JustCare

Category: What’s Buzzing

  • 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:

  • Why it’s so hard to find a primary care doctor?

    Why it’s so hard to find a primary care doctor?

    With the medical profession becoming increasingly corporatized and physicians burdened by administrative ordeals and unable to treat patients as they think appropriate, fewer people are becoming physicians, particularly primary care physicians. A new report on the situation in Massachusetts by the Massachusetts Health Policy Commission explains why it’s so hard to find a primary care doctor.

    These days, you can wait a long time to see a primary care doctor, and you are too often forced to switch from one to another. Insurers do not treat continuity of care as a value and limit your coverage to their ever-changing and often restricted network of providers. It’s hard to get an annual check up without a long wait.

    Massachusetts is looking into the shortage of primary care doctors with the goal of increasing their numbers. You need a primary care doctor. The shortage will continue unless government acts.

    Three key reasons for the shortage:

    1. The bulk of primary care doctors in the US are older, averaging 55 years old, and retiring by the time they are 65. Others are just exhausted by their workload and administrative demands on them.
    2. New physicians are less likely to go into primary care because insurers pay little for preventive services; the provider money is in procedures and tests to treat conditions. Moreover, medical school can be very expensive and becoming a specialist allows physicians to pay off their debt more quickly.
    3. Those primary care doctors who continue to practice either end up doing new services to make money or going into concierge medicine, which gives them more time with patients and less administrative hassle.

    What is the value of having a primary care physician? Preventive services help identify diseases early or stop them altogether.

    What is to be done? We need to pay higher rates to primary care physicians and reduce their administrative burdens. As a society, we need to be investing in primary care.

    Here’s more from Just Care:

  • Should AI help with end-of-life decisions?

    Should AI help with end-of-life decisions?

    Artificial intelligence or AI is on the rise. If you haven’t yet tried using AI, check out Perplexity or ChatGPT. It boggles the mind how quickly they can answer your questions about just about anything, including drafting a research paper, writing a poem and explaining health care options. The Harvard Gazette explores the question of whether we should want AI to help patients and health care providers with end-of-life decision-making?

    For sure, AI has become better than some physicians at diagnosing patients’ conditions and arriving at a prognosis. In addition, hospitals and medical clinics use AI to analyze test results. Large-language models now permit AI to advise on patient care. Patients will make the ultimate decision.

    Of course, some patients are not competent enough to guide providers as to their end-of-life choices. And, some situations are fluid, depending upon the patient’s condition or even the time of the day.

    How could AI help a patient at the end of life? AI could explain what patients could expect. It could describe extremely thoroughly possible physical limitations of a diagnosis, pain, possibilities for treatment and more. Its advice would not be emotionally-laden.

    If the patient at the end of life could not speak for himself or herself, AI would have a more objective perspective perhaps than providers or family members about the patient and the patient’s perspective.

    In theory, AI could provide better advice than a physician about a patient’s chance of survival from a particular treatment. That advice would not dictate a particular outcome. AI probably should not be determining what a patient should do. That should happen between patient and doctor.

    When there’s no doctor available, AI could provide some patient care. Could AI deliver care in compassionate ways? How would that affect the patient’s health outcome?

    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:

  • 2025: Tariffs take effect, your costs likely to rise

    2025: Tariffs take effect, your costs likely to rise

    President Trump is making good on his pledge to place high tariffs on goods from China beginning today, February 4. (Tariffs on goods from Mexico and Canada have been postponed for a month, as of now.) The fallout just from the tariffs on China is likely to be bad for your health and financial well-being. Along with the price of gas, cars, and eggs if the tariffs on Canada and Mexico go into effect, prepare now for increases in prescription drug and other health care costs, reports John Wilkerson for StatNews.

    Trump now acknowledges that his tariffs will cost you. Because China delivers us many prescription drug ingredients (Mexico provides us medical devices and Canada supplies gas, eggs and avocados and other produce) it’s far to assume the prices of prescription drugs will increase as well. In fact, we might end up with shortages of generic drugs if their manufacturing cost increases so much that companies can’t profit off their sale.

    In addition, hospital charges could rise. Hospitals use imported gowns, syringes and other supplies. Sometimes CT and X-ray machines are imported. Consequently, people are likely to see still higher health insurance premiums.

    Trump: “WILL THERE BE SOME PAIN? YES, MAYBE (AND MAYBE NOT!). BUT WE WILL MAKE AMERICA GREAT AGAIN, AND IT WILL ALL BE WORTH THE PRICE THAT MUST BE PAID.” Trump suggested that the Canadian tariffs might lead Canada to agree to become a 51st state!

    Even conservative groups are concerned about the effects of the tariffs. The US Chamber of Commerce called the tariffs a mistake. Tariffs on Mexican and Canadian goods will not address immigration or fentanyl issues, as the President has suggested.

    If the Canadian and Mexican tariffs go into effect, Americans should assume those countries will retaliate. Before Trump backed off the tariffs on Canadian goods (yesterday), Trudeau had asked Canadians to boycott American goods, including Kentucky bourbon and Florida orange juice, and avoid vacations in the US.

    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:

  • Trump’s health care executive orders

    Trump’s health care executive orders

    As with many sectors of our economy, when it comes to health care you should expect a lot of changes from the Trump administration. And, based on Trump’s recent executive orders, millions of Americans could face higher health care and prescription drug costs. Tarena Lofton lays out the latest developments for KFF Health News.

    But, Trump’s most consequential health care act is to push Republicans in Congress to drastically cut Medicaid spending in order to pay for massive tax cuts for the wealthiest Americans. Republicans intend to push through these cuts in a reconciliation package to be finalized shortly. Cuts to Medicaid will affect more than 70 million Americans directly and their families and communities indirectly. If you oppose Medicaid cuts, please reach out to your Congressperson and Senators and let them know.

    Now, to some of the executive orders:

    1. Revoked: Trump revoked a Biden administration executive order requiring the Centers for Medicare and Medicaid Services to focus on new ways to lower prescription drug costs, including a Medicare project that would have established a list of drugs with a $2 copay. The bigger question is whether Republicans will try to undo provisions in the Inflation Reduction Act that allow Medicare to negotiate drug prices and set an annual out-of-pocket cap in Medicare Part D at $2,000.
    2. Revoked: Trump undid a Biden administration executive order that extended the enrollment period for Affordable Care Act health plans, as well as money dedicated to assisting people with enrollment. The bigger question is whether Republicans will end subsidies for people with lower incomes who are insured through the ACA health insurance exchanges. Those subsidies are set to expire at the end of this year.
    3. Withdrawn: Trump withdrew the US from the World Health Organization. The US had been a large supporter, giving the organization $1.3 billion in 2022 and 2023. WHO focuses on global health. It funds health projects around the world and responds to public health emergencies. Trump says he did not like the way the WHO handled the COVID pandemic. The bigger question is how the US will respond to public health emergencies.
    4. Unrecognized: Trump ordered the federal government to not recognize transgender and nonbinary identities. He ended federal support of health care delivered to people on the basis of gender identity. This order will likely be challenged in court. The bigger question is whether this order will be reversed in court.
    5. Expanded: Trump ended a policy that kept immigration officials from arresting people not legally in the US near schools, hospitals and churches.
    6. Withdrawn: Trump withdrew the US from the Paris Climate Agreement for the second time. The agreement specifically states that this process takes a year, but Trump ordered the immediate withdrawal.

    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: