JustCare

Tag: Hospitals

  • Some hospitals now provide at-home rehab services 

    Some hospitals now provide at-home rehab services 

    Felice J. Freyer reports for Kaiser Health News on how some hospitals now provide at-home rehab services for patients post surgery. At-home rehab can be helpful to patients who would otherwise have to wait in hospital until a rehab bed opens up for them.

    People with Medicare in Medicare Advantage plans often struggle to get rehabilitation services after a surgery or other procedure that leaves them in pain, unsteady and/or unable to care for themselves. The cost is high and insurers would prefer to deny the care and save money, even when lack of rehab services keeps patients from a speedy and full recovery.

    People in traditional Medicare are more likely to receive rehab services when needed post hospitalization. But, too often there are no rehab beds available. They are forced to sit in hospital until a bed opens up. And, sometimes the facility is located far from their homes and their loved ones.

    At-home rehab gets patients out of the hospital more quickly. Caregivers can more easily visit patients. And, patients are monitored remotely.

    The at-home rehab program is being tested in New York, Pennsylvania and Wisconsin. Some say it is working well. But, there are no rules surrounding how they should work, which patients qualify, or what services should be offered. And, Medicare does not cover these services as of now.

    In short, at-home rehab is only being offered by a few hospitals that are paid upfront to manage their patients’ care. In some cases, a state Medicaid program pays for the care.

    The trade association representing nursing homes and rehab facilities does not support this at-home rehab model. Skilled nursing facilities (SNFs) and rehab facilities are required to provide a range of services to their patients, which the at-home model does not require. Do these requirements necessarily improve patient care?

    Many SNFs and rehab facilities offer precious little to their patients, other than unhealthy meals, endless hours in bed, and a short period of physical and/or occupational therapy. One quarter of patients end up with bed sores, infections or other poor health outcomes. At home, patients could be up and about a lot more and trained on how to navigate their homes safely.

    One at-home rehab program reports no bedsores, infections or other adverse events for their patients. But, this program provides services only when there is also an in-home fulltime family caregiver to help. Consequently, many patients do not qualify for the at-home program.

    Another at-home rehab program enrolls patients living alone and provides them with a call button to speak with a live person when needed. It’s not clear how well this program works. Home alone, patients needing rehab could be at serious risk of falling or otherwise hurting themselves.

    Here’s more from Just Care:

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

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

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

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

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

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

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

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

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

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

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

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

    Here’s more from Just Care:

  • 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:

  • Medicare prices for all?

    Medicare prices for all?

    It’s as yet unclear what the Trump administration and the Republican Congress will do to Medicare. The Heritage Foundation’s Project 2025, if adopted, would appear to let traditional Medicare wither on the vine and force new Medicare enrollees into Medicare Advantage. But, that’s a politically fraught agenda that would also drive up Medicare spending significantly, as Medicare Advantage costs a lot more than traditional Medicare.

    If Republicans are looking for ways to fund their massive tax cuts, they could address the massive overpayments in Medicare Advantage, which are projected to cost more than $1.4 trillion over the next decade. Republican Senators Cassidy, Blackburn and Braun all see the need for this reform. Taking some of the savings to put an out-of-pocket cap in traditional Medicare would help level the playing field between Medicare Advantage and traditional Medicare and promote competition–but strengthening traditional Medicare is likely a bridge too far for Republicans.

    If Republicans want to lower health care costs and raise wages for Americans, without hurting industry, they might consider Phil Longman’s proposal this week in the Washington Monthly–Medicare prices for all. The idea is simply to have employer-sponsored health plans pay providers Medicare prices–not the current average of 254 percent of Medicare. And, then, Longman would require corporations to share the savings with their workers in the form of higher salaries.

    Of course, hospitals and specialists would push back. But, the data suggests that they would suffer little as a result, according to Longman. Most hospitals are non-profit and could manage on Medicare rates.

    Medicare prices for all would neither raise taxes nor require people to give up their private insurance. It would simply eliminate predatory health care prices to the benefit of Americans. Is there a Republican in Congress who would support it?

