JustCare

Tag: Health equity

  • Aspirin is good at preventing blood clots post-surgery. Why don’t hospitals use it?

    Aspirin is good at preventing blood clots post-surgery. Why don’t hospitals use it?

    A recent study found that patients benefit as much from aspirin post-surgery as they do from costly and painful injectables. Both prevent blood clots in patients who have severely fractured a bone, but most hospitals continue to treat patients with the costly injectables. Researchers make the case that prescribing the injectables has serious health equity consequences in a Stat News op-ed and question provider behavior.

    Patients are burdened with far lower costs for aspirin than the low-molecular weight heparin injectables. And, it’s easier for them to take a pill than to get an injection. However, hospitals and physicians appear not to consider health equity issues or simple cost-effectiveness, for that matter, when they treat patients.

    The goal post bone-fracture surgery is to prevent clots, which keep blood from flowing in the lungs and can cause deadly embolisms. And, again, two aspirins a day work just as well as the painful injections into patients’ stomach wall twice a day for three or four weeks post surgery, even for high-risk patients. Moreover, six days of injections cost at least $70 and as much as $300, while the bottle of aspirin costs a few dollars.

    Health insurers will generally pay for the injectable drug even though the less costly aspirin alternative is just as good. But, the injectable drug drives up  patients’ out-of-pocket costs and members’ premiums. Moreover, people prescribed the injectable after their surgery post bone fracture often don’t take it, making it more likely that they will have a blood clot.

    Physicians do not appear to consider that lower-income people, in particular, often do not have the means–financial or social–to comply with the injectable regimen. Only about 15 percent of physicians prescribe aspirin directly after surgery to treat a bone fracture. Only about half of physicians prescribe aspirin to patients after they are discharged.

    At many hospitals, policies have not changed notwithstanding the results of the clinical study showing aspirin’s efficacy. It appears that the hospitals would benefit financially if they used aspirin and stopped using the injectables.

    The insurers should have a role to play. After all, the insurers claim that they offer “value.” Why aren’t they insisting that aspirin is the most cost-effective treatment and refusing to cover the injectable drug post bone-fracture surgery? Are they somehow benefiting financially from patients taking the injectables?

    Here’s more from Just Care:

  • What we don’t know about Medicare Advantage

    What we don’t know about Medicare Advantage

    [Editor’s note: The following is the response to a request for information about Medicare Advantage data gaps by the Centers for Medicare and Medicare Services, from a coalescence of grassroots organizations and others.]

    May 29, 2024

    The Honorable Chiquita Brooks-LaSure Administrator
    Centers for Medicare and Medicaid Services
    U.S. Department of Health and Human Services
    200 Independence Avenue, SW Washington, DC 20201
    The Honorable Xavier Becerra, Secretary
    U.S. Department of Health and Human Services
    200 Independence Avenue, SW Washington, DC 20201

    Re: CMS-4207-NC–Medicare Program; Request for Information on Medicare Advantage Data Submitted electronically via https://www.regulations.gov

    Dear Administrator Brooks-LaSure and Secretary Becerra,

    Thank you for providing us with the opportunity to share our views on Medicare Advantage (MA) data gaps and needs in order to make critical improvements to MA. Like you, our goal is to promote health equity, protect enrollees, and ensure the fiscal integrity of the Medicare program. Right now, with limited, untimely and incomplete MA data, these goals are a pipe dream.

    This response to the MA Data request for information is submitted on behalf of the below signed organizations and individuals representing a wide and diverse swath of stakeholders. We believe that critical data gaps today undermine MA accountability and allow bad actors to gouge taxpayers, erode the Medicare Trust Fund, endanger the lives and well-being of older adults, and discriminate against Black, Hispanic, Pacific Islander, low-income and critically ill older adults and people with disabilities.

    We salute CMS for trying to enhance enrollee protections in MA but, without better data, there is no way to protect people from plans that do not honor their obligations to cover Medicare benefits and other contractual obligations. CMS cannot cancel their contracts or penalize them appropriately. CMS cannot warn people about MA plans with unconscionably high denial rates, inadequate networks, or high mortality rates. Unfortunately, the available data suggests there are far too many of them.

    We agree with you that we should “have, and make publicly available, MA data commensurate with data available for Traditional Medicare to advance transparency across the Medicare program, and to allow for analysis in the context of other health programs.” Not only is that not the case today, but we know from MedPAC that insurers have never met their obligation to release complete and accurate encounter data. That failure alone indicates either an inability of insurers to effectively manage care, or a blatant disregard for the value of this data for effective oversight, or perhaps a desire to hide the data to avoid appropriate accountability for their bad acts. Whatever the reasons, it is essential that any and all data requirements from insurers be fashioned in ways that ensure their complete, accurate and timely collection and impose appropriate non-discretionary penalties for insurers’ failure to provide the data.

    Without complete, accurate and timely plan-level data, adequate resources for oversight and meaningful penalties for noncompliance, the MA program has become an ATM for the health insurers offering MA plans. This makes the MA program a dangerous choice for older adults and people with disabilities who too often wrongly assume what they are told — that they will get the Medicare benefits to which they are entitled. Further, it makes the MA program an administrative nightmare and a financial risk for providers. If Congress and the administration do not have the tools to identify and punish insurers who withhold Medicare-covered services from MA enrollees or otherwise discriminate against them, they should acknowledge the MA program’s vulnerability to corporate crime and serious or deadly enrollee harm — and overhaul or end the program.

    Recently CMS chose not to call for more detailed data reporting from MA insurers. Rather, it said that “reporting at the specialty level and service level could be overwhelming because of the volume of information presented.” If CMS cannot manage the collection and analysis of granular data to police the insurers offering MA plans effectively, CMS should publicly disclose those constraints and their dangerous consequences, call upon Congress for the needed resources, and warn enrollees upfront and clearly of its inability to protect them from bad actor insurers who have the ability and the financial incentive to deny them needed care.

    We detail below some of the most critical data gaps and needs to prevent the MA program from offering choices to older adults and people with disabilities that no one should have to make, gouging taxpayers and the Medicare Trust Fund, and disrespecting the financial and administrative needs of providers. Before we do, we want to underscore our shared goal with the administration of promoting health equity and the need for a lot more MA data to accomplish this goal.

    That said, if the government simply requires more MA data without robust oversight and non-discretionary penalties on insurers for non-compliance, the requirements would be of little value. The government must use the data to oversee the MA insurers and hold the bad actors accountable for their bad acts in meaningful ways.

    Moreover, if the government simply expects beneficiaries to make sense of volumes of Medicare data to protect themselves against bad actor MA plans or to appeal systemic inappropriate denials of care in order to get the Medicare benefits to which they are entitled, it is promoting health inequities. If the government allows MA plans to hide the data revealing that lower-income enrollees and communities of color are going without needed care because of administrative and financial burdens and inappropriate denials, it is promoting health inequities. CMS must keep bad actor MA plans out of the program and reform the MA program to minimize harm to enrollees.

    In a sadly apt comparison, the Boeing aerospace corporation was allowed to continue its money-saving profit-centric business model that led to the needless deaths of many people before Boeing was forced to suffer material consequences. We have mounting evidence that the worst performing MA plans are behaving similarly, with arguably far more horrific consequences both for their tens of thousands of enrollees and for the Medicare program writ large. And no one is yet identifying these bad actors, let alone stopping them.

    Inadequate provider networks and misleading directories cause harm

    The government cannot protect people enrolled in MA if it cannot block MA plans with inadequate networks or prevent sales agents from misleading people about networks. Today, it cannot do either, even though CMS “requires” insurers to offer adequate networks and restricts the activities of MA sales agents. Consequently, people sign up for MA plans thinking they will get the care they need from the physicians and hospitals they want or need to use and too often find they are not covered for their care from those providers. The network provider directories are inaccurate. They often can’t use a cancer center of excellence. Or, they can’t see a physician at a convenient location. Or, all of the nursing homes in their network are of poor quality. As you know, the plight of enrollees who need costly care is all the worse for Black and Hispanic people, low-income people and people in rural communities—promoting grave and unconscionable health inequities.

    CMS allows insurers to offer MA plans with different networks in a contract and only collects network information at the contract level, preventing it from ensuring network adequacy. CMS likely lacks the resources to oversee more than 4,000 MA plans effectively. To protect enrollees, this cannot continue.

    CMS could require insurers to offer the same provider network to all MA plans in a contract. That requirement would simplify oversight of network adequacy and provider directories. It also would help promote health equity, prevent provider network discrimination, and allow for more meaningful plan choice.

    The simplest way for CMS to collect accurate provider network data would be to create a central web portal on which all providers are required to list their MA plan affiliations. Insurers would then be responsible for ensuring accuracy and could penalize network providers who were not listed. People could far more easily compare MA plan networks.

    The best solution would be for CMS to require all MA plans to eliminate their networks and cover all willing Medicare providers at the Medicare rate.

    Again, whatever CMS chooses to do, it is of no use if the insurers do not have adequate networks. It is of no use if the insurers are not accountable for failing to provide accurate provider information less than 95 percent of the time or failing to have adequate networks. CMS should impose a non-discretionary meaningful penalty on these insurers in the form of a lower star rating, an X or other warning about the plan on its web site or a requirement to stop all marketing. Insurers should be held strictly liable for their errors. Enrollees should not be their victims.

    Additionally, as the Center for American Progress recommends, “CMS should ensure there are explicit protections that would allow for an enrollee to change MA plans or return to TM without being subject to medical underwriting for supplemental Medigap policies if their MA plan directory was inaccurate at their time of enrollment. For example, CMS can clarify that if an enrollee makes such a discovery, it should be considered a misleading MA practice and accordingly trigger a Special Enrollment Period (SEP) for supplemental benefits.”

    Proprietary and non-evidence-based prior authorization rules cause harm

    If MA prior authorization rules have health benefits, insurers should share them openly and freely use them. If not, insurers should be penalized heavily for using them, especially in cases where people’s lives and health are at serious risk, such as for cancer patients. Otherwise, Congress and the administration cannot protect Medicare Advantage enrollees from grave harm.

    For this reason, CMS must require insurers to disclose all prior authorization requirements they intend to use, and CMS must pre-approve them based on evidence. Penalties for non-compliance should be severe and non-discretionary. Insurers should be stopped from making people with Medicare their victims.

    To truly protect people, CMS should dictate the prior authorization rules that MA plans are permitted to use. Specifically, CMS should create a standardized prior authorization system that applies to all MA plans. Only a standardized system will promote health equity and allow people to make an informed MA choice.

    For now, in its insurer contracts, CMS should prohibit insurers from using different prior authorization rules for enrollees depending upon the MA plan they are enrolled in. There is no good rationale for allowing an insurer to discriminate against people in some MA plans through use of more prior authorization rules than other MA plans. Either prior authorization is beneficial and clinically sound or it is not.

    Recent CMS prior authorization rules are a good first step. But, without more details and non-discretionary penalties for plans that apply PA inappropriately, history and experience suggest that insurers will ignore such rules. To repeat, the only way for CMS to ensure MA enrollees get the same Medicare benefits as people in TM — and protect MA enrollees from deadly delays and denials of care as a result of PA — is for CMS to set standardized PA rules. To ensure and promote health equity, CMS should require insurers report PA denial and delay data by type of service and enrollee characteristic at the plan level.

    Insurers should also report MA plan level denials both pre and post treatment and in and out of network. CMS needs the information to ensure insurer compliance with Medicare coverage rules. Individuals need this information to avoid plans with high denial rates. Providers need this information to make informed choices about which networks to be a part of.

    Supplemental benefits are a gift to insurers who wrongly and excessively deny care

    Based on the existing evidence, it is all but certain that insurers are able to offer extra benefits and still profit handsomely because of the money they save from denying care inappropriately, keeping enrollees from seeing high quality providers, attracting a disproportionate share of healthy enrollees and creating incentives for enrollees with costly conditions to disenroll.

    CMS should automatically forbid plans with denial rates above 10 percent in the prior year from offering supplemental benefits. While this would likely mean fewer supplemental benefit offerings, as the Center for American Progress says, “The little research that is available suggests that MA plan coverage for dental, vision, and hearing services has not resulted in improved access for beneficiaries.”

    Immediately, along with the Center for American Progress, “We recommend that CMS collect and publish utilization and OOP spending data for all supplemental benefits, disaggregated by enrollee race, ethnicity, gender, income level, and other important demographic characteristics, at both the plan and beneficiary level. This information should be stratifiable by benefit transaction/service type. We also recommend that complete data on the use of prior authorization for supplemental benefits, including rates of denials on PA requests, be reported to CMS and made publicly available.”

    High disenrollment or mortality rates should disqualify an insurer from offering an MA plan

    CMS should require insurers to report MA plan-level disenrollment and mortality rates. The data should be broken down across demographic and health characteristics of the people who disenroll or die and should be publicly reported. Disproportionately high rates automatically should trigger cancellation of MA contracts. High rates should also trigger lower MA star ratings. Given that some plans have excessively high denial and mortality rates, people choosing an MA plan can only make a meaningful choice with this information. Star ratings that do not meaningfully reflect excessive mortality rates are a cynical perversion of quality methodologies.

    Out-of-pocket costs force people into debt and to forgo care

    CMS should collect and report plan level data on the number of people forgoing critical care based on cost or care denials. How many people in MA are forgoing critical care as a result of high out-of-pocket costs that their MA plan imposes? How many of them are low income, in poor health or are Black or Hispanic? How can CMS promote health equity without this information?

    CMS should collect and report plan level out-of-pocket costs by health condition. What are people’s out-of-pocket costs if they have cancer, suffer a stroke, or need rehab? How can people make an informed choice of an MA plan without this information?

    CMS should collect MA plan-level data to promote health equity

    CMS needs MA plan-level data to promote health equity or it needs to forbid insurers from offering more than one MA plan in a contract area.

    To echo the Center for American Progress, “CMS should consider including some dimension of equity as part of the MA star ratings program, which at the very least could be a reflection of whether MA plans are collecting adequate and stratifiable data.” And, “CMS should prioritize making any necessary adjustments to its race and ethnicity data collection processes given how central accurate underlying data is to the validity of monitoring for inequities.”

    Without oversight and enforcement, data requirements are virtually useless

    We know that tens of thousands of people each year in MA, if not hundreds of thousands, are dying needlessly or suffering greatly because Congress created a program that is impossible to oversee and the insurers have become so big and powerful, both legally and politically, that they can design their MA plans to maximize profits and violate contracts with near impunity.

    The data on health insurance violations reported on violationtracker.org speaks volumes.

    No other wealthy nation allows health insurers to behave as they will to deny and delay care or otherwise restrict care access as MA insurers are able to do. No other wealthy nation provides insurers with an incentive to maximize profits on the backs of their enrollees. Rather, they dictate when, how and where care is covered—and the price. That’s the way to ensure insurers do their job appropriately and protect people.

    A lot more data is urgently needed for adequate oversight. But, without tens of billions of dollars more, CMS will not be able to conduct effective oversight and enforcement. Insurer abuses will persist and vulnerable older adults and people with disabilities will suffer. Only much tighter regulation and non-discretionary automatic penalties for non-compliance will promote health equity and ensure MA enrollees get the care to which they are entitled.

    Conclusion

    This year alone, the government is projected to overpay insurers offering Medicare Advantage plans between $83 and $127 billion, wasting taxpayer dollars and driving up Medicare premiums, indicating serious design defects in the government’s capitated payment structure. Moreover, notwithstanding critical missing data, mounting evidence reveals serious deficiencies in MA’s coverage design, resulting in untold harm to a significant number of enrollees who need critical care.

    Rules and regulations, limited resources, and corporate health insurer power have kept CMS from collecting critical data, auditing plans adequately, and enforcing penalties. Rather, MA is growing quickly, and few people enrolled appreciate that they are taking a big gamble with their health. Medicare Advantage saves money for healthy people, but comes with serious costs and major limitations for the most vulnerable. Instead of pooling and spreading risk, the MA model allows insurers to fragment risk, burdening the sickest; the opposite of a proper insurance design.

    Traditional Medicare is far from perfect and needs improvements, including an out-of-pocket cap. But, it is far more cost-effective than MA. In sharp contrast to MA, Traditional Medicare pools and spreads risk. It is designed to ensure that the 10 percent of enrollees responsible for 70 percent of Medicare spending have quick and easy access to needed care. Traditional Medicare does not create obstacles to care, or second-guess enrollees’ treating physicians in order to maximize profits, much less withhold data in order to prevent appropriate oversight.

    We know that political pressures can prevent dramatic action, often when it is most necessary. We hold Congress largely responsible for refusing to act in meaningful ways to reform MA. And, we thank CMS for calling on the public to bring attention to MA’s limitations, as well as for improving MA as best it can, given so many constraints.

    We hear the nightmare Medicare “Disadvantage” and “Take Advantage” stories on the ground and struggle to sleep at night, concerned for the millions of vulnerable Americans who can’t afford supplemental insurance in TM and have no clue of the challenges they are likely to face in MA when they most need care. We will continue to highlight MA’s inequities and defects and advocate for major reforms to the program, alongside the Office of the Inspector General, the Government Accountability Office, the MedPAC, the Committee for a Responsible Federal Budget, the American Hospital Association, a growing number of Congresspeople and myriad others. We promise that we will not stop speaking out until the day our representatives in Congress unite to pass legislation that will protect MA enrollees and the fiscal integrity of the Medicare program.

    In the meantime, we appreciate your consideration of our comments. For any questions regarding this comment letter, please contact Diane Archer at [email protected].

    American Economic Liberties Project
    Be A Hero
    Center for Economic and Policy Research Center for Health and Democracy
    Center for Medicare Advocacy
    Just Care USA
    People’s Action
    Physicians for a National Health Program
    Public Citizen
    Puget Sound Advocates for Retirement Action
    Social Security Works
    Dr. Don Berwick, Former Administrator of the Centers for Medicare and Medicaid Services (CMS)

  • Administration proposes new rule to address myriad problems with Medicare Advantage

    Administration proposes new rule to address myriad problems with Medicare Advantage

    The Centers for Medicare & Medicaid Services (CMS) has proposed a new rule for 2025 with the goal of addressing some of the problems with Medicare Advantage (MA). The rule is intended to “promote healthy competition” because so many Medicare Advantage plans have been failing to meet people’s needs, in a multitude of ways. The problem is that the proposed rule, like the vast majority of Medicare Advantage rules, has no teeth.

    Here are the rule’s major provisions:

    The Administration proposes more guardrails to ensure that insurance brokers and agents are not steering people into Medicare Advantage plans that do not meet their needs. Mountains of evidence reveal that many Medicare Advantage plans are inappropriately delaying and denying care and otherwise restricting access to care, through limited provider networks and large out-of-pocket costs. No one, including insurance agents, has a clue as to which Medicare Advantage plans to avoid–let alone, whether there are any that put patient needs first–because there is no good data to help people understand which Medicare Advantage plans are the bad actors.

    The biggest takeaway of the new proposed marketing “guardrail” is that brokers and agents steer people to the MA plans that pay them the highest commissions. They also steer people away from Medicare supplemental insurance plans that pick up most out-of-pocket costs in traditional Medicare, which don’t pay them as high commissions as MA plans. The MA commission is now as high as $601, with lots of bonuses, and would increase to a fixed rate of $632 in 2025. Bottom line: Don’t trust the advice of insurance agents!

    The proposed rule also proposes better access for people to outpatient behavioral health providers through changes to Medicare Advantage plan’s network adequacy standards. This year, CMS expanded coverage to marriage and family therapists (MFTs) and mental health counselors (MHCs). About 400,000 more therapists will be able to treat Medicare patients if they so choose. Because reports indicate that Medicare Advantage plans do not often offer easy or any access to mental health providers, as required, CMS is setting a special network adequacy standard for Medicare Advantage plans. But, as it is, CMS does not appear to have the resources to assess network adequacy nor does it have the ability to meaningfully penalize MA plans with inadequate networks.

    And, the proposed rule seeks to help people with Medicare make good on the “supplemental benefits” that Medicare Advantage plans offer. Reports indicate that many of these benefits go unused because they come with unaffordable out-of-pocket costs or other burdens on enrollees. CMS allows MA plans to offer food vouchers and transportation services. But, it appears that few use them. So, if the rule is finalized, MA plans would have to let enrollees know of the availability of supplemental benefits midway through the calendar year.

    CMS states it does not want MA supplemental benefits used as a “marketing ploy,” as they so often are. But, the administration overlooks the fact that few people will read the notice from their MA plans and fewer still will be able to take advantage of these benefits even if they know about them. Many people with Medicare have serious mental and physical health conditions as well as low health literacy levels that impede their ability to understand Medicare’s complex rules.

    To address the disproportionate impact that inappropriate delays and denials of care in Medicare Advantage has on  underserved populations, such as people with disabilities, people with Medicaid and people in Medicare Savings Programs, CMS has proposed that Medicare Advantage plans analyze their utilization management (UM) policies and procedures from a health equity perspective.

    And, CMS’ proposed rule attempts to give Medicare Advantage enrollees faster access to appeals; right now, in some cases, people in MA plans have far less timely appeals than people in traditional Medicare. This proposed rule is an improvement that might help a tiny fraction of MA enrollees. However, the overwhelming majority of MA enrollees do not know to value of appealing MA plan denials and do not appeal.

    Lastly, CMS proposes a rule to allow monthly enrollment in MA plans and appears to help insurers push more people with Medicare and Medicaid into an MA plan. That’s insane given all the reports of bad actors in MA and the availability to this population of traditional Medicare with easy access to care and few if any out-of-pocket costs. Thankfully, the rule also gives these “dual eligibles” the ability to switch to traditional Medicare more easily.

    The proposed rule would limit out-of-network cost sharing for D-SNP preferred provider organizations (PPOs) for specific services, beginning in 2026. The proposed rule also would reduce cost shifting to Medicaid, increase payments to safety net providers, expand dually eligible enrollees’ access to providers, and protect dually eligible enrollees from unaffordable costs.

    It’s great that CMS is acknowledging many of the major issues with Medicare Advantage. It’s unfortunate that even when it proposes a good rule, the insurers offering Medicare Advantage plans can effectively ignore the rule with impunity, and many of them do.

    Here’s more from Just Care:

  • Ten ways to improve Medicare Advantage

    Ten ways to improve Medicare Advantage

    Dear Secretary Becerra and Administrator Brooks-LaSure:

    Social Security Works, Just Care USA and Center for Health and Democracy are delighted that the Biden Administration seeks to protect older adults, people with disabilities and the Medicare program from abuses in the Medicare Advantage program. We thank you for the opportunity to comment on ways to improve Medicare Advantage. We agree with the HHS Office of the Inspector General, Government Accountability Office and MedPac that Medicare Advantage is in need of major reform to ensure the health and well-being of enrollees, promote health equity, and minimize legal violations, Including overpayments. As GAO reported: “The Medicare program, which includes MA, is on GAO’s High Risk List, because of its size, complexity, and susceptibility to mismanagement and improper payments.”

    The health insurers offering Medicare Advantage plans have committed many hundreds of legal violations since 2000, and there is reason to believe these will continue unless the federal government overhauls Medicare Advantage. UnitedHealth Group, the company with the most MA enrollees, has paid nearly $600 million in penalties for 332 violations, 300 of which are for consumer protection-related offenses, since 2000. Humana, the second largest MA plan, has paid more than $77 million in penalties for 79 violations, 57 of which are for consumer protection-related offenses, since 2000. CVS Health, the third largest MA plan, has paid more than $1.6 billion in penalties for 463 violations, 236 of which are for consumer protection-related offenses, since 2000. 

    Today, the MA plans have too much incentive and opportunity for abuse. In September 2019, Senator Sherrod Brown, along with five other Senators, wrote CMS requesting answers to questions regarding key failings in Medicare Advantage. To our knowledge, three years later, CMS has not addressed any of the serious issues raised. Unless MA is overhauled on multiple fronts, including revising the way it pays them, Medicare Advantage plans will continue to undermine the integrity of the Medicare Trust Fund, harm health equity, and put millions of their enrollees at serious risk of harm.

    As soon as possible, CMS should stop misdirecting people to believe they can meaningfully choose a Medicare Advantage plan that meets their needs and that they can rely on a misleading star-rating system to choose among MA plans. CMS should:

    • Educate people about the high out-of-pocket costs in MA;
    • Educate people about MA plans’ torturous prior authorization rules;
    • Identify and publicly report the names of MA plans with high rates of delays and denials;
    • Identify and publicly report adjusted mortality rates per MA plan;
    • Terminate contracts with MA plans that are consistently delaying and denying care inappropriately, have high mortality rates, or otherwise are violating their contractual obligations. 

    People from racial and ethnic minority groups, people with disabilities and serious health conditions, people of disadvantaged socioeconomic status, people with limited English proficiency, and people from rural communities disproportionately choose Medicare Advantage because of its low upfront cost. They are, however, at greater risk in Medicare Advantage than in traditional Medicare for two key reasons: 

    Fundamental problems with the current Medicare Advantage model drive health inequities and poor health outcomes for people with complex conditions. The biggest problem is the risk-adjusted capitated payment model. Medicare Advantage plans that: 1. Attract a disproportionate number of enrollees in relatively good health and/or 2. Delay and deny care inappropriately and/or 3. Do not include high quality specialists and specialty hospitals in their networks, can be sure to profit handsomely. The risk-adjusted capitated payment model for MA plans not only hurt vulnerable populations, they drive up Medicare costs. 

    We propose a suite of ten changes to improve health equity, reduce Medicare Advantage threats, enable appropriate CMS oversight, and minimize health insurer violations in Medicare Advantage. 

    1. Change the way the government pays Medicare Advantage plans. 

    The government should pay MA plans so that they do not have a financial disincentive to cover care for people with costly and complex conditions. Prospective payments, unrelated to actual medical claims, create a powerful financial incentive for MA plans to impede access to high-value care for enrollees with complex conditions in order to maximize profits. This is particularly corrosive to health equity:

    • MA plans can maximize profits by enrolling a disproportionate number of people in good health and impeding care for people in poor health. This is one reason why MA plans seldom contract with Centers of Excellence and rarely, if ever, advertise or promote programs for people with costly conditions. 
    • MA plans can maximize profits by underpaying providers. The Texas Hospital Association has identified that “the rapid growth of Medicare Advantage enrollees threatens Texas’ health care safety net. For rural hospitals, Medicare Advantage causes financial instability on an already fragile provider community.” 

    In theory, a risk-adjusted capitated model would pay MA plans enough to cover the cost of services their members need. In reality, however, capitated risk-adjusted models can never ensure access to timely and good quality care for people with costly and complex conditions. In a world in which 50 percent of the Medicare population accounts for less than five percent of spending, such models wildly overpay for the healthy and significantly underpay for the sick.

    Capitated risk-adjusted models create a powerful incentive for Medicare Advantage plans to “cherry pick” the healthy enrollees and “lemon drop” the sick ones. Any Medicare Advantage plan that meets the needs of people with costly conditions — where demand for high-value care is the greatest — is at risk of attracting a disproportionately high percentage of enrollees with costly conditions and suffering financially. Ten percent of people with Medicare with the most serious conditions account for 60 percent of Medicare spending. It makes business sense for MA plans to do what they can to minimize costs from this population. Even good actors must engage in “cherry picking” and “lemon dropping” to ensure they remain financially afloat.

    2. Base payments to MA plans upon the cost of services MA plans cover plus a reasonable fee for administration and a global cap.

    Risk-adjusting capitation payments based upon an MA plan’s own proprietary assessment of the health of its enrollees creates a powerful financial incentive for the plans to “upcode” or attach as many diagnosis codes as possible to its enrollees. The more diagnosis codes, the higher an MA plan’s payments, and the greater the cost to the Medicare program. 

    Upcoding is not simply about bad actors. In order for “good guy” MA plans to compete with “bad guy” MA plans, the good guys are hard-pressed not to engage in upcoding. Otherwise, their competitors have more resources to offer reduced premiums and additional benefits, driving the “good guy” MA plans out of the market. 

    The Department of Justice has identified more than $100 billion of such inappropriate upcoding and overbilling at UnitedHealth Group, Humana, Cigna, Kaiser, Sutter Health and Anthem, among other insurers. It’s anyone’s guess how many additional billions of dollars in overpayments have gone undetected. As a result of upcoding, CMS is projected to overpay Medicare Advantage plans an estimated $600 billion between 2023 and 2031. 

    CMS should acknowledge that it does not have the tools or resources to ensure the diagnosis codes MA plans assign their enrollees are accurate, much less to recoup overpayments. 

    Risk-adjusted capitation adds additional administrative costs and profits to a fee-for-service model. More than 81 percent of MA plans pay all or nearly all their network providers on a fee-for-service basis. Traditional Medicare’s fee-for-service payment model is far more cost-effective and transparent than the MA capitated payment model. Researchers can see what’s working and not working in the health care system, unlike in MA, and drive system improvements. CMS should be building on that payment model.

    3. Require Medicare Advantage plans that pay providers on a fee-for-service basis to use traditional Medicare’s fee schedule. 

    Allowing Medicare Advantage plans to pay lower rates to providers jeopardizes access to care in MA and undermines health equity. Safety net providers serving vulnerable communities, in particular, have little if any leverage to contest MA plan rates and few resources to challenge inappropriate denials of care and coverage, undermining health equity. The Texas Hospital Association has identified that MA plans pay Texas hospitals well below the traditional Medicare rate, which undermines federal payment policies intended to ensure adequate reimbursement for rural hospitals. Medicare Advantage has caused some Texas hospitals to lose several hundred thousand dollars in revenue a year that they had received from traditional Medicare. 

    Conversely, allowing MA plans to pay higher rates than traditional Medicare creates an unlevel playing field with traditional Medicare and drives up Medicare spending needlessly. 

    4. Require MA plans to include all centers of excellence in their networks and disclose out-of-pocket costs for people with complex conditions.  

    The data suggest notable dissatisfaction among MA plan enrollees who need costly care. They disenroll from Medicare Advantage plans at disproportionately high rates in the last year of life and when medical costs are high. A 2021 GAO report suggests that these high disenrollment rates “may indicate potential issues with beneficiary access to care or with the quality of care provided.” In addition, rural enrollees have substantial rates of switching out of Medicare Advantage to traditional Medicare. The data also show widespread and persistent inappropriate delays and denials of care. 

    Until CMS moves away from a risk-adjusted capitated payment model, it must ensure that every MA plan meets the needs of people with the costliest and most complex conditions. Among other things, every MA plan should include all centers of excellence, such as NCI-designated Cancer Centers, in its network. And, rather than allowing MA plans to spend rebate dollars on additional benefits with no evidence of promoting health equity, CMS should consider establishing a mechanism for this money to go towards covering copays and deductibles for people with complex conditions so as to help ensure they are not forced to choose between their rent and their health care.  

    5. Standardize MA coverage rules and cost-sharing design.

    Even the most diligent people with Medicare have no way to select the MA plan that best meets their needs. Each Medicare Advantage plan structures its out-of-pocket costs and out-of-pocket limits in different ways, uses different medical necessity protocols, different referral and prior authorization requirements, designs different networks, and engages in different levels of inappropriate denials of care and coverage. Consequently, some Medicare Advantage plans could literally be harming their enrollees while others could be ensuring timely access to care and delivering good health outcomes. No one can meaningfully differentiate among these plans.

    These structural differences among MA plans, several of which can change at any time, could be disabling or even killing people with Medicare prematurely – and CMS itself would not know. These differences prevent CMS from both protecting enrollees and evaluating MA plans in a meaningful way. At the same time, they prevent people with Medicare from being able to compare MA plans on the most essential metrics. 

    Structural differences also make it all but impossible for CMS to undertake timely and effective audits of MA plans. CMS has not been able to complete timely MA audits from as far back as 2011. Without such audits, CMS cannot protect enrollees in MA plans or hold MA plans appropriately accountable for their bad acts in a timely fashion. CMS should acknowledge that it will never have the tools or resources to appropriately penalize MA plans for bad acts and protect MA enrollees without standardized MA design. 

    People with Medicare today are inadequately protected against proprietary and non-standardized MA policies that could jeopardize their health and well-being. The data show that CMS cannot effectively monitor them for poor outcomes. A 2022 OIG report, a 2018 OIG report, and endless news stories consistently show that Medicare Advantage plans too often inappropriately deny care that traditional Medicare would have covered and that the MA plans should have covered. CMS should require all MA plans to follow traditional Medicare coverage protocols and only allow evidence-based and transparent differences among MA plan protocols. 

    6. Ensure appropriate oversight of MA.

    CMS does not have the tools or resources to ensure appropriate Medicare Advantage oversight and protect enrollees under the current non-standardized model. Standardizing coverage policies would allow CMS to monitor MA plans more effectively and better protect enrollees. Standardized coverage protocols would help ensure MA plans covered medically necessary care and promoted health equity. 

    The GAO has found that CMS has not validated MA patient encounter data as needed and recommended. In a recent House Ways and Means Subcommittee on Oversight and Investigations hearing, MedPAC reported that “After a decade, MA plans are “not producing complete and accurate enough records needed for MedPAC to conduct oversight activities, to understand differences in service use between MA and FFS, to reflect utilization management techniques, and inappropriate denial of covered care.” 

    The failure of Medicare Advantage plans to turn over complete and accurate encounter data for analysis — as required by law — suggests these plans either lack the tools to collect the data or the ability to appropriately manage their enrollees’ care.

    7. Do not assume value in MA, since it cannot be measured. 

    MedPAC has said repeatedly that MA quality cannot be measured. “The current state of quality reporting in MA is such that the Commission can no longer provide an accurate description of the quality of care in MA. With 43 percent of eligible Medicare beneficiaries enrolled in MA plans, good information on the quality of care MA enrollees receive and how that quality compares with quality in FFS Medicare is necessary for proper evaluation. The ability to compare MA and FFS quality and to compare quality among MA plans is also important for beneficiaries. Recognizing that the current quality program is not achieving its intended purposes and is costly to Medicare, in its June 2020 report the Commission recommended a new value incentive program for MA that would replace the current quality bonus program.” Medicare Advantage plans’ higher per enrollee costs than traditional Medicare suggest Medicare Advantage offers less value than traditional Medicare. 

    We know that MA plans spend less money on medical care than traditional Medicare. But, we do not know to what extent they are failing to cover appropriate medically necessary care that traditional Medicare covers. Moreover, industry data on 2018 hospital stays and emergency room visits reveal that Medicare Advantage appears to have greater inpatient use and emergency room visits than traditional Medicare. In a review of the Medicare Advantage studies, Agarwal and colleagues find “the evidence on readmission rates, mortality, experience of care, and racial/ethnic disparities did not show a trend of better performance in MA plans than traditional Medicare, despite the higher payments to MA plans.”

    Assessing MA plan quality is critical for the health and well-being of MA enrollees. Given the poor performance of some MA plans with four and five-star ratings and no information from CMS on bad actors with these ratings, people are at risk of worsened health outcomes if they choose the wrong MA plan. One MA analysis in NBER found that if CMS cancelled contracts with the worst performing five percent of MA plans, it would save 10,000 lives a year.

    To protect people from misleading quality information, CMS should revise its star-rating system, as proposed by MedPAC. It should also eliminate star ratings for all Medicare Advantage plans that do not release complete and accurate encounter data, as required. And, it should consider removing these MA plans from eligibility for the quality bonus program. 

    8. Rethink Medicare Advantage networks. 

    CMS should stop allowing Medicare Advantage plans, except those that are fully integrated health systems, to design their own provider networks and require them to cover care from all Medicare providers. Many if not most MA plans design their networks to minimize their costs and boost their profits to the detriment of the health and well-being of their enrollees. To our knowledge, no independent expert has ever demonstrated the value of a network in Medicare Advantage plans to people with Medicare or the Medicare program other than those in fully integrated health systems. Conversely, stories abound about Medicare Advantage narrow networks that jeopardize access to care and lead to poor health outcomes, particularly for vulnerable populations.

    If the principal reason for a provider network is to contain medical costs, there is no compelling justification for Medicare Advantage plan networks. MA plans generally piggyback off of Medicare rates, which are already relatively low. If MA plans negotiate even lower rates, there’s good cause for concern that providers in their networks are of lesser quality than in traditional Medicare. If the principal reason for a provider network is to ensure good integrated care, it is difficult to appreciate the value of MA provider networks (except in cases where the Medicare Advantage plan is a fully integrated health care system). 

    The risks to the health and well-being of MA enrollees of allowing MA plans to design their provider networks are grave. Compared to traditional Medicare, the data show that MA plans use lower quality home health agencies and nursing homes, and less frequently use higher quality hospitals. They often do not include NCI-designated Cancer Centers or Centers of Excellence. In 2016, the Kaiser Family Foundation found that only 15 percent of Medicare Advantage plans definitely included Cancer Centers and 41 percent definitely did not.

    Plan networks are often so narrow as to delay or prevent people from accessing needed care. They also often undermine continuity of care. And, many MA plans have never had accurate network directories. Plan provider directories are too often misleading and inaccurate. Without accurate directories, network adequacy cannot be established. 

    Moreover, GAO reports that CMS does not assess provider availability to the extent it oversees network adequacy. This failure undermines health equity. Vulnerable older adults and people with disabilities are more likely to go without care when networks are narrow and accessing care with network providers requires significant time and travel.

    We urge CMS to acknowledge that it has neither the tools nor the resources to ensure network adequacy and promote health equity. A 2015 GAO report found “that CMS’s oversight did not ensure that MAO networks were adequate to meet the care needs of MA enrollees. For example, we found that CMS did not adequately verify the accuracy of provider network information submitted by MAOs, and accordingly could not verify whether MAO networks were in compliance with the agency’s provider network criteria.” In June 2022, GAO stated that its recommendations to address these issues “had not yet been fully implemented.”

    To promote health equity, protect people from misleading MA marketing regarding network providers, and ensure access to and continuity of care, CMS should consider requiring MA plans, except fully integrated health systems, to cover care from all Medicare providers. At a minimum, CMS should require those plans that do not keep their directories up to date to open their networks to all Medicare providers. 

    9. Rethink key consumer information regarding Medicare Advantage and overhaul MA marketing to minimize deception. 

    CMS should ensure that people enrolling in a Medicare Advantage plan are able to identify which of those plans are the bad actors, if not cancel contracts with these bad actors. Allowing these bad actors to continue offering MA plans endangers the health of the most vulnerable people with Medicare and undermines health equity.

    CMS also should ensure that no one enrolls in Medicare Advantage without understanding the financial and administrative barriers to care. A recent Center for Medicare Advocacy report found that even the “Medicare and You Handbook” and Medicare website do not explain out-of-pocket costs or prior authorization requirements in a balanced fashion. 

    CMS reported a doubling of MA marketing complaints in the year between 2020 and 2021. Too often people with Medicare have little clue what they are doing when they enroll in a Medicare Advantage plan. CMS’ review of sales calls showed significant confusion among people with Medicare, including “that the beneficiary may be unaware that they are enrolling into a new plan during these phone conversations.”  Of those people who understand differences between traditional Medicare and MA, few appreciate the risks of enrolling in a Medicare Advantage plan.

    10. Level the playing field with traditional Medicare and ensure health equity in MA.

    We urge the government to put an out-of-pocket cap in traditional Medicare so that traditional Medicare is a meaningful choice for everyone with Medicare, including people with low incomes, people in rural communities, people from racial and ethnic minority groups, and people with complex conditions. Without that out-of-pocket cap, the hundreds of thousands of people who face inappropriate delays and denials of care in Medicare Advantage too often are deprived a meaningful choice of traditional Medicare. If they elect traditional Medicare, they expose themselves to too much financial risk because supplemental insurance is unavailable or affordable for them. 

    CMS should consider allowing people in MA to have supplemental coverage that picks up all out-of-pocket costs. Right now, too many enrollees, particularly the most vulnerable, are skipping or delaying critical care because they cannot afford the deductibles and copays, creating substantial health inequities. One NBER study found that a copay increase of as little as $10.40 resulted in thousands of needless deaths. Supplemental coverage would allow people to better budget for their care. Out-of-pocket costs jeopardize the health and well-being of enrollees, with particularly poor outcomes for Latinx and BIPOC communities. In addition, out-of-pocket costs present a large barrier to care for people with low incomes.

    Conclusion

    Medicare Advantage would be significantly improved by:

    • overhauling the Medicare Advantage payment system,
    • meaningfully disclosing MA encounter and other data,
    • holding accountable those MA plans that violate their contracts, 
    • standardizing coverage policies and provider rates, including prior authorization policies, 
    • requiring a broad Medicare provider network, and 
    • overhauling Medicare Advantage marketing practices. 

    Without these reforms, the federal government puts the lives of the most vulnerable people with Medicare enrolled in MA at serious risk and threatens the integrity of the Medicare Trust Fund. It wrongly drives up Medicare Part B premiums for people in traditional Medicare. 

    Traditional Medicare would benefit from some improvements as well, including an out-of-pocket cap on Part A and B benefits and coverage of dental, hearing, vision and long-term care benefits. CMS also needs to end its Direct Contracting/ACO REACH experiment, which involuntarily assigns vulnerable people with Medicare to entities paid upfront to manage their care and is riddled with many of the same grave problems as Medicare Advantage. That said, traditional Medicare generally still provides easy access to necessary care at substantially lower cost than Medicare Advantage, and CMS should ensure that it is a meaningful choice not only for the wealthiest people with Medicare but for everyone with Medicare. 

    We look forward to working with CMS on Medicare improvements. Thank you for this opportunity to share our thoughts. For questions, please contact Diane Archer at [email protected]. 

    Signed,

    Diane Archer, President, Just Care USA

    Alex Lawson, Executive Director, Social Security Works

    Wendell Potter, President, Center for Health and Democracy

  • Evidence abounds that Medicare Advantage needs an overhaul

    Evidence abounds that Medicare Advantage needs an overhaul

    In a new Health Affairs post, Rick Gilfillan, MD, and Donald Berwick, MD, rebut unfounded claims by supporters of Medicare Advantage, with compelling evidence that Medicare Advantage needs an overhaul. Medicare Advantage is more costly than traditional Medicare, profits from a faulty risk-adjusted capitated payment model, shows no signs of delivering good quality care, and drives inequities in the health care system.

    Medicare Advantage (MA) costs more than traditional Medicare. The additional cost is simply money out of the pockets of taxpayers and people with Medicare to health insurance companies. People with Medicare pay in the form of increased Part B premiums, which cover 25 percent of Part B spending.

    “Upcoding” is responsible in large part for excess payments. MA plans add diagnosis codes–increase patients’ “risk profile,” the severity of their condition–to their charts in order to receive higher “risk-adjusted” capitated payments for those patients. There are more than 10,000 codes. Several large corporations help MA plans include additional diagnosis codes in patient profiles. They are often not reflected in the services patients receive but rather are captured through assessments of patients’ health risk during in-home visits. They generate billions in additional revenues for MA plans and limited costs.

    Gilfillan and Berwick cite Richard Kronick and F. Michael Chua‘s projection “of a 14 percent uncorrected risk score difference, [suggesting that] the total overpayment approaches 15 percent.” According to MedPAC, the agency charged with overseeing Medicare payments, Medicare Advantage plans on average have 6.9 percent profit margins. And, though technically Medicare Advantage plans cannot allocate more than 15 cents of every dollar they receive from the government to administration and profits, they have ways around that.

    Medicare Advantage plans spend less on medical care and profit at a level higher than technically permissible. To look as if they are spending 85 percent of their capitated payments on medical care–to comply with their 85 percent Medical Loss Ratio requirement–and profit more, they allocate 85 cents on the dollar to provider spending. Medicare Advantage plans that own provider companies can simply move the money to those companies, but the providers don’t need to spend the money on medical care. The more the MA plans upcode, the more they allocate to provider costs. Those additional costs are “provider incentive payments,” which the Medicare Advantage plans call medical costs. They have no relation to the amount the Medicare Advantage plans spend on care.

    If the providers are employees of the Medicare Advantage plans, then the incentive payments are actually additional revenue to them. Rather, the medical loss ratio goes from 85 percent down to near 70 percent. Put differently, the Medicare Advantage plans get to keep 30 cents of each dollar they receive from the government.

    Health inequities and underinsurance in Medicare Advantage: For sure, lower-income individuals are disproportionately enrolled in Medicare Advantage. But, because they have limited means, they are likely to end up in Medicare Advantage plans with no premium and high out-of-pocket costs. They are left underinsured, with out-of-pocket costs that can easily be 10 percent or more of their income. The Commonwealth Fund finds that one in four people with Medicare are underinsured.

    Using the Commonwealth Fund formula for underinsurance, about half of people in MA could be underinsured, given that the median income for people with Medicare is under $30,000 and stated out-of-pocket costs in Medicare Advantage are $1,645, on average (though there is no data available to confirm that or to know how many people forgo care rather than spend money out of pocket on it.) Fortunately, some of these people have Medicaid to pick up their costs.

    The data show clearly that underinsurance endangers people’s health. Many people will skip or delay needed care. The Kaiser Family Foundation research shows that about half of adults skip or delay care as a result of being underinsured, with higher proportions of people with low incomes, as well as Black and Hispanic adults. One study shows that 12 percent of people with Medicare spend more than 20 percent of their income on out-of-pocket health care costs.

    N.B. Gilfillan and Berwick agree with supporters of Medicare Advantage that benefits are better in Medicare Advantage than in traditional Medicare. But, I would argue that it depends how you define benefits. The benefits are better in traditional Medicare if benefits are defined as getting the medically necessary care your doctors recommend from the doctors you choose to see. Medicare Advantage does not offer better benefits than traditional Medicare unless benefits are defined as theoretically covered medically necessary services from network providers and extras, putting administrative and financial barriers to care aside. We know from the HHS OIG that some people in MA plans are frequently denied needed care.

    Medicare Advantage is growing, in large part, because it means fewer upfront out-of-pocket costs for enrollees and less upfront hassle figuring out supplemental coverage and a Part D plan that people generally need in traditional Medicare. But, these differences don’t speak to the quality of care or ease of access to care in Medicare Advantage. And, taxpayers are forced to pay Medicare Advantage plans more and people in traditional Medicare have to pay higher Part B premiums so that Medicare Advantage plans can offer these benefits.

    No good data on quality of care in Medicare Advantage: Traditional Medicare has a broad quality improvement agenda, far broader than Medicare Advantage, which tends to focus most on primary care and patient experience. One example is the traditional Medicare Partnership for Patients initiative which helped reduce hospital-acquired conditions and reduced spending. In sharp contrast, there are virtually no reports on Medicare Advantage initiatives to improve care in hospitals or other care facilities. In fact, research shows Medicare Advantage plans tend to include in their networks more lower-quality nursing homes and home health providers and fewer high-quality hospitals than traditional Medicare.

    Integrated or coordinated care is no more the norm in Medicare Advantage than in traditional Medicare. Most Medicare Advantage plans have in-network physicians who also treat people in traditional Medicare. Care coordination exists in traditional Medicare for people with complex conditions through accountable care organizations. The extent to which care coordination exists in Medicare Advantage for high-cost patients is unclear. What is clear is that the Accountable Care Organizations generated almost $4 billion in net Medicare savings in the last eight years, while the Medicare Advantage plans have cost Medicare $75 billion extra.

    Notwithstanding overpayments to Medicare Advantage plans, Gilfillan and Berwick say they offer “no demonstrable clinical benefit to patients.” MedPAC underscores “the flaws in the 5-star system and the QBP [quality bonus payment] and the continuing erosion of the reliability of data on the quality of MA plans …. The current state of quality reporting is such that the Commission’s yearly updates can no longer provide an accurate description of the quality of care in MA. The Commission’s March 2019 report to the Congress contains a detailed discussion of the difficulty of evaluating the quality of care within the MA sector and changes in MA quality from one year to the next.”

    Assessing quality in Medicare Advantage remains a challenge today as MedPAC made clear at a January 2022, meeting. Medicare Advantage data is incomplete and can be inaccurate. There is no way to show better health outcomes in Medicare Advantage. A recent analysis of the five-star rating system finds that there’s no data to conclude that the five-star rating system improved quality of care in Medicare Advantage.

    If you look at data on hospital stays and emergency room visits, in 2018, Medicare Advantage appears to have greater inpatient use and emergency room visits than traditional Medicare.

    In a review of the Medicare Advantage studies, Navathe and colleagues find “the evidence on readmission rates, mortality, experience of care, and racial/ethnic disparities did not show a trend of better performance in MA plans than traditional Medicare, despite the higher payments to MA plans.”

    Gilfillan and Berwick believe that the Medicare Advantage capitated payment model allows Medicare Advantage plans to extract 15 percent (at a minimum) from the government on the total cost of care. The value of capitation, in their view, comes from reshaping care delivery, capitating payments to providers, as Kaiser does with the Permanente Medical Group. UnitedHealthcare and the other large for-profit insurers do not use that model but, generally, a fee-for-service model, to pay providers.

    Medicare Advantage plans spend less on care. They spend, on average, 30 percent less than traditional Medicare. They spend significantly less for nursing home and rehab services, paying for shorter stays, and for home care, paying for fewer visits. They also tend to avoid high-quality and specialty hospitals. (NB: There is no meaningful data as to whether this benefits or endangers the health and well-being of enrollees, but it would stand to reason it leads to poorer health outcomes.) Gilfillan and Berwick adjust the spending number down “for mortality differences” reducing it to 9 percent.

    Direct contracting in traditional Medicare, an experiment that puts insurer and private equity middlemen in charge of coordinating care for a capitated fee, gives insures and private equity firms another chance to take money from the system. More than half of the 99 direct contracting or “REACH” entities are investor-controlled. (They have never proved themselves to add value in Medicare Advantage.) Gilfillan and Berwick say that they should not be allowed in traditional Medicare. At the very least, the direct contracting experiment should be limited in scope. It is already at nearly two million enrollees.

    In short, Medicare Advantage fragments coverage and financing, and adds complexity and additional costs across the health care industry, especially for physicians and other health care providers. Medicare Advantage’s administrative superstructure is expensive and “distorts the actual delivery of care.” Administrative costs and profits for everyone in the health system are estimated at 25 percent, for which Medicare Advantage is largely responsible.“We are not getting much” out of that. “The opacity that comes from the privatization of public payment confounds objective, scientific analysis.”

    Berwick and Gilfillan call for improving the traditional Medicare benefit package, with some care coordination to address overuse, and health care providers focused on improving health outcomes. Insurers should receive a fee to help administer a good benefit plan that manages care, not a capitated payment. Most big insurers do not have the ability or mission to build good healthcare delivery systems.

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  • For our collective health, racism must be destroyed

    For our collective health, racism must be destroyed

    I join the vast majority of Americans in condemning the murder of George Floyd at the hands of the police and share the grief and rage so many are feeling. We stand in solidarity with all those who oppose the violent policing of black and minority communities. Though it should not need to be said, it must be said that black lives matter.

    What we saw on the smug face of Derek Chauvin was a vivid display of the sense of complete impunity that so many police officers apparently have. And it reminds us that of all the inequalities in our society, the most important one is the inequality of power.

    There are a myriad of changes needed to extinguish the culture of arrogance that has taken deep root in too many police departments, but to get real change, this new movement must exercise real power.

    More and more Americans are getting the picture that none of us are safe if any of us are not safe on the streets, in our cars, in our homes. The police cannot be an occupying army but must instead be answerable to the community. Exercising real power means that communities control the police department and they define what safety and security mean.

    A good start would be the demilitarization of local police forces; the creation of civilian review boards with subpoena powers; an end to immunity from prosecution for cops involved in violent assaults on members of the public; and a systematic effort to remove racist cops from the force and prevent their hiring in the first place.

    However, as a member of the health care community, I recognize that the recurring spasms of police brutality are a symptom of a deeper and wider illness, that has percolated, insinuated, its way into every aspect of American life. We will not be able to achieve a just and caring system of health for everyone in the country, until we acknowledge the enormous amount of work that is going to be necessary to eradicate the legacy of racism and white supremacy that contributes to the daily oppression and perpetual violence inflicted on Americans of African descent, ongoing for 400 years.

    In their hearts, everyone in white America knows this to be true, but has looked the other way and carried on with their own lives. Most have their own struggles with economic and health insecurity to deal with. Only after a shock that is desperate, tragic, and undeniable, like the murder of George Floyd or Ahmaud Arbery or Breonna Taylor are people roused from political resignation and forced to face the grim reality of the society they live in.

    The health of the African American community has suffered for decades and decades with higher rates of poverty, high maternal and infant mortality, hypertension, diabetes, food insecurity, income insecurity, and more. These are the results of a structural racism woven into the fabric of American life.

    How are we to behave from this moment forward? An unbiased police force is a necessary beginning, but it won’t solve the problems of unemployment or lack of access to healthcare or education.

    And in those areas, there is much common ground for solidarity with the majority of white America. What’s needed is a serious plan to uproot and obliterate structural racism in our society. That project is good for all of us because it can only succeed by destroying the inequalities of housing, income, education, and healthcare that have been dividing us more and more by race and by class. It means abolishing the conditions that have led to America having the highest rate of incarceration in the world.

    What black Americans need is also what the vast majority of white and brown Americans need: security. It means having national health insurance for all Americans, employed or unemployed, rich or poor. It means access to the highest quality of care for all, based in neighborhoods provided by people from the neighborhood. It also means massive investments in primary and primordial prevention of hypertension, diabetes, strokes and heart attacks by erasing food deserts, crowded housing, college debt and providing a jobs program and financial support as millions struggle to survive in the midst of the COVID-19 economic collapse.

    We are witnessing for ourselves our own Arab spring, the breathtaking power of social media to mobilize people rapidly. But permanent victory will not be won on Twitter; it will take time and effort and will demand a long view and political resilience. If we are to fix these problems finally and completely, we must move from protest to commitment. It requires those who march for justice to build durable new organizations that have the finesse and tactical flexibility to mobilize in the streets or at the ballot box. We have to build an infrastructure for organized popular participation that enables vigilance and exerts enough power to stop the sabotage of legislation by lobbying.

    Suddenly, all of that seems possible. The killing of Floyd is not the news; what’s news is the massive uprising across the land, led by black Americans, whose voices and shouts indicate that their tolerance of pain has been saturated beyond endurance and that large numbers of people of all races have withdrawn their consent from the old order. The protests in the streets, across big cities and small towns, are cause for enormous hope.

    We are witnessing genuine evidence that a mass movement is emerging, powered by young people, black, white and brown, who feel compelled, like so many before them, to advance the cause of American freedom. This is a moment to rejuvenate our withering democracy and to reimagine a country dedicated to liberty, justice and the pursuit of health and happiness for all. The crowds of protestors are telling America that none of it can be achieved without the destruction of racism in our society and that all Americans will be liberated if black Americans win their liberation. We must all follow their lead.

    [This piece was originally published on June 5, 2020 at lowninstitute.org.]

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