Health Care Reform Articles - March 31, 2022

 

Health Care Reform Must Return Ownership to the Community Health Justice Monitor - March 31, 2022

Summary: In a landmark article in The Nation, long-time single payer leaders (including four HJM bloggers) review the pervasive and damaging ownership of providers by corporations. They propose that real reform must transfer ownership and control of providers to communities.

Medicare for All Is Not Enough - The Nation - March 31, 2022 By David U. Himmelstein, Steffie Woolhandler, Adam Gaffney, Don McCanne, John Geyman   We have long advocated for single-payer national health insurance. By eliminating private insurers and simplifying how providers are paid, single-payer would free up hundreds of billions of dollars now squandered annually on insurance-related bureaucracy. The savings would make it feasible to cover the uninsured and to eliminate the cost barriers that keep even insured patients from getting the care they need. And it would free patients and doctors from the narrow provider networks and other bureaucratic constraints imposed by insurance middlemen. We still urgently need this reform.   However, the accelerating corporate transformation of US health care delivery complicates this vision. In the past, most doctors were self-employed, free-standing hospitals were the norm, and for-profit ownership of facilities was the exception. Single-payer proposals hence envisioned payment flowing from a universal, tax-funded insurer (like traditional Medicare) to independent clinicians, individual hospitals, and other locally controlled, nonprofit providers. This was usually the state of play when national health insurance (NHI) was achieved in other nations, such as Canada in the 1960s and ’70s—the model for single-payer reform in the United States.   But insurers are now being joined by a new set of corporate middlemen asserting control over American care. Amazon plans to expand Amazon Care from Seattle to 20 other cities this year, and then to all 50 states. Wall Street is buying up doctors, hospitals, and other health care institutions, distorting care to generate profit. Today, most doctors are employees of large organizations, and most hospitals have become subsidiaries of corporate enterprises encompassing many facilities and firms with tenuous ties to the communities they serve. Meanwhile, for-profit control of health care providers—including by private equity firms—has burgeoned, despite strong evidence that profit-seeking siphons off resources and undermines quality.   These sweeping changes require an expansion of the traditional single-payer vision. Reform needs to go beyond changing the way we pay for care: It also needs to change whom we pay for care. Communities, not corporations, should own our nation’s vital health care assets.   Responding to the evidence of for-profits’ misconduct, most Medicare for All bills and proposals have prudently called for either the exclusion or public buy-out of for-profit providers. However, the first option, excluding them, is not a viable solution, because their facilities—like the 5,300 dialysis clinics owned by Fresenius and Davita, the two dialysis giants—are needed for patient care. And while a public buy-out is economically feasible, who would then own and operate such providers? And what of the nonprofits whose boards often run them as private fiefdoms and increasingly behave like for-profit wannabes?   In both instances, a transition to public, community-based ownership—a reform model generally labeled National Health Service (NHS), in contrast to NHI—seems the most appropriate solution, especially since taxpayers have directly or indirectly bankrolled the construction of most hospitals and other health facilities.   Such an NHS should have federal funding and oversight, similar to the Veterans Health Administration—a publicly owned and operated health system that delivers higher quality of care at lower cost than the private sector. However, as Democratic Representative Ron Dellums proposed in the 1970s, the NHS should delegate day-to-day governance to local communities. The system should direct new investments to currently underserved communities, develop the primary care infrastructure that is the bedrock of effective and efficient care, and build the linkages between public health and medical care whose lack has hobbled the US’s pandemic response—and in so doing, turn the tide of faltering health in America.

Comment by: David Himmelstein & Steffie Woolhandler   Medicare for All would cover the 31 million who are uninsured, relieve the cost burdens faced by the tens of millions more who are under-insured, rein in administrative costs, and ameliorate inequality because providers would receive the same reimbursements for the care of rich and poor patients.   But Medicare for All would not, by itself, address the ill effects of the corporate ownership of physicians' practices, hospitals, and other health care institutions. Avaricious firms -- both for-profit and non-profit – are gobbling up the vital resources needed for care, gaming even traditional Medicare's payment incentives, and prioritizing profitability over patients' and communities' needs. Physicians, like other health care personnel employed by these organizations, must either comply with executives' profit-seeking directives or be shown the exit.   Hence, health care reform must address who owns health care, not only who pays the bill. Taxpayers' and patients' dollars have paid to build the US health care system; the public must reclaim ownership of it. Following Scotland's National Health Service, we should recast patients (in partnership with health care personnel) as owners of the health care system, not its customers.   House of Medicine for Rent by Peter Swenson, Ph. D. - Medscape Internal Medicine - March 29, 2022 Organized medicine has come a long way since the founding of the American Medical Association (AMA) in 1847. For conflicts of interest, the journey has been a downhill slide. At its inception, the AMA declared that it was “reprehensible" for physicians to attest to the efficacy of patent medicines or in any way to promote their use. Holding a patent for any drug or surgical device was "derogatory to professional character" for doctors. Accepting money to shill for industrial patent holders was a breach of ethics. Starting in the 1920s, organized medicine, including hundreds of specialty societies, discarded this staunch defiance of commercialism for wary collaboration and ultimately a full embrace of support from the pharmaceutical and medical device industries. Today, the threadbare remnant of organized medicine's original stance is a weak principle of "transparency" about the flow of money and influence from industry into medical practice. But organized medicine doesn't even hold itself to that flimsy standard. Anyone can now go to the federal government's Open Payments website to see what individual physicians receive from industry. And as of 2022, what physicianassistants and specialty nurses get is also being exposed to sunshine's supposed disinfecting properties. Even money flowing from industry to academic medical centers is reported — but the same isn't true for their professional societies. Why not? The human and economic costs of medicine's commercial entanglements are huge: overdiagnosis, overuse, overmedicalization — and therefore potential doings of harm. Because medical societies actively contribute to the bustling business of continuing medical education, the promulgation of clinical guidelines, and publication of educational material on drug and device therapies, they potentially share responsibility for overpriced and often meretricious drugs, often used for poorly studied off-label indications, contributing to clinical risks and massive waste. The grossest example of economically compromised organized medicine was exposed in the US Senate's 2017 investigation of the opioid epidemic. The public learned how Purdue Pharma and Johnson & Johnson spent close to $9 million between 2012 and 2017 on physician and patient organizations (like the American Pain Society) that together broadcasted the unfounded claim that opiates prescribed for pain rarely led to addiction. The medical-industrial complex's laser focus on expensive medicinal therapies and surgical interventions means neglect of prevention and the social causes of disease in medical organizations' educational and lobbying activities. For example, out of around 300 scientific sessions of the upcoming 2022 meeting of the American College of Cardiology (ACC), only seven concern lifestyle and other nonmedicinal modes of prevention. By contrast, there were at least 38 sessions sponsored by pharmaceutical and medical device corporations on clinical uses of their products are planned. From Arm's Length to Ready Embrace The opioid crisis exposed only the scandalous tip of a deeply rooted problem that was long in the making. Early in the 20th century, AMA executive and JAMA editor George H. Simmons treated drug companies "with suspicion and grave doubt, like diplomats working on an armistice." Simmons told his successor, Morris Fishbein, that negotiating with pharmaceutical manufacturers to clean up their specious advertising was "about the same as Faust trying to make a deal with Mephistopheles." Under Simmons, the AMA succeeded in imposing some ethical standards for industry access to JAMA's advertising pages. It actively lobbied for passage of the Pure Food and Drugs Act of 1906. But after 1924, under Fishbein, the downward slide began. In 1938, the AMA watched passively as lay forces pushed for another major drug law reform, the Federal Food, Drug, and Cosmetic Act, which demanded proof of safety before marketing. In the early 1940s, Fishbein helped raise $1 million for a massive "National Physicians Committee" campaign to fight national health insurance and therefore preserve the "American system of medicine." But the committee was mislabeled —about 90% of its funding came from Hoffman-Laroche and other huge drug companies. "Captive and Beholden" In the 1950s, the AMA and the drug industry became fully enmeshed. JAMA relaxed its control on advertising to increase its revenue. A revolving door opened between the two. The Pharmaceutical Association of America (PMA) rewarded Austin Smith, who had succeeded Fishbein in 1949, with its presidency. In 1963, after Smith moved on to a more lucrative job as president of Parke-Davis, the PMA replaced him with C. Joseph Stetler, the AMA's executive vice president. Money circled back. In the early 1960s, 17 of the largest drug firms gave nearly $1 million to the AMA's lobbying arm to help it fight Medicare, in part out of fear of federal controls on drug pricing. In 1962, the AMA testified along with the PMA against a proposed amendment to the 1906 Food and Drug Act that demanded that new drugs show efficacy, not just safety, in controlled clinical studies. The AMA argued that individual clinicians didn't need government advice on what worked or didn't. It also backed the drug industry's successful objections to provisions breaking its monopoly pricing power. The unholy alliance was cemented in the early 1970s. In 1971, the AMA dropped from its ethical code its historic disapproval of medicine patents held by physicians. The next year, it shut down its semi-independent Council on Drugs that had issued advice on hundreds of products on the market to help bewildered clinicians separate good from useless — or worse — medications. The council had damned many profitable drugs as "not recommended" or even "irrational." In 1973, John Adriani, the chair of the now-disbanded council, indignantly explained to Congress that the AMA was "captive of, and beholden to, the pharmaceutical industry." Rental Payments The ties have only grown tighter. Over the last 40 years, medical specialty societies have eclipsed the AMA in overall importance and political muscle. Much of their growth in revenues and activities was funded by industry. In a 2008 Medscape article, Lawrence Grouse, a disaffected insider in the ranks of organized medicine, estimated that many specialty societies received almost 80% of their revenue from industry for grants-in-aid, project grants, educational enterprises, donations to their spin-off foundations, and in-kind contributions. He had to estimate because of the organizations' secrecy. Since then, nothing has changed. In 2019, for example, membership dues accounted for only about 13% of the almost $150 million that the ACC and its foundation took in. That most of the remaining revenue came from industry can be inferred from the fact that in 2018, 22 of the ACC's 26 leaders had financial ties with industry totaling almost $23 million. In fact, around 80% of specialty society leaders in the 10 costliest areas of medicine, including cardiology, had financial ties with industry. For those with ties, the median reward was about $30,000. For leaders of the American Society of Clinical Oncology with such ties, the median was a little over $500,000. What remains today of the 19th century AMA ethics against entanglement with medical industries? Nothing but a lukewarm endorsement of the need for transparency about which medical practitioners get what from whom. Tellingly, the forceful implementation of that principle had to be pushed for by a coalition of outsiders to organized medicine, including powerful politicians, in the form of the Physician Payments Sunshine Act, which was passed in 2010 as part of the Affordable Care Act. Of course, keeping money out of medicine is impossible and probably not even desirable, given the relative scarcity of federal funding for medical research, continuing medical education, and clinical guideline formulation. But we must do something to restore balance to the system. Medical reformers have offered various solutions to organized medicine's pervasive conflicts of interest, including a total divorce from industry. Those will be slow in coming. An intermediate fix, albeit an insufficient one, would be for the law to subject the entanglements to critical scrutiny by the public and the medical profession at large. But considering the likely opposition to forced reporting and public disclosure, even new federal regulations or congressional action will be hard to achieve. Between 1998 and 2021, the AMA was the fourth largest spender on federal lobbying among trade associations and major corporations — doling out more than $462 million during that period. Without a countervailing alliance of lay forces and reform-minded physicians to force disclosure, the armada of specialty societies and industry powerhouses will continue to have unchecked power and political clout. And that's a prescription for bad medicine. Peter A. Swenson, PhD, is the C.M. Saden Professor of Political Science at Yale University, New Haven, Connecticut, and a prize-winning author on the political history of healthcare and the welfare state. His latest book is Disorder: A History of Reform, Reaction, and Money in American Medicine (Yale University Press, 2021). https://www.medscape.com/viewarticle/970974#vp_3

PACE helps older adults stay in their community

by Dr. Peter DeGolia - Just Care - March 14, 2022

The Program of All-inclusive Care for the Elderly (PACE) is a home and community-based program designed to keep older adults who are at risk for nursing home placement living in their community.  PACE is a partnership between a local sponsoring organization, and Medicare and Medicaid health insurance programs. To become a PACE “participant,” a person must be nursing home eligible. While a person can pay privately for services, most participants have Medicare, Medicaid, or both insurance programs.

The PACE philosophy: PACE members are called “participants” because they are encouraged to participate in their care–decision making and active care–whenever possible.  The overarching goal of the PACE Model of Care is to keep people living in the community and out of institutional care.  While an individual does not need to visit the PACE Center, which offers adult day programs with wrap around health services, it promotes socialization and addresses common problems of isolation, loneliness, and boredom.

Who can get PACE? Programs of All-Inclusive Care for the Elderly (PACE®) serve individuals who are age 55 or older, certified by their state to need nursing home care, able to live safely in the community at the time of enrollment and live in a PACE service area.

How does PACE work? PACE works by providing care and services in the home, the community, and at the PACE center. It is team-based care that provides everything covered by Medicare and Medicaid if authorized by your health care team.  If your health care team decided you need care and services that Medicare and Medicaid doesn’t cover, PACE may still cover them.  The team provides comprehensive coordinated care and includes the PACE participant, physician, nurse, social worker, recreational specialist, rehabilitation specialists, and transportation specialists.

Services: Delivering all needed medical and supportive services, a PACE program is able to provide the entire continuum of care and services to older adults with chronic care needs while maintaining their independence in their home for as long as possible. Services include the following:

• adult day health care that offers nursing; physical, occupational and speech/language therapies; recreational therapies; meals; nutritional counseling; social work and personal care;
• medical care provided by a PACE physician familiar with the history, needs and preferences of each participant;
• home health care and personal care;
• all necessary prescription and over-the-counter medications;
• medical specialties, such as audiology, dentistry, optometry, and podiatry and speech therapy;
• respite care; and
• hospital and nursing home care when necessary.

See more at: http://www.npaonline.org/policy-advocacy/value-pace#services

Find a PACE program near you: Currently, there are 144 PACE organizations in 30 states serving 58,000 people. To find out if you or a loved one is eligible, and if there is a PACE program near you, visit www.pace4you.org or www.Medicaid.gov, or call your Medicaid office.

Beware of for-profit PACE programs: Government audits find for-profit PACE program neglects patients, delays needed care and cancels critical care.

Learn what to do to ensure safety at home for people aging in their communities. And, see how one new program is helping older adults remain at home with assistance from a handyman, occupational therapist and nurse. For those who like technology solutions, check out how sensors can offer peace of mind to caregivers.

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https://justcareusa.org/pace-helps-older-adults-stay-in-their-community/?

 

Albert Lea seniors caught in insurance quagmire, with limited access to new clinic

Residents are asking the Minnesota attorney general to help resolve the issue. 

by Christopher Snowbeck - Star Tribune - March 19, 2022

Albert Lea residents scrambled a few years ago to recruit a new health care provider after Mayo Clinic announced it would start closing many hospital services in the southern Minnesota town.

The effort culminated last summer with the opening of MercyOne Albert Lea Family Medicine & Specialty Care, a new facility that's competing for patients against the clinic and hospital operations that Mayo still runs in the community.

But some patients say their access to the new clinic is being sharply limited by insurance rules that make visits to MercyOne much more expensive. It's a problem for seniors enrolled in Medicare health plans from Blue Cross and Blue Shield of Minnesota, the dominant carrier in the market.

The dust-up is the latest example of how rules governing insurance networks — the subset of clinics and hospitals where subscribers pay less out of pocket to see a doctor — can limit choices for seniors as more elect to receive their government benefits through private Medicare Advantage health plans.

At least some of the affected seniors are asking Blue Cross to work with Mayo to remove the barrier, and recently turned to the state attorney general for help.

"Why would we have a clinic in Albert Lea that we can't use?" asked Jan Mattson, 79, of Albert Lea. "It seems to me like Blue Cross Blue Shield could add Mercy to in-network, and then I would be very happy."

Blue Cross says that it has no plans to add MercyOne to its regional Medicare Advantage network. Mayo has a say in any such change, the insurer says, because contract terms give the Rochester-based clinic "a financial responsibility to improve health outcomes and lower health care costs in southern Minnesota," Blue Cross said in a statement.

Specific contract terms that would illustrate exactly how this all works are confidential. But agreements like the one between Blue Cross and Mayo are described in the insurance industry as "narrow" or "focused" network arrangements.

In these deals, health care providers give insurers a better price for services so they are in the health plan's network and have the chance to treat a greater volume of patients. Patients pay significantly more out-of-pocket when they go out-of-network, so the incentives are strong to get most care in-network.

The agreement between Blue Cross and Mayo is a "total cost of care" contract, an increasingly common type of payment relationship where providers take a degree of financial risk for the overall health costs and outcomes for health plan enrollees.

In such agreements, providers want to control as much of the care given in a population as possible to boost quality while keeping overall expenses down.

Adding too many other clinics and hospitals could introduce more costs, or worsen patient outcomes, in ways that would limit payments for the health system. So, Blue Cross says, it's not unusual in these arrangements for the primary health care system to have a say in creating the network and subsequent changes to it.

Mayo is the "focus" of the current network in the region, but it does include "many other non-Mayo specialty providers, at a competitive price," Blue Cross said.

For its part, Mayo said it "does not oppose the addition of other facilities or providers if they would best serve the community."

Following a meeting with Albert Lea residents this month, Attorney General Keith Ellison "is exploring what tools his office may have to help in this matter," a spokesman said in an e-mail.

Other Medicare Advantage plans available in Albert Lea provide in-network access to the new clinic.

Eagan-based Blue Cross runs by far the biggest Medicare Advantage heath plan in and around Albert Lea with about 2,000 enrollees in Freeborn County.

Because MercyOne is out-of-network, subscribers in that part of the state who want to use the new clinic must pay 45% of the allowed amount for treatments. This "co-insurance" fee typically is much larger than the fixed-dollar copays patients pay at in-network clinics.

Seniors in Albert Lea say they're irritated that the new clinic is actually in-network for people in the Twin Cities and western Minnesota who enroll in Medicare Advantage plans from Blue Cross; it's only out-of-network for those in Freeborn and 14 other counties across southern Minnesota.

"Our Medicare Advantage network in southern Minnesota was built from the ground up in partnership with Mayo to ensure our members have access to high-quality local care at a competitive price," Blue Cross said.

MercyOne didn't know the Medicare Advantage plan from Blue Cross in southern Minnesota had a limited network "until we tried to sign up for it," said Rod Schlader, the president of MercyOne Northern Iowa Medical Center in Mason City.

"We finally got to the bottom of it, and they said: We're sorry, this is a narrow network product that they've come to an agreement with, with Mayo," Schlader said. "And right now, they're not allowing any other providers to join that narrow network product."

The barrier is unique to Medicare Advantage plans from Blue Cross, he added, so people in Albert Lea with other types of coverage from the health insurer have in-network access to the new clinic.

MercyOne, which is based in suburban Des Moines, is not a small player. It's a joint venture between two large, national nonprofit health care systems that operates a number of hospitals and clinics in Iowa. The health system's clinic in Albert Lea was created with some financial support from the Albert Lea Healthcare Coalition, a nonprofit group that recruited MercyOne.

"When you really think about it, shouldn't Blue Cross and Mayo be sitting down and saying: What is in the best interest of the citizens of southern Minnesota?" asked Brad Arends, a benefits consultant and leader with the community group. "The best interest of the people ... is to get MercyOne in that network."

For Annie Mattson, the network snag led her to drive 25 minutes from Albert Lea last summer to get painful symptoms diagnosed at a clinic in a neighboring town.

Mayo's Albert Lea clinic couldn't see her that day and the symptoms didn't seem to require a visit to Mayo's emergency room in town. She could have been seen promptly at the new MercyOne clinic, but doing so would have been more expensive.

Mattson is happy for the care she received for what turned out to be a kidney stone at Mayo's clinic in New Richland. What's upsetting though, she said, was having to drive 20 miles from her home when the MercyOne clinic was just 5 minutes away.

"After all the time and effort of starting this clinic, we certainly want to be a part of it," said Mattson, 70, who collected signatures back in 2017 to protest Mayo's announcement that it would scale back hospital operations in Albert Lea.

"The inflexibility has caused me to change my health care from the Blue Cross Medicare Advantage to UnitedHealthcare," she said.

Mattson and her partner, Paul Stieler, were on a call this month urging the attorney general to intervene. Stieler's health insurance lets him visit MercyOne, but he's concerned the network limit at Blue Cross could hurt the new clinic.

That's a problem, he said, because MercyOne helps the local economy while giving seniors in the region a better shot at accessible and affordable health care.

"I feel that Mayo has created a monopoly down here in this area, and because they have a monopoly they can charge more," said Stieler, 74. "This block that we have on being able to use the Mercy clinic is not good."

Albert Lea residents have long been among the most vocal in criticizing the cost of care at Mayo while feeling captive to the health system.

They cite reports from a Minneapolis-based nonprofit group showing patient care costs in Minnesota are highest at Mayo — a finding that clinic officials over the years have argued stems from flaws in the group's methodology.

The Medicare Advantage plan for southern Minnesota was launched as part of a broader contract agreement struck in 2018 between Mayo and Blue Cross.

Since then, premiums for the primary two Medicare Advantage plans from Blue Cross in the region have increased by more than $12 and $36 per month, while monthly rates for comparable plans in the Twin Cities and western Minnesota have declined.

Blue Cross said premiums are based on a variety of factors including payment rates to health care providers as well as differences in the medical needs of enrollees.

Mayo says it controls costs by coordinating care within its health system including a single electronic health record spanning regional clinics and hospitals as well as its large medical center in Rochester.

"As patients need testing, lab work, radiologic exams, and other diagnostic procedures, they do not need to duplicate those tests as they move through the Mayo Clinic system, thereby saving costs for patients and payers," the clinic said in a statement.

https://www.startribune.com/albert-lea-seniors-caught-in-insurance-quagmire-unable-to-access-new-clinic-mercyone-mayo/600157524/?

 

The case of the $489,000 air ambulance ride

by Julie Applebye - Kaiser Health News - March 25, 2022

 

Sean Deines and his wife, Rebekah, were road-tripping after he lost his job as a bartender when the pandemic hit. But while visiting his grandfather in a remote part of Wyoming, Sean started to feel very ill.

Rebekah insisted he go to an urgent care center in Laramie.

"Your white blood count is through the roof. You need to get to an ER right now," Deines, 32, recalls a staffer saying. The North Carolina couple initially drove to a hospital in Casper but were quickly airlifted to the University of Colorado Hospital near Denver, where he was admitted on Nov. 28, 2020.

There, specialists confirmed his diagnosis: acute lymphoblastic leukemia, a fast-growing blood cancer.

"Literally within 12 hours, I needed to figure out what to do with the next step of my life," said Deines.

So, after he was started on intravenous treatments, including steroids and antibiotics, to stabilize him, the couple decided it was prudent to return to North Carolina, where they could get help from his mother and mother-in-law. They selected Duke University Medical Center in Durham, which was in his insurance network.

His family called Angel MedFlight, part of Aviation West Charters of Scottsdale, Ariz., which told Rebekah Deines that it would accept whatever the couple's insurer would pay and that they would not be held responsible for any remaining balance.

Sean Deines was flown to North Carolina on Dec. 1, 2020, and taken by ground ambulance to Duke, where he spent the next 28 days as an inpatient.

By his discharge, he felt better and things were looking up.

Then the bills came.

The patient: Sean Deines, 32, who purchased coverage through the Affordable Care Act marketplace with Blue Cross Blue Shield of North Carolina.

Medical service: A 1,468-mile air ambulance flight from Colorado to North Carolina, along with ground transportation between the hospitals and airports.

Service provider: Aviation West Charters, doing business as Angel MedFlight, a medical transport company.

Total bill: $489,000, most of which was for the flight from Denver, with approximately $70,000 for the ground ambulance service to and from the Denver and Raleigh-Durham airports.

What gives: Insurers generally get to decide what care is "medically necessary" and therefore covered. And that is often in the eye of the beholder. In this case, the debate revolved first around whether Deines would have been stable enough to safely take a three-plus-hour commercial flight to North Carolina during a pandemic or did he require the intensive care the air ambulance provided. Second, there was the question of whether Deines should have stayed in Denver for his 28-day treatment to get him into remission. Insurers tend not to consider patient stress or family convenience in their decisions.

Also, both air and ground ambulance services have been center stage in the national fight over huge surprise bills, since the for-profit companies that run them frequently do not participate in insurance networks.

Angel MedFlight, which was not in Deines' insurance network, sought prior authorization from Blue Cross Blue Shield of North Carolina. The request was dated Nov. 30, but the insurer said the fax arrived in the predawn hours the same day as the flight, Dec. 1, 2020.

On that day, Angel MedFlight flew Deines to North Carolina in an airplane, along with a nurse to oversee his IV medications and oxygen levels.

Angel MedFlight spokesperson Kimberly Halloran did not answer a specific written question from Kaiser Health News about why the flight went ahead without prior approval; often medical interventions are postponed until it has been obtained. But in an emailed statement to KHN, she said the company "satisfied each step in the health insurance process and transported Sean to his long-term health care providers in good faith."

According to the review of the case done months later by an independent evaluator, Blue Cross on Dec. 3 denied coverage for the air ambulance services because medical records did not support that it was an emergency and Deines was already in an appropriate medical facility.

At the end of December, Angel MedFlight filed an appeal of that decision on Deines' behalf.

Then, in March 2021, Blue Cross sent Deines a check for $72,000 to cover part of the $489,000 bill, which he forwarded to the air ambulance company. The explanation of benefits showed the majority of the charges were ruled "not medically necessary."

Angel MedFlight, through a revenue management firm it hires called MedHealth Partners, continued to appeal to Blue Cross to overturn the denial of the flight portion of the bill.

Then, three months after Blue Cross demanded Deines pay back the $72,000 that he had already sent to Angel MedFlight.

"The initial thought was, 'I can't believe this is happening,' " said Deines.

Medical necessity criteria are set by insurers, with North Carolina Blue Cross covering air ambulances in "exceptional circumstances," such as when needed treatment isn't available locally. 

Sean and Rebekah Deines review his medical bills at their home in Hendersonville, N.C. Eventually, the insurance company dropped its attempt to get repayment.

When Deines, who was still unemployed and undergoing treatment, couldn't pay, the debt was sent to collections.

In late June, Deines' representatives at Angel MedFlight took the next step allowed under the Affordable Care Act, appealing the insurer's internal determination that the flight wasn't medically necessary to an independent third party through the state.

On July 29, the evaluator ruled in favor of Blue Cross.

Normally, such a flight would be appropriate because the patient was "medically unfit to travel via commercial airflight," the review noted. But, it went on to say, there was actually no need to travel, as the University of Colorado Hospital — a member of the National Comprehensive Cancer Network — could have managed Deines' treatment.

His health plan "clearly stipulates their indications for medical flight coverage and unfortunately this case does not meet that criteria," the review concluded.

Resolution: The bill disappeared only after the press got involved. Shortly after a KHN reporter contacted the communications representatives for both the insurer and Angel MedFlight, Deines heard from both of them.

The $72,000 payment was made in error, said Blue Cross spokesperson Jami Sowers.

"We apologize for putting the member in the middle of this complicated situation," she said in an email that also noted "the air ambulance company billed more than $70,000 just for ground transportation to and from the airport — more than 30 times the average cost of medical ground transport."

Such a situation would "typically" be flagged by internal systems, but for some reason, it was not, Sowers said.

"I have never heard of a ground transport that costs that much. That's shocking," said Erin Fuse Brown, director of the Center for Law, Health & Society at Georgia State University College of Law, who studies patient billing and air ambulance costs.

Still, there's good news for Deines: Both the insurer and the air ambulance company told KHN he will not be held responsible for any of the charges. (None of the charges stemmed from his first air ambulance flight from Casper to Denver, which was covered by the insurer.)

"Once North Carolina Blue engages in our formal inquiries about its refund request, the status of the funds will be resolved," the ambulance spokesperson wrote in her email. "One thing is certain, Sean will not have to pay for North Carolina's wavering coverage decision."

In an email, Blue Cross' Sowers said it had "ceased all recoupment efforts" related to Sean Deine's case.

The takeaway: If the flight had happened this year, the couple might have received more price information before they took the flight.

A law called the No Surprises Act took effect Jan. 1. Its main thrust is to protect insured patients from "balance bills" for the difference between what their insurance pays and what an out-of-network provider charges in emergencies.

It also covers nonemergency situations in which an insured patient is treated in an in-network facility by an out-of-network provider. In those cases, the patient would pay only what they would owe had the service been fully in-network.

Another part of the law, called a good faith estimate, might have provided Deines with more transparency into the costs.

That portion says medical providers, including air ambulances, must give upfront cost estimates in nonemergency situations to patients. Had the law been in effect, Deines might have learned before the flight that it could be billed at $489,000.

Insured patients in similar situations today should always check first with their insurer, if they are able, to see whether an air transport would be covered, experts said.

Even if the law had been in effect, it likely would not have helped with the big hang-up in Deines' case: the disagreement over "medical necessity." Insurers still have leeway to define it.

For his part, Deines said he's glad he took the flight to be closer to home and family, despite the later financial shock.

"I would not change it, because it provided support for myself and my wife, who needed to take care of me; she was keeping my sanity," he said. 

https://www.mainepublic.org/npr-news/2022-03-25/the-case-of-the-489-000-air-ambulance-ride

Health Care Reform Articles - March 18, 2022

Editor's Note -

 Check out this 11 minute video about the causes of high health care costs in America from CNBC. 

Not too bad, considering the source.  

https://www.cnbc.com/2022/02/28/why-health-care-costs-are-rising-in-the-us-more-than-anywhere-else-.html?utm_campaign=KHN:%20Daily%20Health%20Policy%20Report&utm_medium=email&_hsmi=205419556&_hsenc=p2ANqtz-_Ze9I3Es0m5sMFScqTP2fJJGufzBmPstSeEONi2GNJsJhGfmqPfG3MGROYkGt0WVevQmTAE3C7TF2sRA-b2dL1r5jXQQ&utm_content=205419556&utm_source=hs_email

-SPC

Disease took my brother. Our health-care system added to his ordeal.

 by Karen Tumulty - Washington Post - March 11, 2022

One family's struggle with cascading medical bills and a system determined to make it harder.

 

My brother Patrick died at the age of 67, after having beat the medical odds again and again, until he could beat them no longer. He lived 4½ years with Stage 4 glioblastoma, the deadliest of brain cancers, for which the survival is normally 12 to 16 months; his oncologist called him “Miracle Man.” This was on top of kidney failure, which required three-times-a-week dialysis, and a lifetime of struggle with Asperger’s syndrome, a disorder sometimes referred to as high-functioning autism.

 

As a child, Pat could multiply three-digit numbers in his head, but social interactions mystified him and making friends did not come naturally. Our father was in the Air Force, and we moved almost every year; at each new school, the bullies quickly found him. Yet no one who knew him could ever remember seeing him angry or bitter. He assumed the best of people, no matter how many times they betrayed that trust; I don’t think he was capable of a mean-spirited act.

As an adult, Pat was proud and protective of his independence. But when he reached his early 50s, his health began to fail. My brother found himself up against not just disease but a broken medical system. Pat’s journey became a story of the best and worst of health care in this country, and it reveals the real-life consequences when health-care policy is treated like a football by two political parties.

None of which our family would have anticipated back in 2007, when Pat, who had always been fit, began having bouts of fatigue and a fluctuating appetite. Then came more alarming signs: His blood pressure crept up to 150/90; his urine turned brown and foamy.

At the time, Pat was unemployed, having been laid off from his $9-an-hour position as an administrative assistant. That job hadn’t paid benefits; nor had the one before it. So he had bought a series of high-deductible, six-month medical insurance policies that promised “the peace of mind and health care access you need at a price you can afford.”

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A skimpy plan was indeed the only policy he could afford — and it turned out to be a big mistake. Though Pat had faithfully kept up the premium payments for more than six years, his insurer began denying his claims a few weeks after a biopsy in July 2008 showed his kidneys were failing.

The company, a subsidiary of Assurant Health, cited a technicality: Each successive six-month policy treated Pat as a new customer. In digging through Pat’s records, it noticed some abnormal bloodwork from the previous December, eight months earlier. Though at the time the test result was inconclusive, the insurer deemed it evidence that Pat had a “preexisting condition,” meaning his policy wouldn’t cover it.

At that point, Pat was facing more than $14,000 in bills from hospitals, doctors and labs — and those were just to figure out what was wrong with him. Dealing with his condition going forward was going to be unimaginably expensive; newer drugs that his specialist thought might help him the most could cost up to $10,000 a treatment; even the older ones could run $500 a month. “Cancel that policy,” the billing coordinator at the doctor’s office advised me. “Your brother is wasting his money on premiums, and he’s going to need it.”

Suddenly stranded with no coverage at all, Pat had plenty of company in our home state of Texas, which, then as now, led the country in both the highest number and the highest percentage of its residents who are uninsured. (The rate was 18.4 percent in 2019, twice the national average.)

Texas’s Medicaid program — which the state has chosen not to expand, despite the incentives offered by the Affordable Care Act — is notoriously stingy; a non-disabled adult without children, such as Pat was, could not qualify if he earned more than $2,274 a year. The offerings of the state’s high-risk pool, for those who are hard to insure, was not only twice as expensive as a typical medical policy, but Pat would have had to wait a year to join with a preexisting condition.

Peter Smolens, his kidney doctor, assured us he would keep treating Pat even if he couldn’t pay — as Smolens did with 10 percent of his other patients. A social worker in his office made countless phone calls seeking forbearance from other providers. (One radiologist gave him a $22 hardship discount off a $626 tab, adding: “We are happy that we could be of assistance to you and your family in this time of need.”) Knowing that creditors could come after his one-bedroom condominium, his 2003 Saturn Ion and his $36,000 in savings, Pat began paying off bills in bits and pieces as best he could: $51.89 a month to one hospital, $76 to another, monthly installments of $4.78 to $111.89 on six different sets of laboratory charges.

I also did research into Assurant Health, and discovered regulators in Connecticut had imposed a record $2.1 million in penalties on two of its subsidiaries for allegedly engaging unfairly in a practice called “postclaims underwriting” — combing through short-term policyholders’ medical records, as they had with Pat’s, to find pretexts to deny their claims or rescind their coverage. We had canceled Pat’s useless policy, but I nonetheless lodged a complaint with the Texas Department of Insurance. In reply, Assurant maintained it had done nothing wrong, but it offered to cover the bills it had rejected the previous year — which it claimed was a gesture of beneficence that nodded to “the extraordinary circumstances involved.”

These practices were common at the time. Insurers argued they were necessary to prevent fraud — specifically, people buying policies only after they learned they are sick. That clearly was not the case with Pat, but that didn’t seem to matter in the case of Assurant’s decision not to cover his care.

One of the more popular provisions of the Affordable Care Act did away with insurance company exclusions for preexisting conditions. Barack Obama’s administration also significantly curtailed short-term plans, such as the junky one Pat naively bought, by prohibiting them from being purchased for more than three months. They were available as a stopgap for people who, say, were briefly between jobs. But for the longer term, the idea was to steer people toward the more comprehensive coverage offered on the ACA’s government-run insurance exchanges for those who do not receive insurance through their employer. As Pat’s experience showed, diagnosing and treating an unexpected illness is not something that can be wedged neatly into six-month increments.

After Donald Trump was elected, Republicans fell short in their efforts to repeal all of Obama’s signature legislative achievement, but they managed to undercut it where they could — including by issuing new regulations that allowed health insurance companies to once again sell short-term policies, renewable for up to three years. The policies were not required to cover preexisting conditions or offer a full array of benefits. Trump Health and Human Services Secretary Alex Azar conceded that short-term insurance “may not be the right choice for everybody,” but insisted, “we believe strongly in giving people options here.”

Assurant Health, the parent company of Pat’s former insurer, meanwhile, got out of the business of selling individual health policies in 2016, after failing to find a buyer for that part of its operation. Its questionable business model was a casualty of the ACA. As Crain’s Chicago Business noted: “Regulators routinely found that Assurant Health failed to pay or unreasonably denied medical claims.”

While Pat’s medical bills mounted and his kidneys continued to fail, he managed to find a job answering queries that came into a text-messaging service, which paid $1,257 a month, but it didn’t offer health coverage. He was almost out of options when he discovered a county program available to low-income people. It operated much like a health maintenance organization, negotiating prices with health-care providers and then billing clients on a sliding scale according to income.

For Pat, it cost only about $40 a month. But the system was complicated, especially for someone with Asperger’s, and he often got confused navigating between his kidney specialist, who prescribed tests and medications, and the county program, which had to approve them. As Smolens, his doctor, told me: “The fact is, for guys like Pat, it requires a lot more work to do the same sorts of things” that would be easily dealt with if he had insurance. At one point, Pat had a bad reaction to steroids and was taken by ambulance to a hospital that was not a participant in the county program. The result — including a pile of bills and a short, unhappy stint for Pat in a group home — was a bureaucratic, emotional and financial nightmare.

While this was going on, I was living in D.C. and covering the ongoing national debate over health-care reform for Time magazine, as I tried to help out as my brother’s long-distance case manager. I thought I was something of an expert on health-care policy; I had even moderated a presidential candidate forum on the issue in 2007.

But experiencing firsthand what so many other families were going through gave me a different understanding of the unending hurdles and real-life stakes that underlie the heated political battles raging around the subject. I wrote about Pat’s ordeal in a March 2009 cover story for Time that carried the headline “So You Think You’re Insured? (Think Again.)”

The January 2014 opening of the health insurance marketplaces created by the Affordable Care Act, though beset by technology glitches, was a godsend for Pat. Along with nearly three-quarters of a million other Texans, he signed up during the enrollment period; government subsidies made a “silver” plan affordable, and his options more flexible, though there were bumps from year to year as several companies dropped out of the marketplace.

But while he no longer had to worry about how to pay for his treatment, even the best care was not enough to hold back the progression of the kidney disease, a condition known as glomerulonephritis. By the end of 2016, he had end-stage renal disease, which meant he needed dialysis.

At this point, Pat encountered yet another paradox of the health-care system. End-stage renal disease is one of only two conditions that make people automatically eligible for Medicare, with no waiting period, regardless of their age. (Pat was 62.)

That meant he was already covered by Medicare and a supplemental policy eight months later, when another, even greater medical calamity struck: In early September 2017, Pat suddenly lost control of his car and crashed it. He was taken to an emergency room, where a scan revealed a baseball-size brain tumor. Surgery and a biopsy produced a diagnosis of Stage 4 glioblastoma; his doctors told me he could expect no more than a year to live. I scrambled to find him a new living situation, a comfortable apartment in Patriot Heights, a retirement community that also offered a separate skilled nursing facility and was near the medical center where most of his specialists practiced.

Pat was now caught: The fact that he was also undergoing dialysis made him ineligible for clinical trials that might have given him a better chance against the glioblastoma; that he had cancer meant he was no longer eligible to stay on the waiting list for a kidney transplant. My gentle, sweet brother accepted this new turn in his life as he had every other one, starting a regimen of radiation and chemotherapy without a trace of anger or despair. It helped enormously, however, that his Medicare coverage allowed all of us to concentrate on getting him what he needed, rather than worrying about how and whether he was going to pay for it.

For reasons the doctors couldn’t explain, Pat lived years longer than anyone thought possible. And he lived fully. He enjoyed raucous gatherings with our large extended family in San Antonio, and looked forward to visits from my brother Mike, who lives near Dallas. Pat’s new home was truly a community, one where he learned everyone’s life story and was greeted like the mayor when he entered the dining room. His fellow aging baby boomers were appreciative of his encyclopedic knowledge of ’60s and ’70s rock-and-roll.

The Patriot Heights staff was indulgent of — and more than a little amused by — his quirks and his routines; how he wanted four packets of honey with his coffee, his juice with and not before his meal, a serving of exactly eight grapes. Pat loved his Wednesday morning Bible study group, where he always volunteered to read aloud the epistle of the week, especially the ones by the apostle Paul, known for their comfort and righteousness. Physically, he was doing well enough to regain his driver's license, which restored a measure of his independence.

But in late 2020, doctors told us that his cancer, which had been stable for more than two years, was coming back. Over the next year, Pat endured a second brain surgery; a craniotomy to relieve a subdural hematoma that he suffered in a fall; and another fall that broke his hip, which required a partial replacement. And yes, Pat also caught covid.

After many trips to the hospital and several stints in nursing care, he was able to return to his apartment but required 24-hour caregivers — something he was able to afford thanks to a modest inheritance from my parents and a bit of savings of his own. But he lost the ability to walk and began suffering small seizures, which required frequent trips to the emergency room. He also began losing track of people’s names, something that really bothered a man who had always been proud of his remarkable memory.

Medicare paid for nurses to visit, and on Feb. 7, one of them called me to say that Pat had told her something I never expected to hear from him: He wanted no more treatment, and wished to be placed in hospice care. She then put him on the phone, and he repeated his wishes to me.

The end for him came gently 10 days later. It was a gift to all of us that he made this decision himself, that he could determine when the medical care that had prolonged his life had begun to make it unbearable.

At his memorial service, the Rev. Linda Gwathmey, a Patriot Heights resident who had led Pat’s Bible study group, read from 2 Timothy 4:7, a passage where Paul, in prison and near death, writes that he has given God and his fledgling church his best effort.

“I think Patrick was a little like Paul here. He was tired, he was depleted, he knew death was approaching, and he thought it might be soon,” she said. “Patrick, like Paul, fought the good fight, finished the race and kept the faith.”

We will miss him every day, but we are left with the soft light of Pat’s spirit, which we had never seen more clearly than in those final, borrowed years of his life. Rest in peace, big brother.

https://www.washingtonpost.com/opinions/2022/03/11/health-insurance-obamacare-karen-tumulty-brother/ 

Envision Healthcare Hits the Skids

Backed into a corner financially, the private equity–owned physician staffing company could put doctors and patients at risk.

by Eileen Appelbaum and Rosemary Batt - The American Prospect - - -March 14, 2022

 

Envision Healthcare—the private equity–owned emergency medicine group with some 70,000 health care professionals staffing 540 health care facilities in 45 states—is in serious financial trouble. Creditors have lost confidence in its ability to repay its huge debt. Envision’s $5.3 billion first-lien term loan, due in 2025, was trading in distressed-debt territory at the beginning of March 2022, at 73 cents on the dollar; and its senior unsecured note due in 2026 was trading at 53 cents on the dollar.

How did this happen to the largest U.S. physician staffing firm, owned by Kohlberg Kravis Roberts (KKR), one of the most financially successful private equity firms in the world? How can KKR extricate itself and protect its investment? And what happens to its doctors and patients?

Private equity firms like to boast about their closely guarded “secret sauce” recipe for how they buy a company, load it with debt, introduce new high-tech practices that increase efficiency and revenue, and exit at a profit. But KKR and Envision demonstrate these assertions are empty. KKR acquired Envision in 2018 in a leveraged buyout that burdened the company with billions in debt. But KKR’s plan for paying off the debt and garnering a high return for its investors was purely low-tech.

Envision’s emergency room doctors do not belong to any insurance network. This let Envision send surprise medical bills to patients even when the hospital was in the patient’s insurance network. Loading patients who sought emergency care with often unpayable medical debt was KKR’s secret sauce. It was as simple as that.

Envision’s reliance on surprise billing became clear by mid-2019. As public anger rose, Congress focused on the two largest physician staffing companies engaged in this tactic, KKR’s Envision and TeamHealth, owned by Blackstone. Both houses of Congress introduced a joint, bipartisan bill to ban surprise medical bills that was expected to pass by the end of that year. (It would take a bit longer.)

Financial markets understood that, if the surprise-billing ban passed, Envision would not be able to pay off its debts. Envision’s first-lien term loan, the most secure debt held by creditors, quickly tanked to 50 cents on the dollar. When House members introduced a competing, PE industry–friendly alternative, stalling the effort, Envision’s debt recovered to around 70 cents, and hovered there through the first half of 2020.

Envision’s debt, however, still traded below 80 cents, which is considered distressed-debt territory. With the outbreak of the COVID-19 pandemic in March 2020, Envision’s finances were further strained, as elective surgeries and ER visits were curtailed throughout the country. The company faced the pandemic without any help from KKR’s deep pockets. It cut salaries of doctors and administrators, laid off clinical staff, and cut other costs at its emergency rooms nationwide. By April 2020, just two years after KKR acquired it, Envision was in bankruptcy talks with creditors and financial consultants.

But Envision avoided bankruptcy thanks to a bailout from the CARES Act (estimated by Axios to be $100 million) and the drawdown of its entire $300 million revolving line of credit with Credit Suisse—a provision included in Envision’s filing following the 2018 buyout. By mid-2020, its term loan was trading above 80 cents.

Congress continued its efforts to rein in surprise medical bills, and finally passed the No Surprises Act as part of the December 2020 omnibus spending bill, with the ban to take effect on January 1, 2022. But the bill included a provision allowing providers to take their case for higher pay to arbitration, which private equity–owned health providers favored.

However, while many viewed the final No Surprises Act as a victory for private equity, a close reading of the arbitration provision suggested otherwise. When the Biden administration’s Department of Health and Human Services wrote the regulations to implement the act, they hewed closely to the intent of Congress. While arbitrators determining payments can consider mitigating facts such as the doctor’s level of training or sickness of the patient, they are expected to start negotiations from the median in-network rate for a specific service in a specific region, not from the amount billed for physician services by the PE-owned staffing company. This allows for exceptions, but holds down health care and premium costs.

The ultimate outcome remains uncertain. In February 2022, a Texas federal judge struck down the rule requiring arbitrators to use in-network bills as a starting point. Patients are still protected from receiving surprise medical bills. But without this anchor, providers may receive outsized payments for services, driving up overall health care costs.

Loading patients who sought emergency care with often unpayable medical debt was KKR’s secret sauce.

Despite this potential lifeline, the value of Envision’s debt continues to get hammered and its financial troubles persist. Envision’s current credit agreement allows it to transfer between $2 billion and $2.5 billion of assets to an unrestricted subsidiary. The company is in talks with Apollo Global Management, HPS Investment Partners, and Pacific Investment Management Company (PIMCO) to raise new capital in a deal that would shift some assets, presumably the most valuable ones, away from the existing creditors.

Drawing on lessons from other PE-owned companies facing financial distress—like Nine West, J. Crew, and Sears—KKR will likely emerge unscathed by dividing Envision into two companies, one with the valuable assets and the second with the remaining assets. For example, after the leveraged buyout of Nine West, Sycamore Partners immediately moved the most valuable brands out of the reach of creditors, leaving all of the original debt on Nine West. It paid itself a $40 million dividend, sold the better brands, and pocketed the proceeds. Nine West, meanwhile, filed for bankruptcy in 2018, laid off its workers, and closed all its stores.

Following suit, KKR may divide Envision’s assets, with “Bad Envision” holding the least profitable assets and the debt, while “Good Envision” gets to make a clean start and raise new debt to pay off creditors holding the debt of Bad Envision, at significantly less than 100 cents on the dollar.

Bad Envision, now left holding the debt, will need to engage in drastic cost-cutting to service debt and stave off bankruptcy. Even without the specter of bankruptcy, Envision physicians are under pressure to meet corporate performance metrics. According to a December 2021 California lawsuit filed by physicians at an ER facility, Envision’s corporate management has “profound and pervasive” control over its doctors. It determines pay and staffing, work schedules, patient volumes, and internal standards for treatment. Envision pits physician performance against the standards, “with the intention of modifying and interfering with” the physicians’ judgment of how best to treat patients.

The situation at Bad Envision can be expected to be even worse, with understaffing to save money imposing costs on both doctors and patients.

HCR ManorCare provides a disturbing preview of what may happen. PE firm Carlyle acquired the chain of over 500 nursing homes in 2007 for $6.3 billion, with $4.8 billion in debt. In 2011, Carlyle sold off the chain’s real estate to Healthcare Properties (HCP), a real estate investment trust, for $6.1 billion, pocketing more than $1.3 billion on the deal. Carlyle’s sale-leaseback arrangement unfairly burdened ManorCare with unaffordable rent payments. By 2012, unable to make these payments, ManorCare began laying off hundreds of employees. HCP responded to ManorCare’s decline by retaining its own “good performing” assets and spinning off ManorCare’s bad ones into a new REIT called Quality Care Properties (QCP). QCP sued Carlyle for back rent payments, and in 2018 ManorCare filed for bankruptcy. Between the time ManorCare’s real estate was split in two and the time of its bankruptcy, investigators had cited the chain for thousands of health code violations, as exposed in an investigative report by The Washington Post. Health code violations increased by 25 percent to 2,000 per year, almost all related to understaffing. Serious health code violations posing “immediate jeopardy” rose 29 percent.

Similarly, Bad Envision may find itself hurtling toward bankruptcy while understaffing emergency rooms to fend off that outcome, turning life-threatening emergencies into deadly ones for some patients. Congress was right to put an end to surprise medical bills; now it must act quickly to prevent KKR from extricating itself from a bad financial situation of its own making at the expense of Envision’s doctors and patients.

https://prospect.org/health/envision-healthcare-hits-the-skids/

Groups Reject Biden Rebrand of Trump's Medicare Privatization Ploy

"Tweaks aren't good enough—President Biden and Secretary Becerra must end this dangerous experiment immediately," said one progressive healthcare advocate.

by Jake Johnson - Common Dreams - March 8, 2022

More than 250 advocacy groups representing seniors, people with disabilities, doctors, and other constituencies made clear Tuesday that they're not remotely satisfied with the Biden administration's rebrand of a Trump-era pilot program that allows private industry to gain a foothold in traditional Medicare.

"HHS gave Direct Contracting a fresh coat of paint, but we can see right through it."

In a new letter addressed to Health and Human Services Secretary Xavier Becerra and Centers for Medicare and Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure, the coalition warned that the revamped pilot program known as ACO REACH "retains the most dangerous elements" of the Trump administration's Medicare Direct Contracting experiment, which officially debuted in 2020 despite internal concerns about its legality.

"If allowed to continue, REACH would completely transform traditional Medicare by allowing third-party middlemen to manage seniors' care, without seniors' full understanding or consent," the letter states. "Millions of seniors who actively chose traditional Medicare will be automatically enrolled into REACH entities, many of which will likely be run by for-profit businesses, such as commercial insurers, venture capital and private equity investors, and even dialysis centers."

"Although REACH middlemen are required to notify seniors of their enrollment, few seniors are likely to understand the implications," the letter continues. "Because seniors are automatically enrolled into REACH based upon their relationship with their primary care provider, the only way for a beneficiary to opt out is to change primary care providers."

Last week, the Biden administration announced that instead of terminating the Trump administration's Medicare pilot program—as physicians and progressive activists demanded—it is moving ahead with the program under a different name and a slightly different structure. That approach won applause from the healthcare industry, which had lobbied for such reforms and against complete elimination of the program.

The Biden administration's changes are set to take effect in January 2023.

Doctors leading the charge against Direct Contracting (DC) argued that the new tweaks will do little to mitigate the threat the experiment poses to traditional Medicare, which covers roughly 36 million Americans.

In a Tuesday statement, Physicians for a National Health Program (PNHP) president Dr. Susan Rogers said that "HHS gave Direct Contracting a fresh coat of paint, but we can see right through it."

"REACH is simply a new name for the same backdoor scheme to privatize Medicare."

"Hundreds of community leaders joined forces to say: You can't fool us, we know Medicare privatization when we see it," said Rogers.

While Biden officials shrouded ACO REACH in a veneer of progressivism—emphasizing such goals as "addressing historical healthcare disparities" and achieving "greater transparency"—PNHP notes in a policy brief that the redesigned initiative "includes major giveaways to profit-seeking REACH middlemen that will open the door to increased profiteering in marginalized communities."

"Compared to DC, REACH gives middlemen less financial risk for health costs and quality, and more potential for profit at the expense of traditional Medicare and its beneficiaries," notes PHNP, which coordinated the new letter opposing REACH.

The group also accused the Biden administration of making a "superficial nod to equity that may lead to profiteering in underserved communities," pointing specifically to the REACH program's "no-strings-attached bonus for enrolling vulnerable beneficiaries."

"CMS created a 'Health Equity Benchmark Adjustment' to incentivize REACH middlemen to enroll underserved beneficiaries, determined by residence and Medicaid eligibility," PNHP observed. "CMS will give REACH middlemen an additional $30/month ($360/year) for each beneficiary in the top decile of the Benchmark, regardless of how much care each beneficiary receives."

Alex Lawson, executive director of Social Security Works—one of the signatories to the Tuesday letter—argued in a statement Tuesday that "REACH is simply a new name for the same backdoor scheme to privatize Medicare."

"Unless the Biden administration pulls the plug now, this program will put for-profit insurers and Wall Street between seniors and their doctors," said Lawson. "This letter shows how broad-based the opposition to REACH is. Tweaks aren't good enough—President Biden and Secretary Becerra must end this dangerous experiment immediately."

 

https://www.commondreams.org/news/2022/03/08/cant-fool-us-250-groups-reject-biden-rebrand-trumps-medicare-privatization-ploy? 

Can Public Health Be Saved?by James Hamblin - NYT - March 13, 2022

At the end of February, the Centers for Disease Control and Prevention issued a consequential turn in its mask guidance. The new recommendations meant that most of the country could stop requiring masks indoors — largely passing the decision on to local authorities, many of whom had already decided to roll back mask mandates. This was greeted with a mix of contempt and indifference. Depending on whom you ask, it was either too late (Masks? What masks? Fire Fauci.) or too soon and too cavalier. A unifying thread was that the C.D.C. is wrong, its rules are politically motivated and it needs to do … better.

As of this January, trust in the C.D.C. had plummeted. At the beginning of the pandemic, 69 percent of Americans believed what they heard from the agency, according to an NBC News poll. Now that has fallen to 44 percent. The numbers for Dr. Anthony Fauci have also substantially declined, despite his decades of government service under seven presidents and attempts to remove himself from political rhetoric.

Without this foundational trust, contempt for guidelines trickles down to anyone tasked with applying the rules. Retail workers, teachers and flight attendants asking people to wear masks end up serving as a proxy target for a deep-seated rage against the science.

To understand how the public health establishment has fallen, and what might be done to redeem it, one needn’t look far back. While the Trump administration may have created a new level of distrust by directly undermining experts, the issues are more deeply ingrained and something a changing of the guard alone couldn’t fix.

No moment in the pandemic underscores this better than July of 2021. You were there. It was great. The long-awaited — if regrettably nicknamed — “hot vax summer” was nearing a premature peak. It was a fleeting period of blissful ignorance. Many vaccinated people had stopped wearing masks after the C.D.C. told them they didn’t have to in most settings. Cases of Covid-19 had dropped, and the number of vaccinated Americans was growing. The long-promised return to normalcy was supposedly finally imminent.

Americans had been assured as much before. But this time, the United States had a new president who promised to follow science and surrounded himself with an esteemed team of doctors. Most notable was the chief of infectious diseases at Massachusetts General Hospital, Rochelle Walensky, whose appointment to lead the C.D.C. was greeted by resounding praise in the public health community. Under Donald Trump, the agency’s pandemic response had been defined by shortages and chaotic messaging. But that was finally over.

Then, the new hope crumbled. Leaked internal C.D.C. information suggested that vaccinated people who were infected with the new Delta variant might be able to spread the virus by way of breakthrough infections.

Americans squinting over their sunglasses weren’t sure what to make of the news. Immunologists had long mentioned the potential for post-vaccination infection, though it was unclear how often it would actually happen. Now the agency apparently had changed its recommendation on masks for the vaccinated based on data that the infections could be more common and consequential than originally thought. This had the potential to upend President Biden’s promise to end the pandemic. Yet the first word the public heard on the data was from a leaked presentation, devoid of context. This seemed the inverse of the candor and transparency Americans had been promised.

“I think there was a shortsighted hope that messaging that vaccines were perfect would ensure people get vaccinated,” said Julia Raifman, an assistant professor of health law, policy and management at Boston University.

By the height of the Delta surge, some 2,000 Americans were dying each day. Then during the Omicron wave in early 2022, the United States would see an even more severe wave of illness and death. Amid all of this, the public has received few news conferences from agency experts, instead parsing cryptic guidance on their own, amid news of testing shortages and reports of the C.D.C. withholding Covid data.

Many politicians and pundits actively work to highlight such failures as proof that nothing the agency says is to be trusted. Others are spreading outright falsehoods in bad faith. “It’s disgraceful, and it’s shameful, and it’s killing people,” said Dr. Francis Collins, former director of the National Institutes of Health. “Politicians and media and social media personalities who are distributing misinformation have blood on their hands.”

Some leaders brazenly do the opposite of what the C.D.C. recommends. In Florida, mask mandates have been banned, and the state is defying medical consensus by recommending that healthy children not be vaccinated against Covid. The overall effect can erode a common factual basis for reality, leaving many people believing that everything is simply a matter of opinion.

No country in the world has had a perfect pandemic response. America is not alone in its struggles to develop and communicate effective policies. But one of the few constants of the pandemic is the fact that countries with high levels of social cohesion and trust in leadership fare better than those without it. The authority of the public health establishment lies in its trustworthiness among the public. Without that, it is ineffective. The Biden administration seemed to understand this and has made real attempts to restore the public trust that was lost under Mr. Trump. But America’s public health apparatus remains beleaguered.

How could it be that this happened, since it seemed all the best people were in place?

***

For all the blame placed on Mr. Trump for his failed pandemic response, many of the same issues of distrust and confusion have plagued the Biden administration, for nearly opposite reasons.

Under Mr. Trump, the silencing of health officials was overt. The administration blocked some C.D.C. officials from television interviews and reportedly reviewed C.D.C. reports and in some cases, requested word changes. Dr. Robert Redfield, the agency’s director at the time, and the coronavirus response coordinator, Dr. Deborah Birx, seemed to struggle to avoid contradicting Mr. Trump. The image of Dr. Fauci chuckling and cupping his head with his hand as the president spoke of the “Deep State Department” during a coronavirus briefing became indelible.

By contrast, Dr. Fauci has told me, President Biden is far more interested to hear from him and the other experts on the team. And the administration’s messaging is confident, concise and unified. There is very little daylight between what Dr. Fauci says and what Mr. Biden and Dr. Walensky say and what Jeff Zients (Dr. Birx’s successor) and Surgeon General Dr. Vivek Murthy say. This is, theoretically, ideal.

And yet the system is struggling. Public distrust, uncertainty and skepticism are at a low ebb. The generous read on the situation is: When leaders attempt to follow science earnestly — and wait for consensus among people who think in nuances — they risk being slow to respond and vague in advice and conclusions. The less generous read is that politics and science have melded so completely that the result has been neither scientifically nor politically effective.

“I think the administration has been thinking: ‘We want to speak with one voice. We don’t want to confuse people. We don’t want mixed messages,’” said Dr. Thomas Frieden, a former director of the C.D.C. who dealt with outbreaks such as Zika, H1N1 influenza and Ebola during his tenure. “‘So, all of the briefings will be from the White House.’ The problem is, then you don’t get the granular briefings you need.”

In the attempt to have a cohesive message, there appear to be delays and failures to say anything at all. Whatever the intent, the effect has left Americans feeling uncertain of whom to trust, at best. At worst, lied to. The issues go beyond messaging, to failures to update basic definitions or policies that could easily — instantly — be carried out.

For example, the definition of “fully vaccinated” has not yet been changed to include booster shots, even months after the C.D.C. recommended them for everyone. It can be argued there’s a political benefit to not doing so: If the definition were updated, the administration would no longer be able to tout the success of 65 percent of people being fully vaccinated. Suddenly that number would drop to around 44 percent. (The C.D.C. says people who have gotten their booster are considered “up to date.”)

Other decisions have been similarly vexing. During the Omicron surge, the administration maintained a travel ban against South Africa for weeks despite the fact that the virus was already in the United States. And for months there was persistent hesitation to acknowledge the usefulness of N95 masks and rapid tests, coinciding with a national shortage of both.

In isolation, any of these decisions might be dismissed as an earnest oversight. The agency is small, understaffed and underfunded. But taken together, there is a pattern of alignment between health information and political expediency. This approach may placate people in the short term, but it makes the crisis of trust only worse with time.

It is not too late for the Biden administration to make lasting changes expressly aimed at stopping the decline in trust. But it must act now. Because there is a real chance that America’s public health institutions will slide further into the realm of serving political agendas.

The situation could be far darker if another president came to office who proudly derided expertise and silenced agencies when their message became inconvenient. It’s not so hard to imagine that a second term for Donald Trump, for example, could see requirements of total fealty from scientists.

It doesn’t have to be this way. There are real steps that the government can take to rebuild public trust.

***

No system of public health is perfect. But protecting science from politics as best as possible, without siloing it into obscurity, is a good goal and would go a long way to healing many of the divisions over public health that we’ve seen during this pandemic. In a hypothetical world, a president could assure Americans that everything is fine and churches could be packed by Easter. Then, a C.D.C. director could step to the podium to tell the public: “Well, I’m not sure they will be. Here are the numbers we have ….” And the public would be able to draw their own conclusions.

In any crisis, serious disagreement over values and priorities is inevitable. How many lives saved should justify, say, closing schools? Is preventable illness acceptable as long as our hospitals are not overcrowded? There is no single correct answer when choosing between losses that people value differently. Trust in a system does not mean always agreeing that the correct decision has been made but that decisions were made in good faith, transparently, taking all perspectives into account. We haven’t had enough of this in the pandemic.

This process cannot happen without a baseline of evidence and facts, from which people can agree or disagree about policy. A good example is weather. Meteorologists say that a hurricane is approaching the coast. Local leaders advise people to take precautions, maybe to shelter in place or evacuate. Some will decline to do so. But it’s not because they don’t believe in hurricanes or think the meteorologists are trying to fool them.

Similarly, people should be able to trust that a deadly virus is spreading and evolving, and agree on the numbers of cases and the potential consequences of various policy approaches, and then disagree about what approach to take. As it is, science and policy are packaged together. This causes situations in which people who disagree with a policy like school closures are accused of dismissing the seriousness of the virus altogether.

A healthy distance between the C.D.C. and other political leaders would allow the agency to quickly and transparently communicate information to the public, even when it’s politically inconvenient. When health agencies, scientists and politicians appear to be working as one, especially in a highly polarized political climate, people can dismiss the messages altogether. “For the people to whom the Biden White House is anathema, you basically get them to turn off to C.D.C.,” Dr. Frieden said.

One of the key steps to take, according to Dr. Frieden, would be freeing up the C.D.C. to do independent briefings. “If you look at H1N1, Ebola or Zika, we were giving nearly daily press conferences,” he said. “It hurts the public to not hear regularly from C.D.C.”

And not just the C.D.C. — Americans should hear from, and be heard by, all involved in a pandemic response and bear witness to a transparent process of decision-making. Even when it gets messy, the end result will feel less like a decree from an ivory tower and more like the imperfect product of continuing dialogue. The new mask guidelines in February may have felt too abrupt to some because the C.D.C. hadn’t yet explained the imperfection of relying on case numbers alone to define risk calculations; its new community-based guidance now includes the share of hospital beds being used and hospital admissions, in addition to case numbers.

Inevitably, pundits and political opportunists would attempt to paint disagreement as conflict, and changes in guidance as hypocritical contradictions. This could lead people to believe that no one knows what they’re doing, and so you may as well eat horse paste. This effect is not insurmountable. But it requires active work to earn trust and retain credibility.

To ensure that this kind of separation between politics and health can happen regardless of the presidential administration, new measures may need to be enacted. For example, Congress could move agencies like the C.D.C. and the Food and Drug Administration outside of the Department of Health and Human Services to allow for more independence. This has been called for many times over the years, and the case is only growing clearer. Within that arrangement, it may also be possible to limit the influence of any given president over public health, for example by requiring congressional approval of C.D.C. directors, possibly for a term that does not coincide with presidential terms.

And though communication lies at the heart of rebuilding public trust, the agencies must also have timely and credible — ideally impeccably vetted and contextualized — information to communicate. This means expanding them significantly, possibly via a mandatory funding stream that can allow for long-term planning and independence from political whims. In 2021, the C.D.C.’s discretionary funding was $7.1 billion, equal to roughly 1 percent of the funding for Department of Defense. Having just witnessed how costly a pandemic can be, we should take this moment to treat public health as a matter of national security and provide the agency the tools and personnel to live up to its own advice on crisis communication: “Be first, be right, be credible, express empathy, promote action and show respect.”

Absent this, Americans are witnessing what happens. Regular cycles of panic and confusion have worn everyone’s patience to the bone.

And this virus is not going away; there will be more surges. And there will be other pandemics. Our system has proved to be unprepared to deal with them. Investing in rebuilding sources of information is the only way forward.

https://www.nytimes.com/2022/03/12/opinion/public-health-trust.html?referringSource=articleShare