JustCare

Tag: AHA

  • AHA warns Medicare oversight agency about dangers of Medicare Advantage

    AHA warns Medicare oversight agency about dangers of Medicare Advantage

    In a letter to the Medicare Payment Advisory Commission (MedPAC), the American Hospital Association (AHA) expresses serious concerns about the dangers of Medicare Advantage, including the consequences of inappropriate coverage and payment denials and delays. MA is not delivering the health coverage people need; and, prior authorization requirements delay potentially life-saving time-sensitive treatments, such as cancer treatment regimens.

    The AHA explains that the insurers offering Medicare Advantage plans use prior authorization in ways that create “dangerous delays in care.” The AHA’s greatest concern is that MA plans use prior authorization to deny medically necessary care. To show clinical appropriateness, providers are required to spend an excessive amount of resources documenting the need, while patients’ care is delayed, to their detriment.

    The stories the AHA recounts of insurer MA bad acts are disturbing, appearing to put insurers’ profits ahead of patient needs: “For example, an AHA member indicated that a patient with traumatic brain injury was medically ready for discharge but stayed four additional days in the hospital without access to essential [post-acute care] because the insurer had not responded to the provider’s request to move the patient into a rehabilitation facility. Another AHA member … reports that 11% of their MA referrals take 10 days or longer to resolve. Furthermore, another AHA member reported that, in 2022, over 400 MA patients at its academic medical center had delayed discharges due to insurance issues, the vast majority of which were attributable to prior authorization delays, and the delays amounted to 1,233 avoidable inpatient days.”

    More than nine in 10 physicians report patient care delays because of prior authorization and one in three of them say that prior authorization resulted in a “serious adverse event for a patient in their care such as hospitalization or death.” Not only does the prior authorization process endanger the health and well-being of patients, it can be extremely burdensome for providers. Moreover, the process is not transparent or consistent across MA plans. Different rules for different plans and different electronic portals make it all the harder for providers to comply.

    MedPAC is an independent Congressional agency established to advise Congress on the Medicare program. MedPAC can write reports on MA issues, but it has no real authority to do anything. And, neither Congress nor the Centers for Medicare and Medicaid Services seem to respond in meaningful ways to MedPAC recommendations.

    Right now, the benefits of prior authorization appear more than outweighed by the harm to patients and the burdens on providers. That will continue so long as each insurer can develop its own proprietary prior authorization protocols. CMS should mandate that insurers all use one standardized set of public and medically justified prior authorization protocols and one standardized system for handling them. Without standardized and public prior authorization protocols, people cannot know whether the MA plan they enroll in will delay and deny their care excessively and inappropriately, as appears to be the case for people in UnitedHealth and Humana Medicare Advantage plans.

    Here’s more from Just Care:

  • Medicare Advantage: Denials and more denials, some deadly

    Medicare Advantage: Denials and more denials, some deadly

    Remember the line about the bridge in Brooklyn? “If you believe that, I have a bridge in Brooklyn to sell you.” Don’t fall for the con. It applies in spades to all the hype about Medicare Advantage. You might save a little money, but it could cost you your life. No joke.

    The families of two Medicare Advantage enrollees are suing UnitedHealthcare, in a proposed class action suit, for wrongly cutting off their medically necessary care in a rehabilitation facility. The enrollees have died. The families allege that UnitedHealthcare used artificial intelligence to deny their relatives care, without appropriate attention to their relatives’ particular care needs, as required under Medicare rules. UnitedHealthcare  denies any wrongdoing.

    You always can save money by not having health insurance or not getting health care when you really need it. That’s effectively what’s happening to some people in Medicare Advantage plans. When Medicare Advantage enrollees get sick–when they really need health insurance to cover their health care–they could be out of luck, without the coverage to meet their needs. And, that goes for people in Medicare Advantage HMOs with restricted networks, as well as people in PPO’s, with more open networks.

    The American Hospital Association just sent another letter to the Centers for Medicare and Medicaid Services, CMS, which is charged with overseeing the insurers offering Medicare Advantage, urging CMS to enforce rules intended to keep the Medicare Advantage plans from inappropriately denying care. The problem is that the rules have no teeth. So, corporate health insurers are flouting them, denying care to people whose care would be covered in Traditional Medicare.

    An earlier letter from the American Hospital Association to CMS documented the serious harm some insurance companies are inflicting on Medicare Advantage plan enrollees needing critical hospital care. 

    CMS appears to believe that its ability to protect people from Medicare Advantage plan bad actors is circumscribed, even when the insurers offering Medicare Advantage are clearly violating their contractual obligations. Consequently, people enrolled in Medicare Advantage plans are taking a huge gamble. If they need costly care, it’s not clear they will get it.

    There could be some insurers offering Medicare Advantage that are doing right by their enrollees. But, if there are, no one knows which ones. Do you really want to roll the dice with your health and well-being?

