“How’s the knee?” a pitcher asks another athlete across the lanes. Their conversation in a Super bowl advertisement focused on a Biden administration proposal that one pitcher warned another would “cut off Medicare Advantage.”
“Someone in Washington is smarter than that,” the friend replies, before a narrator urges viewers to call the White House to express their displeasure.
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. It would significantly reduce payments — billions of dollars a year — to Medicare Advantage, private plans that currently cover about half of government health plans for older Americans.
The change The payment formulas are an effort, Biden administration officials said, to address widespread abuse and fraud in the increasingly prevalent private program. Over the past decade, a flood of evidence has been uncovered in lawsuits and audits showing that the government is systematically overcharging. A final decision on payments is expected to be made soon and is one in a series of decisions tough new regulations control in the industry. The changes are consistent with a broader effort by the White House to strengthen the Medicare trust fund.
Without the reform, taxpayers will spend about $25 billion next year in “excess” payments to private programs, according to the Medicare Payments Advisory Committee, a non-partisan research group. advisor to the National Assembly.
The proposed changes have created a large and noisy protest front, with lobbyists and insurance executives swarming Capitol Hill to join their fiercest fight of all time. many years. The biggest insurers, including UnitedHealth Group and Humana, are among the most vocal, according to congressional staffers, with UnitedHealth executives personally pushing for the company’s case. grandfather. Physician groups, including the American Medical Association, have also voiced their objections.
“They’re pouring a ton of money into this,” said Mark Miller, a former MedPAC executive who is now executive vice president of healthcare at Arnold Ventures, a research and advocacy group. Proponents of the restrictions have begun to spend money to counter the opposition.
Insurers say the new rule will harm medical care for millions, especially in vulnerable communities.
They say the change will force companies to reduce benefits or increase premiums for Medicare beneficiaries, leaving doctors with less money to treat conditions like diabetes and depression.
Dr Patrick Conway, a former Medicare official who is now chief executive officer of Optum, a subsidiary of UnitedHealth that owns one of the nation’s largest groups of doctors, said the changes were “stripping resources”. funding for the prevention and early treatment of disease. “When you reduce payments for those conditions, you have a direct impact on patients.”
Healthcare in the United States
Since the proposal was hidden deep in a routine document and published with little fanfare in early February, Medicare officials have received more than 15,000 comments in favor of and against the policies, and about two-thirds consisted of identical phrases from the single samples. Insurers have used television advertising and other strategies to urge Medicare Advantage customers to contact their legislators. The effort has generated about 142,000 calls or letters protesting the changes, according to the Better Medicare Alliance, one of the relevant lobbying groups and the group behind the bowling ad.
The confrontation underscores how important — and lucrative — Medicare Advantage has become for insurers and groups of doctors paid by the federal government to care for older Americans. About $400 billion in taxpayer dollars went to these private plans last year. Profits from Medicare Advantage plans are at least double what insurance companies make from other types of policies, according to one recent analysis by the Kaiser Family Foundation.
To the surprise of many in the industry, leaders in Congress did not come out in strong defense of the private plans.
In interviews this month, the administration’s top health officials said they would not be swayed by the outcry from the industry.
“We need to monitor this program closely, adding that the agency is committed to ‘holding the industry accountable for misleading the system,'” said Dr. Meena Seshamani, Medicare’s top official. system”.
Stacy Sanders, an adviser to Xavier Becerra, secretary of the Department of Health and Human Services, said:
“We will not be discouraged by industry hacks and deep-pocketed disinformation campaigns.”
More and more evidence of abuse
Older Americans have flocked to Medicare Advantage, finding that many policies offer lower premiums and more benefits than traditional government plans.
Insurers receive a flat rate for each person they sign up for — and receive bonuses for people with serious health conditions, since their medical care is often more expensive.
But many studies from academic Researchers, government watchdog organ and federal fraud prosecutions highlight how insurers have manipulated the system by attaching as many diagnostic codes as possible to their patient records to collect these bonuses.
Four of the five largest insurance companies have have settled or are currently facing lawsuits fraudulent encryption claims. Similar lawsuits have also been brought against a range of smaller health plans.
Medicare officials propose removing more than 2,000 specific diagnostic codes — about one-fifth of the total — from the billing formula for these private plans. Regulators focus more on diagnoses unrelated to medical care. Some heuristics were dropped because they were susceptible to abuse by privacy schemes.
Insurers have focused their objections on three Common diseases to be cleared code: mild depression; Blood sugar disease; and “complicated diabetes.”
A group of 19 policy experts advocating for these changes, led by two former Medicare officials, compared the “diagnosis” of these specific diseases by private plans with those of Medicare. traditional. For example, some UnitedHealth Medicare Advantage plans report that half of their patients have vascular disease, as opposed to just 14% in the basic government plan. UnitedHealth says the research has highlighted how their plans provide better care.
Fraud lawsuits against the companies also show that plans that deliberately inflated the rules are being reviewed by Medicare officials.
IN its lawsuit such as against Cigna last October, the Justice Department described an insurance executive’s email referring to diabetes with complications; depression; and vascular disease are the “golden gems we are looking for.”
The insurance companies are arguing the charges in court.
Not all plans are opposed to the Medicare payment regime overhaul. The group’s executive director, Ceci Connolly, said the Coalition for Public Health Plans, which represents nonprofit insurers, supports the Biden administration’s move on the issue. In its comment letter, the group requested a one-year delay.
And at least one company executive, Bruce Broussard of Humana, recently told investors that the Medicare proposal might not have much of an impact. At a conference, he said the company usually does well in years when Medicare is less generous. Modern healthcare. “I feel that 2024 is going to be like that,” he said.
Undermining support in Congress
Medicare Advantage plans are so popular that these changes could affect many people, but lawsuits, audits, and widely publicized reviews have influenced the views of former advocates in the Congress. Last year, nearly 80 percent of the members of the House of Representatives signed a letters to Medicare urged its officials to “provide a steady rate and policy environment for Medicare Advantage.”
But this year, support among lawmakers appears to have waned, despite a barrage of calls from voters. Several congressional aides said so many lawmakers were so frustrated by the House letter that the insurance industry refused to circulate it. That change is partly due to increased awareness of overpayments, but also because of concerns about deceptive marketing And refuse carethey said
Representative Pramila Jayapal, Democrat of Washington, held a letters This year requires stricter regulation. It was endorsed by some of the House Democrats themselves, who supported last year’s industry letter. “A lot of people just log in because they think, ‘Oh, my voters are on Medicare Advantage,’” Ms. Jayapal said. “Members are listening to voters because they are unhappy, and from within, we have deeply educated all of this against all the lobbyists. “
ONE some Republic lawmakers voiced a proposal to accuse the president of cutting off Medicare. However, the overall Republican response to the rule has been muted, with some request for More information but less attack on the approach.
Mary Beth Donahue, executive director of the Better Medicare Alliance, said the group has been very active in its efforts to educate lawmakers about complex change, within a compressed timeframe.
“The changes are very dense,” she said.
‘A hammer for a snail’
Critics of the new Medicare approach argue that the complex shift will have unintended consequences for other priorities of the Biden administration. They warned that it would significantly reduce funding for Medicare serving minority communities and the poorest patients.
Recently Analysis from the accounting firm Milliman, commissioned by UnitedHealth, suggests that this change could have a larger impact on plans to serve patients in those circumstances.
In the comment letters, some insurance groups and doctors argued that reducing payments would make it more difficult to provide preventive care to ailing patients.
Dr Clive Fields, chief medical officer at VillageMD, developer of primary care clinics, said: “It seems like a small blow to snails. He said he’s aware that some plans have engaged in excessive coding fraud, but said changes to the formula mean fewer resources will be available to care for patients with diagnostic has been removed from the formula.
An increasing number of physician practices, including those of VillageMD, have developed relationships with insurance companies for which they are paid a percentage of premiums, and some groups of physicians oppose Medicare proposal.
But Dr. Donald Berwick, former administrator of the Centers for Medicare and Medicaid Services, said allowing private plans to overcharge for additional diagnoses is not an appropriate way to fund health services for people in need.
“It is a very high fee in a very opaque way to get some money for some people who need more support,” he said. “It’s the wrong tool to solve that problem.”
Dr. Seshamani goes even further, noting that because Medicare finds that diagnoses are not related to additional treatment, she does not think this change will have any disproportionate effect on worse patients: “We do not recommend any policy that would harm vulnerable beneficiaries.”
Aatish Bhatia contributed reporting.
