An Oct. 9, 2022, NY Times piece by Reed Abelson and Margot
Sanger-Katz for the first time described in glaring detail how Medicare Advantage plans are
bleeding Medicare dry. They are basically "insatiable
cash monsters," quoting the words of one physician whistle
blower from Kaiser Permanente.
But The Wall Street Journal's hyper-capitalist editorial nabobs have been raging against this portrayal from the beginning. Case in point the April 9th Journal Editorial, The Truth About Medicare Advantage - featuring the (subheader) claim “About half of seniors use a program that is under Democratic assault.”
"The Trump Administration is considering automatically
enrolling Medicare beneficiaries in private insurance plans—aka Medicare
Advantage—as a default. This may be the single most effective way to reduce
Medicare waste, fraud and abuse. So why do Democrats oppose it?
Democrats are trying to flip the script by claiming that Medicare Advantage is wasting money. Insurers, Democratic Senators last week wrote to the Centers for Medicare and Medicaid Services (CMS), “are endangering the solvency of the Medicare Trust Funds.
This misinformation deserves a
rebuttal."
No, YOUR misinformation deserves a rebuttal, and from another section of your own paper! The real mischief is the unsupported claim that Medicare Advantage is "the single most effective way to reduce Medicare waste, fraud and abuse."
Contradicting that bunkum is the fact - in a later WSJ regular article (Exchange, (April 18-19, p.B12) - that:
"For two decades, making money in Medicare Advantage followed a simple formula: Sign up seniors and document as many diagnoses as possible. The more codes for patient sickness on paper, the more the government paid."
There in blunt, no-nonsense words was (and still is) the template for Medicare Advantage wasting money in colossal fashion: by deliberately running up the diagnoses for seniors which the government must then cover to fill up the insurers' coffers. So, of course, contrary to the WSJ editors' spin, it is wasteful - MEGA wasteful. And these editors have been screaming about it ever since the Biden administration finally decided to derail the Medicare Advantage gravy train and demand more accountability from insurers.
As the piece describes the Biden move:
"The government has been trying to rein in aggressive coding for years. Starting in 2024 the Biden administration phased in a new payment model, V28, which reduced or eliminated the impact of certain diagnostic codes."
Surely, this is something the Journal's editorial Pooh Bahs ought to be cheering, but no - instead they heap scorn on the Dems by claiming that "Medicare Advantage is wasting money." One wonders if these illustrious twerps even read the content of the more recent regular page WSJ article.
Well, what the hell do you call upcoding and piling on diagnoses?
Again, let's review the basics: The government pays Medicare Advantage insurers a set amount for each person who enrolls, with higher rates for sicker patients. And the insurers, among the largest and most prosperous American companies, from the get-go developed elaborate systems to make their patients appear as sick as possible, often without providing additional treatment. See graphic (from NY Times, Oct. 9, 2022):
As a result, a program originally proposed to help lower health care spending has instead become a voracious financial gobbler. Now even more costly than the traditional government program it was meant to improve. So the Biden administration, reclaiming fiscal sanity, proposed adjustments to halt the bleeding of standard Medicare.
And now the insurers (and WSJ editors) are squealing like stuck pigs.
But the monstrous money grabbing doesn't end with hyper diagnosing to bill the government, it includes massive denials of service as well.
A fall, 2022 Kiplinger Retirement Newsletter was clear on what is now happening to new Medicare Advantage beneficiaries: being denied access in record numbers. Indeed, according to Kiplinger, at a rate nearly twice that before the pandemic struck in 2020. Why? Because the number of new Advantage beneficiaries has itself nearly doubled as we're now approaching the stage of nearly half of Medicare being privatized. (E.g. NY Times, 10/9/23):
Again, it's important to process what the WSJ editors are bitching about. Prior to the changes adopted by the Biden administration doctors in the MA system diagnosed illnesses which either: (a) never existed in the first place, or (b) diagnosed conditions that were much worse than they actually were. The effects of either tactic were to amp up the money collected by the MA plans. But also to siphon money from traditional Medicare to bolster the parasitic Advantage plans.
This despite critics complaining for years that insurers' tactics (a, b above) led to overpayments and more rapid approach of traditional Medicare to insolvency. As the NY Times reported (10/9/22),
"Eight of the 10 biggest Medicare Advantage insurers — representing more than two-thirds of the market — have submitted inflated bills, according to the federal audits. And four of the five largest players — UnitedHealth, Humana, Elevance and Kaiser — have faced federal lawsuits alleging that efforts to overdiagnose their customers crossed the line into fraud."
This is exactly why Medicare itself is heading for insolvency, likely within the next 3 years. The government now spends nearly as much on Medicare Advantage’s 29 million beneficiaries as on the Army and Navy combined. If the nation operated under an economically sound system the Bush -incepted private plan MA system would be abandoned in a heartbeat. But, of course, the predatory capitalist system under Trump won't hear of it.
See Also:
by Diane Archer | April 8, 2023 - 6:05am | permalink
Excerpt:
The corporations that run Medicare Advantage plans are engaged in widespread waste, fraud and abuse, resulting in tens of billions of dollars of overpayments to them every year. The advocates and government agencies overseeing Medicare Advantage have spent nearly two decades reporting on this fraud and waste and urging Congress to overhaul the program. Few in Congress or the administration were listening. Now, the Biden administration is finally taking action, but it’s only a first step.
by Wendell Potter | January 15, 2023 - 7:23am | permalink
Excerpt:
Right now, well-funded lobbyists from big health insurance companies are leading a campaign on Capitol Hill to get Members of Congress and Senators of both parties to sign on to a letter designed to put them on the record “expressing strong support” for the scam that is Medicare Advantage.
But here is the truth: Medicare Advantage is neither Medicare nor an advantage.
And I should know. I am a former health-care executive who helped develop PR and marketing schemes to sell these private insurance plans.
And:
Excerpt:
Congress must pass a law to stop the deceptive advertising of Medicare Advantage plans. Only Medicare should be able to call itself Medicare.
Unless you’ve been out of the country for the past few years, you’ve seen the ads on TV featuring Joe Namath, Jimmy Walker, or William Shatner hawking so-called “Medicare Advantage” plans.
Medicare Advantage is not Medicare.
It’s private health insurance being offered to people over 65, with the bill paid for by Medicare. Once you get on an Advantage plan it’s very difficult to get off, and if you’ve been on for more than a year you may not be able to go back to regular Medicare with a Medigap plan at all.
And:
Excerpt:
In my multiple writings on the Medicare Advantage scam, the most common two responses I get (besides, “Thanks, you may have saved my life!”) are, “I’ve never had a problem with my Advantage plan,” and “If it’s so bad, how come so few people are saying so?”
Both are honest, good-faith questions and highlight how easy it is for insurance companies to get away with their Medicare Advantage scams. The answer to both boils down to the unique nature of insurance being the only “product” we buy where we have no idea if it’s any good until something bad happens — which can take years.
Every state in the union has an insurance commissioner. But why?
Why would any state go to the trouble and expense of creating a new layer of bureaucracy?
We don’t have “auto dealership commissioners” or “big-box retailer commissioners”: only insurance has an elected or appointed overseer.
Why would a state want to elect or appoint a very well-paid person to a new position in state government? Why would they appropriate money for a staff, for offices, in some cases even for buildings for a state insurance commissioner?
It turns out the answer is quite simple. One of the easiest scams in the history of scams, going all the way back centuries before Alfred Ponzi set up shop in Pie Alley, is done with insurance.
Here’s how it works.
If you have insurance, you send them a check every month. You think you’re covered and they’ll be there for you when you need them.
But you have no way of knowing if they’ll really be there for you when you need them because you’ve never used the service in a real health crisis.
