JustCare

Category: Medicare

  • 2025: Will Congress extend Medicare telehealth coverage?

    2025: Will Congress extend Medicare telehealth coverage?

    Congress will decide whether to extend Medicare Coverage of telehealth services this year. Ruth Reader and Erin Schumaker report for Politico that cost should not be an issue. The latest findings, published in JAMA Internal Medicine, show that Medicare telehealth actually results in lower Medicare spending.

    Congress first expanded Medicare coverage of telehealth services to everyone with Medicare and for a range of services during the COVID pandemic. Until then, Medicare telehealth coverage was largely restricted to people in rural communities. At the end of March of this year, expanded Medicare telehealth coverage will expire unless Congress acts.

    Many policymakers appear to believe that telehealth is driving up Medicare spending and leading to worse health outcomes. But, this new research suggests otherwise. Researchers found that patients received less low-value care or, put differently, higher quality care at lower cost.

    The researchers looked at the records of 2.3 million people with Medicare across 286 health systems. Medicare spending for those patients using telehealth was lower. Patients in health systems using telehealth visited the doctor more but received fewer low-value tests and less unneeded care.

    What were the Medicare savings? The researchers projected at least $66 million. Telehealth visits generally cost less than in-person visits. That said, the Congressional Budget Office projects that two additional years of Medicare coverage of telehealth services will cost about $4 billion.

    Another study published in Health Affairs last year found that people who receive telehealth treatment saw their physicians on an ongoing basis and were more likely to comply with their prescription drug regimens. They also were responsible for fewer emergency room visits.

    Here’s more from Just Care:

  • Congressional Budget Office finds $1 trillion in Medicare Advantage overpayments

    Congressional Budget Office finds $1 trillion in Medicare Advantage overpayments

    Merrill Goozner writes for his Gooznews Substack “if only the GOP was more like Willie Sutton.” Republicans in Congress are working to cut $880 billion from the budget to pay for tax cuts for the wealthy. If they followed the health care money, they would be looking no further than Medicare Advantage.

    The government is currently overpaying insurers in Medicare Advantage about $1 trillion over the next ten years., according to the Congressional Budget Office. This past year alone, overpayments totaled $83 billion according to the Medicare Payment Advisory Commission. Medicare Advantage is the program to target; eliminating overpayments to insurers in Medicare Advantage would help eliminate fraud and waste, strengthen the Medicare Trust Fund and bring down Medicare Part B premiums.

    Republicans want to resurrect Trump’s tax cuts from 2017, which would increase the federal deficit by more than $2 trillion in the next 10 years. Cutting Medicaid, which they are looking to do, would mean major cuts to  hospitals, nursing homes, and other health care providers as well as loss of insurance coverage for millions of low-income Americans.

    Some Republicans are pushing back against House Speaker Mike Johnson because many of their constituents depend upon Medicaid and the federal dollars it brings to their states.

    The House voted on a budget resolution that would cut health care by $880 billion over ten years. Most of that money is likely to come out of Medicaid, although the resolution does not say that. So, there’s still some opportunity to guide Republicans to Medicare Advantage as a source of money.

    Goozner notes that our national debt tends to rise more during Republican administrations than during Democratic administrations.
    Source: Statista; data through 2023

    People in Medicare Advantage are no sicker than people in traditional Medicare–the government-administered Medicare program–even though the insurers would like you to believe otherwise. A new study out of Beth Israel Deaconness Medical Center, published in the Annals of Internal Medicine, found no difference in health status between enrollees in Medicare Advantage and traditional Medicare on four key metrics–obesity, high blood pressure, high cholesterol, and chronic kidney disease. Medicare Advantage enrollees are slightly more likely to have diabetes than traditional Medicare enrollees.

    To address overpayments in Medicare Advantage, the Centers for Medicare and Medicaid Services could simply adjust the amount they pay insurers down by 20 percent or so. Medicare would save about $1 trillion.

    In an editorial accompanying the research paper, Amal Trivedi and Richard Kronick wrote “Policymakers seeking to reduce health spending would better serve taxpayers by curbing MA overpayments rather than targeting Medicaid for savings.” Indeed they would!

    Here’s more from Just Care:

  • Congress could end overpayments to big insurers in Medicare Advantage and save $1 trillion, without gutting Medicaid

    Congress could end overpayments to big insurers in Medicare Advantage and save $1 trillion, without gutting Medicaid

    Instead of gutting Medicaid, Congress could save $1 trillion by ending hundreds of billions of dollars in overpayments to corporate health insurers in Medicare Advantage. A new report by Arnold Ventures details how our federal government could effectively end Medicare Advantage and other health care wasteful spending, save as much as $4 trillion, and not touch Medicaid spending.

    The Arnold Venture report spells out 10 ways for Congress to spend less and 10 ways to close tax loopholes that could pay for a permanent extension of the 2017 Tax Cuts and Jobs Act (TCJA). It proposes four smart ways to spend less on health care.

    Arnold Ventures recommends fixing the broken Medicare Advantage payment system that leads to as much as $140 billion a year in overpayments to corporate health insurers. Insurers use a variety of methods to maximize government payments, including “upcoding.” Insurers add diagnosis codes to enrollees’ medical records, which allows them to bill Medicare at higher rates for these enrollees, even when the insurers provide no additional services to these enrollees. The government could adjust down the rate it pays insurers to reduce overpayments significantly. This policy could save as much as $1 trillion over 10 years.

    If Congress ended overpayments to health insurers, the health insurers would claim that the government was “cutting” people’s Medicare benefits. But, the government would still be spending as much on enrollees in Medicare Advantage as in Traditional Medicare. The government would simply be reducing fraud and waste.

    Arnold Ventures recommends “site-neutral payments,” a policy that would require Medicare to pay the same amount for care in a hospital setting as for care in a physician’s office. For reasons that make little sense other than bolstering hospital coffers, today Medicare pays hospitals as much as four times more when a service is performed in a hospital setting. Hospitals have gamed the Medicare payment system by buying physicians’ practices; they can then legally charge the hospital outpatient rate for services, even though the services are identical to what they were before the hospital owned the practices.

    A few years ago, Congress limited the ability of hospitals to continue to game the Medicare payment system through purchases of physician practices. But, Congress grandfathered in the higher rates for hospital outpatient clinics established before the law passed. Ending this grandfathering provision alone would save $30 to $40 billion over ten years.

    Shockingly, the current Medicare payment system still creates an incentive for hospitals to steer patients to get care in a hospital setting, even when the service can be provided at far lower cost in a physicians’ office. Site-neutral payments could save as much as $157 billion over ten years. It would also lower out-of-pocket costs for people with Medicare.

    Arnold Ventures recommends penalizing pharmaceutical companies if they raise the price of their drugs above the rate of inflation for people in the commercial marketplace. The Inflation Reduction Act enacted this policy for Medicare and Medicaid but not for working people. This policy could save the federal government as much as $40 billion over 10 years.

    Arnold Ventures supports requiring Medicaid managed care plans to pay hospitals and nursing homes no more than the Medicare rate.

    Today, states can direct Medicaid managed care plans to pay hospitals and nursing homes at “average commercial rates.” Those rates are far higher than the Medicaid fee-for-service rates. They also incentivize hospitals with monopoly power to increase their rates, which are already twice Medicare rates. Medicaid managed care plans should not be allowed to pay hospitals and nursing homes more than the Medicare rates. This policy would save as much as $120 billion over 10 years.

    Here’s more from Just Care:

  • Does UnitedHealth use flawed AI to deny care in Medicare Advantage?

    Does UnitedHealth use flawed AI to deny care in Medicare Advantage?

    Bob Hermann reports for StatNews that a case against UnitedHealth for using flawed AI algorithms to deny care to Medicare Advantage enrollees is making it way through the US District Court in Minnesota. (A similar suit has been filed against Humana, which uses the same AI system as UnitedHealth.) Will the judge agree that the artificial intelligence (AI) system is flawed and remedy the issue? First, the judge must find he has the authority to rule on this issue.