    Right now, during the Medicare Open Enrollment period, you should seriously consider making a switch to Traditional Medicare. If you have Medicaid, you will have almost all your costs covered. Even if you don’t have Medicaid, if you don’t need a lot of health care, you will have few out-of-pocket expenses. If you want good protection from financial risk, you will need to buy supplemental coverage, which can be costly and hard to come by. But, in most states, Medigap plans K and L are low-cost. Even without Medigap coverage, your out-of- pocket costs are not likely to be any higher than your out-of-pocket costs in Medicare Advantage, which can be as high as $8,850 for in-network care alone. And, in Traditional Medicare, you can be sure that you will get the care you need when you need it.

    The Biden Administration could protect people in Medicare Advantage immediately, as it figures out how to ensure that the Medicare Advantage insurers are accountable for their bad acts. The Administration could, through executive order, require CMS to put an out-of-pocket cap in Traditional Medicare. The cap should save Medicare money, as the government is so wildly overpaying the insurers offering Medicare Advantage plans, that giving people the ability to enroll in Traditional Medicare without having to buy supplemental coverage would guarantee them access to the care they need at a lower cost to the Medicare program.

    Here’s more from Just Care:

  • Hospitals find a lot wrong with Medicare Advantage

    Hospitals find a lot wrong with Medicare Advantage

    August 31 was the deadline for filing responses to the government’s request for information on Medicare Advantage. Thousands of individuals and organizations filed comments, including Just Care, and we are still poring over them. Of particular note, the American Hospital Association’s comments reveal that hospitals find a lot wrong with Medicare Advantage. The government, along with anyone thinking of joining a Medicare Advantage plan, should give its 43-pages of comments close attention.

    Here’s an excerpt from the opening:

    “In this context, we are writing to share several serious concerns about the negative effects of Medicare Advantage Organization (MAO) practices and policies, which impede patient access to health care services, create inequities in coverage between Medicare beneficiaries enrolled in MA versus those enrolled in Traditional Medicare, and in some cases, even directly harm Medicare beneficiaries through unnecessary delays in care or outright denial of covered services.

    As enumerated below, such practices include abuse of utilization management programs, inappropriate denial of medically necessary services that would be covered by Traditional Medicare, requirements for unreasonable levels of documentation to demonstrate clinical appropriateness, inadequate provider networks to ensure patient access, and unilateral restrictions in health plan coverage in the middle of a contract year, among others. These practices add billions of wasted dollars to the health care system, are a major driver of health care worker burnout,1 and worst of all, harm the health of Medicare beneficiaries.”

    The AHA goes on to explain that MA plans are failing to pay the hospitals hundreds of millions of dollars they are due. There’s no collection agency that will go after the MA plans for payment.

    “Insurer practices that deny and delay payment for services appropriately rendered to patients exacerbate these financial challenges and destabilize providers of critical health care services. For example, in our most recent survey, 50% of hospitals and health systems reported having more than $100 million in accounts receivable for health insurance claims that are older than six months. This amounts to $6.4 billion in delayed or potentially unpaid claims that are six months old or more among the 772 reporting hospitals, leaving providers with untenable financial liability. In MA specifically, one-third of hospitals reported having $50 million or more in accounts receivable that are six months or older, suggesting that MA plans make up a significant portion of the problem.”

    MA horror stories are not uncommon for patients needing inpatient hospital care:

    “Our most recent AHA survey data shows that health plans serving public programs are more likely to deny inpatient prior authorization requests, and specifically that MA plans have the highest inpatient prior authorization denial rate across all payers, followed by Medicaid managed care and then commercial products. These rates vary despite physicians following the same clinical guidelines and regardless of a patient’s type of coverage, suggesting that the denials are linked to financial, not clinical, considerations. Further, these survey data reflect that MA plans are aggressively and systematically denying nearly 20% of all inpatient prior authorization claims off the bat, most of which are later overturned.”

    The Texas Hospital Association submitted its own comments and told this story:

    “Misuse of utilization management practices directly jeopardizes lifesaving care. One hospital in rural Texas shared a story of a patient over age 90 on blood thinners, who presented after falling and hitting their head. The MA plan denied authorization for a CT scan to check for a suspected brain bleed, stating it was not medically necessary. The hospital performed the CT scan anyway, confirming a brain bleed requiring transfer to a higher level of care. That night, the patient was flown to another facility and received treatment that saved their life. If the local hospital had abided by the CT scan denial from the MA plan, this patient would not  survived.”

    Here’s more from Just Care:

  • Hospitals speak out against corporate health insurance

    Hospitals speak out against corporate health insurance

    Americans have a new ally in the fight for health care reform. The American Hospital Association is speaking out against corporate health insurance. Hospitals are feeling the squeeze from corporate health insurers and making clear that patient safety is at risk, as costs increase.

    With nearly half of the Medicare population now enrolled in corporate health insurance plans–Medicare Advantage–hospitals are increasingly dealing with corporate health insurer shenanigans. It comes in many forms.

