – star ratings to some of these plans misleading older adults and people with disabilities about MA performance.
- CMS has discovered a sizeable number of Medicare Advantage plans have had inaccurate provider directories for years. The GAO has noted “concerns about ensuring enrollee access to care.” Many of these health plans have also narrowed their provider networks. GAO suggests that it is not at all clear which of these Medicare Advantage plans have an adequate number and mix of health care providers in their networks. Enrolled patients in these plans may find they can not access the right doctor or their illnesses and disorders are not adequately addressed by plan resources
- With the new Executive Order, it appears the administration and its congressional allies are playing a game of bait and switch with older adults and people with disabilities. They allow Medicare Advantage plans to lure people with benefits traditional Medicare does not offer, such as dental, and transportation services to the doctor and do so without exposing their inability to perform the functions they advertise. It appears by issuing this Executive Order, the Trump administration’s goal is attempting to privatize Medicare and shift the costs onto older and disabled Americans.
- To be clear, Trump’s executive order does nothing to hold the Medicare Advantage plans accountable for their overcharges, inappropriate denials of care and coverage, and inability to perform the healthcare in their policies. Trump’s Executive Order rewards the MAOs for their performance regardless of its short comings. Trump has given them even more discretion regarding the services covered and the freedom to create new bells and whistles to lure in new members. In the end, the health and financial well-being of older and disabled Americans hangs in the balance.
Indeed, Trump’s Executive Orders gives MA Organization greater abilities to charge what the market will bear.
The Stealth Attack on Seniors, AlterNet, Diane Archer
run75441 (Bill H)