    Here’s more from Just Care:

  • Louisiana: Medicare Advantage denials harm patients, while gouging taxpayers

    Louisiana: Medicare Advantage denials harm patients, while gouging taxpayers

    Since 2018, the U.S. Department of Health and Human Services’ (HHS) Office of Inspector General (OIG) has warned that Medicare Advantage (MA) plans sometimes deny enrollees’ requests for essential services they need.1 2

    In response to these findings, the Centers for Medicare and Medicaid Services (CMS) finalized a 2024 rule to clarify “clinical criteria guidelines to ensure people with MA receive access to the same medically necessary care they would receive in traditional Medicare.”3 Unfortunately, providers report little improvement since the rule became effective in January. Inappropriate denials continue to cause poor outcomes for patients, hospital readmissions and increased waste of taxpayer dollars.

    Inpatient Rehab Denials

    The 2024 MA rule did not help U.S. Air Force veteran and Pearl River, LA resident George Carrigan. After complications from diabetes required an amputation of his leg, Humana denied his doctors’ recommendation for care at an inpatient rehabilitation facility (IRF), despite Medicare rules listing amputation as a condition requiring such services.4

    Humana’s two denial letters said he did not need supervision from a rehab physician or interdisciplinary care team, even though these clinicians would have helped control his diabetes, monitored the healing of his wound, managed his medications, and prepared him to return home independently. “The services you need can be provided safely in other settings,” wrote Humana, before sending him to a less expensive setting where his condition deteriorated.

    Carrigan’s daughter and family caregiver, Colleen Fickle, said her dad slipped in the nursing home’s shower and now needs wound care on the amputated limb. Poor catheter maintenance also caused him to be readmitted to the hospital with sepsis. Fickle, who works full time while also caring for her child with a brain injury, said her father is now bedbound at home and dependent on family. She believes none of these complications would have happened and that her father would be walking today if Humana had permitted him to receive close medical supervision at an IRF.5

    Mandeville resident William Sercovich, also a U.S. Air Force veteran, suffered two strokes and faced multiple denials before Humana approved his request for IRF services. Both Humana denial letters repeated Medicare’s rehab criteria without explaining why Sercovich did not need a rehab doctor, intensive team or three hours of therapy per day.

    “We were in the hospital for two weeks longer than we should have been because of denials from the insurance company,” said his daughter, Sondra Sercovich. “I hope people take action, so it doesn’t take so many denials to get the proper medical care.”

    The OIG estimated a difference of more than $8,500 in average payments per stay between IRFs and nursing homes for 2018.6 OIG has also warned that MA plans may deny needed care “in an attempt to increase their profits,” misusing funds that CMS paid for people’s healthcare.7 In 2022, OIG physicians audited MA care denials for IRF services and found that in some cases patients met admission criteria, needed higher-level care and alternatives were insufficient to meet their needs.8 Studies have found that MA enrollees “are more likely to enter lower-quality nursing homes compared to fee-for-service enrollees.”9

    When used appropriately, prior authorization can limit low-value services, but healthcare providers also caution that “cost containment provisions that do not have proper medical justification can put patient outcomes in jeopardy.”10

    A recent Kaiser Family Foundation (KFF) study comparing MA plans found that “prior authorization requests were most common for Humana plans.”11 Humana did not respond to requests for comments on its prior authorization practices under new federal rules.

    This year, CMS warned MA plans they may not deny a hospital patient’s request for discharge to an IRF or redirect care to a different setting if a physician orders these services and the patient qualifies under Medicare coverage rules.12 Yet, plans have significant leeway in how they interpret this directive, and families often lack the time to appeal when the patient is ready to leave the hospital.