    • Insurers often require prior authorization when it can delay patient care and jeopardize health, while also raising administrative costs for providers.
    • Insurers often require patients to get less expensive treatment that physicians know will not work before agreeing to cover the care people need. They are using “step therapy” or “fail-first policy”  more frequently in order to save money. At the same time, these policies add to administrative costs for providers as well as keep people from getting the care they need.
    • Insurers often design coverage policies that override physicians as to care that is medically necessary.
    • Insurers often prevent physicians and hospitals from treating patients with medications they have in stock–“white bagging”–and require them to use medications from an outside pharmacy.  This practice can harm patient safety.
    • Insurers use electronic payment methods that sometimes require hospitals to pay money in order to receive reimbursement.

    The American Hospital Association recognizes the need for Congressional fixes. Unfortunately, short of ending the filibuster or having 60 Democratic votes in the Senate, meaningful fixes will not happen.

    1. The AHA wants to measure unnecessary administrative costs resulting from corporate health insurer requirements that are inappropriate.
    2. The AHA wants standardization and reform of administrative policies in order to reduce the large administrative burden on providers and their patients.

    NB: A bi-partisan bill in the House of Representatives would appear to improve the prior authorization process. While it has many good provisions, it includes no penalties for insurers that fail to comply. Apparently, had the bill included penalties for non-compliance it would not have bi-partisan support.

    Until we stop insurers from gaming the system to the detriment of patient health, it is likely that administrative obstacles to care will continue, that health insurance costs will continue to increase, that more patients will not be able to afford health care, and that more hospitals will fail. Insurance premiums alone are up 47 percent since 2011.

    Here’s more from Just Care:

  • Trump HHS pick is fierce opponent of Medicare and ACA

    Trump HHS pick is fierce opponent of Medicare and ACA

    President-elect Trump‘s choice of Tom Price to head the Department of Health and Human Services (HHS) sends a strong signal that the Trump Administration will be allied with Speaker Paul Ryan in repealing the Affordable Care Act. Price also is a fierce opponent of Medicare. He supports gutting both Medicare and Medicaid and rationing health care based on people’s ability to pay for it.

    As a Congressman and Chair of the House Budget Committee, Price has made his views on health care known. He authored a bill that turns over much control over health insurance to the industry, with the Orwellian name, Empowering Patients First Act. He supports health insurance regulations that allow insurers to charge older people significantly more than they may today and to sell policies that offer less than adequate coverage. And, he is opposed to subsidies to help people with low incomes afford their health care.

    If Price has his druthers, Congress would privatize Medicare and Medicaid, turning them over entirely to private insurance companies. Like Ryan, he wants to eliminate their guaranteed benefits and leave older adults, people with disabilities and people with low-incomes at the mercy of insurers, with inadequate coverage, in the health care marketplace.

    Just recently, Price’s Budget Committee released a plan that would have Congress automatically cut Medicare, Medicaid and Social Security substantially to pay for tax cuts mainly for the wealthiest Americans, which president-elect Trump and Congressional Republicans support. The Center for American Progress reports that under his plan, over ten years, Social Security would be cut $1.7 trillion, Medicare would be cut $1.1 trillion, and Medicaid would be cut by nearly $700,000 billion.

    And, even without Congressional action affecting our health care system, as head of HHS, Price will have tremendous power to drive changes in Medicare, Medicaid and health insurance in America. As head of HHS, Price will determine how laws are interpreted. He can choose for HHS to limit its oversight of health insurers or to stop spending money on enforcement or to revise provider payment policies.

    There’s no candy-coating what will happen if Ryan and Price get their way in Congress. Here’s what we should expect:

    • The ACA will be repealed, Medicare will no longer guarantee basic health care coverage, and Medicaid will likely be turned over to the states in the form of federal block grants.
    • Hospitals and doctors will ratchet up their charges.
    • Drug companies will increase drug prices.
    • Insurance companies will compete for business by keeping their premiums as low as possible for the young and healthy and denying coverage or charging high deductibles and out-of-pocket costs when people need care; people with costly conditions will be forced to pay exorbitant premiums as well as high deductibles and copays for coverage or forego care.
    • Insurers will restrict their coverage as much as possible and give people only a limited choice of doctors and hospitals. There may not be a guaranteed package of Medicare benefits.
    • Government will provide little oversight of the health care industry and/or will not hold insurers accountable for failing to deliver good quality care.

    The American Medical Association, AMA, and American Hospital Association, AHA, are both supporting Tom Price. They likely see deregulation of the health care industry as a way for doctors and hospitals  to charge higher rates and operate with less accountability. However, deregulation of the health insurance industry will ultimately bite doctors and hospitals in the back.

    If Price’s views prevail and Congress kills Medicare and Medicaid, insurers are more than likely to use their leverage to form narrow networks, keeping their enrollees from using costly specialists and specialty hospitals. Alternatively, insurers will raise out-of-pocket costs for specialty care so high that patients won’t be able to afford them, and doctors and hospitals will be left holding the bag.

    If you oppose deregulation of our health insurance system and an end to Medicare’s guaranteed benefits, please sign this petition and visit your Senators to make your views known.

    Here’s more from Just Care: