DCMedical News: Tuesday, October 11, 2022
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
THE BIG STORY Tuesday, October 11, 2022
Medicare Advantage Under Attack as Open Enrollment Approaches: Cheats and Frauds, Threats to Health
The Medicare Advantage (MA) industry (commercial health insurers and others who create privatized versions of Medicare) is under attack as October 15, the first day of “open enrollment” (when Medicare beneficiaries can decide to leave “traditional” Medicare and join an MA plan) approaches.
Cheats and Frauds
STAT+ publishes a chart (here) summarizing news coverage showing the top five MA plan sponsors, with checkmarks to indicate their reported behavior. Been accused of fraud by a whistleblower? UnitedHealth Group, Humana and Kaiser Permanente. Been accused of fraud by the government? United, Elevance (formerly Anthem), Kaiser. Been accused of overbilling the government? United, Humana, CVS Health, Elevance.
The New York Times (here) publishes on this theme, “By next year, half of Medicare beneficiaries will have a private Medicare Advantage plan. Most large insurers in the program have been accused in court of fraud” [9 of 10 in the Times’ version of the chart].
Twisting Arms
Says the Times, “The health system Kaiser Permanente called doctors in during lunch and after work and urged them to add additional illnesses to the medical records of patients they hadn’t seen in weeks. Doctors who found enough new diagnoses could earn bottles of Champagne, or a bonus in their paycheck.”
“Anthem, a large insurer now called Elevance Health, paid more to doctors who said their patients were sicker. And executives at UnitedHealth Group, the country’s largest insurer, told their workers to mine old medical records for more illnesses — and when they couldn’t find enough, sent them back to try again.”
“Each of the strategies — which were described by the Justice Department in lawsuits against the companies — led to diagnoses of serious diseases that might have never existed. But the diagnoses had a lucrative side effect: They let the insurers collect more money from the federal government’s Medicare Advantage program.”
Innovative Ways to Provide Better Care at Lower Cost—Congress
The Times reports that “Medicare Advantage, a private-sector alternative to traditional Medicare, was designed by Congress two decades ago to encourage health insurers to find innovative ways to provide better care at lower cost.”
MA “Quality” (Star) Measures
Another blow, this time to the “quality” measures of MA programs: CMS, with oversight of the Medicare program, including MA plans, had artificially inflated “quality” measures to give more money to MA plans during the pandemic, although health insurance plans—because of lower utilization of health services—were remarkably profitable during the pandemic. Now CMS has decided to take away the quality bump (here), and the share prices of MA plan sponsors have plummeted.
MA Nursing Home Coverage
A final indignity: A new report from Kaiser Health News, also published in Fortune (here), says that MA plans, when they cover nursing home expenses, are paying less than traditional Medicare, assuming there will be shorter lengths of stay for patients who are their beneficiaries.
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
IV Self Care at Home
MedPage Today reports (here) that “The FDA approved the first furosemide (Furoscix) formulation for subcutaneous self-administration by patients with congestive heart failure . . .The IV-equivalent formulation is indicated for the treatment of congestion due to fluid overload in people with New York Heart Association class II/III chronic heart failure. It is administered at home with use of a single-use Furoscix On-Body Infusor, which involves a pre-filled cartridge containing the loop diuretic that attaches to the patient's abdomen for delivery of an 80-mg dose over 5 hours.”
“‘This marks a tremendous opportunity to improve the at-home management of worsening congestion in patients with heart failure who display reduced responsiveness to oral diuretics and require administration of intravenous diuretics, which typically requires admission to the hospital,’ said William Abraham, MD, of The Ohio State University in Columbus, in the company press release.”
Vox Clamantis in Deserto: Physician Groups Seek Congressional Attention, With No Response
Becker’s reports (here) that “More than 120 state and national medical associations are asking Congress to reform Medicare's physician payment rates, according to a Sept. 28 blog post [here] from the American Medical Association.”
Says Becker’s, “Physician practices are preparing for an 8.42 percent drop in Medicare payment rates next year. CMS has proposed a 4.42 percent reduction in conversion factor along with the 4 percent statutory Pay-As-You-Go sequester, which was implemented to offset congressional spending outside of healthcare. Additionally, physicians' Medicare payment update for 2020 is 0 percent, and both the 5 percent bonus for participating in an alternative payment model and the $500 million bonus pool for the Merit-based Incentive Payment System are expiring.”
HOSPITALS, NURSING HOMES AND OTHER HEALTH CARE FACILITIES
Hospital Readmission Reduction (HRR) Ends With a Whimper
Three physician thought leaders write a Viewpoint in JAMA (here) in which “We argue that the persistent focus on [hospital] readmissions [reduction] during the past decade, although undoubtedly leading to some improvements in care, has had minimal demonstrable benefit. Moreover, the HRRP has distracted clinicians and health system leaders from other crucial quality concerns. As with many other quality measures, the HRRP has led to gamesmanship (described below) whereby hospitals have taken predictable actions in their coding practices and admission processes and protocols in an effort to minimize the probability of receiving penalties.”
The Cost of the HRR Program
The authors note that the HRR Program may have saved Medicare some money, but also that it had substantial indirect costs for providers. “Although difficult to quantify, these costs are incurred by hospitals when they devote personnel and resources to myriad interventions designed to reduce readmissions (some of which are likely beneficial for patients) . . . A systematic review of interventions to reduce hospital readmissions found that the average per-patient cost was $600 to $700 (in 2015 dollars). If such programs were extended to 50% to 100% of Medicare’s 9 million annual hospital admissions, this would equate to an estimated $3 to $6 billion annually. Regrettably, well-designed (and often quite intensive) interventions have often failed to meaningfully reduce hospital readmissions.”
“In 2010, reducing hospital readmissions appeared to be a fruitful target for quality improvement. In 2022, after more than a decade of concerted effort, it is time to focus limited hospital resources on more tractable and evidence-based targets that are more directly under the control of hospitals.”
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
October 12, 13, 14, 17, 18, 19, 20, 21
November 14, 15, 16, 17, 18, 29, 30
December 1, 2, 5, 6, 7, 8, 12, 13, 14, 15
Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org