    Fickle said her father needed intensive therapy at Northshore Rehabilitation Hospital in Lacombe, LA. Speaking of the value of IRF care, the hospital’s CEO Laurel Dupont said “one single hospital readmission would cost [MA plans] as much if not more than the entire rehab stay. Northshore Rehab had zero readmissions of an amputee patient during all of 2023.” A study by Dobson DaVanzo & Associates comparing IRF and skilled nursing facility patients found that IRF patients returned home earlier and remained there longer, with lower mortality rates, emergency room visits and hospital readmissions.13

    Several providers report concerning automatic denials for IRF services. In recent months, TIRR Memorial Hermann Health System in Houston reported receiving automatic MA denials for 90% of prior authorization requests. “If they give us a denial, they’ll say you can go to [a peer-to-peer call with our physician] or you can go ahead and discharge to a nursing home, and I’ll give you that approval now,” said financial clearance manager Courtney Roberson, adding that these automatic denials often keep a patient in the hospital for four to five days longer, taking weekends into account.

    Patients also stay in the hospital longer because MA plans are not required to include IRFs in their provider networks, even though IRF services are a Medicare covered benefit. “It’s not right for Medicare beneficiaries to not have access to this level of care,” said TIRR Memorial Hermann CEO Rhonda M. Abbott. “It doesn’t make sense to eliminate a whole level of care.”

    Last year during a congressional hearing, the American Hospital Association (AHA) described how MA plans financially benefit from these post-acute care delays, explaining that “the plan has already paid the hospital a flat rate for care and is either delaying or attempting to avoid discharging the patient to the next site of care, which would require a separate, additional reimbursement. AHA claims data analysis reflects that length of stay in the referring hospital is typically longer for MA beneficiaries than traditional Medicare beneficiaries being discharged to a post-acute setting.”14

    These transfer delays also contribute to the overcrowding of emergency departments. “An example is a patient who is on a regular floor bed who needs to go to post-acute care,” said Baton Rouge emergency physician Dr. John Jones. “I need that bed for my next congestive heart failure patient who’s in the emergency department, and I can’t put them in there because it’s being occupied by somebody who’s waiting three days over the weekend to get placed.”

    Cardiology and Cancer Care

    MA plans also deny care for patients who need high-quality, Medicare-covered cardiology and cancer care services.

    Cardiologist Dr. Joe Deumite, in Baton Rouge, offered two examples. In one case, Humana twice denied care to a man who needed a pacemaker. “He had 73 episodes where his heart paused for more than three seconds and several episodes where his heart paused for up to 5.2 seconds,” he said, adding that the care was finally approved by an independent review entity.

    In another instance, Dr. Deumite said a woman who suffers from irregular heart rhythms has had to go to the emergency room and take medications because Humana denied her appeals to receive a cardiac ablation. “There are several heart rhythms that respond to ablation, where you just slide up a catheter and cauterize a circuit, and its curative.”

    In April, Baton Rouge medical oncologist Dr. Gerald Miletello recorded a social media video testimonial where he described a dangerous care delay for one of his lung cancer patients.15 “A six-week delay is not following the guidelines because you can easily die with stage four cancer in six weeks,” he said.

    Radiation oncologist Dr. William Russell, in Baton Rouge, said his patients have faced delays when they need to start concurrent chemotherapy with radiation. He also criticized MA plans’ requirement that he conduct a CT scan before they will approve a PET scan. “You have to do diagnostic tests that are not going to be as relevant as the one that you wanted,” he said. “It costs the payers more money to go through that process.” The 2024 MA rule prohibits this practice of step therapy for non-drug services.

    Medical oncologist Dr. Michael Castine, in Baton Rouge, said MA plan documentation requests require him to factor in 10 days between planning and implementation of a patient’s cancer treatment. He mentioned risks for patients with small cell lung cancer, aggressive lymphomas or risks of brain metastasis, warning that “a delay of treatment by a week or two might actually change the whole plan.”

    Peer to Peer Frustrations

    Physicians also criticized the quality of communication they received from MA plan physicians when they call to appeal a patient-care denial.

    “They’re making it up as they go along,” said physical medicine and rehabilitation physician Dr. Adam Carter, who serves as medical director of ClearSky Health Rehabilitation Hospital in Flower Mound, Texas. “I see them as constrained by their employer.”

    “You can almost tell by the first 10 seconds into your conversation whether it’s going to work or not, because you can tell whether that physician is reasonable,” said Dr. Deumite. “They’re looking at year-and-a-half old guidelines.”

    Policy Solutions for Improving Medicare Advantage

    Federal leaders have designed a broad range of solutions to help hold MA plans more accountable. Some changes will not begin until 2026, and stakeholders want additional timeliness and transparency requirements for meaningful patient-care improvements.

    Timeliness

    Today, MA plans must make a prior authorization decision within 14 business days for standard requests and 72 hours for expedited or emergency requests. In 2026, the deadline for standard requests will become seven business days. Stakeholders have called for a 24-hour deadline for emergency requests; pending federal legislation would suggest, but not require, CMS to institute such an expedited timeline.16 17

    Reporting

    In 2026, MA plans must begin publicly reporting aggregate contract-level prior authorization metrics, including denial rates and timeliness. Much of this information already exists today. According to KFF, MA plans denied 3.4 million prior authorization requests in 2022. Only one in ten denials were appealed, but more than 8 out of 10 appeals resulted in overturning the denial. With limited data, it’s not possible to determine the initial reasons for these improper care delays. A study by Premier found that MA denials are more common for higher cost treatments, and that hospitals’ average administrative cost to fight these denials is nearly $20 billion a year.18

    Federal leaders, including Louisiana’s U.S. Sen. Bill Cassidy, and multiple provider groups have asked CMS to require MA companies to report more specific and meaningful data.19 20 KFF researchers found that “substantial data gaps remain that limit the ability of policymakers and researchers to conduct oversight and assess the program’s performance, and for Medicare beneficiaries to compare Medicare Advantage plans offered in their area.”21 KFF also found that “without plan-level data, by type of service, it will not be possible to determine whether plans are complying” with the 2024 MA rule.

    KFF also reported that MA companies “do not report the reasons for prior authorization denials to CMS. If most denials of prior authorization requests are because the service was not deemed medically necessary, efforts to increase transparency of the coverage criteria, such as those recently included in a final rule, may be more likely to have an impact.” KFF has also pointed to a lack of transparency related to decisions from the independent review entity that considers appeals after an MA physician denies a request.22

    CMS opted against requiring plan-level data in 2026, saying it did not want to overwhelm consumers and that it wanted to “limit plan burden.”23 The agency will consider more detailed reporting requirements during future rulemaking.

    Internal MA Plan Monitoring

    CMS now requires all MA plans to establish a Utilization Management Committee to review prior authorization policies annually and ensure compliance with traditional Medicare’s national and local coverage guidelines.24 The AHA urged the Medicare Payment Advisory Commission to monitor whether these committees will have authority to overturn harmful policies, writing that “many providers fear that these committees will serve as little more than a rubber stamp for plan policies.”25

    During the public comment period on the 2024 MA final rule, health insurance companies argued that forcing them to follow traditional Medicare’s clinical criteria would lead to “fewer affordable, high-quality plan choices for beneficiaries” and “adverse health impacts.”

    “CMS in the rule does give MA plans certain limited sets of circumstances where they can use their own internal coverage criteria when traditional Medicare criteria is not fully established,” said Michelle Millerick, AHA director for health insurance coverage and policy. “Some MA plans are over-extending that limited flexibility, and there’s not necessarily a clear definition of exactly when Medicare criteria is fully established, especially for level of care determinations. Stronger enforcement of these provisions from the 2024 MA final rule is needed to ensure plans do not continue to use more restrictive criteria than Medicare.”

    Denial Letter Language

    Beginning in 2026, CMS said the prior authorization denial letters must be “sufficiently specific to enable a provider to understand why a prior authorization has been denied and what actions must be taken to resubmit or appeal.” The agency said the MA plans’ reason for denial “could include” a variety of explanations, such as “how documentation did not support a plan of care for the therapy or service” or “specifically, why the service is not deemed necessary.” Experts say they are cautiously optimistic, but that it remains to be seen how effectively CMS will enforce this policy for patients like Carrigan and Sercovich.

    Targeted Auditing/Aggressive Enforcement

    This year, CMS said it will conduct routine and focused audits to assess compliance with the 2024 MA rule. In a statement, the agency said that it “may issue compliance and enforcement actions, including civil monetary penalties to MA organizations who fail to comply with our regulations.” Providers may send complaints with specific examples of MA plans’ noncompliance to [email protected].

    The OIG recently announced plans to audit MA IRF denials and will issue a report in 2026.26 “I can tell you with great certainty that you will see us expanding our oversight of Medicare Advantage in the coming months and years,” said HHS Inspector General Christi A. Grimm during a recent speech to MA company leaders. “We want Medicare Advantage to be successful. OIG’s work helps ensure that the program works as intended for Medicare enrollees and for taxpayers.”27

    In a statement for this article, OIG said providers may email specific concerns to the agency at [email protected]. “Input from health care providers about managed care practices are regularly sent to relevant subject matter experts, including in our agency’s leadership, for their awareness and to inform our work,” wrote OIG.

    Last year, the federal government paid MA plans more than $454 billion to provide high-quality care to more than 30 million people.28 KFF reports that nearly 60 percent of Louisiana’s Medicare beneficiaries are enrolled in an MA plan this year.29 Providers have applauded the OIG for exposing dangerous care denials and for calling on MA corporate leaders to provide better value to patients and taxpayers.30 “The Medicare Advantage plans aren’t going to change until their board of directors at the company understands as a matter of corporate policy that this isn’t the way to go,” said Dr. Carter.

    [1] https://oig.hhs.gov/oei/reports/oei-09-16-00410.asp

    [2] https://oig.hhs.gov/reports-and-publications/all-reports-and-publications/some-medicare-advantage-organization-denials-of-prior-authorization-requests-raise-concerns-about-beneficiary-access-to-medically-necessary-care/

    [3] https://www.cms.gov/newsroom/fact-sheets/2024-medicare-advantage-and-part-d-final-rule-cms-4201-f

    [4] https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientRehabFacPPS/downloads/fs1classreq.pdf

    [5] https://www.facebook.com/LAHospitals/videos/252495247935007

    [6] https://oig.hhs.gov/documents/evaluation/3150/OEI-09-18-00260-Complete%20Report.pdf

    [7] https://oig.hhs.gov/oei/reports/oei-09-16-00410.pdf

    [8] https://oig.hhs.gov/documents/evaluation/3150/OEI-09-18-00260-Complete%20Report.pdf

    [9] https://pubmed.ncbi.nlm.nih.gov/29309215/

    [10] https://www.ama-assn.org/system/files/principles-with-signatory-page-for-slsc.pdf

    [11] https://www.kff.org/medicare/issue-brief/use-of-prior-authorization-in-medicare-advantage-exceeded-46-million-requests-in-2022

    [12] https://www.aha.org/system/files/media/file/2024/02/faqs-related-to-coverage-criteria-and-utilization-management-requirements-in-cms-final-rule-cms-4201-f.pdf

    [13] https://amrpa.org/portals/0/dobson%20davanzo%20final%20report%20-%20patient%20outcomes%20of%20irf%20v_%20snf%20-%207_10_14%20redated.pdf

    [14] https://www.aha.org/testimony/2023-05-17-aha-statement-senate-subcommittee-medicare-advantage-delays-and-denials

    [15] https://www.facebook.com/LAHospitals/videos/1156382158614094

    [16] https://www.congress.gov/bill/118th-congress/senate-bill/4532/text

    [17] https://amrpa.org/Portals/0/AMRPA%20Comments%20on%20MA%20Data%20RFI%20May%202024_Final.pdf

    [18] https://premierinc.com/newsroom/blog/trend-alert-private-payers-retain-profits-by-refusing-or-delaying-legitimate-medical-claims

    [19] https://www.cassidy.senate.gov/newsroom/press-releases/cassidy-warren-blackburn-cortez-masto-call-for-better-medicare-advantage-data-collection-reporting/

    [20] https://www.aha.org/lettercomment/2024-05-29-aha-rfi-response-cms-medicare-advantage-data-and-oversight

    [21] https://www.kff.org/medicare/issue-brief/gaps-in-medicare-advantage-data-remain-despite-cms-actions-to-increase-transparency/

