“How’s your knee?” one bowler asked another across the lane.their conversation super bowl ad It highlighted the Biden administration’s proposal that one bowler warned another to “reduce their Medicare advantage.”
“Someone in Washington is smarter than that,” the friend replied, prompting the narrator to call the White House to express his displeasure with the viewer.
The multi-million dollar ad purchase is part of an aggressive campaign by the health insurance industry and its allies to block Biden’s proposal. This would significantly reduce payments by billions of dollars annually to Medicare Advantage, a private plan that covers about half of government health programs for seniors in the United States.
of change The effort, according to Biden administration officials, is to address widespread abuse and fraud in increasingly popular private programs. Over the past decade, a large body of evidence uncovered in lawsuits and audits has exposed the government’s systematic overcharging. A final decision on payments is expected soon, one of a series of draconian new rules aimed at curbing the industry. The change fits in with a broader White House effort to strengthen the Medicare Trust Fund.
Without reform, taxpayers will spend about $25 billion next year on “excessive” payments to private plans, according to the Medicare Payments Advisory Board, a bipartisan study group that advises Congress.
The proposed changes have unleashed a large and tumultuous opposition front, with lobbyists and insurance executives flooding the Capitol to engage in some of the fiercest fighting in years. The largest insurers, including UnitedHealth Group and Humana, are one of the most vocal groups with the UnitedHealth CEO directing his company’s lawsuit, according to congressional staff. . Medical associations, including the American Medical Association, have also voiced their opposition.
“They’re pouring a lot of money into this,” said Mark Miller, former executive director of MedPAC and now executive vice president of healthcare at Arnold Ventures, a research and advocacy group. Proponents of the restrictions have started spending money to counter their objections.
Insurers say the new rules will harm health care for millions, especially in vulnerable communities.
The changes will force companies to reduce benefits or raise premiums for Medicare beneficiaries, leaving less money available for doctors to treat conditions like diabetes and depression, they say.
The change “takes money away from prevention and early-stage disease,” said Patrick Conway, Ph.D., an executive at Optum, a subsidiary of UnitedHealth that owns one of the largest groups of doctors in the United States. and have a direct impact on patients.”
US healthcare
Since the proposal was embedded deep within regular documents and made public in early February, Medicare officials have been inundated with more than 15,000 comment letters either for or against the policy, about two-thirds of them It contained identical phrases from a form letter. Insurance companies used TV commercials and other tactics to encourage Medicare Advantage customers to contact lawmakers. According to the Better Medicare Alliance, the effort generated about 142,000 calls or letters protesting the change.
This showdown highlights just how important and profitable Medicare Advantage is to the insurance companies and physician groups paid by the federal government to care for aging Americans. About $400 billion of taxpayer money went into these private programs last year. According to one study, the benefits of a Medicare Advantage Plan are at least double what insurers get from other types of insurance. Recent analysis By the Kaiser Family Foundation.
To the surprise of many in the industry, congressional leaders have not stepped forward to actively defend the private sector’s plans.
In an interview earlier this month, the top government health official said he was unfazed by the massive outcry from the industry.
“We need strong oversight of this program,” said Medicare chief executive Dr. I was.
Stacey Sanders, an adviser to Secretary of Health and Human Services Xavier Becerra, said:
“We will not be deterred by industry hacks or well-funded disinformation campaigns.”
Growing Evidence of Abuse
Older Americans are flocking to Medicare Advantage, finding many policies offer lower premiums and more benefits than traditional government programs.
An insurance company pays a flat premium to everyone who enrolls. Also, people with serious health conditions receive bonuses because their medical bills are higher than usual.
However, many studies from academic researcher, government watchdog agency The federal fraud indictment also highlights how insurance companies manipulated the system by attaching as many diagnostic codes as possible to patient records to earn these bonus payments.
Four of the top five insurers have settled or are currently facing lawsuits alleging fraudulent coding. Similar lawsuits have also been filed against a series of smaller health insurance schemes.
Medicare officials are proposing to remove over 2,000 specific diagnostic codes (about one-fifth of all codes) from these private plan payment methods. Regulators focused on more nonmedical diagnoses. A small number of diagnostics have been removed as they tend to be abused by private plans.
The insurance company focused its objections on three Common ailments for which codes are removed: Mild depression. vascular disease; and “diabetes with complications.”
A group of 19 policy experts in support of this change, led by two former Medicare employees, compared the private program’s “diagnosis” of these specific diseases to traditional Medicare. For example, some UnitedHealth Medicare Advantage plans reported that half of their patients had vascular disease, compared with just 14% in the basic government program. UnitedHealth said the study highlighted how its plans are providing better care.
A fraud lawsuit filed against the company suggests that the plan was deliberately inflating the code being reviewed by Medicare officials.
of the lawsuit For example, in a lawsuit against Cigna last October, the Justice Department described an insurance executive’s emails that referred to comorbid diabetes. depression; and vascular disease as “the golden nugget we are looking for.”
The insurance company is challenging the allegations in court.
Not all plans are against overhauling the Medicare payment system. The Alliance of Community Health Plans, which represents nonprofit insurers, supports the Biden administration’s move on the issue, said Ceci Connolly, the group’s chief executive. In a comment letter, the group asked for a one-year delay.
Also, Humana CEO Bruce Broussard recently told investors that Medicare’s proposals may not have much of an impact. He said he has been doing well over the years. modern healthcare“I think 2024 will be,” he said.
weakening support in parliament
Because the Medicare Advantage Plan is so popular, these changes could affect many people, but widely publicized lawsuits, audits, and reviews reflect the views of past congressional supporters. Nearly 80% of House members signed last year letter It called on the agency to “provide a stable fee and policy environment for Medicare Advantage.”
But this year, despite an influx of calls from voters, lawmakers’ support appears to have waned. Several congressional aides said the insurance industry refused to circulate the letter because so many lawmakers dropped out of it. The change is partly due to increased awareness of overbilling, but also concerns about deceptive marketing and denial of care, they said.
Washington Democratic Rep. Pramila Jayapal said: letter This year we are demanding stricter regulations. This was backed by some of the very same House Democrats who backed last year’s industry letter. “So many people just signed on thinking, ‘Oh, all my voters are on Medicare Advantage,'” said Jayapal. “Members are not happy, so we hear from voters. Internally, we have done all this deep education to go against all the lobbyists.”
a a bit Republican Party member of parliament Proposed to accuse the president of cutting Medicare. But the overall Republican reaction to the rule has been lukewarm. request of For more information But there are few attacks on the approach.
Mary Beth Donahue, CEO of the Better Medicare Alliance, said the group has been very active in its efforts to educate lawmakers about complex change, given the limited time frame. He said there was
“Change is dense,” she said.
“Snail and Hammer”
Critics of the new Medicare approach argue that this complex change would have unintended consequences that run counter to the Biden administration’s other priorities. It warns that it will disproportionately reduce funding for the insurance it offers.
Recent analysis A study by actuarial firm Milliman commissioned by UnitedHealth showed that the change would likely have a significant impact on plans to serve patients in such circumstances.
In comment letters, several insurance and physician groups argued that the cuts in payments would make it more difficult to provide preventive care to sicker patients.
said Dr. Clive Fields, chief medical officer at VillageMD, developer of primary care clinics. He said he was aware that some plans were implicated in incorrect overcoding, but the changes to the formula meant that resources would be available to treat patients with diagnoses removed from the formula. He said it meant less.
Many physician practices, including VillageMD, have established relationships with insurance companies to pay a percentage of their premiums, and several physician groups are opposing Medicare’s proposals.
But Dr. Donald Berwick, former administrator of the Center for Medicare and Medicaid Services, said: It said allowing private plans to be overcharged for additional diagnostics is not an appropriate way to fund medical services for people in need.
“We pay a very high price in a very opaque way to fund some people who need more help,” he said. “It’s the wrong tool for solving that problem.”
Dr. Seshamani further said Medicare did not believe the change would disproportionately affect patients with the disease because it found the diagnosis was not related to additional treatment.
Aatish Bhatia contributed reporting.