    UnitedHealth has moved to dismiss the case on the ground that plaintiffs have not worked their way through the lengthy appeals process and that federal Medicare law preempts state law. The judge will decide on that motion as early as this month. But, the stories of enrollees denied basic critical care by UnitedHealth abound. One older man, Frank Perry, needed rehab care to regain his strength after a brain disorder that caused him to fall a lot and landed him in the hospital each time. He couldn’t get it.

    UnitedHealth would only approve skilled nursing home care for Perry. Skilled nursing care is less costly than rehab care. Moreover, UnitedHealth only approved nursing care for two weeks, even though Medicare covers this care for up to 100 days when medically reasonable and necessary. Perry kept challenging the denials but he ended up dying before resolution of his case.

    UnitedHealth says it does not rely exclusively on AI to deny care. But, Stat got hold of UnitedHealth materials that run contrary to UnitedHealth’s claim. For sure, people who appeal win, more than four out of five times, suggesting that many denials are inappropriate. Unfortunately, most people don’t know to appeal or how easy it is to do so.

    Keep in mind that people enrolled in traditional Medicare do not face these barriers to care. As a general rule, they get the care they need when they need it.

    Here’s more from Just Care:

  • Medicare Advantage inappropriate denials of care abound

    Medicare Advantage inappropriate denials of care abound

    Just as with restaurants, automobiles and homes, Medicare Advantage plans vary from awful to excellent. But, unlike with restaurants, automobiles and homes, you can’t choose a Medicare Advantage plan knowing it will meet you needs. It’s a total crapshoot. Inappropriate denials of care abound.

    Beware. And take a hard look at your Medicare Advantage plan, if you’re in one. Choosing the wrong Medicare Advantage plan could kill you. A report from a few years ago revealed that if the Centers for Medicare and Medicaid Services cancelled contracts with the five percent of worst performing Medicare Advantage plans, it would save tens of thousands of lives a year!

    To ensure you have access to the care you need when you develop a serious condition or suffer a bad injury, consider switching to traditional Medicare, the government administered program that covers your care from most physicians and hospitals anywhere in the US. You have until the end of March to switch. But, unless you have Medicaid, you will need to be sure you can buy supplemental coverage to fill gaps in traditional Medicare.

    If you stay in a Medicare Advantage plan, be prepared to fight your insurer when you need costly care. CMS not only does not cancel contracts of insurers with high rates of inappropriate denials, it doesn’t tell you which are the worst-performing Medicare Advantage plans.

    Do not assume that a Medicare Advantage plan with a five star rating will meet your needs. The ratings do not factor in inadequate networks or inappropriate denial rates, much less mortality rates. And, while CMS has worked to improve those ratings, the insurers have successfully sued to prevent changes to the ratings. For reasons yet unknown, the Trump administration just dropped a Biden administration appeal of one of those lawsuits.

    If you stay in Medicare Advantage, consider denial rates. The latest report from the Kaiser Family Foundation reveals that CVS and Centene have the highest prior authorization denial rates in 2023. On average, MA plans denied 6.4 percent of prior authorization requests, which might sound reasonable. But, MA insurers use prior authorization predominantly for costly services, which only a small fraction of their enrollees need.

    Centene’s denial rate was 13.6 percent in 2023. CVS Health’s was 11 percent. Typically, denials are overturned 80 percent of the time when appealed. When people appealed Centene’s denials, they prevailed 93.6 percent of the time. Unfortunately, only about 10 percent of coverage denials are appealed.

    Here’s more from Just Care:

  • Government should be spending more on Medicare and Medicaid

    Government should be spending more on Medicare and Medicaid

    A new KFF tracking poll shows that a large majority of Americans–Republicans, Democrats and Independents–support Medicare and Medicaid. And, twice as many Americans believe the government should be spending more on Medicare and Medicaid than believe we should be spending less. Still, Republicans are looking at slashing Medicaid, and possibly cutting Medicare as well.

    Out-of-pocket costs in Medicare are formidable. They keep people from getting care or lead people to delay needed care, compromising their health So, major support for Medicare expansion is not surprising. (It should go hand in hand with ending the waste and fraud in Medicare Advantage, which is costing taxpayers tens of billions of dollars a year, eroding the Medicare Trust Fund and driving up Medicare Part B premiums.)

    There is general agreement among Americans across the political spectrum that we should know a lot more about healthcare prices. But, what people don’t appreciate is that knowing these costs offers them little if any protection. The surgery costs at one hospital might be higher than another, but the anesthesia cost could be lower. Moreover, the specialists at one facility might deliver more medical services than at the other, affecting a patient’s total costs.

    The simplest and fairest way to ensure everyone can afford their care is a government-administered system for everyone. Such a system could keep costs down through low deductibles and copays, as well as by ensuring everyone pays the same price for a given procedure in a given community. Suggesting that people can shop around for the best health care prices is insane.

    Most people receiving care need care urgently. Those people cannot shop around. But, even people who are receiving elective procedures are hard-pressed to determine where they will save money on care.

    Republicans and Democrats alike also favor regulation of health insurer prior authorization rules. Health insurers are using prior authorization to delay and deny care, inappropriately and with impunity. Through prior authorization, they can spend less and profit more.

    Lastly, Republicans and Democrats support lower prescription drug prices in Medicare through negotiation. Americans should overwhelmingly support drug-price negotiation for more Medicare drugs; we pay as much as four or five times what people in other wealthy countries pay for the same drugs.

    The vast majority of Americans do not support as a priority removing fluoride from our water, as Robert Kennedy Jr. recommends. They also do not support reducing access to abortions or lower federal support of Medicaid as priorities.

    Here’s more from Just Care:

  • Will Medicare continue negotiating drug prices?

    Will Medicare continue negotiating drug prices?

    Among other things, the Biden Administration’s Inflation Reduction Act authorized the Centers for Medicare and Medicaid Services (CMS) to negotiate the prices of a number of costly prescription drugs. Back in August, CMS announced prices for the first ten drugs subject to price negotiation and, more recently, it announced the next 15. Jonathan Cohn reports for Huffington Post on the forces at work to undermine Medicare drug price negotiation.

    Medicare drug price negotiation not only lowers federal spending on prescription drugs to the tune of billions of dollars, it should also save people with Medicare money, both in premiums for Medicare Part D and in copays. But, few people with Medicare appear to be aware of these cost-saving reforms, according to a recent Kaiser Family Foundation poll. They are not yet benefiting from lower drug prices.

    People won’t see savings from the 10 drugs in the first round of Medicare drug price negotiations until 2026. And, they won’t see savings for the next 15 drugs with negotiated drug prices until 2027. Those drugs are: Ozempic; Rybelsus; Wegovy; Trelegy Ellipta; Xtandi; Pomalyst; Ibrance; Ofev; Linzess; Calquence; Austedo; Austedo XR; Breo Ellipta; Tradjenta; Xifaxan; Vraylar; Janumet; Janumet XR; and, Otezla.

    To date, prices for some diabetes and cancer drugs, as well as drugs that treat blood clots, have been negotiated. In addition, as of January 1 of this year, Medicare Part D includes an out-of-pocket cap of $2,000, which was also part of the Inflation Reduction Act.

    It’s not clear yet whether Republicans in Congress will succeed at repealing these cost-savings provisions in the Inflation Reduction Act. Many of them appear to want to do so, even though it would drive up prescription drug costs for older adults and people with disabilities, as well as increase Medicare spending.

