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physicians for a national health program pnhp
Medicare Advantage Overbills Taxpayers by $140 Billion a Year—Enough to Wipe Out Medicare Premiums
"Medicare Advantage is just another example of the endless greed of the insurance industry poisoning American healthcare," says a new report from Physicians for a National Health Program.
Oct 04, 2023
A report published Wednesday estimates that privately run, government-funded Medicare Advantage plans are overcharging U.S. taxpayers by up to $140 billion per year, a sum that could be used to completely eliminate Medicare Part B premiums or fully fund Medicare's prescription drug program.
Physicians for a National Health Program (PNHP), an advocacy group that supports transitioning to a single-payer health insurance system, found that Medicare Advantage (MA) overbills the federal government by at least $88 billion per year, based on 2022 spending.
That lower-end estimate accounts for common MA practices such as upcoding, whereby diagnoses are piled onto a patient's risk assessment to make them appear sicker than they actually are, resulting in a larger payment from the federal government.
But when accounting for induced utilization—"the idea that people with supplemental coverage are likely to use more health care because their insurance pays for more of their cost"—PNHP estimated that the annual overbilling total could be as high as $140 billion.
"This is unconscionable, unsustainable, and in our current healthcare system, unremarkable," says the new report. "Medicare Advantage is just another example of the endless greed of the insurance industry poisoning American healthcare, siphoning money from vulnerable patients while delaying and denying necessary and often lifesaving treatment."
Even if the more conservative figure is accurate, PNHP noted, the excess funding that MA plans are receiving each year would be more than enough to expand traditional Medicare to cover dental, hearing, and vision. Traditional Medicare does not currently cover those benefits, which often leads patients to seek out supplemental coverage—or switch to an MA plan.
The Congressional Budget Office has estimated that adding dental, vision, and hearing to Medicare and Medicaid would cost just under $84 billion in the most costly year of the expansion.
"While there is obvious reason to fix these issues in MA and to expand traditional Medicare for the sake of all beneficiaries," the new report states, "the deep structural problems with our healthcare system will only be fixed when we achieve improved Medicare for All."
Properly spent, these overpayments could make a huge difference in the lives of Medicare beneficiaries. We could either:
💰 Totally eliminate Medicare Part B premiums
💊 Fund the entire Medicare Part D prescription drug program
🦷 Establish dental, hearing, and vision coverage pic.twitter.com/Q2zEBMMnaZ
— Physicians for a National Health Program (@PNHP) October 4, 2023
Bolstered by taxpayer subsidies, Medicare Advantage has seen explosive growth since its creation in 2003 even as it has come under fire for fraud, denying necessary care, and other abuses. Today, nearly 32 million people are enrolled in MA plans—more than half of all eligible Medicare beneficiaries.
Earlier this year, the Biden administration took steps to crack down on MA overbilling, prompting howls of protest and a furious lobbying campaign by the industry's major players, including UnitedHealth Group and Humana. Relenting to industry pressure, the Biden administration ultimately agreed to phase in its rule changes over a three-year period.
Leading MA providers have also faced backlash from lawmakers for handing their top executives massive pay packages while cutting corners on patient care and fighting reforms aimed at rooting out overbilling.
As PNHP's new report explains, MA plans are paid by the federal government as if "their enrollees have the same health needs and require the same levels of spending as their traditional Medicare counterparts," even though people who enroll in MA plans tend to be healthier—and thus have less expensive medical needs.
"There are several factors that potentially contribute to this phenomenon," PNHP's report notes. "Patients who are sicker and thus have more complicated care needs may be turned off by limited networks, the use of prior authorizations, and other care denial strategies in MA plans. By contrast, healthier patients may feel less concerned about restrictions on care and more attracted to common features of MA plans like $0 premiums and additional benefits (e.g. dental and vision coverage, gym memberships, etc.). Insurers can also use strategies such as targeted advertising to reach the patients most favorable to their profit margins."
A KFF investigation published last month found that television ads for Medicare Advantage "comprised more than 85% of all airings for the open enrollment period for 2023."
"TV ads for Medicare Advantage often showed images of a government-issued Medicare card or urged viewers to call a 'Medicare' hotline other than the official 1-800-Medicare hotline," KFF noted, a practice that has previously drawn scrutiny from the U.S. Senate and federal regulators.
PNHP's report comes days after Cigna, a major MA provider, agreed to pay $172 million to settle allegations that it submitted false patient diagnosis data to the federal government in an attempt to receive a larger payment.
Dr. Ed Weisbart, PNHP's national board secretary, toldThe Lever on Wednesday that such overpayments are "going directly into the profit lines of the Medicare Advantage companies without any additional health value."
"If seniors understood that the $165 coming out of their monthly Social Security checks was going essentially dollar for dollar into profiteering of Medicare Advantage, they would and should be angry about that," said Weisbart. "We think that we pay premiums to fund Medicare. The only reason we have to do that is because we're letting Medicare Advantage take that money from us."
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Medicare for All, Not Medicare Advantage
The private insurance industry has spend millions on advertising in order to hide the ugly truth: Their MA plans raid taxpayer funds and routinely fail to deliver the care that patients expect and deserve.
Aug 23, 2023
Wendell Potter, a New York Times bestselling author, highly respected healthcare and campaign finance reform advocate, and authority tackling corporate and special interest propaganda, alerts us to the dangers of Medicare Advantage plans now offered by the private health insurance industry.
“In just a few weeks,” says Potter, “we’re once again going to be bombarded with ads featuring healthy and happy-looking seniors playing tennis and telling us how wonderful their Medicare Advantage plan is and how much of a no-brainer it is to shun traditional Medicare and opt instead for a plan operated by a big corporation like Humana and Cigna. We’ll hear insurers’ shills tell us about the extra benefits we’ll get, like discounts on gym memberships; $900 for groceries; and some coverage for dental, vision, and hearing. They’re short on details of course, and we never hear that coverage for those extra things can be pretty meager.”
Potter adds, “We also never hear about the potentially deadly side effects of Medicare Advantage plans. Make sure that insurers’ pitchmen—like ‘Broadway Joe’ Namath—are more forthcoming about what we’ll be getting ourselves into if we do as he suggests. Why should he be allowed to leave out important (Medicare Advantage) details we better know about before we sign on the dotted line?”
How Medicare Advantage Plans Differ From Conventional Medicare
- They are owned and operated by for-profit, private insurance corporations;
- Unlike traditional Medicare, Medicare Advantage plans often refuse to pay for treatments and medications physicians prescribe;
- Unlike traditional Medicare, many physicians, other healthcare professionals, and hospitals will be off-limits to patients because Medicare Advantage companies create their own proprietary and often skimpy “networks” of healthcare providers;
- If patients go out of network, they could be on the hook for thousands of dollars out of their own pocket; and
- They likely will have to pay extra—often a lot extra—for some of those extra benefits.
Private Health Insurance Industry Dominates
The for- profit, private insurance industry thoroughly dominates our national health insurance system and defines the basic concept and purpose of health insurance . The U.S. private business model of health insurance defines insurers as commercial entities, and maximize profits by mainly limiting benefits, maximizing health policy premiums, or by not covering people with health problems. Like all businesses, their goal is to make money. Under the business model, the greed of casual inhumanity is built in and the common good of the citizens and nation is ignored; excluding the poor, the aged, the disabled, and the mentally ill is sound business policy since it maximizes profit.
Political Support for Private Health Insurance Industry
Because our government permits private health insurance companies to exact large profit from its citizens, Wall Street banks and investors who back Big Insurance turn public money into a bonanza of private riches. High health insurance costs are the result of a political decision to essentially allow Big Insurance to do what they want and charge whatever they want. It’s no wonder so many beholden members of Congress want to protect the interests of their donors, Big Insurance and Big Pharma, industries that spent $371 million on lobbying in 2017.
The website/blog The Lever reported that The Better Medicare Alliance, an advocacy group for Medicare Advantage plans,
spent $570,000 lobbying Congress in the first quarter of this year, nearly double the $330,000 spent in the prior quarter. All told, the four major publicly traded health insurance companies that operate Medicare Advantage plans, as well as the insurance lobby America’s Health Insurance Plans, spent nearly $19 million on federal lobbying in the first quarter of 2023, a 66% increase from the prior quarter, according to a Lever analysis of data from OpenSecrets.
U.S. political and oligarch support for privatization of health insurance is grounded in the philosophy espoused by University of Chicago economist the late Milton Friedman. Friedman said, “The corporations should not take into account the public interest,” and added that “the government itself should not take into account the public interest. The job of the government is to simply let everybody make as much money as they can, however they can.”
In contrast, classical economist Michael Hudson notes that Big Insurance doesn’t want any kind of anti-monopoly legislation:
Essentially you have what is called a free market, as advocated by Milton Friedman. A free market means the wealthiest people dominate the market and the supply of credit, the management of the economy that allocates credit, and who gets what shifts from Washington to Wall Street. It shifts from the government to the private financial sector, and allows the financial sector to do the planning. One problem with this is the financial sector lives in the short run. So, it means that they only look for the next three months, the next year’s balance sheet, because the free market is so complex you don’t know what’s going to happen. Well, of course, since you’re managing it from Wall Street you in reality do know what’s going to happen, but you don’t want to tell people exactly what’s going to happen.
Big Insurance Profiteering Statistics
Wendall Potter reports on recent profiteering by Medicare Advantage plans:
- Big Insurance revenues and profits have increased by 300% and 287% respectively since 2012 due to explosive growth in the insurance companies’ pharmacy benefit management (PBM) businesses and the Medicare replacement plans called Medicare Advantage.
- The for-profits now control more than 70% of the Medicare Advantage market. In 2022, Big Insurance revenues reached $1.25 trillion and profits soared to $69.3 billion. That’s a 300% increase in revenue and a 287% increase in profits from 2012, when revenue was $412.9 billion and profits were $24 billion.
- Big insurers’ revenues have grown dramatically over the past decade, the result of consolidation in the PBM business and taxpayer-supported Medicare and Medicaid programs.
- What has changed dramatically over the decade is that the big insurers are now getting far more of their revenues from the pharmaceutical supply chain, Medicare, Medicaid, and from taxpayers as they have moved aggressively into government programs. This is especially true of Humana, Centene, and Molina, which now get, respectively, 85%, 88%, and 94% of their health-plan revenues from government programs.
- The two biggest drivers are their fast-growing pharmacy benefit managers (PBMs), the relatively new and little-known middleman between patients and pharmaceutical drug manufacturers, and the privately owned and operated Medicare replacement plans marketed as Medicare Advantage.
- Huge strides in privatizing both Medicare and Medicaid have been made. More than 90% of health-plan revenues at three of the health industry companies come from government programs as they continue to privatize both Medicare and Medicaid, through Medicare Advantage in particular. Enrollment in government-funded programs increased by 261% in 10 years.
Voters Don’t Matter
The voters don’t matter because the American definition of democracy is oligarchy, where a small group exercises control especially for selfish purposes. Polls have shown large popular support by citizens for Medicare for All, but neither political party nor Wall Street donors have supported it. Michael Hudson writes that by “conquering the brains of a country by shaping how people think, you can twist their view into ‘unreality economics’ and make them think you are there to help them and not to take money out of them, then you’ve got them hooked.” This is how Big Insurance and Big Pharma maintain control of U.S. health insurance. Our system is privatized, financialized, and unregulated so that private, big insurance companies can make money.
The assumption that whatever the market produces is rational and functional is the bedrock of Western economies. “And it’s wrong,” says Hudson, “because It negates the fact that you really need some government power strong enough to override the self-serving special interests of oligarchs and other 1% corporate interests. And that takes a very strong government, which is why the free market /privatization people have always opposed strong government and why their economic models don’t give any acknowledgement for government investment in infrastructure that Biden wants or any government activity that is able to override that of the 1% rentier class, the financial class, the property-owning class, and the corporate monopolists. That’s the problem we have.”
Traditional Medicare Threatened by New Private Profiteers
Private profit “Medicare Advantage” and “REACH” plans present new threats to Traditional Medicare.
1. What Is Medicare Advantage?
Medicare Advantage is a program offering private health insurance plans as options to replace traditional Medicare. Medicare Advantage plans differ from traditional Medicare in that they are paid with capitation (per member), they are required to limit enrollees’ out-of-pocket spending, and can offer extra benefits (e.g. gym memberships, $900 worth of groceries, dental benefits). They almost always offer prescription drug coverage and use a defined and often restricted network of providers that can require enrollees to pay more for out-of-network care. Utilization management techniques are used, such as prior authorization, and they can also fund special programs such as rewards for beneficiaries to encourage healthy behaviors. The hope is that these differences will lead to improved care at lower cost compared to Traditional Medicare.
In reality, “Medicare Disadvantage” is a better, more accurate name for the programs however, as insurance companies push Congress to corporatize all of Medicare, yet keep the name for the purposes of marketing, deception, and confusion.
Dismantling Medicare With Medicare Advantage: Over 50% of Medicare beneficiaries now have for-profit corporations in charge of their care through Medicare Advantage (MA). Insurance companies are paid handsomely for these plans, and much of that money goes to corporate profits instead of care. The companies running MA plans want to take over Medicare entirely, leaving patients with no option but to give their money to private insurers.
Denying Treatment: Investigations into claim denials in MA found that insurers were inappropriately denying treatments and tests that should be covered under Medicare. Physician surveys show that these practices often cause patients to suffer unnecessarily, and can even be life-threatening. In some cases, MA insurers were found to spend just seconds on each claim, and even denied claims using artificial intelligence instead of medical experts.
Deceiving Patients and Taxpayers: Reports from journalists, researchers, and government agencies have shown that health insurance companies like UnitedHealth and Cigna overcharge Medicare by giving patients exaggerated or entirely false diagnoses. Several companies have been fined, or sued, and agreed to large settlements. MA insurers are taking citizens’ tax dollars for conditions they aren’t even treating.
Bottom Line: Medicare Advantage is not the same Medicare program that Americans have come to know and love. The private insurance industry has spend millions on advertising in order to hide the ugly truth: Their MA plans raid taxpayer funds and routinely fail to deliver the care that patients expect and deserve.
Terminate Medicare Advantage: Physicians for a National Health Program, concludes that the Center for Medicare Services (CMS) should terminate the Medicare Advantage program. It would be far more cost-effective for CMS to improve traditional Medicare by capping out-of-pocket costs and adding improved benefits within the Medicare fee-for-service system than to try to indirectly offer these improvements through private plans that require much higher overhead and introduce profiteers and perverse incentives into Medicare, enabling corporate fraud and abuse, raising cost to the Medicare Trust Fund, and worsening disparities in care. These problems are not correctable within the competitive private insurance business model, and the Medicare Advantage program should be terminated.
2. What Is a ‘Direct Contracting Entity’ and ‘REACH’?
This program hands traditional Medicare to Wall Street by inserting a profit-seeking middlemen in Traditional Medicare to “manage” care for seniors and people with disabilities, allowing companies to keep up to 40% of what they don’t spend on care as overhead and profit. Beneficiaries are assigned. without their knowledge or consent. automatically to a ‘Direct Contracting Entity’ (DCE) if their primary care physician has joined one. The only way for beneficiaries to opt out is to find a different primary care physician.
Profits Over Patient Care: Profits are put ahead of patient care by virtually any type of company to be a Direct Contracting/REACH middleman, including commercial insurance companies, private equity investment firms, and other Wall Street profiteers. DCE’s expand profiteering to all of Medicare. Direct Contracting companies have already enrolled 1.8 million beneficiaries, with plans to take over all of Traditional Medicare in the next decade.
Terminate DCE’S and REACH: It would be far more cost-effective for CMS to improve traditional Medicare by capping out-of-pocket costs and adding improved benefits within the Medicare fee-for-service system than to try to indirectly offer these improvements through private plans that require much higher overhead and introduce profiteers and perverse incentives into Medicare, enabling corporate fraud and abuse, raising cost to the Medicare Trust Fund, and worsening disparities in care. These problems are not correctable within the competitive insurance business model, and the DCE/REACH program should be terminated.
Free Ourselves From Profiteers
We now have several decades of experience with the conversion of health and mental healthcare into a business. Our healthcare is being rationed, with care guidelines determined by profitability and secrecy decided in private Wall Street corporate boardrooms. To realize large profits demanded by Wall Street investors, our health system must attract the healthy and turn away the sick, disabled, the poor, many of the old, and the mentally ill.
To maintain corporate control of U.S. healthcare insurance, our system is privatized and unregulated. Private, big insurance companies are in the business of making money, not providing full healthcare, and when they undertake the latter, it is likely not to be in the best interests of patients or to be efficient. Administrative costs (and immense profiteering) are greater in the private healthcare insurance system, and even Medicare itself is weakened by having to work through the private system.
The USA is a country where health insurance for medical and mental healthcare is a function of socioeconomic status. Everyone knows that this inhumane system should have been corrected long ago. We must immediately end our moral crime of having the greatest health system in the world, but only for those who can afford it. We must support the common principles that healthcare is a human right, must be free from corporate profit, and must be achieved through national legislation.
Let’s never forget that universal Medicare for All is a solid investment in all citizens of our country by simply promoting a social service for universal access to affordable healthcare insurance for all. Aren’t we a society that cares enough to see that everyone receive the healthcare they need? That’s the basic purpose of Medicare for All. The history of our most successful national health insurance program, Medicare, provides one of the best arguments for expanding the program to cover everyone. It’s time to end inadequate and dangerous health insurance programs. Insist on real health insurance reform essential for individuals and families.
Contact your legislators asking them to oppose and end Medicare Advantage, DCE’s, and REACH plans . Most importantly, ask them to strongly support new legislation now filed in Congress, “The Medicare for All Act of 2023” House Bill (H.R. 3421) and Senate Bill (S. 1655) that would establish this badly needed reform.
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'Cancel This Failed Experiment': Physicians Tell Biden HHS to End Medicare Privatization Pilot
The program "presents a threat to the integrity of traditional Medicare, and an opportunity for corporations to take money from taxpayers while denying care to beneficiaries," said Physicians for a National Health Program.
Jan 19, 2023
A national physician group this week called for the complete termination of a Medicare privatization scheme that the Biden White House inherited from the Trump administration and later rebranded—while keeping intact its most dangerous components.
Now known as the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model, the experiment inserts a for-profit entity between traditional Medicare beneficiaries and healthcare providers. The federal government pays the ACO REACH middlemen to cover patients' care while allowing them to pocket a significant chunk of the fee as profit.
The rebranded pilot program, which was launched without congressional approval and is set to run through at least 2026, officially began this month, and progressive healthcare advocates fear the experiment could be allowed to engulf traditional Medicare.
In a Tuesday letter to Health and Human Services Secretary Xavier Becerra and Centers for Medicare and Medicaid Services Administrator Chiquita Brooks-LaSure, Physicians for a National Health Program (PNHP) argued that ACO REACH "presents a threat to the integrity of traditional Medicare, and an opportunity for corporations to take money from taxpayers while denying care to beneficiaries."
The group, which advocates for a single-payer healthcare system, voiced alarm over the Biden administration's decision to let companies with records of fraud and other abuses take part in the ACO REACH pilot, which automatically assigns traditional Medicare patients to private entities without their consent.
CMS said in a press release Tuesday that "the ACO REACH Model has 132 ACOs with 131,772 healthcare providers and organizations providing care to an estimated 2.1 million beneficiaries" for 2023.
"As we have stated, PNHP believes that the REACH program threatens the integrity of traditional Medicare and should be permanently ended," Dr. Philip Verhoef, the physician group's president, wrote in the new letter. "Whether or not one agrees with this statement, we should all be able to agree that companies found to have violated the rules have no place managing the care of our Medicare beneficiaries."
Among the concerning examples PNHP cited was Clover Health, which has operated so-called Direct Contracting Entities (DCEs)—the name of private middlemen under the Trump-era version of the Medicare pilot—in more than a dozen states, including Arizona, Florida, Georgia, and New York.
PNHP noted that in 2016, CMS fined Clover—a large Medicare Advantage provider—for "using 'marketing and advertising materials that contained inaccurate statements' about coverage for out-of-network providers, after a high volume of complaints from patients who were denied coverage by its MA plan. Clover had failed to correct the materials after repeated requests by CMS."
Humana, another large insurer with its teeth in the Medicare privatization pilot, "improperly collected almost $200 million from Medicare by overstating the sickness of patients," PNHP observed, citing a recent federal audit.
"It appears that in its selection process [for ACO REACH], CMS did not prevent the inclusion of companies with histories of such behavior," Verhoef wrote. "Given these findings, we are concerned that CMS is inappropriately allowing these DCEs to continue unimpeded into ACO REACH in 2023."
\u201cOur full letter to the @HHSGov secretary and @CMSGov administration highlighting troubling trends in Direct Contracting and REACH, and asking them to cancel this failed experiment: https://t.co/fnAT18CAtr\u201d— Physicians for a National Health Program (@Physicians for a National Health Program) 1674090685
While the Medicare pilot garnered little attention from lawmakers when the Trump administration first launched it during its final months in power, progressive members of Congress have recently ramped up scrutiny of the program.
Last month, Sen. Elizabeth Warren (D-Mass.) and Rep. Pramila Jayapal (D-Wash.) led a group of lawmakers in warning that ACO REACH "provides an opportunity for healthcare insurers with a history of defrauding and abusing Medicare and ripping off taxpayers to further encroach on the Medicare system."
"We have long been concerned about ensuring this model does not give corporate profiteers yet another opportunity to take a chunk out of traditional Medicare," the lawmakers wrote, echoing PNHP's concerns. "The continued participation of corporate actors with a history of fraud and abuse threatens the integrity of the program."
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