Where Does Medicare Go From Here: Profit-Driven Chaos or Patient-Centered Community?

[Celerity]

https://prospect.org/health/2024-04-19-where-does-medicare-go-from-here/

President Joe Biden arrives to speak about his administration’s plans to protect Social Security and Medicare and lower health care costs, February 9, 2023, at the University of Tampa.

Medicare, the country’s largest and arguably most successful health care program, is under duress, weakened by decades of relentless efforts by insurance companies to privatize it. A rapidly growing Medicare Advantage market—now 52% of Medicare beneficiaries, up from 37% in 2018—controlled by some of the largest and most powerful corporations in the world, threatens to both drain the trust fund and eliminate Medicare’s most important and controversial component: its ability to set prices. It is not an overstatement to call it a heist of historic proportions, endangering the health not only of the more than 65 million seniors and people with disabilities who depend on Medicare but all Americans who benefit from the powerful role that Medicare has historically played in reining in health care costs. The giant corporations that dominate Medicare Advantage have rigged the system to maximize payments from our government to the point that they are now being overpaid between $88 billion and $140 billion a year. The overpayments could soar to new heights if the insurers get their way and eliminate traditional Medicare.

All of America’s seniors and disabled people who depend on Medicare could soon be moved to a managed care model of ever-tightening networks, relentless prior authorization requirements and limited drug formularies. The promise of a humane health care system for all would be sacrificed at the altar of the almighty insurer dollar. The Medicare Payments Advisory Commission (MedPAC), the independent congressional agency tasked with overseeing Medicare, last month released a searing report which found that Medicare spends 22% more per beneficiary in Medicare Advantage plans than if those beneficiaries had been enrolled in traditional fee-for-service Medicare. That’s up from a 6% estimate in the prior year. A similar cost trend exists for diagnosis coding. Medicare Advantage plans and their affiliated providers increasingly upcode diagnoses to get higher reimbursements. In 2024, overpayments due to upcoding could total $50 billion, according to MedPAC, up from $23 billion in 2023. These enormous overpayments drive up the cost of premiums—MedPAC’s conservative estimate is that the premiums paid to Medicare out of seniors’ Social Security checks will be $13 billion higher in 2024 because of those overpayments.

There is evidence that Americans and lawmakers are starting to wake up. Medicare Advantage enrollment growth slowed considerably in 2023. Support within the Democratic Party for Medicare Advantage is cratering. In 2022, 147 House Democrats signed an industry-backed letter supporting Medicare Advantage. This year, just 24 House Democrats signed the letter. Earlier this month, the Biden administration cut Medicare Advantage base payments for the second year in a row (while still increasing payments overall), over the fierce opposition of the insurance lobby. The investment bank Stephens called Biden’s decision a “highly adverse” outcome for insurers. Wall Street has taken note, punishing the stock price of the largest Medicare Advantage insurers, with Barron’s noting that Wall Street’s “love affair” with Humana is “ending in tears.” The cargo ship is turning. It is up to us to determine if that will be enough.



We can’t attack a problem if we don’t know how to diagnose it. I spoke with some of the most knowledgeable critics of Medicare Advantage about the danger the rapid expansion of Medicare privatization presents to the American public. Rick Gilfillan is a medical doctor who in 2010 became the first director of the Center for Medicare and Medicaid Innovation (CMMI). He would go on to serve as CEO of Trinity Health from 2013 to 2019. In 2021 he launched an effort to halt the involuntary privatization of Medicare benefits. “Right now, all investigations are finding tremendous overpayments,” Gilfillan said. “The overpayments are based on medical diagnoses that may or may not be meaningful from a patient care standpoint. Insurers are using chart reviews, nurse home visits and AI software to find as many diagnoses as possible and thereby inflate the health risks of the patients and the premium they get from Medicare. The overpayments are just outrageous,” he said. The problem could get worse if the Supreme Court curtails the powers of regulatory agencies, as it may do this year. “It would make a huge difference in what CMS would be able to do,” Gilfillan said.

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[yellowdogintexas]

1. lf traditional Medicare added a dental option and made prescription coverage simpler

folks would change from Advantage plans. By doing so they would rid themselves of networks and nitpicky case managers. One of the reasons folks take out those "Advantage" plans is to get the dental/vision etc.

Traditional Medicare is so much simpler for providers and patients, and you can get treatment anywhere without worrying about extra fees for being out of network. The coverage is exactly the same no matter where you are.

Traditional Medicare has the lowest error percentages, lowest cost per claim, fastest turnaround time and is not designed to create profit for Big Insurance. Providers like it because there is so much less hassle to get paid, it is easy to request a review, and they know that every 2 weeks that bulk check is going to arrive.

When I was a claims examiner for Part B back before Advantage came to be, I thought then that everyone who did not have employer based coverage should be able to get Medicare.