AMA: Insurance industry consolidation is "unhelpful" to patients

[Winehole23]

privatization, working as intended.

die faster, plebs.

As the privatization of Medicare via insurer-owned Medicare Advantage plans expands to half of Medicare beneficiaries — 31 million people — care denials by Medicare Advantage insurers are threatening the foundational premise of the government’s health care safety net for seniors and people with disabilities: that people in Medicare should get the care that is recommended by a doctor.


A 2022 investigation by the Inspector General of the Department of Health and Human Services found that in 2019, 13 percent of the total prior authorization requests denied by Medicare Advantage plans would have been covered under traditional Medicare, leading to an estimated 85,000 additional care denials. That year, Medicare Advantage plans also wrongly denied 18 percent of payment claims — covering an estimated 1.5 million claims — reducing the likelihood that doctors will recommend the costliest yet often most effective care, for fear of not being paid.


In the subsequent two years, as total Medicare Advantage enrollment increased from 22 million to 27 million, such denials have reportedly skyrocketed. A February report from the Kaiser Family Foundation found that two million prior authorization requests had been denied by Medicare Advantage in 2021, more than triple the 640,000 prior authorization requests these plans denied in 2019, according to an estimate in the Inspector General’s report.

https://www.levernews.com/care-denie...are-advantage/

[Winehole23]

raking fees from their own payments to doctors

Almost 60% of medical practices said they were compelled to pay fees for electronic payment at least some of the time, according to a 2021 survey. And the frequency has increased since then, according to medical clinics. With more than $2 trillion in medical claims being paid electronically each year, these fees likely add up to billions of dollars annually.


Huge sums that could be spent on care are instead being siphoned off to insurers and middlemen. The fees can cost larger medical practices $1 million a year, according to an April poll by the Medical Group Management Association, which represents private medical practices. The figure sometimes runs even higher, according to a 2020 complaint to CMS from a senior executive of AdventHealth, which has 53 hospitals in nine states: “I have to pay $1.8M in expenses that I could use on PPE for our employees, or setting up testing sites, or providing charity care, or covering other community benefits.” Most clinics are smaller, and they estimated annual losses of $100,000 or less. Even that figure is more than enough to cover the salary of a registered nurse.


The shift from paper to electronic processing, which began in the early 2000s and accelerated after the Affordable Care Act went into effect, was intended to increase efficiency and save money. The story of how a cost-saving initiative ended up benefiting private insurers reveals a lot about what ails the U.S. medical system and why Americans pay more for health care than people in other developed countries. In this case, it took less than a decade for a new industry of middlemen, owned by private equity funds and giant conglomerates like UnitedHealth Group, to cash in.


How these players managed to create this lucrative niche has never previously been reported. And the story is coming to light in part because one doctor, initially incensed by the fees, and then baffled by CMS’ unexplained zigzags, decided to try to figure out what was going on. Dr. Alex Shteynshlyuger, a urologist who runs his own clinic in New York City, made it his mission to take on both the insurers and the federal bureaucracy. He began filing voluminous public records requests with CMS.

https://www.propublica.org/article/t...ons-every-year

[Winehole23]

What he discovered in internal emails and government do ents, which he shared with ProPublica, was a picture sharply at odds with the image of CMS as a hugely powerful force in health care. The records showed, again and again, federal officials deferring not only to a single company, but to a single executive.

Over the past five years, CMS adopted that company’s positions on fees. Shteynshlyuger discovered that, when it comes to the issue he cares about, the most powerful decision-maker wasn’t a CMS official. It was the chief lobbyist for a middleman company called Zelis. And that man just happened to be a former CMS staffer who had authored a key federal rule on electronic payments.

[RandomGuy]

There are reasons people here don’t go visit their PCP (if they have one to being with). That’s what I was pointing out. It’s more than one, and include being able to take time off work for preventive care, having to pay out of pocket due to deductibles, not being able to foot the bill for super expensive medications, and others I mentioned before. Some of those things have made people avoid care until it’s an emergency, which at this point is a cultural problem that would also need to change, tbh.

FYI, my wife is an RN. I also worked on medical systems with doctors for many years. Doesn’t mean I know more or less than anybody else, but I’ve seen the nitty gritty of running a practice.

.. and I have seen the HMO/insurer side.

How much simpler would single payer be, if the providers didn't have to hire armies of billing people to figure out who covers what and for how much?

[Thread]

.. and I have seen the HMO/insurer side.

How much simpler would single payer be, if the providers didn't have to hire armies of billing people to figure out who covers what and for how much?

If we can afford to give to Ukr/Nazi's we can certainly afford to give it to Americans.

[Winehole23]

weeding out patients with AI, punishing employees who buck against it on behalf of patients

The nation’s largest health insurance company pressured its medical staff to cut off payments for seriously ill patients in lockstep with a computer algorithm’s calculations, denying rehabilitation care for older and disabled Americans as profits soared, a STAT investigation has found.

UnitedHealth Group has repeatedly said its algorithm, which predicts how long patients will need to stay in rehab, is merely a guidepost for their recoveries. But inside the company, managers delivered a much different message: that the algorithm was to be followed precisely so payment could be cut off by the date it predicted.

Internal do ents show that a UnitedHealth subsidiary called NaviHealth set a target for 2023 to keep rehab stays of patients in Medicare Advantage plans within 1% of the days projected by the algorithm. Former employees said missing the target for patients under their watch meant exposing themselves to discipline, including possible termination, regardless of whether the additional days were justified under Medicare coverage rules.

https://archive.ph/sNafJ#selection-1283.0-1303.365

[Winehole23]

STAT previously reported UnitedHealth began limiting employees’ discretion to deviate from the algorithm after it bought NaviHealth in 2020. The newly obtained do ents show that, since then, executives have sought to almost entirely subordinate clinical case managers’ judgment to the computer’s calculations. That has resulted in inflexible coverage decisions that legal experts say may violate longstanding case law and regulations that govern Medicare benefits.


Three former case managers said the individual stories behind the algorithmic denials were haunting: An older woman found in the laundry room by her grandson after a stroke, her right side paralyzed, was allotted 20 days of rehab by the algorithm, when the average for severely impaired stroke patients is almost double that. A 78-year-old legally blind man who needed care for a failing heart and kidneys, and then fell in the nursing home, was granted 16 days. Another older man nearing his discharge date after knee surgery was expected to learn how to “butt bump” up and down stairs. If case managers disagreed, and tried to extend a patient’s stay, they ran the risk of missing their targets.


The final call on whether a patient receives more care — or a payment denial — is left up to one of NaviHealth’s physician medical reviewers. The case managers working underneath them are in charge of assembling the medical records, running the algorithm, and deciding whether to press for additional care or recommend to the medical reviewer that the patient get a denial. With a 1% target over their heads, former case managers said, making that decision too often meant choosing between their job performance and their conscience.


“By the end of my time at NaviHealth I realized — I’m not an advocate, I’m just a moneymaker for this company,” said Amber Lynch, an occupational therapist and former NaviHealth case manager who said she was fired earlier this year for failing to meet performance goals. “And that is not why I went into health care. I went into health care to help people, not to say, ‘Well, we’ve got all the money, see you later.’”

[baseline bum]

weeding out patients with AI, punishing employees who buck against it on behalf of patients

https://archive.ph/sNafJ#selection-1283.0-1303.365

Hard to imagine Medicare Advantage is getting even tier by the day. When my mom was about to turn 65 I told her under no cir stance should she pay attention to any of the plethora of ads on TV about Medicare Advantage as it's just a scam for private insurance to loot your Medicare benefits. So picked out a Part G and Part D plan for her that have stayed relatively sane on premiums without having to worry about denials and out of network charges you get from privatized insurance. Just disgusting that half of Medicare recipients are now getting their benefits looted by Medicare Advantage, what a joke of a system but with a great name for conning seniors.

[Thread]

Hard to imagine Medicare Advantage is getting even tier by the day. When my mom was about to turn 65 I told her under no cir stance should she pay attention to any of the plethora of ads on TV about Medicare Advantage as it's just a scam for private insurance to loot your Medicare benefits. So picked out a Part G and Part D plan for her that have stayed relatively sane on premiums without having to worry about denials and out of network charges you get from privatized insurance. Just disgusting that half of Medicare recipients are now getting their benefits looted by Medicare Advantage, what a joke of a system but with a great name for conning seniors.

That's American Democracy, bum.

Betcha by golly wow the Nazi's in Ukraine have fine coverage provided by America & again thru American Democracy.


You & your mom have to scramble for your's though.

[baseline bum]

That's American Democracy, bum.

Betcha by golly wow the Nazi's in Ukraine have fine coverage provided by America & again thru American Democracy.


You & your mom have to scramble for your's though.

Nothing democratic about America cubby.

[Thread]

Nothing democratic about America cubby.

Sad, but bitterly true.

[ElNono]

This is the we have going on... "If it doesn't save us money now, it"

There are huge health care savings to be had from reducing obesity, which is associated with a host of chronic conditions including cardiovascular disease, but people may realize those savings decades later when they are enrolled in Medicare or with another employer’s plan. In effect, private insurers may invest in these drugs only to see public payers reap the rewards.

“That’s where employers and health plans are doing this cost-benefit analysis of where does the payoff start to take place, and is it likely that that enrollee is still going to be on our health plan when we do start to see any cost benefit?” Cox said.

...

The value of the drugs to patients’ health outcomes should matter more to states than the potential cost burden, Cutler added, especially if the medications can extend a person’s life.

“The plans are saying, ‘Why should I pay for this when I’m not going to benefit?’ And the short answer is of course your patients will benefit, but the cost savings which may occur, when they occur, will accrue to Medicare,” he said.

https://www.politico.com/news/2023/1...drugs-00127203

[Winehole23]

Related, in the NYT yesterday:

The rate of serious medical complications increased in hospitals after they were purchased by private equity investment firms, according to a major study of the effects of such acquisitions on patient care in recent years.

The study, published in JAMA on Tuesday, found that, in the three years after a private equity fund bought a hospital, adverse events including surgical infections and bed sores rose by 25 percent among Medicare patients when compared with similar hospitals that were not bought by such investors. The researchers reported a nearly 38 percent increase in central line infections, a dangerous kind of infection that medical authorities say should never happen, and a 27 percent increase in falls by patients while staying in the hospital.

“We were not surprised there was a signal,” said Dr. Sneha Kannan, a health care researcher and physician at the division of pulmonary and critical care at Massachusetts General Hospital, who was the paper’s lead author. “I will say we were surprised at how strong it was.”

https://www.nytimes.com/2023/12/26/u...al-errors.html

[Winehole23]

*twirls mustache*

*struts with das ly brio*

iin highly polished boots

over a woman

tied to the train tracks.

https://x.com/matthewstoller/status/1785081802601701799

[pgardn]

This is a good thread.
It helps me understand what some of my friends fathers gripe about.
I will say I have no love for the AMA.
However, the private doctors practices being gobbled up by these money making business types via health care is alarming.

Keep this thread alive. get it..?
But seriously do.

[ElNono]

*twirls mustache*

*struts with das ly brio*

iin highly polished boots

over a woman

tied to the train tracks.

https://x.com/matthewstoller/status/1785081802601701799

Not the first time this happens, either....

Insurance policy was illegal wager on stranger’s life, appeals court holds

https://www.reuters.com/legal/litiga...ds-2022-08-18/

[MultiTroll]

Related, in the NYT yesterday:

Do hospitals have to reveal whether or not they are owned in whole or part by?

private equity investment firms

[Winehole23]

Do hospitals have to reveal whether or not they are owned in whole or part by?

private equity investment firms

I've posted a few articles ITT about it, so I would assume so...the journalistic and academic exposés are already out there.

[MultiTroll]

Embiid playing like he's drowsy on painkillers.