    [22] https://www.kff.org/private-insurance/issue-brief/final-prior-authorization-rules-look-to-streamline-the-process-but-issues-remain/

    [23] https://www.govinfo.gov/content/pkg/FR-2024-02-08/pdf/2024-00895.pdf

    [24] https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-C/section-422.137

    [25] https://www.aha.org/lettercomment/2023-11-30-aha-urges-medpac-examine-medicare-advantage-denials-hospital-market-basket

    [26] https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000873.asp

    [27] https://oig.hhs.gov/documents/speeches/1106/IG-Grimm-RISE-transcript.pdf

    [28] https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2024-enrollment-update-and-key-trends

    [29] https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2024-enrollment-update-and-key-trends/

    [30] https://youtu.be/fDzAb-6aog8?si=KIuiXj23d2yr8eoP

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  • 24 health systems drop their Medicare Advantage contracts

    24 health systems drop their Medicare Advantage contracts

    When Congress passed legislation allowing corporate health insurers to offer Medicare benefits, our representatives may not have appreciated that the new law would effectively be increasing shareholder value for the biggest health insurers and putting millions of vulnerable older adults and people with disabilities at risk of not getting needed care. They likely did not imagine that Medicare Advantage insurers would inappropriately underpay hospitals, nursing homes, home health agencies and rehabilitation facilities, harming them financially or, worse still, forcing them to close their doors. Jakob Emerson reports for Beckers on how 24 health systems across the country are dropping their Medicare Advantage contracts because they are not able to deliver Medicare Advantage enrollees the care they need and because insurers are not paying them appropriately.

    In all likelihood, the corporate health insurers offering Medicare Advantage likely did not start off engaging in the bad acts many of them currently engage in, including using prior authorization processes excessively, delaying and denying care inappropriately, and failing to pay physicians and hospitals adequately. Nor were they overcharging the government excessively at the outset. But, today, more than six in ten provider CFOs say that the obstacles to care and payment are only getting worse.

    Beckers now lists 24 health systems that are ending their Medicare Advantage contracts, some with all Medicare Advantage insurers. Other health systems are cancelling contracts with UnitedHealthcare and/or Humana, two of the largest Medicare Advantage insurers. The list is not comprehensive. So, if you’re in a Medicare Advantage plan now, check to see whether you will be able to continue to use the doctors and hospitals you want to use or whether they are no longer in the provider network.

    In California, Scripps Health ended all its Medicare Advantage contracts for its integrated medical groups this year.

    In Delaware, ChristianaCare cancelled its contract with Humana’s Medicare Advantage plans as of Jan. 1.

    In Illinois, Blessing Health is only continuing its contracts with BCBS, UnitedHealthcare, Molina and Total Retiree Advantage.

    In Indiana, Powers Health (formerly Community Healthcare System) cancelled their contracts with Humana and Aetna’s Medicare Advantage plans on June 1.

    In Kansas, LMH Health is cancelling contracts with Aetna and Humana Medicare Advantage in 2025.

    In Kentucky, Baptist Health cancelled its contract with UnitedHealthcare Medicare Advantage and Centene’s WellCare this year.

    In Maine, Northern Light Health is cancelling its Medicare Advantage contract with Humana beginning October 1.

    In Michigan, MyMichigan Health is cancelling its Aetna Medicare Advantage contract in 2025.

    In Minnesota, HealthPartners is cancelling its contract with UnitedHealthcare Medicare Advantage plans in 2025. Essentia Health is cancelling its contracts with UnitedHealthcare and Humana Medicare Advantage in 2025.

    In Missouri, Cameron (Mo.) Regional Medical Center cancelled its Aetna and Humana Medicare Advantage contracts this year.

    In Nebraska, Kimball (Neb.) Health Services is cancelling all its Medicare Advantage contracts in 2025.

    In Nevada, Carson Tahoe Health is cancelling its contract with UnitedHealthcare Medicare Advantage in 2025.

    In New York, Med Health System cancelled its contract with Humana Medicare Advantage on July 1.

    In North Carolina, ECU Health cancelled its Humana’s Medicare Advantage plans in January.

    In Ohio, Aultman Health System hospitals are cancelling their contracts with Humana Medicare Advantage in 2025. Genesis Healthcare System cancelled contracts with Anthem BCBS and Humana Medicare Advantage plans in January.

    In Oklahoma, Comanche County Memorial Hospital cancelled its contract with UnitedHealthcare Medicare Advantage plans on May 1.

    In Oregon, Samaritan Health Services‘ hospitals cancelled its contracts with UnitedHealthcare’s Medicare Advantage plans on Jan. 9. They are cancelling contracts for physicians and provider services on Nov. 1. St. Charles Health System cancelled its contracts with Humana Medicare Advantage and Centene MA.

    In Pennsylvania, WellSpan Health ended its Humana Medicare Advantage and UnitedHealthcare Medicare Advantage plans on Jan. 1. It still accepts some UnitedHealthcare D-SNP plans.

    In South Dakota, Sanford Health is cancelling its Humana Medicare Advantage in Minnesota in 2025. Brookings (S.D.) Health System cancelled all its Medicare Advantage contracts this year.

    In Texas, Memorial Hermann Health System ended its contract with Humana Medicare Advantage on Jan. 1.

    Here’s more from Just Care:

  • Medicare Advantage plans continue to endanger hospitals and patients

    Medicare Advantage plans continue to endanger hospitals and patients

    Jakob Emerson reports for BeckersHospital on the plight of hospitals dealing with Medicare Advantage plans. The insurers offering Medicare Advantage plans often try to maximize profits by denying payments to hospitals inappropriately. Or, they refuse to pay for patient inpatient stays and downgrade them to outpatients stays, which cost less. In short, Medicare Advantage plans continue to endanger hospitals and patients.

    Patients are beginning to feel the unhappy consequences of insurer misbehavior towards hospitals. In some cases, Medicare Advantage plans are denying patients needed care or forcing them to jump through multiple hoops in order to get critical care. Hospitals are cancelling their Medicare Advantage contracts, leaving patients to scramble to find other network providers. This year alone, at least 17 hospital systems have cancelled or will cancel their Medicare Advantage contracts.

    More than half the Medicare population is now enrolled in a Medicare Advantage plan, so hospitals tend to need the Medicare Advantage business. At the same time, they face financial risks when they contract with the insurers offering Medicare Advantage plans. S&P Global’s new report finds hospitals extremely vulnerable to Medicare Advantage bad acts.

    The risks to hospitals is only growing, as the insurers in Medicare Advantage are wildly overpaid. It is more than likely that Congress and the administration will do more to eliminate these overpayments. When that happens, the hospitals will likely face even more challenges getting paid appropriately by Medicare Advantage insurers.

    Another deep concern with Medicare Advantage is that there’s no counting on insurers to stay in business from one year to the next. Three big insurers, Centene, Aetna and Humana are saying they are pulling out of some of the Medicare Advantage markets in 2o25. The government and Medicare Advantage enrollees cannot rely on insurers to continue offering Medicare Advantage plans.

    If they continue in business, there’s also no counting on insurers to keep their Medicare Advantage provider networks, cost-sharing and additional benefits. Insurers can narrow their provider networks, increase cost-sharing, and eliminate additional benefits. Everything can change.

    “[W]e expect insurers to prioritize margin over membership, and we expect large insurers will use their scale and market clout to limit provider rate increases over what will prove to be a challenging contract negotiation season,” reports S&P Global.

    Here’s more from Just Care:

  • 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:

  • Emergency or urgent care? Why it matters

    Emergency or urgent care? Why it matters

    A growing number of hospitals are offering people both hospital emergency room services and urgent care at one site, reports Philip Galewitz for KFF Health News. This model could be a financial winner for Intuitive Health, which is offering it in partnership with hospitals. Patients have little say over whether the care is billed as ER or urgent care or the cost.

    The doctors at the Intuitive Health facilities decide whether patients receive ER care or urgent care. And, they have every financial incentive to choose hospital ER care. If the doctors decide the wound treatment is ER care, the cost could be thousands of dollars more than if urgent care.

    There’s no bright line between what services are urgent and what services are emergency. Often care received in a hospital ER could have been gotten at an urgent care facility, such as ultrasounds and blood work. Physicians notify patients when the physicians determine the care needed is emergency care. While patients can choose not to receive ER care, the facilities can still charge them a triage fee.

    The value proposition for Intuitive Health–backed by Altamont Capital Partners, a private equity firm–is even greater than being able to bill for ER care for services that need not be treated as ER care. Intuitive Health can build a large patient base that leads to more medical tests, more physician and hospital services and more revenue.

    Patients using the Intuitive Health facility in Florida had short waits for care. They appear to like having access to both emergency and urgent care services at one location. Intuitive is responsible for administrative activities, such as collecting payment; their hospital partners provide the physicians and do the billing.

    Medicare pays for these services because of the hospital affiliation, as do most other insurers. But, what patients pay varies considerably. If patients pay the “all-inclusive” fee out of pocket, it’s $250. With insurance, their copays could be higher than that, depending upon what the facility charges their insurers.

    Patients with commercial insurance have no federal protection from surprise medical bills, since the protections do not cover urgent care facilities.

    Here’s more from Just Care:

  • More hospitals are dropping Medicare Advantage

    More hospitals are dropping Medicare Advantage

    Jakob Emerson reports for Becker’s Hospital Review that at least 17 large hospital systems are dropping their Medicare Advantage contracts this year. As we’ve seen over the last couple of years, hospitals are making clear that Medicare Advantage enrollees risk not getting needed care in a timely manner, if at all. In addition, with hospitals refusing to be part of Medicare Advantage networks, Medicare Advantage enrollees are struggling to access hospital services.

    More than 30 million older adults and people with disabilities are now enrolled in Medicare Advantage plans. The insurers offering Medicare Advantage plans mislead them to believe that they will get all the benefits of Medicare and more, as they should, in Medicare Advantage. But, report after report shows that Medicare Advantage enrollees face huge obstacles to care when they most need it. They face bureaucratic prior authorization hurdles when they have cancer, or need rehab or skilled nursing services as well as other costly treatments. Their Medicare Advantage plans too often deny them critical care.

    Hospital systems offer several reasons why they are ending their Medicare Advantage contracts. The biggest reason, by far, is that Medicare Advantage plans deny care excessively through their prior authorization processes. And, when patients get care, Medicare Advantage plans too often do not reimburse the hospitals for the care they get.

    A recent survey of 135 health system CFOs by the Healthcare Financial Management Association found that 16 percent intend to end contracts with at least one Medicare Advantage plan in the next two years. Nearly half of them reported that they are considering cancelling their Medicare Advantage contracts. Sixty-two percent said that it had become increasingly more difficult to get the Medicare Advantage plans to pay for the care the hospitals provide.

    UnitedHealth and Humana are the two insurers with the largest share of Medicare Advantage enrollees. They appear to be among the worst offenders when it comes to prior authorization abuses and denied payments from the hospital systems’ perspective.

    In Canton, Ohio Aultman Health System is ending its hospital and physician contracts with Humana Medicare Advantage. Med Health System in Albany, New York, Power Health in Munster, Indiana, Memorial Hermann Health System in Houston, Texas, WellSpan Health  in York, Pennsylvania, Christiana Care in Newark, Delaware, EcuHealth in Greenville, North Carolina, and Genesis Healthcare System in Zanesville, Ohio either have cancelled or will cancel their Humana Medicare Advantage contracts this year.

    Comanche County Memorial Hospital in Lawton, Oklahoma is ending its UnitedHealthcare Medicare Advantage contract as is Samaritan Health Services in Carvallis, Oregon and Health Partners in Bloomington, Minnesota.

    Powers Health and MyMichigan Health are cancelling their Aetna Medicare Advantage contracts.

    Genesis Healthcare System also dropped its Anthem BCBS Medicare Advantage contract.

    Here’s more from Just Care: