JustCare

Tag: Physician

  • UnitedHealth physicans help boost insurers’ Medicare payments

    UnitedHealth physicans help boost insurers’ Medicare payments

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

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

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

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

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

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

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

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

    Here’s more from Just Care:

  • UnitedHealth care delays, denies and grows ever bigger

    UnitedHealth care delays, denies and grows ever bigger

    At the same time that UnitedHealth is growing its Medicare Advantage business, it is growing many of its other businesses and controlling a sizeable portion of the health care sector, often to the detriment of patients and providers. Dan Diamond, Christopher Rowland and Daniel Gilbert report for the Washington Post on the attention Congress is now giving to UnitedHealth. Will Congress rein in UnitedHealth and hold it accountable for its bad acts. Can the federal government break up UnitedHealth at this point, or is it too big to fail?

    Chairman Ron Wyden, who heads the Senate Finance Committee, is holding a hearing with Sir Andrew Witty, UnitedHealth’s CEO. United is now a $400 billion company, with $22 billion in profits in 2023, and the biggest health insurer, as well as the biggest employer of physicians in the US; it employs about 10 percent of providers. It also processes about a third of provider claims for reimbursement through its Change Healthcare subsidiary. Recently, its cybersecurity system was hacked, and UnitedHealth forced tens of thousands of physicians and hospitals to go without pay; some providers were forced to take out loans and some patients had to pay out of pocket for care.

    It is not at all clear why UnitedHealth did not address grave gaps in Change Healthcare’s security when it acquired the company a few years ago. Nor is it clear that UnitedHealth is holding anyone at the corporation accountable for this failure.

    How can Congress help ensure UnitedHealth appropriately covers care and coverage and hold the corporation account when it fails to do so? In the words of Don Berwick, former head of the Centers for Medicare and Medicaid Services, “They’ve grown too big for this country’s good, and for their own good.” “They became the best at playing the game of charging the federal government more and using that wealth to gain political power, advertising power, some changes in benefits.” Some say UnitedHealth presents an economic and national security risk.

    Republicans and Democrats agree that the size and power of UnitedHealth raises serious concerns. Senator Wyden, a Democrat, wants Witty to explain his company’s use of prior authorization, which too often keeps people from getting needed care. He is concerned with the ways UnitedHealth increases health care costs. Congressman Buddy Carter, a Republican, says “It needs to be busted up.” Here, here!

    The Justice Department has tried to prevent some of UnitedHealth’s mergers and acquisitions, but UnitedHealth has put up legal challenges and tends to prevail. Hayden Rooke-Ley, a senior fellow at the American Economic Liberties Project, an antitrust-focused nonprofit, explains the consequences: “What we are seeing now is there are really significant risks of letting a company like United own a physician group, ambulatory surgical centers, a mail order pharmacy, home health providers … and claims processing and revenue cycle management.”

    The fact remains that a number of Democrats and Republicans receive significant campaign contributions from UnitedHealth, which they depend upon. Moreover, many policymakers receive veiled threats from UnitedHealth if they don’t support the corporation. For now, you can expect UnitedHealth to grow and our healthcare system to remain at serious risk of higher costs and inappropriate denials of care as a result.

    Here’s more from Just Care:

  • Hospitals, physicians and pharmacies left unpaid after a UnitedHealth cyberattack

    Hospitals, physicians and pharmacies left unpaid after a UnitedHealth cyberattack

    What happens when a corporate health insurance company, Change Healthcare, a division of UnitedHealth Group, has its computer system hacked and can’t pay claims electronically? Even when Medicare claims are at issue, the Centers for Medicare and Medicaid Services (CMS) can only urge UnitedHealth to behave ethically. Darius Tahir et al. report for Kaiser Health News that physicians, hospitals and pharmacies are left in the lurch.

    Our health care system is so poorly designed that even when a government program is involved, the government can do little more than ask the insurer to mitigate a problem–even serious problems such as inability to pay electronically about 50 percent of all physician claims–voluntarily. The insurer wants to spend as little money as possible to resolve the problem and feels no ethical, let alone legal obligation, to find a workaround. One advocate nails the problem: “the purely optional, do-this-out-of-the-goodness-of-your-heart model clearly is not working.”