    Project 2025, the Heritage Foundation plan for the Trump Administration calls for repealing these provisions. And Senator Mike Crapo of Idaho, the new chair of the Senate Finance Committee, is fully on board. Pharmaceutical companies will continue to innovate in a world with drug price negotiations. They must. But, hundreds of thousands more Americans will die needlessly without negotiated drug prices, as they won’t fill their prescriptions. Drugs don’t work if people can’t afford them.

    Here’s more from Just Care:

  • Medicare Advantage dental, vision and hearing benefits offer little value

    Medicare Advantage dental, vision and hearing benefits offer little value

     

    Medicare Advantage plans advertise their “extra” benefits as a way to lure in new enrollees. But, new research published in JAMA Network finds that Medicare Advantage dental, vision and hearing benefits offer little value to enrollees. Enrollees have no better access to dental, vision and hearing benefits than people in traditional Medicare.

    The most recent MedPAC data show that the federal government is spending 22 percent more per Medicare Advantage enrollee than for enrollees in traditional Medicare. The data are increasingly also showing that, notwithstanding the estimated $83 billion more the insurers offering Medicare Advantage received from the federal government in 2024, Medicare Advantage enrollees get fewer benefits than people in traditional Medicare.

    For the most part, insurers offering Medicare Advantage only cover care for their enrollees from a restricted network of physicians and hospitals. In rural communities, people have to travel long distances to see a doctor or get treated at a hospital because their local providers are not in their Medicare Advantage plan network. And, the specialists qualified to treat certain conditions are also often not in-network.

    Moreover, Medicare Advantage insurers often inappropriately delay and deny care to their enrollees, particularly when they have complex and costly conditions. The insurers’ financial incentive is to withhold care because the government pays them upfront regardless of the amount of money they spend on care. The less care they cover the more money they get to keep.

    A team at Mass General Brigham looked at whether the “extra” benefits Medicare Advantage insurers offer add value. Insurers misleadingly claim that they give their enrollees more than traditional Medicare in the form of extra benefits. But, that is not true in fact.

    Insurers often deny Medicare Advantage enrollees coverage for treatments that traditional Medicare covers. And, while insurers technically offer enrollees additional benefits, too often, enrollees are not aware of these benefits or the out-of-pocket costs present a barrier to care. The researchers found that fewer than six in ten enrollees knew their Medicare Advantage plan covered these “extra” benefits.

    Between 2017 and 2021, people in traditional Medicare and Medicare Advantage spent about the same amount for dental, vision and hearing services, notwithstanding that Medicare Advantage plans claim to offer these benefits and traditional Medicare does not.  They also received about the same number of services. There is no reason to be paying Medicare Advantage insurers more per enrollee than the government spends in traditional Medicare.

    “Medicare Advantage plans receive more money per beneficiary than traditional Medicare plans, but our findings add to the evidence that this increased cost is not justified,” said first author Christopher L. Cai, MD. At best, people in Medicare Advantage are getting a discount of less than 10 percent on vision, hearing and dental treatment. Out-of-pocket costs are high, even with the benefits, and the panel of covered providers is narrow.

    “Supplemental benefits are a major draw to Medicare Advantage, but our findings show that people enrolled in Medicare Advantage have no better access to extra services than people in traditional Medicare, and that much of the cost comes out of their own pockets,” according to senior author Lisa Simon, MD, DMD, assistant professor in the Division of General and Internal Medicine at Brigham and Women’s Hospital. “Older adults and people with disabilities deserve better from Medicare.”

    Here’s more from Just Care:

  • Medicare Advantage insurers are killing rural hospitals and communities

    Medicare Advantage insurers are killing rural hospitals and communities

    Write-Off Warrior, a research and advocacy firm that supports rural health systems, just released “Preyed On: How Insurance Corporations are Bleeding Rural Hospitals and Communities to Death.” The report documents the many harmful behaviors of large insurance corporations responsible for endangering the health of rural America. The report also highlights the far-reaching consequences for our country if Congress fails to address insurer behaviors driving rural health disparities.

    Rural Americans represent about 20 percent of the US population. They tend to suffer more from chronic conditions than other Americans. But, they struggle more to get the care they need than other Americans and their plight is worsening.

    The authors surveyed 41 rural hospitals in 15 states across the US and found that the biggest problems they faced were burdensome insurer prior authorization procedures, insurers’ second-guessing of treating physicians, and insurers’ long delays and denials of provider payments. Moreover, insurers take advantage of rural hospitals’ weak bargaining power to negotiate excessively low rates or to keep these hospitals from being in-network. Rural hospitals are foundering.

    Medicare Advantage insurers are the biggest threat to rural hospitals and communities, according to 31 of 41 hospital execs surveyed. These corporate insurers have undermined the hospitals’ financial stability. These insurers have led rural hospitals to end important mental health and rehab services. And, these insurers are leading many rural hospitals to shut down altogether.

    While the top six Medicare Advantage insurers profited to the tune of $41.7 billion in 2023 alone, Medicare Advantage enrollees continue to face rising costs, notwithstanding these insurer practices. They also are often forced to travel long distances for care. Congress must recognize that Medicare Advantage does not work for rural Americans and reform the system.

    Until Congress reforms the Medicare Advantage program to meet the needs of rural Americans, insurers will profit more at the expense of rural communities. Nearly 200 rural hospitals have closed in the last 2o years. And, more than 700 are at serious risk. These hospital closures put rural America on life support.

    Without vibrant rural communities and good rural health, critical food and energy production, vital to the entire country, are at risk of failing.

    Here’s more from Just Care:

  • UnitedHealth physicans help boost insurers’ Medicare payments

    UnitedHealth physicans help boost insurers’ Medicare payments

    UnitedHealth now employs or contracts with about 10 percent of the physicians in the US. It’s one way UnitedHealth maximizes Medicare Advantage profits, report Anna Wilde Mathews, Christopher Weaver and Tom McGinty for the Wall Street Journal. UnitedHealth incentivizes its physicians to include additional diagnoses codes on Medicare Advantage patient records, which enables UnitedHealth to receive higher Medicare payments.

    UnitedHealth advises its physicians to check their Medicare Advantage patients for certain diagnoses. So, in Eugene, Oregon, one physician explained that before he could move from one patient to another, he must enter into a software system whether his patient had any of a list of diagnoses. In many cases, the diagnoses had nothing to do with the patient, such as hyperaldosteronism, which is a hormone condition related to high blood pressure.

    Rather than ensuring their doctors focus on treating Medicare Advantage patients for the conditions these patients are reporting, UnitedHealth is focused on having its doctors document as many conditions as possible that will increase the company’s Medicare payments.

    UnitedHealth does nothing to ensure its doctors document additional conditions for their patients in traditional Medicare. That’s not surprising.  Because of the way Medicare pays insurers in Medicare Advantage, adding diagnoses codes to traditional Medicare patient records would hurt UnitedHealth financially.

    The Wall Street Journal found that patients leaving traditional Medicare for Medicare Advantage in the three years ending 2022 had many more diagnoses in their medical records once they were in Medicare Advantage. Their “sickness scores” typically increased 55 percent. To put it succinctly, once in Medicare Advantage, from a sickness perspective, patients effectively had HIV and breast cancer.

    While UnitedHealth does more than other insurers to raise sickness scores for its Medicare Advantage patients, other insurers raised scores by 30 percent for new patients in Medicare Advantage. There is no evidence whatsoever that entering more diagnoses into Medicare Advantage enrollees’ medical records benefits patients in any way. In fact, UnitedHealth doctors do not use the company’s diagnoses software for patients outside of Medicare Advantage.

    By the Wall Street Journal’s calculations, United’s Medicare Advantage enrollees who saw UnitedHealth physicians had such high sickness scores that UnitedHealth benefited financially to the tune of $4.6 billion over three years.

    This insurer gaming of the Medicare payment system must end. Among other things, it is gouging taxpayers, depleting the Medicare Trust Fund, and driving up Medicare Part B premiums.

    Here’s more from Just Care: