by Kenneth Dolkart - Valley News - July 15, 2019
“Medicare for All” is at the confluence of currents running through
our nation. Consciousness is rising that we might enjoy the automatic,
universal and high-quality care that is taken for granted in many
nations. We trail the developed world in metrics of care like longevity,
access, equity, infant and maternal mortality, and rates of death from
causes otherwise amenable to care. All too often, ZIP code determines
life expectancy.
The health industry sector outperforms the stock market, even as schools cannot afford insurance premiums for teachers.
Nurses and doctors watch countless people lose their health, since absent or inadequate medical coverage promotes belated attention to symptoms.
As some Americans enjoy wondrous medical advancements, others cannot afford the insulin they need. And a growing undertow of “diseases of despair,” such as suicide, alcoholism and opioid overdose, have taken their toll.
U.S. life expectancy has been declining the past three years, for the first time since 1918.
The consequences of the deregulation of medical insurance are obvious.
Costs of employee-sponsored family health insurance plans leaped ahead of inflation, from $5,791 in 1999 to $18,142 in 2016, according to the Kaiser Family Foundation. Middle-class incomes have been stagnant as wages are diverted to the “health dollar” and destined for insurance company profits and CEO salaries. Health insurance deductibles have risen 200 percent since 2008, along with other tactics that shift costs to the enrollee and discourage obtaining services.
The private managed care bureaucracy is geared to profit, and overall U.S. administrative costs are four times that of Canada and three times that of European nations, according to the Organization for Economic Cooperation and Development. Absent regulation allows unbridled and unjustified increases in drug and equipment prices. The cartel-like practice of “pay-for-delay” occurs regularly as drugmakers pay off generic companies to not produce cheaper — but otherwise identical — medication.
Apart from antitrust actions, the prices of medical products and services explode beyond what a reasonably functioning market would dictate.
It is evident that applying free-market consumer models to health care is as appropriate as applying rules of baseball to hockey.
Profits above patientsThe recent effects of the corporatization of medical “providers” are also clear.
The vanishing primary care doctor runs gauntlets to get tests reimbursed and hires staff solely to interact with insurers. Burnout from the ever-expanded clerical burdens of electronic medical records thins the ranks of doctors and nurses. The promise of electronic medical records was lost when it was hijacked for capturing billings, rather than clinical utility.
(Wouldn’t it be nice if the clinician could “ask Siri” to “find last pathology report” and “schedule blood count in two weeks,” or “analyze drug interactions”?)
Companies with a duty to put stock prices above patient interests cynically exploit the professional accountability of medical staff, as physician and author Danielle Ofri observed in a recent New York Times piece, “Is Exploiting Doctors the Business Plan?”)
Abuse of the public trust is certainly not unique to health care.
Industry-aligned Cabinet billionaires dismantle the federal oversight agencies they command. “Dark money” influence is unabated and oligarchs pull the levers of national legislation. Lobbyists for Big Oil mythologize climate change, big banks set the terms of their next failures and the National Rifle Association legislates a gun dystopia. So too, Big Pharma and health insurers profit from the legislation they draft.
Urban hospitals convert health dollar surplus into real estate investments, while rural hospitals collapse in the absence of coordinated support. The Justice Department tries to dismantle the Affordable Care Act scaffolding while millions of Americans are still on it.
Our multiple, episodically introduced, parallel public insurance systems still leave 30 million Americans uninsured.
Now there are numerous proposals to achieve universal coverage, reduce complexity and cut overall costs. Some “Medicare for All” plans propose incremental dissolution of profit-directed insurance bureaucracies with a single federal payer built upon Medicare. There is no “nationalization” of hospitals or doctors, as some critics charge.
“Medicare for Some” proposals, such as the “public option,” allow non-seniors to purchase Medicare and may be more politically palatable to those with employer-coverage, but they do not reduce complexity nor lower costs, and future recessions will eliminate such coverage for many.
Other well regulated and simplified hybrid systems can be envisioned. Still, any cost-effective system, “all-payer” or otherwise, requires transparent and uniform insurance industry practices, enforcement of existing regulations and the enabling of negotiation between tax-supported payers and drugmakers. So expect smoke, mirrors and twitters of fear, uncertainty and disinformation from the Partnership for America’s Health Care Future — a coalition of lobbying groups including America’s Health Insurance Plans, the American Medical Association, the Federation of American Hospitals and BigPharma — which is already hard at work.
We realize that the anonymous “dark money” financing of election efforts and the sanctioned bribing of Congress is incompatible with a representative democracy. Citizen efforts to create legislation for policies that have long had overwhelming support have been stymied by misinformation and the stoking of division, whether it be by the AMA or the NRA.
Still, the tide may be turning. Young people and an energized electorate are clamoring to “promote the general welfare, and secure the blessings of liberty” offered in the preamble to the Constitution. We will recognize such a democracy when, among other changes, this wealthy nation fulfills the moral imperative of assuring modern, universal and affordable health care to all Americans.
Kenneth Dolkart is a physician who lives in Grantham
The health industry sector outperforms the stock market, even as schools cannot afford insurance premiums for teachers.
Nurses and doctors watch countless people lose their health, since absent or inadequate medical coverage promotes belated attention to symptoms.
As some Americans enjoy wondrous medical advancements, others cannot afford the insulin they need. And a growing undertow of “diseases of despair,” such as suicide, alcoholism and opioid overdose, have taken their toll.
U.S. life expectancy has been declining the past three years, for the first time since 1918.
The consequences of the deregulation of medical insurance are obvious.
Costs of employee-sponsored family health insurance plans leaped ahead of inflation, from $5,791 in 1999 to $18,142 in 2016, according to the Kaiser Family Foundation. Middle-class incomes have been stagnant as wages are diverted to the “health dollar” and destined for insurance company profits and CEO salaries. Health insurance deductibles have risen 200 percent since 2008, along with other tactics that shift costs to the enrollee and discourage obtaining services.
The private managed care bureaucracy is geared to profit, and overall U.S. administrative costs are four times that of Canada and three times that of European nations, according to the Organization for Economic Cooperation and Development. Absent regulation allows unbridled and unjustified increases in drug and equipment prices. The cartel-like practice of “pay-for-delay” occurs regularly as drugmakers pay off generic companies to not produce cheaper — but otherwise identical — medication.
Apart from antitrust actions, the prices of medical products and services explode beyond what a reasonably functioning market would dictate.
It is evident that applying free-market consumer models to health care is as appropriate as applying rules of baseball to hockey.
Profits above patientsThe recent effects of the corporatization of medical “providers” are also clear.
The vanishing primary care doctor runs gauntlets to get tests reimbursed and hires staff solely to interact with insurers. Burnout from the ever-expanded clerical burdens of electronic medical records thins the ranks of doctors and nurses. The promise of electronic medical records was lost when it was hijacked for capturing billings, rather than clinical utility.
(Wouldn’t it be nice if the clinician could “ask Siri” to “find last pathology report” and “schedule blood count in two weeks,” or “analyze drug interactions”?)
Companies with a duty to put stock prices above patient interests cynically exploit the professional accountability of medical staff, as physician and author Danielle Ofri observed in a recent New York Times piece, “Is Exploiting Doctors the Business Plan?”)
Abuse of the public trust is certainly not unique to health care.
Industry-aligned Cabinet billionaires dismantle the federal oversight agencies they command. “Dark money” influence is unabated and oligarchs pull the levers of national legislation. Lobbyists for Big Oil mythologize climate change, big banks set the terms of their next failures and the National Rifle Association legislates a gun dystopia. So too, Big Pharma and health insurers profit from the legislation they draft.
Urban hospitals convert health dollar surplus into real estate investments, while rural hospitals collapse in the absence of coordinated support. The Justice Department tries to dismantle the Affordable Care Act scaffolding while millions of Americans are still on it.
Our multiple, episodically introduced, parallel public insurance systems still leave 30 million Americans uninsured.
Now there are numerous proposals to achieve universal coverage, reduce complexity and cut overall costs. Some “Medicare for All” plans propose incremental dissolution of profit-directed insurance bureaucracies with a single federal payer built upon Medicare. There is no “nationalization” of hospitals or doctors, as some critics charge.
“Medicare for Some” proposals, such as the “public option,” allow non-seniors to purchase Medicare and may be more politically palatable to those with employer-coverage, but they do not reduce complexity nor lower costs, and future recessions will eliminate such coverage for many.
Other well regulated and simplified hybrid systems can be envisioned. Still, any cost-effective system, “all-payer” or otherwise, requires transparent and uniform insurance industry practices, enforcement of existing regulations and the enabling of negotiation between tax-supported payers and drugmakers. So expect smoke, mirrors and twitters of fear, uncertainty and disinformation from the Partnership for America’s Health Care Future — a coalition of lobbying groups including America’s Health Insurance Plans, the American Medical Association, the Federation of American Hospitals and BigPharma — which is already hard at work.
We realize that the anonymous “dark money” financing of election efforts and the sanctioned bribing of Congress is incompatible with a representative democracy. Citizen efforts to create legislation for policies that have long had overwhelming support have been stymied by misinformation and the stoking of division, whether it be by the AMA or the NRA.
Still, the tide may be turning. Young people and an energized electorate are clamoring to “promote the general welfare, and secure the blessings of liberty” offered in the preamble to the Constitution. We will recognize such a democracy when, among other changes, this wealthy nation fulfills the moral imperative of assuring modern, universal and affordable health care to all Americans.
Kenneth Dolkart is a physician who lives in Grantham
Medicare for All and Private Insurance: It is like mixing oil and water
by James Kahn - Tarbell.org - July 19,, 2019
At the recent Democratic debate, Lester Holt asked for a show of hands: Who would end the role of private insurance companies as part of health care reform? Four hands went up – Bernie Sanders, Bill de Blasio, Elizabeth Warren, and Kamala Harris. Other candidates argued for incremental expansions of Medicare within our current heavily private insurance system. John Delaney made a plea to “keep what’s working” – i.e., private insurance that people like. After the debate, Harris muddied the waters a bit, saying she misheard the question, and favored a role for private supplemental insurance.How do we make sense of all this? In this perspective, I unpack the idea of private insurance – considering benefit design, marketing, financial coverage, and profit status. I examine the potential role of private insurance in Medicare for All (M4A) or single payer health care. Preview: the role is minimal to none.
Let’s start with the current system. Private insurance, mainly employment-based, covers two-thirds of the population and one-third of health spending. It is typically fairly broad in the kinds of services covered, but with many limits and exclusions, and no standardization. Certain features, such as wellness care, are added to attract healthier enrollees. Marketing is intense. Financial coverage is highly variable, often with extensive cost-sharing (high deductibles, copays, and excluded services or providers). Most insurers are for-profit, and even among not-for-profits executive salaries are sky high. In these ways, private insurance echoes many features of other free market products.
Over the last decade, private insurance got a little better, then worse again. Obama’s Affordable Care Act (ACA) established standards for insurance to protect the policy holders, including required types of coverage (e.g., hospital and ambulatory), specified tiers of actuarial rates (percent of covered health care paid), community-based premiums (based on age and gender) rather than charging more for individuals with medical problems, maximums on out-of-pocket costs, and prohibition of egregious practices like “recission” (retroactively revoking insurance based on trivial errors in applying). The ACA also imposed an individual mandate, and set up insurance exchanges to facilitate that. Here’s the worse again part: The Trump administration has undone the mandate and created massive loopholes to foster insurance plans without protections for policyholders.
Private insurance has also permeated public programs. “Medicare Advantage” is the capitated (monthly set payment) alternative to traditional Medicare fee-for-service, which has been subsidized by Congress for years and still overcharges. Medigap policies cover costs not paid by Medicare. And the Medicaid program is now also largely capitated via private plans.
As you can see, private insurance is highly variable in the U.S.
Not so in other wealthy democracies. Outside the debates, some experts and pundits have proposed following the Swiss or German model of relying on private insurers instead of a government payer. This may leave the impression that their private insurance is like ours. In fact, they differ in nearly all important ways. First, the private insurers sell mainly a single, standardized benefit package. This broad benefit package assures excellent coverage. It also profoundly simplifies system administration – providers deal with a single set of rules and billing procedures. Second, financial coverage is much better: little or no deductible, low cost-sharing, and access to any provider, so no out-of-network charges. Third, marketing is very subdued. Finally, insurers are not-for-profit for these primary health plans. (Some ancillary insurance can be for-profit.)
So… is there a role for private insurance under M4A?
The big answer is “no”. All M4A proposals, including the Sanders bill, have a single payer. This strategy is what confers the many gains of M4A. First, a single payer (the government) means simplicity for enrollees and providers, yielding a massive 10% overall savings via administrative streamlining. Having multiple insurers covering core services would undermine those gains. In addition, a single payer can effectively negotiate on prices, in particular with drug companies. Finally, and importantly, having private insurance would undermine equity and a shared commitment to the public payment system. Imagine someone making $1 million per year and because of progressive tax-based financing is paying the costs of five people on the public plan. People in that position may feel it’s justified to reduce the public system generosity by 20% to pay for his insurance plan. Or that wealthy person may insist on tax subsidies for private insurance premiums, again stealing money from the public system. We’d be exacerbating inequality.
OK, so no major private insurance role within single payer. Is there any role?
- What about emulating the Swiss system? Perhaps…but can we really get there, given our corporate culture? One product, not-for-profit? What companies would be interested?
- What about insuring gaps in coverage? Good question. M4A proposals don’t have major gaps in coverage, except sometimes long term care. Private insurance might have a focused role there, but nothing as large as Medigap today. In my view this would be suboptimal, but it’s a reasonable discussion.
- What about Kaiser and other HMO models? Some M4A proposals allow for capitated care systems. Personally I think that’s a good idea. But it wouldn’t be insurance, it would be a care system.
- What about supplemental coverage for low-value/non-core medical services, such as private hospital rooms or alternative care models? As long as it’s not totally discretionary (like most cosmetic surgery), could be.
- Could private insurers handle the billing process? There could be private vendors for these services, and current insurers have some expertise in this area. But it’s not really private insurance.
- What about for individuals who want care from providers who choose not to participate in M4A, e.g., concierge medicine? That will be out-of-pocket, not insurance. See above for all the problems with allowing private insurance for core services.
- What do we say to people who like their health insurance? We ask them, is it your insurance you like, or excellent access to providers and coverage of care? Because under single payer both will improve – access to any provider, and low or no cost-sharing.
James G. Kahn MD MPH is Emeritus Professor of health policy at the University of California San Francisco.
https://tarbell.org/2019/07/medicare-for-all-and-private-insurance-it-is-like-mixing-oil-and-water/?
Send Me Back to the Country I Came From
by Timothy Egan - NYT - July 19, 2019
He’s right, this angry old man in melting bronzer shouting
in the July heat: Those of us who don’t like what’s going on in this
country should get the hell out. “Go back,” as he said, to the
“crime-infested places from which they came.” A fine idea.
For me, as with more than 30 million other Americans with my hyphenate, that’s tiny Ireland, the country once so infested with crime, famine, disease and assorted horrors of foreignness that its British overlords said a merciful God was doing a favor by killing off the starving masses.
So back I went to have a look. This, mind you, was just before President Trump’s suggestion to his fellow citizens to get out. And also, generations after someone on my father’s side made the choice to flee for life itself, rather than fall into the cold Irish ground through the bottom of a reusable coffin.
What I found on that island where typhus once took entire families as they shivered on floors of mud, where, by one medical estimate, 50 percent of the children in Dublin once died before their first birthday, is now a land of universal health care.
For me, as with more than 30 million other Americans with my hyphenate, that’s tiny Ireland, the country once so infested with crime, famine, disease and assorted horrors of foreignness that its British overlords said a merciful God was doing a favor by killing off the starving masses.
So back I went to have a look. This, mind you, was just before President Trump’s suggestion to his fellow citizens to get out. And also, generations after someone on my father’s side made the choice to flee for life itself, rather than fall into the cold Irish ground through the bottom of a reusable coffin.
What I found on that island where typhus once took entire families as they shivered on floors of mud, where, by one medical estimate, 50 percent of the children in Dublin once died before their first birthday, is now a land of universal health care.
Health care for all residents: It’s still a surprise to someone from a nation where the number of uninsured Americans has gone up by seven million under
Trump. I had left a place where nearly one in seven people are left to
fend for themselves when sick, to a fully covered country, the norm in
most of the industrialized world.
What I found in that place where barefooted, Gaelic-speaking hordes once could not read an English sign are colleges nearly free to its citizens — good colleges, at that. Imagine, a family not having to bankrupt itself to help a child off to a better life.
What I found is a republic where nearly one in eight people were born abroad, nearly as high a percentage as the foreign-born population of the United States. The prime minister, Leo Varadkar, is himself a son of an Indian immigrant. His father was born in Mumbai, while his mother hails from County Waterford, the home also of my mother’s distant family.
That 19th-century hellhole has become a 21st-century heaven. The Irish have become us — what we wanted and aspired to. They are living our national narrative, a country open to those fleeing oppressors and lack of opportunity. Its prime minister would never gloat over a “send her back” chant at a hatefest directed at new members of the republic.
Back home in America, the unimaginable is the new norm: a fully blossoming fascism. We’re stuck in a hideous loop of hate. But it‘s also an idiocy loop.
What I found in that place where barefooted, Gaelic-speaking hordes once could not read an English sign are colleges nearly free to its citizens — good colleges, at that. Imagine, a family not having to bankrupt itself to help a child off to a better life.
What I found is a republic where nearly one in eight people were born abroad, nearly as high a percentage as the foreign-born population of the United States. The prime minister, Leo Varadkar, is himself a son of an Indian immigrant. His father was born in Mumbai, while his mother hails from County Waterford, the home also of my mother’s distant family.
That 19th-century hellhole has become a 21st-century heaven. The Irish have become us — what we wanted and aspired to. They are living our national narrative, a country open to those fleeing oppressors and lack of opportunity. Its prime minister would never gloat over a “send her back” chant at a hatefest directed at new members of the republic.
Back home in America, the unimaginable is the new norm: a fully blossoming fascism. We’re stuck in a hideous loop of hate. But it‘s also an idiocy loop.
Read the resolution the House of Representatives passed on Tuesday, citing Ronald Reagan, John F. Kennedy and Benjamin Franklin, and quoting Franklin Roosevelt’s call to “remember always, that all of us, and you and I especially, are descended from immigrants and revolutionists.” It’s the kind of immigrants-make-a-nation-stronger boilerplate that would normally pass the House with unanimous consent, but it drew only four Republican votes.
This is how low Trump has taken us. We are a debased nation fighting over the scraps of our former principles. Should someone offer a resolution saluting the “purple mountain majesties” of the United States, every Republican would vote against it if Trump tweeted against a color that is not orange. Senator Mitch McConnell, whose immigrant wife is indirectly a target of this sludge, would say, as he did about the “send-her-back chants,” that the president is “on to something.”
I’m against the dismissal of others with the pre-emptive pejorative of “white privilege.” It closes minds and ends conversations. But this is one case where white privilege applies. For Trump’s tweet wasn’t aimed at me. Nor was it directed at his vice president, the cipher and coward Mike Pence, himself an Irish-American.
Trump’s hate blast was directed solely at people of color.
His tweet was the textbook definition of racism. And I should add in the interest of full transparency, I disagree with much of the policy initiatives of the four left-wing congresswomen targeted by Trump. It was wrong and incorrect for them to make Nancy Pelosi’s disagreement with them about race. That episode was another textbook illustration of why the far left has trouble winning a majority.
But let’s leave that discussion for another day. Back in the country from which I came, the Irish appear genuinely perplexed at this American vomiting of principle. Writing in “Irish Times,” Oliver Sears, a British-born resident of Ireland and son of a Polish holocaust survivor, wondered how any immigrant could ever vote for Trump.
I heard a similar thing when I went back: How could Irish-Americans vote for this awful man without becoming traitors to their heritage? For this Ireland has become what America used to be. If only America could be more like this Ireland.
https://www.nytimes.com/2019/07/19/opinion/send-her-back-ilhan-omar.html
Health Insurers Make It Easy for Scammers to Steal Millions. Who Pays? You.
by Marshall Allen - Pro Publica - VOX - July 19, 2019
Ever since her 14-year
marriage imploded in financial chaos and a protective order, Amy
Lankford had kept a wary eye on her ex, David Williams.
Williams, then 51, with the
beefy body of a former wrestler gone slightly to seed, was always
working the angles, looking for shortcuts to success and mostly
stumbling. During their marriage, Lankford had been forced to work
overtime as a physical therapist when his personal training business
couldn’t pay his share of the bills.
So, when Williams gave
their three kids iPad Minis for Christmas in 2013, she was immediately
suspicious. Where did he get that kind of money? Then one day on her
son’s iPad, she noticed numbers next to the green iMessage icon
indicating that new text messages were waiting. She clicked.
What she saw next made her
heart pound. Somehow the iPad had become linked to her ex-husband’s
personal Apple device and the messages were for him.
Most of the texts were from
people setting up workouts through his personal training business, Get
Fit With Dave, which he ran out of his home in Mansfield, Texas, a
suburb of Fort Worth. But, oddly, they were also providing their
birthdates and the group number of their health insurance plans. The
people had health benefits administered by industry giants, including
Aetna, Cigna and UnitedHealthcare. They were pleased to hear their
health plans would now pay for their fitness workouts.
Lankford’s mind raced as
she scrolled through the messages. It appeared her ex-husband was
getting insurance companies to pay for his personal training services.
But how could that be possible? Insurance companies pay for care that’s
medically necessary, not sessions of dumbbell curls and lunges.
Insurance companies also
only pay for care provided by licensed medical providers, like doctors
or nurses. Williams called himself “Dr. Dave” because he had a Ph.D. in
kinesiology. But he didn’t have a medical license. He wasn’t qualified
to bill insurance companies. But, Lankford could see, he was doing it
anyway.
As Lankford would learn,
“Dr. Dave” had wrongfully obtained, with breathtaking ease, federal
identification numbers that allowed him to fraudulently bill insurers as
a physician for services to about 1,000 people. Then he battered the
system with the bluntest of ploys: submit a deluge of out-of-network
claims, confident that insurers would blindly approve a healthy
percentage of them. Then, if the insurers did object, he gambled that
they had scant appetite for a fight.
By the time the authorities
stopped Williams, three years had passed since Lankford had discovered
the text messages. In total, records show, he ran the scheme for more
than four years, fraudulently billing several of the nation’s top
insurance companies — United, Aetna and Cigna — for $25 million and
reaping about $4 million in cash.
In response to inquiries,
Williams sent a brief handwritten letter. He didn’t deny billing the
insurers and defended his work, calling it an “unprecedented and
beneficial opportunity to help many people.”
“My objective was to create
a system of preventative medicine,” he wrote. Because of his work,
“hundreds of patients” got off their prescription medication and avoided
surgery.
There are a host of reasons
health care costs are out-of-control and routinely top American’s list
of financial worries, from unnecessary treatment and high prices to
waste and fraud. Most people assume their insurance companies are
tightly controlling their health care dollars. Insurers themselves boast
of this on their websites.
In 2017, private insurance
spending hit $1.2 trillion, according to the federal government, yet no
one tracks how much is lost to fraud. Some investigators and health care
experts estimate that fraud eats up 10% of all health care spending,
and they know schemes abound.
Williams’ case highlights
an unsettling reality about the nation’s health insurance system: It is
surprisingly easy for fraudsters to gain entry, and it is shockingly
difficult to convince insurance companies to stop them.
Williams’ spree also lays
bare the financial incentives that drive the system: Rising health care
costs boost insurers’ profits. Policing criminals eats away at them.
Ultimately, losses are passed on to their clients through higher
premiums and out-of-pocket fees or reduced coverage.
Insurance companies “are
more focused on their bottom line than ferreting out bad actors,” said
Michael Elliott, former lead attorney for the Medicare Fraud Strike
Force in North Texas.
As Lankford looked at the
iPad that day, she knew something else that made Williams’ romp through
the health care system all the more surprising. The personal trainer had
already done jail time for a similar crime, and Lankford’s father had
uncovered the scheme.
Scanning her ex-husband’s
texts, Lankford, then 47, knew just who to call. During the rocky end of
her marriage, her dad had become the family watchdog. Jim Pratte has an
MBA in finance and retired after a career selling computer hardware,
but even the mention of Williams flushed his face red and ratcheted up
his Texas twang. His former-son-in law is the reason he underwent
firearms training.
Lankford lived a few
minutes away from her parents in Mansfield. She brought her dad the iPad
and they pored over message after message in which Williams assured
clients that their insurance would cover their workouts at no cost to
them.
Lankford and Pratte, then
68, were stunned at Williams’ audacity. They were sure the companies
would quickly crackdown on what appeared to be a fraudulent scheme.
Especially because Williams had a criminal record.
In early 2006, while
Williams and Lankford were going through their divorce, the family
computer started freezing up. Lankford asked her dad to help her recover
a document. Scrolling through the hard drive, Pratte came upon a folder
named “Invoices,” and he suspected it had something to do with
Williams.
His soon to be
ex-son-in-law had had a promising start. He’d wrestled and earned
bachelor’s and master’s degrees at Boise State University, and a Ph.D.
at Texas A&M University, before landing a well-paying job as a
community college professor in Arlington. But the glow faded when the
school suddenly fired him for reasons hidden by a confidential
settlement and by Williams himself, who refused to reveal them even to
his wife.
Out of a job, Williams had
hustled investments from their friends to convert an old Winn-Dixie
grocery store into a health club called “Doc’s Gym.” The deal fell apart
and everyone lost their money. The failure was written up in the local
newspaper under the headline: “What’s up with Doc’s?”
Inside the “Invoices”
folder, Pratte found about a dozen bills that appeared to be from a Fort
Worth nonprofit organization where his daughter and Williams took their
son Jake for autism treatment. As Pratte suspected, the invoices turned
out to be fake. Williams had pretended to take Jake for therapy, then
created the false bills so he could pocket a cash “reimbursement” from a
county agency.
In November 2008, Williams
pleaded guilty in Tarrant County District Court to felony theft. He was
sentenced to 18 months in jail and was released on bail while he
appealed.
Things took an even darker
turn about two years later when Williams and Lankford’s 11-year-old son
showed up to school with bruising on his face. Investigators determined
that Williams had hit the boy in the face about 20 times. Williams
pleaded guilty to causing bodily injury to a child, a felony, which,
coupled with the bail violation, landed him in jail for about two years.
The time behind bars
didn’t go to waste. Williams revised the business plan for Get Fit With
Dave, concluding he needed to get access to health insurance.
Williams detailed his plans
in letters to Steve Cosio, a tech-savvy friend who ran the Get Fit With
Dave website in exchange for personal training sessions. Cosio, whose
name later popped up on Lankford’s son’s iPad, kept the letters in their
original envelopes and shared them with ProPublica. He said he never
suspected Williams was doing anything illegal.
In his letters, Williams
said that when he got out, instead of training clients himself, he would
recruit clients and other trainers to run the sessions. “It has the
potential for increased revenue.”
He asked Cosio to remove
the term “personal training” from his website in another letter, adding
“95 percent of my clients are paid for by insurance, which does not
cover ‘personal training,’ I have to bill it as ‘therapeutic exercise.’
It is the same thing, but I have to play the insurance game … Insurance
pays twice as much as cash pay so I have to go after that market.”
Williams downplayed his
child abuse conviction — “I can honestly say that I am the only one in
here for spanking their child” — and included a dig at his
ex-father-in-law, Pratte: “an evil, evil man. He is the reason for my
new accommodations.”
Williams told Cosio he
needed to raise a quick $30,000 to pay an attorney to get him access to
his children. “I will need to get a bunch of clients in a hurry.”
To set his plan in motion,
Williams needed what is essentially the key that unlocks access to
health care dollars: a National Provider Identifier, or NPI number.
The ID number is little
known outside the medical community but getting one through the federal
government’s Medicare program is a rite of passage for medical
professionals and organizations. Without it, they can’t bill insurers
for their services.
One would think obtaining
an NPI, with its stamp of legitimacy, would entail at least some basic
vetting. But Williams discovered and exploited an astonishing loophole:
Medicare doesn’t check NPI applications for accuracy — a process that
should take mere minutes or, if automated, a millisecond. Instead, as
one federal prosecutor later noted in court, Medicare “relies on the
honesty of applicants.”
Records show Williams first
applied for an NPI under his own name as far back as 2008. But it
wasn’t until 2014 that Williams began to ramp up his scheme, even though
now he wasn’t just unlicensed, he was a two-time felon. He got a second
NPI under the company name, Kinesiology Specialists. The following
year, he picked up another under Mansfield Therapy Associates. In 2016,
he obtained at least 11 more, often for entities he created in the areas
where he found fitness clients: Dallas, Nevada, North Texas and more.
By 2017, he had 20 NPIs, each allowing him a new stream of billings.
For every NPI
application, Williams also obtained a new employer identification
number, which is used for tax purposes. But he never hid who he was,
using his real name, address, phone number and email address on the
applications. He added the title “Dr.” and listed his credentials as
“PhD.” Under medical specialty he often indicated he was a “sports
medicine” doctor and provided a license number, even though he wasn’t a
physician and didn’t have a medical license.
Medicare officials
declined to be interviewed about Williams. But in a statement, they
acknowledged that the agency doesn’t verify whether an NPI applicant is a
medical provider or has a criminal history. The agency claims it would
need “explicit authority” from the Department of Health and Human
Services to do so — and currently doesn’t have it. Regulations, and
potentially the law, would need to be revised to allow the agency to vet
the applications, the statement said.
Medicare does verify the
credentials of physicians and other medical providers who want to bill
the agency for their Medicare patients.
To those charged with rooting out fraudsters, the current regulations seem like an invitation to plunder.
“Medicare has to make sure
that the individuals who apply for NPIs are licensed physicians — it’s
that simple,” said Elliott, the former prosecutor who ran about 100
health care fraud investigations.
Elliott, who now does
white-collar criminal defense, said he knows of two other cases
currently under federal investigation in which non-licensed clinic
administrators lied to obtain NPI numbers, then used patients’
information to file false claims worth millions.
Medicare warns NPI
applicants that submitting false information could lead to a $250,000
fine and five years in prison. But since Medicare started issuing NPIs
in 2006, officials said they could not identify anyone who had been
sanctioned.
So, for those bent on fraud, the first step is easy; the online approval for an NPI takes just minutes.
Williams got out of jail
in November 2012 and launched an aggressive expansion with an
irresistible pitch: Time to get those private personal training sessions
you thought you couldn’t afford!
“Now accepting most health
insurance plans,” his Get Fit With Dave website announced. He added a
drop-down menu to his site, allowing potential clients to select their
health insurance provider: Aetna. Blue Cross Blue Shield. United.
He began building a team,
soliciting trainers from the strength and conditioning department at
Texas Christian University. He met with new recruits at local fast food
joints or coffee shops to set them up. To the trainers, the business
appeared legit: They even signed tax forms. Before long, Williams’
network stretched throughout Texas and into Colorado, Idaho and Nevada.
One Fort Worth trainer
recalled meeting Williams through one of his clients, a Southwest
Airlines flight attendant. Williams, he said, seemed like a real doctor,
and it wasn’t hard to imagine an insurer’s wellness program covering
fitness. Plus, it was good money — about $50 an hour and Williams paid
him for multiple clients at once if he did boot camps, said the trainer,
who asked that his name not be used so he wouldn’t be tarnished by his
association with Williams. Williams, he said, even gave him an iPad,
with “Kinesiology Specialists” etched on the back, to submit bills and
paid him via direct deposit.
Clients came to Williams
through his business cards, his website and word-of-mouth. Williams,
records show, quickly verified if their insurance companies would cover
his fees — although he didn’t tell clients that those fees would be
billed as medical services, not personal training. To ensure the clients
paid nothing, he waived their annual deductibles — the portion patients
pay each year before insurance kicks in. Authorities said Williams
banked on being able to file enough claims to quickly blow through their
deductibles so he could get paid.
Meredith Glavin, a flight
attendant with Southwest, told the authorities she got in touch with
Williams after her co-workers said insurance was covering their
workouts. After providing her name, address and insurance information on
the Get Fit With Dave website, Williams emailed back with the good
news: “Everything checks out with your insurance. My services will be
covered at no cost to you.”
During a follow-up phone
call, Glavin said, they discussed her fitness and weight loss goals and
then Williams connected her with a trainer. The workouts were typical
fitness exercises, she said, not treatment for a medical condition. But
insurance claims show Williams billed the sessions as highly complex
$300 examinations to treat “lumbago and sciatica,” a condition in which
nerve pain radiates from the lower back into the legs.
He used his favorite
billing code — 99215 — to bill Glavin’s insurer, United, the claims
show. The code is supposed to be used less often because it requires a
comprehensive examination and sophisticated medical decision-making,
warranting higher reimbursement. In all, Williams used the code to bill
United for more than $20.5 million — without apparently triggering any
red flags at the insurer. For that code alone, the insurance giant
rewarded him with $2.5 million in payments.
Eventually, Get Fit With
Dave expanded to about a dozen trainers and around 1,000 patients, said a
source familiar with the case. And, court records show, the checks from
insurance companies, some over $100,000, kept rolling in.
Williams bought a couple
of pick-up trucks, a new Harley Davidson motorcycle and a fancy house.
But greed didn’t seem his only motivation. “I made $50K last week,” he
wrote in a December 2014 text to a friend. “Seriously it means nothing.
It is not about the money. I have had a lot taken away from me, and
maybe I am trying to prove something ... Maybe it is my way of giving
the finger to everyone???”
A few miles away, his
former father-in-law watched Williams’ illegal business blossom with
growing outrage. Pratte kept his grandson’s iPad on his desk, near his
computer, and checked it every day. The texts appeared boring, even
routine, but Pratte knew they were evidence of ongoing fraud.
“I have another flight attendant friend who is interested in signing up as well,” a new client texted to Williams.
“Tell him to show up with his insurance card,” Williams replied.
To Pratte, the text
messages were a “gold mine.” This is the stuff that will really nail his
rear end, he recalled thinking as he read the messages. He couldn’t
wait to share his findings with the insurers. How often do they get
cases wrapped up in a bow?
But when he and Lankford
began contacting insurers, they were soon bewildered. When Pratte told
Aetna that he wanted to report a case of fraud, he said the customer
service representative asked for his member number, then told him
non-members couldn’t report criminal activity. Lankford, who happened to
be covered by Aetna, made the complaint, but they say they never heard
back.
An Aetna spokesman told
ProPublica that the insurer could find no record of Pratte’s call but
said the company’s fraud hotline takes tips from anyone, even anonymous
callers.
Lankford sent an email to
Cigna’s special investigations unit in January 2015 “regarding one of
your providers that concerns me.” She provided Williams’ company name,
address, cellphone number, Social Security number and more, and she
described his scheme. “He has no medical license or credentials,” she
wrote. “He was in prison for felony theft.”
A supervisory
investigator called to ask for the names of personal trainers, which
Lankford provided. But, again, there was silence.
Pratte could see many of
the clients worked for Southwest and had their benefits administered by
United. He jotted down the name, address, phone number, birthdate and
member identification number of the potential clients on a yellow legal
pad — all the information the insurer and Southwest would need to
investigate the fraud. This is so easy, Pratte recalled thinking as he
wrote down the details, all they have to do is cross-reference this.
Because Southwest
self-funds its benefits, the company was on the hook for the bills,
which would eventually total about $2.1 million according to a source
familiar with the case. It paid United to administer the company’s plan
and ensure the claims it covered were legitimate. Pratte said he called
the airline in the fall of 2015 and spoke to someone in the human
resources department who said they would pass the information to the
right people. “That was the last I heard,” he said. Southwest declined
to comment for this story. It still pays United to administer its
benefits.
Pratte started calling
United in the fall of 2014 and spoke to a fraud investigator who took
the information with interest, he said. But within a couple of weeks he
was told she moved to a different position. Pratte continued calling
United over the following two years, making about a dozen calls in
total, he said. “He is not a doctor,” Pratte told whoever picked up the
phone. “So, I don’t see how he can be filing claims.”
In early 2015, Lankford
emailed additional information to the investigator. The investigator
wrote back, thanking Lankford and saying she forwarded the details to
the people who research licenses. “They will investigate further,” she
said in the email.
Meanwhile, the text messages showed Williams continuing to sign up — and bill for — United members.
Frustrated, Pratte made
one final call to United in 2016, but he was told the case was closed.
United said he’d have to call the Texas Department of Insurance for any
additional details. Pratte had already filed a complaint with the
regulator but reached out again. The department told him that because he
hadn’t personally been defrauded, it would not be able to act on his
complaint.
To Pratte, it appeared he
had struck out with Aetna, United, Southwest and the Texas Department
of Insurance. “I was trying to get as many people as possible to look
into it as I could,” Pratte said recently. “I don’t know if that tells
me they are incompetent. Or they don’t care. Or they’re too busy.”
A case summary, prepared
by the Texas Department of Insurance, shows it first learned of the
Williams case in January 2015 but lacked staff to investigate. A
spokesman said the regulator later received Pratte’s complaint but
didn’t pursue it after learning that United had already investigated and
closed its case.
Meanwhile, some Get Fit With Dave clients had begun noticing odd claims on their insurance statements.
Nanette Bishop had heard
about Williams when a fellow Southwest flight attendant handed her the
trainer’s business card and said, “You’ve got to meet Dr. Dave.” (Bishop
said the Southwest legal department advised her not to speak with
ProPublica. Details about her interaction with Williams come from court
records.)
Bishop said she started
strong with the workouts but “fizzled” quickly. Her daughter, who was
also on her plan and signed up for workouts, only did a couple sessions.
Bishop said she had a hard time staying consistent because she was
traveling a lot — for much of October 2014 she was in Germany. Later,
she noticed in her insurance records that Williams had been paid for
dozens of sessions over many months, even during the time she’d been
abroad.
Bishop texted Williams in
January 2015 to tell him he needed to refund all the money. “I never
worked out four [times] a week and [my daughter] quit the first week of
September,” she wrote. Bishop also called United and Southwest Airlines
to report the overbilling.
About a month later, Williams received a letter from a subsidiary of United ordering a review Bishop’s medical records.
Another client texted
Williams with concerns that her United insurance plan had been billed
for 18 workouts in December 2015. That couldn’t be accurate, the woman
wrote. “I had to take December off due to my work schedule and family in
town,” she wrote. “I understand that people need to be paid but this
seems excessive.”
While Pratte, Lankford and
some of Williams’ clients repeatedly flagged bogus bills, the mammoth
health insurers reacted with sloth-like urgency to the warnings. Their
correspondence shows an almost palpable disinterest in taking decisive
action — even while acknowledging Williams was fraudulently billing
them.
Cigna appears to have been
the quickest to intervene. In January 2015, Cigna sent Williams a
letter, noting that he wasn’t a licensed medical provider and had
misrepresented the services he provided. The insurer said he needed to
pay back $175,528 and would not be allowed to continue billing.
“I just got a $175K bill
in the mail,” Williams texted to a friend. “Cigna insurance has been
overpaying me for the past 18 months and they want it back. I knew that
they were reimbursing at too high of a rate so I can’t really complain.”
By then Williams had more
than one National Provider Identifier, so he just switched numbers and
kept billing Cigna. More than a year later, in May 2016, Cigna sent
another letter, saying he now owed $310,309 for inappropriate payments.
In total, the company paid him more than $323,000. Williams never gave
any of it back. Cigna declined to comment about the Williams case.
Aetna wrote Williams in
January 2015 to say it had reviewed his claims and found he wasn’t
licensed, resulting in an overpayment of $337,933. The letter said there
appeared to be “abusive billing” that gave “rise to a reasonable
suspicion of fraud.” But the insurer also gave him a month to provide
documentation to dispute the assessment. When Williams hadn’t responded
in three months, an Aetna investigator wrote to Williams’ attorney,
saying, “We are willing to discuss an amicable resolution of this
matter,” and gave him two more weeks to respond.
That August, an Aetna
attorney sent Williams’ attorney another letter, noting that Williams
had submitted “fraudulent claims” and had continued to submit bills
“even after his billing misconduct was identified.”
In January 2016 — a year
after Aetna first contacted him — Williams agreed to a settlement that
required him to refund the company $240,000 “without admission of fault
or liability by either party.”
But that didn’t stop, or
even appear to slow, Williams. Not only did he renege on that promise,
he picked one of his other NPI numbers and continued to file claims
resulting in another $300,000 in payments from Aetna. In total, Aetna
paid Williams more than $608,000.
In emails, Ethan Slavin, a
company spokesman, didn’t explain why Aetna settled with Williams
instead of pursuing criminal prosecution. He blamed the insurer’s slow
response on the lengthy settlement process and Williams’ tactic of
billing under different organizations and tax identification numbers.
Williams did repay some of the money before defaulting, Slavin said.
United, one of the largest
companies in the country, paid out the most to Williams. The insurer
brought in $226 billion last year and has a subsidiary, Optum, devoted
to digging out fraud, even for other insurers. But that prowess is not
reflected in its dealings with Williams.
In September 2015, United
wrote to Williams, noting his lack of a license and the resulting
wrongful payments, totaling $636,637. But then the insurer added a
baffling condition: If Williams didn’t respond, United would pay itself
back out of his “future payments.” So while demanding repayment because
Williams was not a doctor, the company warned it would dock future
claims he would be making as a doctor.
Williams responded a month
later, noting that he had a Ph.D. in kinesiology and did rehab, so he
met the qualifications of a sports medicine doctor.
United responded in
November 2015 with the same argument: he wasn’t licensed and thus needed
to repay the money, again warning that if he didn’t, United would
“initiate repayment by offsetting future payments.”
Williams took United up on its offer. “Please offset future payments until the requested refund amount is met,” he responded.
Then Williams turned to another NPI number, records show, and continued submitting claims to United.
In January 2016, Williams
agreed to settle with United and repay $630,000 in monthly installments
of $10,000. Inexplicably, the agreement refers to Williams as “a
provider of medical services or products licensed as appropriate under
the laws of the state of TX” and notes that the settlement doesn’t
terminate his continued participation in United’s programs.
In 2016, Williams
obtained a new batch of NPI numbers from Medicare. As usual, he used his
real name, address and credentials on the applications. The additional
numbers allowed him to continue to make claims to United.
In November 2016, United
investigators caught Williams again — twice. They sent two letters
accusing him of filing 820 claims between May 2016 and August 2016 and
demanded repayment. Again, almost inconceivably, the company threatened
to cover his debt with “future payments.”
In December 2016, United
notified Williams he had only repaid $90,000 of the initial $630,000 he
owed and was in default. The following month, United told him he had to
pay the remaining $540,000 within 20 days or he could face legal action.
Williams replied, saying he wanted to renegotiate the settlement, but
the insurer declined. Late that month, United said its inappropriate
payments to Williams had ballooned to more than $2.3 million.
A United spokeswoman said
it was difficult to stop Williams because he used variations on his
name and different organizations to perpetrate the fraud. “He did
everything he could not to get caught,” Maria Gordon-Shydlo said.
She acknowledged getting
the complaints from Lankford and Pratte, as well as United members, but
defended the response of the company, saying it had eventually referred
Williams to law enforcement.
The insurer is continuing
“to improve our processes and enhance our systems so we can catch these
schemes on the front-end,” she said, “before a claim is paid and to
recoup dollars that were paid as a result of provider misconduct.”
In all, United paid Williams more than $3.2 million — most of it after the insurer had caught him in the act.
But in reality, the losses weren’t all United’s. Most of the fraud was funded by its client, Southwest.
Many health care experts
and fraud investigators said they weren’t surprised to hear that
insurers were slow to stop even such an outlandish case of fraud.
“It’s just not worth it
to them,” said Dr. Eric Bricker, an internist who spent years running a
company that advised employers who self-funded their insurance.
For insurance behemoths
pulling in billions, or hundreds of billions, in revenue, fraud that
sucks away mere millions is not even a rounding error, he said.
And perhaps
counterintuitively, insurance companies are loath to offend physicians
and hospitals in their all-important networks — even those accused of
wrongdoing, many experts have said. They attract new clients by
providing access to their networks.
This ambivalence toward
fraud, Bricker and others said, is no secret. Scammers like Williams are
“emblematic of gazillions of people doing variants of the same thing,”
Bricker said. Insurers embolden them by using a catch-and-release
approach to fraud, in which the insurers identify criminals, then let
them go.
Joe Christensen has
pursued fraud for both government and commercial insurers, serving as a
director in Aetna’s Special Investigations Unit, a team of more than 100
people ferreting out fraud, from 2013 to 2018 and as the director of
Utah’s insurance fraud division for 13 years. Fraud in government
programs, like Medicare and Medicaid, gets more publicity, he said, and
has dedicated arms of agencies pursuing fraudsters. But the losses may
be even greater in the commercial market because the dollar levels are
higher, he said.
Some commercial insurers
take a passive approach, Christensen said, in part because it’s
expensive to press a fraud case. At Aetna, he said, investigators would
identify cases of apparent fraud, but it was up to the executives and
legal team to decide how to handle them. Taking fraudsters to civil or
criminal court requires resources, so the company often settled for
trying to get repaid through settlements or blocking a suspect provider
from billing, he said.
Christensen said while he
was at Aetna, investigators almost never sought to partner with law
enforcement agencies to pursue criminal cases. Last spring, he became
the SIU director for a Southern California-based Medicaid plan called
L.A. Care Health Plan, where he was allowed to take a proactive
approach. In just about a year, he said, his much smaller team began 37
criminal investigations with law enforcement agencies. The cases are in
different stages, but so far there have been seven arrests, four search
warrants and one conviction. Christensen recently took a job with an
insurer in Utah, where his family lives, so he could be closer to them.
ProPublica asked Aetna how
many criminal cases it had pursued in 2017 and 2018. A company official
said the question could not be answered because it does not track such
cases.
In the spring of 2017,
more than four years after Williams first began billing insurers, one of
them, United, finally brought him to the attention of the FBI’s heath
care fraud squad.
One May day, agents from
the FBI and the newly engaged Texas Department of Insurance knocked on
the door of Williams’ sprawling six-bedroom home — a spread he’d boasted
to one trainer that he’d purchased with cash. Williams didn’t invite
them in. He refused to answer questions, claiming his attorney had dealt
with the questionable billings.
Undaunted, just days
later, Williams used a freshly minted NPI number to send another bill to
United. The last known claim he submitted was on June 3, 2017,
according to a source familiar with the investigation.
That October, Williams’ long run came to an end when he was arrested by the FBI.
The following May,
Williams’ trial began in the United States District Court for the
Northern District of Texas. The prosecution didn’t have to make a
complex argument. Williams had billed for non-medically necessary
services and wasn’t a medical provider — a “slam dunk case” said the
agent on the case.
But the testimony served as a cheat sheet for how to defraud the health insurance industry and mostly get away with it.
Without irony, the
prosecutor, P.J. Meitl, argued that Williams had preyed on a health
insurance system that relies “on trust, relies on honesty” when it pays
claims.
He called fraud
investigators from Aetna, Cigna and United, who testified that their
companies auto-pay millions of claims a year. It’s not cost effective to
check them, they said. “Aetna relies on the honesty of the person
submitting the claim verifying that it’s true,” testified Kathy Richer, a
supervisor in Aetna’s Special Investigations Unit.
In a similar manner,
Medicare trusts that people who apply for NPI numbers are actually
medical providers, Meitl told the jury. Medicare “does not investigate
or verify whether an individual is actually a health care provider
before issuing an NPI number.”
Williams’ attorney, Wes
Ball, argued that the case was the sign of a “broken” health care system
and blamed insurers for making a financial decision not to review
Williams’ claims before paying them. United failed to protect
Southwest’s money, Ball said, and “might be a vendor you might not want
to hire.”
As for the NPI numbers, anyone could have checked Williams’ credentials, he said.
The jury wasn’t convinced, convicting Williams of four counts of health care fraud.
The judge sentenced him to
a little more than nine years in federal prison and ordered him to pay
$3.9 million in restitution to United, Aetna and Cigna.
Insurers promote
themselves as guardians of health care dollars. United says on its
website it wants to “help employers manage” medical expenses, resulting
in “lower costs.” Aetna promises employers “affordability.” Cigna
promises “increased savings.”
But private health
insurers allow so much fraud that prosecutors use an idiom to describe
the rare person who gets caught: “Pigs get fat, hogs get slaughtered.”
“Pigs” can steal millions,
if they bill just enough to avoid notice. But if they get greedy and
bill too many millions, they “become a data outlier,” said Elliott, the
former fraud task force prosecutor. “You get slaughtered.”
Williams took years to reach hog status.
Part of the problem,
experts say, is that health care fraud is often misunderstood as
shafting greedy insurers — not the folks paying for health insurance.
Ultimately, insurers don’t bear the cost. For their self-funded clients,
like Southwest, they merely process the claims. For their traditionally
insured clients, they can recover any losses by increasing deductibles
and premiums and decreasing coverage.
Williams appears to have
duped more than insurers. His twin brother, Dan Williams, recently
retired as the assistant special agent in charge of the Dallas field
office for criminal investigation for the Internal Revenue Service. He
spent 27 years ferreting out fraud, and he gets the irony. “You’re not
the first person to point that out,” he said.
Dan Williams said his
brother’s sudden riches from the training business piqued his
investigative instincts, but he “trusted” his brother when “he told me
he was authorized to bill insurance companies.”
In his letter to
ProPublica, Williams did not address the issues in the case or even
acknowledge that any of his activities were wrong. Instead, he blamed
his former wife.
“It grieves me that the
consequences of a bitter and hurtful divorce have resulted in the ending
of this unprecedented and beneficial opportunity to help many people,”
he wrote.
Lankford and Pratte are
proud of their part in ending his scheme, if still baffled that they had
to play such a central role in uncovering it.
If it hadn’t been for the
iPad messages, “I have to believe he would still be billing insurance
companies from a Caribbean island,” Pratte said.
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Sanders and Biden Fight Over Health Care, and It’s Personal
By Sydney Ember and Katie Glueck - NYT - July 18, 2019
WASHINGTON
— Senator Bernie Sanders does not understand Joseph R. Biden Jr.’s
position on health care. To Mr. Sanders, the health care system is
broken, and the only way to fix it is to replace it with his signature
policy plan known as Medicare for All.
“I am disappointed, I have to say, in Joe, who is a friend of mine, really distorting what Medicare for All is about,” Mr. Sanders said in an interview hours before he delivered a speech on Wednesday defending his health care proposal. “And unfortunately, he is sounding like Donald Trump. He is sounding like the health care industry in that regard.”
To Mr. Biden, the current Democratic front-runner, Medicare for All is a costly and complex proposal that means eliminating private health insurance — and scrapping the Affordable Care Act.
“I knew the Republicans would do everything in their power to repeal Obamacare,” he said in a video this week as he rolled out his own health care proposal. “They still are. But I’m surprised that so many Democrats are running on getting rid of it.”
“I am disappointed, I have to say, in Joe, who is a friend of mine, really distorting what Medicare for All is about,” Mr. Sanders said in an interview hours before he delivered a speech on Wednesday defending his health care proposal. “And unfortunately, he is sounding like Donald Trump. He is sounding like the health care industry in that regard.”
To Mr. Biden, the current Democratic front-runner, Medicare for All is a costly and complex proposal that means eliminating private health insurance — and scrapping the Affordable Care Act.
“I knew the Republicans would do everything in their power to repeal Obamacare,” he said in a video this week as he rolled out his own health care proposal. “They still are. But I’m surprised that so many Democrats are running on getting rid of it.”
After months of warily watching
each other from afar, Mr. Sanders and Mr. Biden, two Democratic
septuagenarian contenders for president, have taken aim at each other on
the fraught and critical battleground of American health care policy.
Mr. Sanders in particular has escalated the attacks in recent days. His campaign called Mr. Biden’s health care plan “Bidencare” and even released a video that accuses him of “lying” about Medicare for All. But Mr. Biden, too, has been a more-than-willing participant, openly criticizing Medicare for All on multiple campaign swings over the last week.
[Sign up for our politics newsletter and join the conversation around the 2020 presidential race.]
Their sparring reflects strategic political calculations. For Mr. Biden, who appears increasingly willing to draw contrasts with his Democratic rivals after a rocky first presidential debate, health care provides a way to highlight distinctions between himself and several opponents who support Medicare for All, including Mr. Sanders and Senators Kamala Harris and Elizabeth Warren.
For Mr. Sanders, outraised by several rivals including Ms. Warren and falling in some polls, Medicare for All — which he has preached for decades — offers a possible path back to the center of the national political conversation.
But there is more to their jousting than just normal campaign maneuvering. Health care is a personal issue for both men — to Mr. Sanders, it is a fundamental human right and embodies his lifelong message of economic equality. To Mr. Biden, who was vice president to Barack Obama when the Affordable Care Act was passed, it is also connected to the death of his son Beau Biden, who died after a battle with brain cancer.
Mr. Sanders in particular has escalated the attacks in recent days. His campaign called Mr. Biden’s health care plan “Bidencare” and even released a video that accuses him of “lying” about Medicare for All. But Mr. Biden, too, has been a more-than-willing participant, openly criticizing Medicare for All on multiple campaign swings over the last week.
[Sign up for our politics newsletter and join the conversation around the 2020 presidential race.]
Their sparring reflects strategic political calculations. For Mr. Biden, who appears increasingly willing to draw contrasts with his Democratic rivals after a rocky first presidential debate, health care provides a way to highlight distinctions between himself and several opponents who support Medicare for All, including Mr. Sanders and Senators Kamala Harris and Elizabeth Warren.
For Mr. Sanders, outraised by several rivals including Ms. Warren and falling in some polls, Medicare for All — which he has preached for decades — offers a possible path back to the center of the national political conversation.
But there is more to their jousting than just normal campaign maneuvering. Health care is a personal issue for both men — to Mr. Sanders, it is a fundamental human right and embodies his lifelong message of economic equality. To Mr. Biden, who was vice president to Barack Obama when the Affordable Care Act was passed, it is also connected to the death of his son Beau Biden, who died after a battle with brain cancer.
Politically, polls
show that health care is a top priority for Democrats, and an emphasis
on protecting people with pre-existing conditions and reducing health
care costs helped Democrats in last year’s midterms when they picked up
40 seats in the House. With Mr. Trump and Republicans repeatedly
threatening to unravel Obamacare, Democrats hope that the issue of
health care will again work in their favor.
If Mr. Sanders and Mr. Biden have both seemed at times to relish the debate, it has also thrown into sharp relief two competing visions for the Democratic Party.
Mr. Biden embraces fixes to the health care system and the addition of a public option, rather than a full-scale overhaul, portraying that approach as more pragmatic in today’s fractured political landscape, to say nothing of appealing to a nostalgia for the Obama era. The other view, championed by Mr. Sanders and others on the left, is that the nation’s challenges are so significant that only the boldest, most transformational proposals will do.
The philosophical clash erupted on Wednesday when Mr. Sanders delivered a formal address in Washington on the merits of replacing the current health care system with Medicare for All, saying his plan would “save lives” and urging presidential candidates to reject contributions from the health care industry.
Though he did not mention Mr. Biden by name, he took several veiled swipes at him, joking about how much Americans love their private insurance (they do not, Mr. Sanders claimed, though polls tell a more complicated story) and about how they love paying their insurance premiums (ditto).
If Mr. Sanders and Mr. Biden have both seemed at times to relish the debate, it has also thrown into sharp relief two competing visions for the Democratic Party.
Mr. Biden embraces fixes to the health care system and the addition of a public option, rather than a full-scale overhaul, portraying that approach as more pragmatic in today’s fractured political landscape, to say nothing of appealing to a nostalgia for the Obama era. The other view, championed by Mr. Sanders and others on the left, is that the nation’s challenges are so significant that only the boldest, most transformational proposals will do.
The philosophical clash erupted on Wednesday when Mr. Sanders delivered a formal address in Washington on the merits of replacing the current health care system with Medicare for All, saying his plan would “save lives” and urging presidential candidates to reject contributions from the health care industry.
Though he did not mention Mr. Biden by name, he took several veiled swipes at him, joking about how much Americans love their private insurance (they do not, Mr. Sanders claimed, though polls tell a more complicated story) and about how they love paying their insurance premiums (ditto).
Senator Bernie Sanders announced his Medicare for All plan in Washington on Wednesday.CreditSamuel Corum for The New York Times
It was a conflict that had been simmering for days.
Last week, Mr. Biden told reporters in Portsmouth, N.H., that Medicare for All is not “Medicare as you know it.”
Last week, Mr. Biden told reporters in Portsmouth, N.H., that Medicare for All is not “Medicare as you know it.”
“It
is one that I think is going to be difficult to pass, No. 1,” he said.
“But No. 2, I think people should be able to be in a situation, if they
want to keep their employer-based insurance, they should be able to do
it.”
Though Mr. Biden said that Mr. Sanders had been “very honest” about the costs of Medicare for All, he still drew a forceful rebuke from the Vermont senator, who accused Mr. Biden of echoing the insurance and pharmaceutical industries — and Republicans — in his criticisms of Medicare for All.
And on Monday, Mr. Sanders blasted Mr. Biden’s health care plan, suggesting it was aligned with “corporate greed.”
Aides to Mr. Sanders suggest the escalating confrontation plays into his hands: They have been trying to frame the primary as a competition between him and Mr. Biden, hoping to set up the same kind of insurgent-versus-establishment contrast that worked to Mr. Sanders’s advantage in 2016, when he was the foil to Hillary Clinton. And they view poaching supporters from Mr. Biden, particularly working-class Democrats, as the most promising way for Mr. Sanders to grow his base.
To help their case, they have been urging Mr. Sanders to go after Mr. Biden more aggressively.
Yet for weeks, they have remained frustrated with polls showing Mr. Biden still leading Mr. Sanders by comfortable margins, some allies said. The recent surges by Ms. Warren and Ms. Harris and the fund-raising prowess of Mayor Pete Buttigieg have also dispelled the notion that it is a two-person contest.
“He’s clearly losing support, both in the national polls and in states,” Stan Greenberg, a veteran Democratic pollster, said of Mr. Sanders. “He has no choice. I think he’s made a decision, he’s got to make himself relevant again. Health care was the issue in which he was relevant last time, and it was very important in the campaign in 2016, so I think it makes a lot of sense for him to try to draw this contrast on health care, particularly in the primary.”
Mark Longabaugh, who was one of Mr. Sanders’s top advisers in 2016 but left the 2020 team this year, said Mr. Sanders was “really good in a contrast.”
Though Mr. Biden said that Mr. Sanders had been “very honest” about the costs of Medicare for All, he still drew a forceful rebuke from the Vermont senator, who accused Mr. Biden of echoing the insurance and pharmaceutical industries — and Republicans — in his criticisms of Medicare for All.
And on Monday, Mr. Sanders blasted Mr. Biden’s health care plan, suggesting it was aligned with “corporate greed.”
Aides to Mr. Sanders suggest the escalating confrontation plays into his hands: They have been trying to frame the primary as a competition between him and Mr. Biden, hoping to set up the same kind of insurgent-versus-establishment contrast that worked to Mr. Sanders’s advantage in 2016, when he was the foil to Hillary Clinton. And they view poaching supporters from Mr. Biden, particularly working-class Democrats, as the most promising way for Mr. Sanders to grow his base.
To help their case, they have been urging Mr. Sanders to go after Mr. Biden more aggressively.
Yet for weeks, they have remained frustrated with polls showing Mr. Biden still leading Mr. Sanders by comfortable margins, some allies said. The recent surges by Ms. Warren and Ms. Harris and the fund-raising prowess of Mayor Pete Buttigieg have also dispelled the notion that it is a two-person contest.
“He’s clearly losing support, both in the national polls and in states,” Stan Greenberg, a veteran Democratic pollster, said of Mr. Sanders. “He has no choice. I think he’s made a decision, he’s got to make himself relevant again. Health care was the issue in which he was relevant last time, and it was very important in the campaign in 2016, so I think it makes a lot of sense for him to try to draw this contrast on health care, particularly in the primary.”
Mark Longabaugh, who was one of Mr. Sanders’s top advisers in 2016 but left the 2020 team this year, said Mr. Sanders was “really good in a contrast.”
But he cautioned that the senator would be ill-advised to discount his other opponents at this point.
“You’ve got obviously several other significant candidates and actors in this thing,” he said. “I just don’t see this election turning into a Biden-versus-Bernie race.”
Mr. Biden’s allies point to the current political realities in Washington — which includes a Republican-controlled Senate — as evidence that passing a sweeping overhaul of the nation’s health care system would be exceedingly difficult, and argue that Mr. Biden’s proposal is more realistic.
“I’m not so sure anyone believes Americans are ready to go through a wholesale change in the health care system,” said John Anzalone, a Biden pollster. “Joe Biden is approaching this as, people are hurting, what can we do now, or in the very near future, when a Democrat is president?”
In a separate interview over the weekend with The New York Times, Mr. Sanders appeared to acknowledge the steep political requirements of his proposal, saying “a Democratic Senate is certainly absolutely imperative if we’re going to go forward,” and added that members on both sides of the aisle would have to come together to create “a system which is designed not to provide huge profits for the drug companies and the insurance companies but quality care to all people.”
As the battle over health care continues, even Mr. Sanders’s advisers are no longer hiding their distaste for Mr. Biden’s criticisms.
“This campaign will not be a punching bag for misinformation out of the Biden campaign,” said Jeff Weaver, Mr. Sanders’s 2016 campaign manager and his closest adviser.
Referring to the last presidential contest, he added, “If people want to go into the general election in 2020 with a candidate with the same set of policy prescriptions as 2016, that’s a real roll of the dice.”
https://www.nytimes.com/2019/07/18/us/politics/sanders-biden-health-care.html?action=click&module=News&pgtype=Homepage
“You’ve got obviously several other significant candidates and actors in this thing,” he said. “I just don’t see this election turning into a Biden-versus-Bernie race.”
Mr. Biden’s allies point to the current political realities in Washington — which includes a Republican-controlled Senate — as evidence that passing a sweeping overhaul of the nation’s health care system would be exceedingly difficult, and argue that Mr. Biden’s proposal is more realistic.
“I’m not so sure anyone believes Americans are ready to go through a wholesale change in the health care system,” said John Anzalone, a Biden pollster. “Joe Biden is approaching this as, people are hurting, what can we do now, or in the very near future, when a Democrat is president?”
In a separate interview over the weekend with The New York Times, Mr. Sanders appeared to acknowledge the steep political requirements of his proposal, saying “a Democratic Senate is certainly absolutely imperative if we’re going to go forward,” and added that members on both sides of the aisle would have to come together to create “a system which is designed not to provide huge profits for the drug companies and the insurance companies but quality care to all people.”
As the battle over health care continues, even Mr. Sanders’s advisers are no longer hiding their distaste for Mr. Biden’s criticisms.
“This campaign will not be a punching bag for misinformation out of the Biden campaign,” said Jeff Weaver, Mr. Sanders’s 2016 campaign manager and his closest adviser.
Referring to the last presidential contest, he added, “If people want to go into the general election in 2020 with a candidate with the same set of policy prescriptions as 2016, that’s a real roll of the dice.”
https://www.nytimes.com/2019/07/18/us/politics/sanders-biden-health-care.html?action=click&module=News&pgtype=Homepage
Why the House plans to pass a bipartisan bill repealing a controversial Obamacare tax
The Cadillac tax is on the chopping block.
by Tara Golshan - VOX - July 17, 2019
The House of Representatives is about to pass a
bipartisan health care and tax bill Wednesday to get rid of a long-hated
part of the Affordable Care Act: the “Cadillac tax.”
The Cadillac tax levies a 40 percent tax on the most
expensive employer-sponsored health insurance plans, those worth about
$11,200 for individuals and $30,100 for families, starting in 2022. The
tax on businesses would hit the part of the plan above the price
threshold. It was supposed to go into effect in 2018 at a lower price
threshold, but was delayed. Repealing the tax would cost the United
States an estimated $197 billion over 10 years, according to an analysis
by the Joint Committee on Taxation.
The House bill, the Middle Class Health Benefits Tax
Repeal Act of 2019, has more than 350 co-sponsors and is expected to
pass with bipartisan support. While Senate Republicans have shown
interest in the bill, it’s not clear whether Senate Majority Leader
Mitch McConnell will bring the bill up for a vote.
The Cadillac tax has been a controversial provision in
Obamacare from the beginning — and almost by design. Its passage
resulted in some strange ideological bedfellows. In 2008, John McCain
campaigned on it. Obama’s advisers endorsed it. Sen. Marco Rubio
included a Cadillac tax in his 2015 Obamacare repeal proposal.
But in the 2016 presidential election, both Hillary Clinton and Sen.
Bernie Sanders called to repeal it. Advocates for repealing the Cadillac
tax include conservative chambers of commerce and big business.
But the issue remains divisive among Democrats and Republicans, even within their own parties.
The Cadillac tax was always controversial — and unpopular
The point of this tax was to encourage employers to offer less expensive health insurance. Sarah Kliff explained why for Vox in 2015:
Traditionally, the government doesn’t tax employer-sponsored insurance. This has created a huge incentive for companies to spend more money on generous insurance plans and less on cash wages. This, in turn, pushes up health-care costs across the system. When workers have expensive plans with no copays or deductibles, they’re likely to use lots of health care, including trips to the doctor they don’t really need.
The economists and policy advisers under the Obama
administration who supported the Cadillac tax argued that by encouraging
companies to scale back insurance benefits, businesses would in turn
give employees a wage increase (there’s some evidence that could happen). And, they said, it would only hit the wealthiest executives, most generous union plans, and major companies (which there’s not much evidence to support).
At the end of the day, the Cadillac tax was literally
designed to encourage companies to make insurance plans worse. Not
necessarily terrible — but just to reduce benefits and control costs.
“The Cadillac tax is one of the most important tools we
have to control health care cost growth in the private sector,” the
Committee for a Responsible Federal Budget, a deficit reduction think
tank, said in a statement.
“Repealing it will drive up health care costs while adding more than
$1.2 trillion to the debt over the next two decades and reducing wages
by trillions over that time period.”
That said, according to a 2018 study by the Kaiser Family Foundation,
increases in deductibles for insured workers have outpaced any real
wage increases for employees. So it makes sense that both businesses
that would have to pay the tax and labor unions who negotiate generous
health benefits for their members argued against it.
The Cadillac tax had some fundamental flaws
Advocates for the tax’s repeal point out a few fundamental problems with it.
First, it’s not just rich corporate bosses getting robust
health care package; it’s teachers, state workers, and other employees
who aren’t necessarily ultra-high earners. As Kliff writes that the Cadillac tax is a “blunt instrument”:
There’s no adjustment, for example, for people who live in places where health care is really expensive — so the threshold is the same in the Midwest, where health insurance is pretty cheap, as it is in remote states like Alaska, where it’s more expensive to deliver health care. It’s the same for teachers as it is for bankers, for someone who has a chronic disease that really does require many doctor visits and for someone who is perfectly healthy.
Second, the way the tax is set up means it could affect
more and more plans down the line. As written, the price threshold under
the Cadillac tax rises with the rate of inflation. So in 2022, an
analysis by the Kaiser Family Foundation found, 21 percent of employers would face the tax. But by 2030, 46 percent of employers would be hit.
That’s because health care costs typically grow faster
than the economy. While in 2017, health care spending grew at nearly the
same rate as the economy, last year the government projected that
health care spending would rise by an average of about 1 percentage
point faster than economic growth annually through 2026.
That means that down the road the Cadillac tax would no
longer be on just the most expensive plans. It would hit much more than
that.
Blue Cross’s approach to paying doctors based on quality of care shows results, Harvard study finds - The Boston Globe
by Shirley Leung - Boston Globe - July 18, 2019
The study published Thursday in the New England Journal of Medicine is the longest evaluation to date of this type of payment model. With eight years of data, it adds to the body of evidence that suggests changing incentives for doctors and hospitals could moderate costs.
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Rising
health care costs are a perpetual concern in Massachusetts and across
the country, and many experts believe spending growth will not let up
unless the payment system changes.“This contributes to a growing sense that smarter ways of paying for health care are going be to an important part of the solution to rising health care costs,” said Katherine Baicker, dean of the University of Chicago Harris School of Public Policy, who was not involved in the study.
Doctors and hospitals traditionally have been rewarded for every test, procedure, and service they provide, regardless of whether those things help patients get healthier.
Blue Cross’s payment program, called the Alternative Quality Contract, has been closely watched since it began in 2009. Other insurers, including Harvard Pilgrim Health Care and Tufts Health Plan, have since launched similar programs.
The federal government has also pushed new payment plans in Medicare through accountable care organizations: groups of doctors and hospitals that work together to coordinate care for patients. And in Massachusetts, the Medicaid program for low-income individuals is in the midst of similar changes.
The programs all share two lofty goals: improve patient health and slash costs.
The Harvard study shows that spending increased for patients in the experimental Blue Cross program — but it grew more gradually than spending for other patients. The savings may be too modest for patients to notice in their health care premiums, which generally continue to rise.
The program was linked to an average 12 percent savings on medical claims over eight years. Some of the savings came when patients shifted their medical care to less expensive facilities. Costs also moderated because patients used fewer services; for example, they received fewer expensive MRIs and visited hospital emergency departments less frequently.
At the same time, the quality of care they received stayed steady or improved, said Dr. Zirui Song, the study’s lead author. Quality was calculated through a variety of measures, including whether patients received the proper cancer screenings, and whether they maintained a healthy blood pressure.
Song said his analysis shows that alternative payment programs are sustainable over several years. But he cautioned, “Behavior change is difficult, and sustaining behavior change is even more difficult.”
The study, funded by the National Institutes of Health, was welcomed by executives at Blue Cross, Massachusetts’ largest private health insurer.
“For so many years, the health care field was really paralyzed by the belief that controlling costs would actually harm quality,” Blue Cross chief executive Andrew Dreyfus said. “What this study again reinforces is with the proper incentives, you can control costs and improve quality.”
The Blue Cross program and others like it differ from earlier experiments in payment reform because of their emphasis on quality measures. Blue Cross requires doctors to score well on dozens of different measures before they can earn bonuses.
In the 1980s and 1990s, “there were concerns about doing too few things — like people would not do a cardiac bypass procedure because it would be too expensive,” said Dr. Steven Strongwater, chief executive of the physician group Atrius Health. “What these measures have done is erase that risk, by virtue of the fact that you’re measuring outcomes.”
The Blue Cross program gives doctors special funds to invest in care management. Atrius — among the first medical groups to join the Blue Cross program — used some of that money to hire new care managers who worked with patients to control their blood pressure. In 2009, 65 percent of Atrius patients had blood pressure in a healthy range. A decade later, that has grown to 85 percent.
Meanwhile, Atrius — which includes Harvard Vanguard and other physician practices — is also working to save money by moving common surgeries, such as joint replacements, from hospitals to ambulatory surgery centers.
Alternative payment programs account for about 41 percent of patients with private insurance in Massachusetts, according to state data. The popularity of these programs varies in other states, and nationally, the traditional fee-for-service payment system remains the norm.
Massachusetts has been more aggressive than other states in taking on health care costs. It set a target — 3.6 percent — for controlling annual increases in total statewide health spending. It also created a new watchdog agency, the Health Policy Commission.
In 2017, the most recent year for which figures are available, total health care spending in Massachusetts increased 1.6 percent — the lowest level in five years — even though costs remained a burden for many patients.
Dr. David Blumenthal, president of the New York-based Commonwealth Fund, a nonprofit that does health policy research, said the Harvard study demonstrates that payment reform is a critical piece of the strategy to control costs.
“We generally don’t give experiments in health system reform enough time to prove themselves,” Blumenthal added. “This is an eight-year study, which is unusually long for a social experiment. It shows we may have to wait a certain amount of time to reach judgment in the experiments we launch.”
https://www.bostonglobe.com/business/2019/07/18/blue-cross-approach-paying-doctors-based-quality-care-shows-results-harvard-study-finds/wf4GBM1Giro2OevOyZCr0M/story.html?