    UnitedHealth appears in no rush to help providers, saying its systems for paying claims will get fixed later this month. In the meantime, it has created inadequate workarounds. It is offering practices with hundreds of thousands of dollars in weekly revenue as little as $540 a week.

    CMS is asking UnitedHealth to do better. Providers need more money. Alternatively, CMS is suggesting that providers file paper claims or switch away from Change Healthcare to a different company to pay their bills, which for many providers is easier said than done.

    The White House is also asking UnitedHealth to do more to help ensure providers are reimbursed appropriately and without delay.

    Meanwhile, some pharmacies are asking patients to pay the full cost of medications. Some physician practices are struggling to pay their bills. They are out millions of dollars.

    Policymakers and experts would like the Biden administration to do more. But, except with regard to claims it pays directly in Traditional Medicare, it has limited authority since it turned over Medicare Advantage claims payment to corporate insurers. Congress should reconsider the consequences of the government not fully controlling claims payment in our healthcare system.

    Saad Chaudhry, an executive at Maryland hospital system raises a darker issue. What is UnitedHealth really up to? He asks, “Do you believe these thieves? Do you believe the organization itself, that has everything riding on their public image, who have incentives to minimize this kind of thing?” Whether you believe UnitedHealth or not, health care providers and their patients should never be in this situation.

    How does the government protect against cyberattacks down the road, when our health care system is so fragmented? There are scores of cyberattacks each year against health care entities. For sure, the government should require system redundancies so that if one insurer is hacked providers have other options for getting paid. But, if the government were in control of claims payments, it would have the power to do whatever workarounds were necessary to ensure payment to providers if its systems were hacked.

    Congress should be on top of this now. One thing’s for sure. Cyberattacks will continue.

    Here’s more from Just Care:

  • AMA wants Medicare to pay doctors more

    AMA wants Medicare to pay doctors more

    The AMA is telling Congress not to cut Medicare payments to physicians. The AMA would be smart to speak up for patients and the problems their physicians have getting patients the care they need in Medicare Advantage. The Medicare Advantage plans are getting tens of billions in overpayments, money that could go to pay physicians higher rates. 

    The AMA has spoken directly against prior authorization policies, the policies that insurers use in Medicare Advantage and in the commercial market to delay and deny care. The policies are all different in each Medicare Advantage plan. And, CMS is hard-pressed to regulate them. But, one AMA survey finds that physicians say these policies are often not evidence-based and can result in premature death and disability, along with other patient harms.

    Meanwhile, Medicare cut physician rates by 3.4 percent on January 1. Since the deadline for government funding is January 19, budget negotiations present an opportunity for Congress to reverse that cut.

    Is the AMA whining about nothing really when it comes to Medicare rates? Will doctors continue to treat people with Medicare even given the Medicare rate cuts? It’s hard to say. The Medicare Payment Advisory Commission, MedPAC, supports raising physician rates in keeping with inflation.

    MedPAC will report to Congress in March on whether Medicare physician rates are appropriate or should be changed. Jesse Ehrenfeld, the AMA President, claims that “if you look at physician payments over time adjusted for inflation, rates actually fell  26% from 2001 to 2023.”

    Here’s more from Just Care:

  • AMA unhappy with Medicare payments, silent on health insurer interference in the practice of medicine

    AMA unhappy with Medicare payments, silent on health insurer interference in the practice of medicine

    The AMA President, Jesse Ehrenfeld, MD, says he is concerned about “government interference in the practice of medicine.” He is also unhappy with Medicare payments. But, his complaints focus heavily on the behaviors of the health insurers and corporate interference in the practice of medicine. Why is he not calling out the health insurers?

    The health insurers impose huge administrative challenges on physicians, in the form of paperwork and prior authorization requirements that drive up costs and create obstacles to care, which Ehrenfeld decries.

    In fact, Ehrenfeld claims progress for the AMA because it successfully advocated for some prior authorization fixes in Medicare Advantage, without criticizing the insurers offering Medicare Advantage plans and imposing all sorts of valueless prior authroization requirements. Why is Ehrenfeld withholding criticism of the Medicare Advantage plans when his members have said that the insurers offering these plans are denying, delaying and downgrading needed care to the detriment of their patients?

    One in three AMA members have said that insurers’ prior authorization rules have “led to a serious adverse event for a patient in their care.” One in four physicians have said that prior authorization has led to an unnecessary hospitalization. And, almost one in five physicians have said prior authorization has led to “a life-threatening event or required intervention to prevent permanent impairment or damage.”  Nine percent of physicians report that “PA has led to a patient’s disability/ permanent bodily damage,”

    Ehrenfeld says that physicians are facing a 26 percent revenue cut in Medicare. To what extent are the Medicare Advantage plans to blame for their inadequate payments, as a result of low rates and inappropriate claim denials? We know that the insurers deny payment to physicians inappropriately and, sometimes, often.

    The AMA has a new website called Fix Medicare Now. It opposes proposed cuts to Medicare provider payments. But, it also talks about promoting “value-based” care. In my book, that’s code for give the insurance industry the money to oversee care and coverage, to come between patients and their doctors. I hope that’s not what the AMA is saying.

    Here’s more from Just Care:

  • If you’re in a Medicare Advantage plan, watch out! Your doctor or hospital might no longer be in-network

    If you’re in a Medicare Advantage plan, watch out! Your doctor or hospital might no longer be in-network

    Health care providers across the country look to be dropping their Medicare Advantage plan contracts like flies. Sometimes, physicians or hospital systems cancel contracts with Humana, UnitedHealthcare, Aetna, Cigna and other health insurers because they deny too many prior authorization requests, causing patient safety concerns. Sometimes, these health insurers fail to pay physicians and hospitals what they owe them. Whatever the reason, if you’re in a Medicare Advantage plan, watch out. Your doctors or hospital might no longer be in-network.

    Over the last few years, Medicare Advantage plans have been found to inappropriately delay and deny care. The Office of the Inspector General has twice now reported widespread and persistent inappropriate denials of care in some Medicare Advantage plans, with an average of 13 percent of claims wrongly denied. However, our government won’t tell us which Medicare Advantage plans are the bad actors.

    Data as basic as Medicare Advantage plan denial rates and disenrollment rates are not publicly available. Social Security Works has sent a Freedom of Information Act to the Centers for Medicare and Medicaid Services, requesting this information. But, so far, Social Security Works has not received a substantive response.

    Instead, we are seeing several large hospital systems and physician groups end their contracts with corporate health insurers offering Medicare Advantage. Most recently, MedPage Today reports that “two influential medical groups with San Diego-based Scripps Health are cancelling their Medicare Advantage contracts for 2024 because of low reimbursement and prior authorization hassles, leaving 30,000 enrolled seniors to look for new doctors, or different coverage.”

    The problem is not going away but rather looks to be getting worse. As Becker’s reports:

    • Mayo Clinic in Arizona and Florida no longer contracts with most Medicare Advantage plans.
    • Samaritan Health Services in Oregon terminated its contract with UnitedHealthcare.
    • Scripps is terminating Medicare Advantage contracts for its integrated medical groups in California.
    • Stillwater Medical Center, a 117-bed hospital in Oklahoma ended contracts will all its MA plans. It said that MA plans denied 22 percent of prior authorization requests; traditional Medicare denied 1 percent.
    • Brookings Health System, a 49-bed hospital in South Dakota ended its MA contracts effective 2024.
    • St. Charles Health System in Oregon is still on the fence but told its patients to enroll in Traditional Medicare.
    • Baptist Health Medical Group in Louisville, Kentucky ended its Medicare Advantage contract with Humana.
    • Adena Regional Medical Center is ending its Medicare Advantage contract with Anthem BCBS and managed Medicaid plans in Ohio, effective Nov. 2.
    • Regional Medical Center in Missouri ended its Medicare Advantage contract with Cigna and plans to drop Aetna and Humana in 2024.

    Here’s more from Just Care:

  • Medicare should increase physician pay to ensure good access to care

    Medicare should increase physician pay to ensure good access to care

    The Medicare Payment Advisory Commission’s (MedPAC’s) most recent report to Congress recommends that Medicare increase physician pay in traditional Medicare.  Its recommendation came in the context of recognizing good access to care for people in traditional Medicare–as good as or better than people who are privately insured–but inflationary pressures on physician practices. MedPAC does not address the rates Medicare Advantage plans–corporate health plans offering Medicare benefits–pay physicians.

    MedPAC recommends that traditional Medicare increase physician pay by 1.45 percent. It also recommends an increase in pay of 15 percent to primary care physicians who serve dual-eligibles–people with both Medicare and Medicaid. And, MedPAC recommends a 5 percent increase in pay for other physicians serving people in traditional Medicare with low incomes.

    Not surprisingly, the American Medical Association supports these recommendations and wants them to be even higher. The AMA argues that physician pay in traditional Medicare has not gone up at the same rate as the cost of practicing medicine. AMA says with inflation adjustment, physician pay in Medicare has dropped 26 percent in the last 22 years. Physicians in small practices, in rural communities, and serving low-income populations are most hurt.

    In addition, MedPAC recommends moving more Medicare support to safety-net hospitals. And, MedPAC believes that Medicare should not be paying different amounts for the same service depending upon where the service is provided.

    Medicare Advantage plans can set their own physician rates; they also can piggyback off of traditional Medicare rates. Given access to care issues in Medicare Advantage plans, particularly access to high quality specialists, it would be helpful to know whether Medicare Advantage plans are paying in-network specialists at the same rate as traditional Medicare today or at a lower rate. To ensure access to care in Medicare Advantage, while delivering cost-effective care, Medicare Advantage plans should be paying the Medicare rate for specialty care.

    Six years ago, Medicare Advantage plans paid physicians somewhat less than traditional Medicare. In 2017, “MA paid 96.9% of what traditional Medicare paid for a mid-level office visit, 91.3% of what traditional Medicare paid for a cataract removal in an ambulatory surgery center and 102.3% of what traditional Medicare paid for a complex evaluation and management of a patient in the emergency department. Laboratory services and durable medical equipment saw much lower MA rates, including only 67.4% for a walker and 75.8% for a complete blood cell count.” It’s not clear whether Medicare Advantage provider rates have come down further since then. People in Medicare Advantage plans should be concerned about their ability to access good quality providers if they have come down further.

    Here’s more from Just Care:

  • Patient safety at risk in private-equity controlled emergency rooms

    Patient safety at risk in private-equity controlled emergency rooms

    Gretchen Morgenson reports for NBC News.com on a medical director fired after exposing the risks of emergency treatment at his hospital in Kansas City. Inadequate staffing jeopardized patient safety. But, his private-equity employers, Kolberg Kravis (KKR) and, before that, Clayton, Dubilier & Rice, like other for-profit owners of medical groups, were focused on maximizing profits.

    Ray Brevont, the medical director and independent contractor, complained about the fact that, at times, understaffing in the emergency department meant no physician was present when a patient’s life was at risk. Brevont was let go. How often does this happen? For sure, many other doctors in Brevont’s position fear speaking out against their employers and putting their jobs at risk.

    Today, four in ten emergency departments are controlled by for-profit entities, which are responsible for the staffing. KKR, which owns Envision Healthcare, and Blackstone, another private equity group, which owns TeamHealth, are two big companies in this space.

    Private equity firms are generally in the business of buying up companies, finding ways to increase their profits, often through cutting costs, and selling them off a few years later at a profit. Because emergency departments are big profit centers, private equity firms are buying up control of these departments and have been charged with interfering in the practice of medicine to the detriment of patients.

    Private equity firms implement policies in hospital emergency departments that are often unavailable for public scrutiny. But, Brevont claimed that KKR’s “code blue” policy put patients’ lives in danger. Emergency room physicians were expected to care for patients outside the hospital’s emergency department. The consequence: No emergency room physician in the emergency department.

    Brevont sued Emcare, the company that hired him, which is a subsidiary of Envision, saying he had been wrongfully let go. Under federal law, the emergency department was required to have a physician present at all times. Brevont’s boss told him that profits explained the failure to have a physician present but “Profits are in everyone’s best interest.”

    This is not the first suit against KKR for interfering wrongly in the practice of medicine. Recently, ER physicians in California sued KKR’s Envision Healthcare for wrongful interference in the practice of medicine.

    Brevont won $26 million in damages. Envision blamed a hospital policy for the understaffing and took no responsibility. The appellate court ruling stated that Envision “makes a physician the owner of these subsidiaries to comply with the regulations, which prohibit a publicly traded company from providing medical services.” Of note, the named physician owner had nothing to do with the emergency departments he allegedly owned.

    Most states require physicians to be owners of these companies as nonphysicians cannot be practicing medicine or directing decisions about treatment. But, for-profit companies find ways around the issue. When they are found to violate the law, they tend not to be penalized in a way that would deter future activity of the same sort. The penalty too often does not fit the crime.

    Why is the profit motive so dangerous? Companies might decide how much time a physician can spend with a patient, what tests the physician can administer and whether the patient needs to see a physician at all, with little focus on evidence-based medical practice or patient needs.

    For reasons that are impossible to justify, the federal government often continues to allow these companies to continue their businesses after they have been found guilty of fraud and other wrongs if they say they will commit to behaving appropriately down the line. Curious how we throw people in jail for the rest of their lives for far less serious crimes.

    Here’s more from Just Care:

  • UnitedHealth could force nearly 3,000 patients to forgo care or find new physicians

    UnitedHealth could force nearly 3,000 patients to forgo care or find new physicians

    Because the US Congress leaves it to corporate health insurers to negotiate health care provider rates and agreements, our health care costs are far higher than they should be. In addition, access to health care is often far more difficult than it should be. In Vermont, Valley News reports that UnitedHealth’s negotiations with doctors at the University of Vermont Medical Center might fail and UnitedHealth would then cut ties with physicians for nearly 3,000 patients, forcing them to forgo care or find new physicians.

    Corporate health insurers are legally obligated to think first and foremost about their own profits. The effects of their administrative, financial and other activities on patient care do not seem top of mind. So, it’s no surprise that UnitedHealth’s failure to reach agreement with physicians providing in-network care at UVM Medical Center could leave its members without a treating physician. If fewer members are getting in-network care, it would increase profits further for UnitedHealth.

    UnitedHealth’s members will all have to find new network physicians if United does not reach agreement with the providers at UVM. But, that means that some members in the midst of cancer treatment could be without treatment as of April 1. Notably, people in Medicare Advantage are not affected by these negotiations, likely because the government negotiates provider rates for people with Medicare, and Medicare Advantage plans can piggyback off those rates for their Medicare members.

    UnitedHealth claims UVM provider rates are rising too much. UVM, in turn, says that it is facing rising staffing and other costs and needs higher rates to survive. It adds that administrative and other operational barriers UnitedHealth imposes keeps patients from getting the care they need in a timely fashion. “Despite our best efforts to resolve these issues, patients continue to experience unnecessary delays in and restrictions on approvals for common tests, imaging, treatments and medications, among other challenges, due to United’s own policies and reimbursement practices.”

    UnitedHealth told one cancer patient currently getting treatment at UVM Medical Center to get her chemotherapy from a hospital 95 miles away. Really? If Congress does not yet deem it appropriate to step in and guarantee everyone access to care, it’s hard to imagine what it will take to move policymakers.

    Here’s more from Just Care:

  • New government rules to protect patients from surprise medical bills face pushback from doctors

    New government rules to protect patients from surprise medical bills face pushback from doctors

    New rules issued by the US Department of Health and Human Services (HHS) that protect patients from surprise bills face pushback from doctors and scores of members of Congress. Secretary of HHS, Xavier Becerra, says that the goal is to keep physicians and hospitals from charging prices that are significantly higher than the average market price. Most important, patients will no longer have to deal with these unexpected bills.

    The rules are the Biden administration’s attempt to make good on Congress’s No Surprises Act. The Act is intended to protect patients with private health insurance from unexpected bills sent to them from out-of-network providers, excluding ambulance companies. Instead of burdening patients with these bills, doctors and hospitals are required to negotiate their rates with insurers. If that doesn’t work, they must go to arbitration.

    The HHS rules appropriately assume that a fair rate is around the average that health insurers are paying for similar services. Some doctors groups are suggesting that they might be driven out of business if their rates are forced down to an average rate. But, HHS feels that the primary goal needs to be protecting patients. Moreover, HHS does not believe it will hurt physicians who are charging well over the average rate to accept an average rate.

    No patient should be forced to pay two or three times more than the average cost. A recent HHS report on surprise medical bills reveals that out-of-network charges average $1,219 for anesthesiologists and $24,000 for air ambulances.

    The HHS rules are projected to bring down health insurance premiums by as much as one percent, according to the Congressional Budget Office.

    One hundred and fifty-two Republican and Democratic members of Congress are not happy with the HHS rules and would like to see them revised. They argue that the rules give too much power to the insurers but don’t seem to consider the fact that many physicians and hospitals are using their power to gouge patients and send them into medical debt.

    Here’s more from Just Care: