Editor's Note -
The following clip is a press release from Maine Health, the umbrella organization for The Maine Medical Center and a number of other hospitals and health care delivery entities in southern Maine. agilon health (sic) is a hedge-fund backed entity.Click on the hot-link titled "agilon health" in the release to learn more about agilon health.
- SPC
MaineHealth, agilon health agree to form partnership supporting primary care for Medicare Advantage patients
March 11, 2022
Contact
For MaineHealth: John Porter
207-329-8594 / john.porter@mainehealth.org
For agilon: Claire Mulhearn
310-463-5047 / media@agilonhealth.com
The organizations plan to enter a long-term partnership that will enable a greater investment in value-based models of care, emphasizing preventive services and chronic care management for MaineHealth’s senior patients.
PORTLAND, Maine – MaineHealth said today it has signed a letter of intent to enter into a long-term partnership with agilon health (NYSE: AGL), a company that empowers physicians to transform community health.
Through the partnership, MaineHealth will work with agilon health to transform its primary care delivery system for its Medicare Advantage patients from a fee-for-service model to a sustainable value-based care model that will improve patient care while working to lower costs to the health system.
"Our partnership with agilon health is a direct reflection of our vision of ‘working together so our communities are the healthiest in America’,” said Andy Mueller, MD, Chief Executive Officer, MaineHealth. “Through the partnership with agilon health, we will be accelerating the transition to a payment model defined by value and investing more deeply in our primary care delivery system. The depth of patient need, especially among our growing senior population, necessitates us to think very differently about what the primary care delivery system in our community needs to look like today and in the future."
Value-based care is an important health care delivery model under which providers are paid based on the health outcomes of their patients and the quality of services delivered versus the quantity. Through agilon health’s partnership model and purpose-built platform, the company has helped 17 of the nation’s best physician groups accelerate at scale their transition to a value-based, Total Care Model that places the primary care physician at the center of delivering patient care. MaineHealth is the first integrated health system to partner with agilon health.
“Through our partnership, agilon health is proud to support MaineHealth’s vision to create the nation’s healthiest communities and to help build a more sustainable model for their Medicare Advantage business,” said Steve Sell, Chief Executive Officer, agilon health. “By helping to establish a new primary care delivery system within MaineHealth’s integrated care ecosystem, we will be able to deliver better outcomes and quality of care for their patients, particularly the most vulnerable.”
MaineHealth and agilon health have begun implementation work and will finalize their agreement in coming months, When the partnership is in place, agilon will support MaineHealth physicians in identifying patient conditions and mapping out care plans, making sure senior patients get the preventive care they need as well as ongoing management of any health concerns. This will allow MaineHealth to more confidently enter into value-based contracts within the Medicare Advantage system that reward providers for keeping patients healthy.
“We are constantly researching better ways to provide care for our patients,” said Aileen Mickey, MD, MHA, president, MaineHealth Medical Group. “With the acceleration in the shift to value-based care across the country, this partnership is a significant milestone in ensuring we are ahead of the curve in the future of primary care delivery, and it advances our mission to provide our senior patients and communities high-quality, affordable care.”
###
About MaineHealth
MaineHealth is a
not-for-profit integrated health system whose vision is, “Working
together so our communities are the healthiest in America.” It consists
of nine local hospital systems, a comprehensive behavioral healthcare
network, diagnostic services, home health agencies, and more than 1,500
employed and independent physicians working together through the
MaineHealth Medical Group. With approximately 22,000 employees,
MaineHealth provides preventive care, diagnosis and treatment to 1.1
million residents in Maine and New Hampshire. It includes Franklin
Memorial Hospital/Franklin Community Health Network in Farmington,
LincolnHealth in Damariscotta and Boothbay Harbor, Maine Behavioral
Healthcare in South Portland, MaineHealth Care at Home in Saco, Maine
Medical Center in Portland, Memorial Hospital in North Conway, N.H., Mid
Coast-Parkview Health in Brunswick, NorDx in Scarborough, Pen Bay
Medical Center and Waldo County General Hospital in Rockport and
Belfast, Southern Maine Health Care in Biddeford and Sanford, Spring
Harbor Hospital in Westbrook and Stephens Memorial Hospital/Western
Maine Health Care in Norway. MaineHealth Affiliates include Maine
General Health in Augusta and Waterville, New England Rehabilitation
Hospital in Portland and St. Mary's Regional Medical Center in Lewiston.
It is also a significant stakeholder in the MaineHealth Accountable
Care Organization in Portland.
About agilon health
agilon health is the trusted
partner empowering physicians to transform community health. Through
our partnerships and purpose-built platform, agilon is accelerating at
scale how physician groups transition to a value-based, Total Care
Model. agilon provides the technology, people, capital, and process and
access to a peer network that allow physician groups to maintain their
independence and devote the right amount of time to their most
vulnerable patients. Together, agilon and its physician partners are
creating the healthcare system we need – one built on the value of care,
not the volume of fees. The result: healthier communities, and
empowered doctors. Today, agilon is the trusted partner in 17 diverse
communities and is here to help more of our nation’s best physician
groups and health systems have a sustained, thriving future. For more
information go to www.agilonhealth.com connect with us on Twitter, Instagram, LinkedIn and YouTube.
The biggest threat to Medicare you've never even heard of
Every year on July 30, advocates across the nation bake cakes and hold rallies to celebrate the anniversary of Medicare, the popular federal program established in 1965 to provide health care to seniors and Americans living with disabilities. The festivities are for good reason: Seniors love Medicare. It is simple, efficient, and empowers them to manage their own health.
But starting this year, millions of seniors are quietly being enrolled into a program run by third-party middlemen called Medicare Direct Contracting (DC). This is occurring without their full knowledge or consent. If left unchecked, the DC program could radically transform Medicare within a few years, without input from seniors or even a vote by Congress.
Developed late in the Trump administration, the Medicare DC program allows commercial insurers and other for-profit companies to “manage” care for seniors enrolled in Traditional (fee-for-service) Medicare. Instead of paying doctors and hospitals directly for seniors’ care, Medicare gives these middlemen (called Direct Contracting Entities, or DCEs) a monthly payment to cover a defined portion of each seniors’ medical expenses. DCEs are then allowed to keep what they don’t pay for in health services, a dangerous financial incentive to restrict and ration seniors’ care.
A majority of seniors choose Traditional Medicare over Medicare Advantage, the version of Medicare run by commercial insurers, because they value having free choice of providers and the power to manage their own care. But under the Medicare Direct Contracting program, older Americans who actively chose the popular Traditional Medicare program are automatically enrolled into a Direct Contracting Entity without their full knowledge or consent.
Seniors in Traditional Medicare may be “auto-aligned” to a DCE if any primary care physician they’ve visited in the past two years is affiliated with that DCE. That means Medicare automatically searches two years of seniors’ claims history without their full consent to find any visits with a participating DCE provider as the basis for enrollment. It’s no wonder that the current DC pilot phase includes potentially 30 million Traditional Medicare beneficiaries enrolled in 53 DCEs across 38 states.
It gets worse. Who are we trusting to “manage” our seniors’ care? Virtually any type of company can apply to be a DCE, including commercial insurers, venture capital investors, and even dialysis centers. In fact, applicants are approved without oversight from Congress. Unlike other care management models, there isn’t even a requirement that DCEs be majority owned by health care providers. This opens the door to ownership by for-profit entities with no health care expertise at all.
Wall Street investors are already tripping over themselves to get into the DC program. This should be a huge red flag for taxpayers and anyone concerned about funding Medicare for future generations. While Traditional Medicare spends an impressive 98 percent of its budget on patient care, Direct Contracting Entities only spends 60 percent of our tax dollars on patient care — keeping up to 40% of revenues for their own profit and overhead. We can’t think of any other industry with numbers like these, let alone one entrusted to care for the health of our nation’s seniors.
If you’ve never heard of Direct Contracting, you’re not alone. The DC program was created by the Center for Medicare and Medicaid Services’ “Innovation Center”, which was established to pilot health payment models without congressional authorization. The Innovation Center can approve and sign contracts with Direct Contracting Entities. They can even scale up the program to cover all of Medicare, without so much as a vote or hearing in Congress.
That’s why doctors from across the nation are gathering at the Department of Health and Human Services (HHS) this week to ring the alarm bells about Direct Contracting. They’re calling on HHS Secretary Xavier BecerraXavier BecerraDemocrats worry their grip on Hispanic vote is loosening Becerra names incoming acting NIH director The biggest threat to Medicare you've never even heard of MORE to end the DC program immediately. They’re also urging members of Congress to demand a hearing on this attempt to sell our beloved Medicare to Wall Street investors.
Since Direct Contracting is a pilot program, it can and should be stopped in its tracks by the Biden administration while we have the chance. After our experience with commercial Medicare Advantage plans, we already know that inserting a profit-seeking middleman into Medicare ends up costing taxpayers more, with fewer choices and worse outcomes for seniors.
As a physician and a member of Congress, we’ve never heard a senior ask for their health care to be more complicated, or to have their choice of Traditional Medicare taken away. But that’s exactly what Direct Contracting would do. Traditional Medicare has proven its value for more than half a century. Instead of selling it off to the highest bidder, let’s strengthen and improve its benefits while working to expand it to cover every American.
Editor's Note -
Here's an oldy but goody
-SPC
Cultural production of ignorance provides rich field for study
by Michael Hiltzik - LA Times - March 9, 2014
Robert Proctor doesn’t think ignorance is bliss. He thinks that what you don’t know can hurt you. And that there’s more ignorance around than there used to be, and that its purveyors have gotten much better at filling our heads with nonsense.
Proctor, a professor of the history of science at Stanford, is one of the world’s leading experts in agnotology, a neologism signifying the study of the cultural production of ignorance. It’s a rich field, especially today when whole industries devote themselves to sowing public misinformation and doubt about their products and activities.
The tobacco industry was a pioneer at this. Its goal was to erode public acceptance of the scientifically proven links between smoking and disease: In the words of an internal 1969 memo legal opponents extracted from Brown & Williamson’s files, “Doubt is our product.” Big Tobacco’s method should not be to debunk the evidence, the memo’s author wrote, but to establish a “controversy.”
When this sort of manipulation of information is done for profit, or to confound the development of beneficial public policy, it becomes a threat to health and to democratic society. Big Tobacco’s program has been carefully studied by the sugar industry, which has become a major target of public health advocates.
It’s also echoed by vaccination opponents, who continue to use a single dishonest and thoroughly discredited British paper to sow doubts about the safety of childhood immunizations, and by climate change deniers.
And all those fabricated Obamacare horror stories wholesaled by Republican and conservative opponents of the Affordable Care Act and their aiders and abetters in the right-wing press? Their purpose is to sow doubt about the entire project of healthcare reform; if the aim were to identify specific shortcomings of the act, they’d have to accompany every story with a proposal about how to fix it.
Proctor came to the study of agnotology through his study of the Nazi scientific establishment and subsequently of the tobacco industry’s defensive campaign.
Early in his career, he told me, he asked an advisor if Nazi science was an appropriate topic of research. “Of course,” he was told. “Nonsense is nonsense, but the history of nonsense is scholarship.” As part of his scholarship, Proctor says he “watches Fox News all the time.”
Proctor acknowledges that not all ignorance is bad.
“There are reasons we don’t want people to know how to make an airborne AIDS virus or biological weapons,” he says. “And the right to privacy is based on a kind of sanctioned ignorance — we don’t want everyone to know everything about us all the time.”
But then there’s ignorance custom-designed to manipulate the public. “The myth of the ‘information society’ is that we’re drowning in knowledge,” he says. “But it’s easier to propagate ignorance.”
That’s especially so when issues are so complicated that it’s easier to present them as the topics for discussion in which both sides are granted equal time.
Big Tobacco’s public relations campaign against the anti-smoking movement, for example, was aimed at “manufacturing a ‘debate,’ convincing the mass media that responsible journalists had an obligation to present ‘both sides’ of it,” reported Naomi Oreskes and Erik Conway in their 2010 book, “Merchants of Doubt.”
The industry correctly perceived that no journalist would ever get fired for giving the two sides equal weight, even when that balance wasn’t warranted by the facts.
What has made the modern era so nurturing for ignorance and doubt is the decline of scientific credibility. Norton Wise, a historian of science at UCLA, says scientists deserve a good deal of the blame for that.
“The question is the degree to which the commercialization of academic science is increasing public doubt and destroying the public good at the university and at places like the CDC [Centers for Disease Control],” he says. “Such that they no longer look distinctly different from the tobacco industry or Big Pharma. This is a big problem, given the rampant commercialization at major research universities like UCLA.”
Wise cites a 2004 British parliamentary report showing that three-quarters of all randomized trials appearing in the New England Journal of Medicine, the Journal of the American Medical Assn. and the British Journal Lancet are funded by the pharmaceutical industry. “These are the kinds of things emerging that undermine public trust,” he said.
Indeed, efforts to stamp out the canard that the measles vaccine causes autism are often countered by anti-vaccination activists asserting that government assurances of vaccine safety are part of a conspiracy to safeguard Big Pharma’s profits.
The dangers of ignorance’s foothold in public discourse are twofold.
First, once allowed to take root, misinformation — whether cultural or manufactured — is very hard to dislodge.
In a recent study, a research team headed by Brendan Nyhan of Dartmouth College tried four methods to change the minds of parents who had decided not to immunize their children with the measles, mumps and rubella vaccine — a factual refutation of the vaccine-autism link; two different means of warning about the risks to children from contracting measles, mumps or rubella, including “a dramatic narrative about an infant who almost died of measles”; and horrific photos of children suffering from the diseases.
Some of the interventions persuaded the parents that the autism link was specious, but not a single one made the parents more willing to vaccinate their children. And some intensified opposition to the vaccine, a “backfire” effect.
A second danger is that ignorance interferes with the creation of intelligent policy. Citing the results of a 2012 Gallup poll, Proctor asks, “If half the country thinks the Earth is 6,000 years old, how can you really develop an effective environmental policy? This sort of traditional or inertial ignorance bars us from being able to act responsibly on large social issues.”
Still, it’s commercially manufactured ignorance that’s most insidious. And Big Tobacco, that great pioneer in the field, is still at it.
The industry has succeeded in persuading the public and politicians that it has lost the smoking war, but that’s a myth. Proctor says 40 million Americans still smoke and tobacco use is still rising in much of the world. Moreover, the industry’s program isn’t just about cigarettes, but part of “a larger agnotological project to promote free-market fundamentalism,” he points out.
As Stanton A. Glantz of UC San Francisco documented last year, the tobacco industry was deeply involved in the evolution of the tea party movement, which promoted some of the industry’s cherished aims, such as fighting tobacco taxes and anti-smoking laws.
“The Tea Party of the late 2000s has become the ‘movement’” envisioned by a Reynolds executive 10 years earlier, Glantz concluded, “grounded in patriotic values of ‘freedom’ and ‘choice’ to change how people see the role of ‘government’ and ‘big business’ in their lives.”
Given the torrent of misinformation washing about the public space and the multiplicity of pathways for its distribution, is there any hope for beating back the tide? Agnotologists are divided. “I don’t see any easy out,” says UCLA’s Wise. “All of the forces are on the side of undermining public trust in science.”
But Proctor has hope. “My whole career is devoted to pushing back,” he told me. “There is opportunity to expose these things through good journalism, good pedagogy, good scholarship. You need an educated populace.”
The effort needs to begin at a young age, he says. “You really need to be teaching third-, fourth-, fifth-, sixth-graders that some people lie. And why do they lie? Because some people are greedy.”
https://www.latimes.com/business/la-xpm-2014-mar-09-la-fi-hiltzik-20140307-story.html
Vulture Capitalists Want to Flood the Health Care System With Cheap Medical Labor
A private equity–owned emergency room staffing firm cofounded by a wealthy Republican congressman has been openly hailing a coming “oversupply” of doctors, promising prospective investors that a surplus of emergency physicians — soon projected to reach nearly ten thousand — will drive doctors’ wages low enough to offset the haircut that health care reforms have imposed upon its profit margins.
The physician glut was highlighted in a recent pitch deck prepared by the cash-strapped Nashville ER staffing firm American Physician Partners (APP). The company, which operates ERs in 155 hospitals, has been trying — and failing — for months to raise $580 million to pay off creditors, including Representative Mark Green (R-TN), who holds somewhere between $5 million and $25 million of the company’s debt.
Like most of its competitors, APP has watched its profit margins and credit ratings sink since various laws banning surprise billing were enacted last year. While APP claims it never sent surprise bills to patients, it has also told its doctors in email exchanges reviewed by us that various laws banning the practice had resulted in a 50 percent drop in the company’s revenues from certain large insurers.
But in its November 2021 pitch deck to investors, APP tells a different story, promising the company will more than make up for the expected $5.8 million to $11.6 million hit to its $122 million in annual gross earnings, by slashing some $19.6 million from its payroll costs. APP can do this in the midst of a once-in-a-generation health care labor shortage, according to the presentation, thanks to a coming glut of ER doctors.
This ER doctor glut was primarily caused by a recent explosion in the number of emergency medicine residency programs founded to train medical school graduates in the specialty — and was part of a deliberate scheme by vulture capitalists to flood the health care system with cheap medical labor.
“It is remarkable to me that in the midst of a global pandemic where health care workers have sacrificed so much, APP brazenly shares its plans to further exploit physicians,” said Philip Sossenheimer, a Stanford Health Care physician who helped organize a recent landmark union victory at the Palo Alto, California–based hospital system.
While this physician glut is currently a phenomenon specific to emergency medicine, Sossenheimer suspects more specialties will soon face similar problems. As he put it, “I hope all physicians see this as the harbinger of what corporate health care will bring.”
The Doctor Glut Has Arrived
This “oversupply” of emergency physicians will likely never be apparent to the average patient sitting in an ER waiting room, where skeleton staffing has been thoroughly baked into the business model.
As the APP presentation points out, 70 percent of hospital ERs are outsourced, and most contracts are awarded to the lowest bidder. Nearly all of the biggest bidders on ER contracts — Envision Healthcare, TeamHealth, SCP Partners, ApolloMD, and APP — are owned by private equity firms that have accumulated nine- or ten-figure sums of debt buying out smaller competitors. Making the interest payments required by that debt leaves no room for extravagances like higher doctor-patient ratios.
Indeed, as the media will often remind us, we are by most standards a nation in the throes of an acute physician shortage. Most countries have far higher numbers of doctors per capita than the United States, partly because we force doctors to endure three or four times as many years of postgraduate education as most European countries, pay an average of $300,000 for the privilege to save lives, and partake in a cutthroat competition for a fixed number of residency positions.
Each year more than a thousand new medical school graduates, most of them deeply in debt, fail to “match” into residency programs and fall into a kind of professional limbo. This is in part because Congress, in 1997, froze the number of residency slots it would allow Medicare to subsidize — a Republican policy the conservative Wall Street Journal editorial board last year shamed congressional Democrats for failing to reverse, in light of what it characterized as a rampant “shortage” of doctors, particularly emergency physicians.
Assessing the physician labor market in February, the Atlantic argued that the barriers to achieving a medical license in America amount to “a conspiracy to limit the amount of doctors practicing in America.”
And yet, younger ER doctors will tell you a starkly different story — one in which ER specialists toil four years in med school and another three or four in residencies, only to spend another six months looking for a job, during which they find that employers are delegating an increasing number of their former duties to nurse practitioners.
A surging rate of doctor resignations in response to the pressures of the pandemic has done little to improve the remaining physicians’ lot. While nurses who are willing and able to quit their jobs and become travel nurses have had little problem quadrupling their short-term pay, doctors who become travel physicians are regularly hit with more pay cuts.
In August 2021, a statistical analysis published in the Annals of Emergency Medicine put hard numbers to the sense of disposability doctors had been experiencing: a near doubling in the number of emergency room visits being handled by nurse practitioners and physician assistants had conspired with a boom in the number of med school students specializing in emergency medicine (EM) to produce an ER doctor glut that was growing bigger every year. The study projected the ER physician oversupply will reach 7,485 doctors by 2030.
By all accounts, the glut has already arrived. A recent thread on a popular ER physician forum dissected two emergency room job listings offering $125 an hour — one a day-shift travel nurse on the West Coast, and the other a midwestern emergency physician gig with unspecified teaching responsibilities involved. Other discussions have focused on how doctors are increasingly getting paid the same amount as registered nurses. More recently, a labor lawyer posted an employment contract with Apollo-controlled ER staffing firm US Acute Care Solutions, specifying an hourly base physician pay of $21 an hour.
“This should be a wake-up call to the speciality that emergency medicine is becoming a less desirable specialty due to its reputation for increasing corporatization, loss of autonomy, and exploitation,” said Mitch Li, a traveling emergency room physician who also runs Take Back Medicine, a grassroots support network for doctors grappling with private equity buyouts.
The Residency Gravy Train
There’s an obvious reason for the doctors’ unique lack of labor market leverage: the emergency medicine specialty is bringing in nearly twice as many med school grads as it did a decade ago, and almost triple the number it attracted in 1998.
That is thanks to a near doubling of residency programs designed to train doctors in emergency medicine since 2008; no other medical specialty has experienced such a boom. The residency surge became particularly overheated in the years before the pandemic, when the Accreditation Council for Graduate Medical Education accredited seventy-seven new emergency residencies in three years alone — only nineteen of which claimed any affiliation with a university medical school.
And while most of those programs would be profitable solely on the basis of the deeply discounted medical labor and physician recruitment costs associated with hosting a residency, the government subsidies associated with most residencies, most of which are subsidized by Medicare, make them bona fide gravy trains. When Philadelphia’s Hahnemann University Hospital auctioned off its 550 residency slots in 2019 in the aftermath of a complex private equity acquisition and looting of the facilities, the residencies fetched $55 million. And according to its pitch deck, APP calculates that the expansion of a Medicaid-subsidized residency program it manages in a chain of Michigan hospitals will add an extra $3 million to its annual earnings.
Residency programs’ financial rewards likely would have caused a physician glut much sooner, had Congress not frozen the number of Medicare-funded medical residency spots as part of its 1997 Balanced Budget Amendment. In the years that followed, hospital lobbies began complaining that the caps were causing a “doctor shortage.”
The scare tactics worked. In 2013, after local newspapers eagerly reported on the coming dearth of doctors, Florida hospitals convinced then governor Rick Scott (R) to earmark an extra $80 million a year in Medicaid funds to subsidize new medical residencies.
The most prominent driver of the ER doc glut, doctors say, is the hospital giant HCA Healthcare, which has emerged as the nation’s largest single sponsor of post–med school residency programs.
This is a recent development: until 2015, HCA’s annual report contained a boilerplate sentence about how its hospitals “do not typically engage in extensive medical research and education programs.” Last year, the company issued a press release welcoming an incoming class of two thousand medical residents and boasting of being the “largest provider of graduate medical education” in the country.
Physicians with experience in various outposts of the hospital chain’s burgeoning educational empire say that HCA is exploiting residents at the expense of their educations and future patients. Doctors familiar with HCA residencies in Florida, for example, say the programs are often run by physicians with flimsy-to-nonexistent academic credentials, and many say they are mystified as to how the programs first gained accreditation.
“These hospitals have so few nurses left that the residents are stuck doing all the IV bags, changing the sheets, while any patient with a moderately complex case is going elsewhere,” said one physician familiar with HCA residency programs, who asked to remain anonymous because they live in a state where the company has substantial market power:
Now, there’s nothing wrong with doing a few IV bags or doing what needs to be done in a crunch, but a residency is where you’re supposed to learn how to handle the big complex cases. HCA is just destroying the educational experience of a lot of these young docs.
HCA’s entrance into the residency business opened the floodgates, paving the way for dozens of smaller health systems to launch residency programs and lobby their state Medicaid agencies to subsidize them. Unsurprisingly, many of these efforts also offer subpar training opportunities.
And one APP physician shared details of a side gig supervising a new EM residency program launched by a struggling nonprofit hospital in what they called an “apocalyptically poor” Rust Belt town.
“[It has] no business running a residency program,” said the physician, adding that the hospital hadn’t even employed a board-certified ER doctor prior to launching the program. “But they’re desperate to bring in money and they’re desperate to bring in doctors.”
Stuck On The Corporate Medicine Hamster Wheel
While APP might be expecting the growing ER doctor glut to pad its bottom line, that hasn’t stopped it from resorting to questionable tactics to slash services and pay in the meantime.
For years, contract management groups like APP have used their ability to bill affluent patients at “out of network” rates as a calling card to squeeze extra revenue out of patients and insurance companies, and their private equity overlords exploited this calling card by financing the vast majority of their small practice buyout sprees with junk debt. But since various laws began to chip away at surprise billing in late 2020, these staffing firms have been left deeply indebted, and bordering on insolvent.
APP is probably among the least overleveraged companies in the private equity ER business right now — and still the company has struggled to refinance its half-billion dollar debt load. In response, several employees say APP is taking its financial woes out on doctors and using surprise billing legislation as an excuse to enact deep cuts.
A doctor whose practice was acquired by APP in 2019 says the company has repeatedly made contradictory statements about revenue in what the doctor perceived as an attempt to force through gratuitous wage and staffing cuts. “They’re using the legislation to mask their own looting,” the doctor says, who asked to remain anonymous for fear of retaliation.
Like most doctors working full-time for private equity–backed ER contractors, APP’s physician pay is calculated using a complex formula that theoretically compensates doctors based on the revenues their ERs generate during their shifts. But even though ER volumes have now fully recovered to pre-pandemic levels, the APP doctor said their pay is still roughly 30 percent lower than it was before 2020.
Similarly, a Texas lawsuit filed against APP by nine physicians in March accuses the company of using its wage formulas as a smokescreen for arbitrarily slashing pay. The lawsuit claimed APP was funneling wages from physicians in a bid “to artificially inflate its books to appeal to investors and avoid insolvency by maintaining cash flow at the direct expense of the doctors.”
While their wages are falling, doctors say these private equity–backed compensation schemes and staffing cuts are leading them to see more patients than they can handle.
Li of the anti–private equity group TMB said the proliferation of such private equity–imposed pay formulas is another factor pushing doctors in his specialty to consider labor unionization. “Basically, these pay structures create a really toxic workplace culture even when they don’t jeopardize patient safety, where doctors are fighting one another for [high revenue] patients,” said Li, whose popular Facebook group has attracted nearly four thousand members, mostly physicians. “And I think doctors are sick of being pitted against one another.”
In early May, Li’s Take Medicine Back group hosted a forum with physician union organizer Joe Crane. Nursing unions, Crane pointed out, had not simply achieved higher wages and work-life balance for the profession, but safer staffing ratios in the hospitals in which they organized and even whole states like California. The message had a special resonance, said Li, for ER doctors stuck on the “corporate medicine hamster wheel of doing more work for less pay.”
As Li added, “There are probably regional exceptions to this, but the basic fact is that we wouldn’t have an ‘oversupply’ of ER doctors if ERs were staffed appropriately.”
Democrats are facing a ticking time bomb on health-care costs
by Karen Tumulty - Washington Post - May 24, 2022
You might call it a disastrous “October surprise” for Democrats in this year’s crucial midterm campaign — except it wouldn’t be a surprise at all, and it is completely avoidable.
The governing party’s inability thus far to reach some kind of agreement on a scaled-back version of President Biden’s Build Back Better legislation is raising a real possibility that millions of middle-class Americans will see their health insurance costs go up by hundreds of dollars per month next year. And if it happens, they will hear the news about it just weeks before Election Day.
That’s because the temporary subsidies for people who buy their coverage through the Affordable Care Act exchanges — assistance that was provided in last year’s massive covid-19 relief package — are scheduled to expire at the end of 2022. The stalled BBB legislation would provide an extension of the subsidies.
The exchanges were set up for people who do not receive health insurance through their jobs or government programs such as Medicare and Medicaid. They include early retirees, gig workers and others who are self-employed, as well as people employed by small businesses that do not offer group coverage. In its original version, the 2010 health-care law provided premium assistance only to households earning between 100 percent and 400 percent of the poverty level.
Follow Karen Tumulty's opinionsFollow
In 2021, the American Rescue Plan Act made temporary premium assistance available to an estimated 3.7 million additional people, mostly with incomes between four and six times the poverty level, according to the Kaiser Family Foundation. This new help for those whose incomes previously were too high to qualify for assistance is a major reason that a record 14.5 million Americans signed up to get health coverage this year through Obamacare marketplaces, passing the previous peak by nearly 2 million.
How much benefit have people been receiving from those subsidies? Again, some figures from Kaiser: They are enough to cover more than half the annual $11,000 premiums for a relatively low-deductible “silver” plan for a 60-year-old making just over $51,000, or about four times the poverty level. Without the assistance, the monthly premium paid this year by a couple over the age of 50 earning $75,000 would go up by close to $700, bringing their plan’s total cost to more than $1,200 a month.
So losing those subsidies would be a big hit for people who make a living wage but are far from wealthy. And that is not all they are likely to face when the annual signup for the Obamacare exchanges rolls around. Because hospitals are paying significantly higher labor and other costs, insurance premiums are expected to rise by double digits next year.
That kind of sticker shock will force many people to buy plans with lower coverage or higher deductibles and other out-of-pocket costs. They might be priced out of the health insurance market entirely.
All of this should add some urgency to the seemingly moribund negotiations between the White House and Democrats on Capitol Hill to figure out which parts of the president’s original multitrillion-dollar proposal to transform the U.S. economy might still be salvageable. (The Congressional Budget Office estimates that extending the temporary subsidies for people who purchase insurance on the health-care exchanges would cost about $210 billion over the next decade.)
Time is running out, and Democrats may not get a second chance if they blow this opportunity. Republicans, should they take over one or both chambers after this fall’s elections, are unlikely to shore up the ACA, which they detest. “Members of Congress — particularly Democrats — are not acting like this is a crisis. They can fix this,” Chris Jennings, who was a top health-care adviser in both the Clinton and Obama administrations, told me.
Extending the subsidies would require a simple majority under the Senate’s budget reconciliation rules. The frustratingly opaque Sen. Joe Manchin III (D-W.Va.) remains the pivotal vote, but there is reason to believe he would not be an obstacle. He has been a supporter of the Affordable Care Act and generally expressed openness to measures that would lower health-care costs, including by allowing Medicare to negotiate prescription drug prices, which is another provision of the Biden agenda and something Democrats have promised for many years.
Democrats, even with their narrow majorities in the House and Senate, can still get a few things over the finish line. Preventing an entirely foreseeable explosion in health-care costs should be one of them.
Millions risk losing US healthcare when Covid emergency declaration expires
An estimated 5.3 million to 14.2 million could lose Medicaid coverage when the public health emergency ends in July
by Michael Sainato - The Guardian - May 25, 2022
When the US federal government’s pandemic health emergency declaration expires, millions of Americans are at risk of losing healthcare coverage through Medicaid with potentially devastating consequences.
According to an analysis by the Kaiser Family Foundation, an estimated 5.3 million to 14.2 million could lose their Medicaid coverage when the Covid-19 public health emergency ends on 15 July if it is not extended.
The analysts cited the wide range due to uncertainty on how states will respond to the end of continuous enrollment and how many people will lose coverage as a result. Medicaid enrollment is estimated to reach 110.2 million people by the end of fiscal year 2022, with enrollment expected to decline significantly when continuous enrollment ends.
Dylan Brown of New Jersey is disabled and relies on Medicaid for a home aide he requires around the clock to be able to get out of bed, dress and feed himself. He constantly worries about losing his Medicaid and Social Security disability insurance due to income and asset eligibility requirements and is very concerned about losing Medicaid when continuous enrollment ends.
“As I’ve been learning, trying to maintain my eligibility, you get a different story every time and you just have to hope one of them is right. And I’ve sort of been learning, none of them are really right,” said Brown.
Without Medicaid, he would have to rely on his parents, who work full-time, to provide the care he needs and pay out of pocket for care to the extent his family could afford it. These options, Brown argued, aren’t feasible as he is planning to start law school this fall at Rutgers University, and his parents shouldn’t have to uproot their lives to help him function, which is the responsibility of Medicaid.
“There shouldn’t be a cutoff date. There’s no reasonable argument for not giving disabled people the care they need to survive,” added Brown. “Regardless of what you’re feeling on whether people should have free healthcare, the disabled need it. There are no alternatives for us. It’s Medicaid or bust, and when the Medicaid rules are this convoluted and hard to keep track of, it almost feels like a full time job just keeping my benefits.”
During the pandemic, the federal government required states to continuously enroll Medicaid recipients into the program, providing $100.4 bn in new funds to cover the costs of doing so, halting coverage gaps and loss of eligibility for those who rely on healthcare coverage through Medicaid.
The current pandemic health emergency declaration is set to expire in mid-July. It is expected to be extended again, but an extension date has yet to be set by the US Department of Health and Human Services.
“Medicaid provided invaluable coverage to individuals during the pandemic. And there’s evidence that it helped insulate people from loss of coverage that is associated with job losses, especially in the early stages of the pandemic,” said Dr Eric T Roberts, assistant professor of health policy and management at the University of Pittsburgh. “Now, we face this unwinding of those provisions and a lot of confusion to beneficiaries and the public about how individuals will navigate that process and the schedule on which they will be required to do so. I think the great concern is that people lose their coverage without really knowing it, until they need it.”
Roberts said policymakers need to address these problems, as Medicaid determination and redetermination is complex already. Those complexities are magnified when states have to start conducting those determinations on such a large scale without the proper administrative and navigational assistance and resources in place.
“There is already a significant amount of administrative complexity to navigate Medicaid from the beneficiaries’ perspective and that can uniquely disadvantage people who have greater difficulty just navigating the healthcare system in general, the most vulnerable,” added Roberts.
Federal government subsidies to make healthcare plans more affordable on the insurance marketplace are expected to end on 31 December 2022, making health insurance plans more expensive, possibbly resulting in more Americans losing health insurance coverage because they can’t afford it.
Zachary Fusfeld of Philadelphia, Pennsylvania, a PhD candidate in epidemiology at Drexel University, is anticipating the loss of his Medicaid coverage when continuous enrollment ends, because his university stipend increase will put him over the income limit.
A type one diabetic who suffers from other illnesses, Fusfeld said he will have to rely on his student healthcare and pay out of pocket for copays on medications, medical supplies, and doctor visits when his Medicaid coverage ends later this year, the costs of which are not affordable and not covered by his pay increase.
He recently required surgery on his ankle and is worried about affording the physical therapy he requires, though he noted there are many people who are facing the loss of Medicaid and don’t have any sort of supplemental insurance coverage as he does.
“I’m really worried that I’m just not going to be able to properly manage my health and life in a way that I can stay as healthy as I need to be,” said Fusfeld.
Chris Bergh of St Louis, Missouri, relies on Social Security disability insurance for income and Medicaid for medical coverage. He’s concerned about the risk of losing medical coverage through Medicaid when the pandemic emergency is lifted.
“I’m at risk of losing coverage because I lost track of a piece of mail and the instructions in the letter were unclear about how I was supposed to proceed,” said Bergh.
He has repeatedly attempted to call Medicaid’s service hotline, but hasn’t been able to get through to speak to an actual person. Without Medicaid, he wouldn’t be able to see his doctors, afford his prescription medicine, or get dental care.
“I think they make this system harder than it has to be, in the hopes of weeding people out, just like other public assistance programs,” added Bergh. “I’m on social security so I have a fixed income and don’t make enough to cover the out of pocket cost of these things and still be able to eat and do other things.”
The Doctor Prescribed an Obesity Drug. Her Insurer Called It ‘Vanity.’
by Gina Kolata - NYT - June 1, 2022
Maya Cohen’s entree into the world of obesity medicine came as a shock.
In despair over her weight, she saw Dr. Caroline Apovian, an obesity specialist at Brigham and Women’s Hospital, who prescribed Saxenda, a recently approved weight-loss drug. Ms. Cohen, who is 55 and lives in Cape Elizabeth, Maine, hastened to get it filled.
Then she saw the price her pharmacy was charging: $1,500 a month. Her insurer classified it as a “vanity drug” and would not cover it.
“I’m being treated for obesity,” she complained to her insurer, but to no avail.
While Ms. Cohen was stunned by her insurer’s denial, Dr. Apovian was not. She says it is an all too common response from insurers when she prescribes weight-loss drugs and the universal response from Medicare drug plans.
Obesity specialists despair but hope that with the advent of highly effective drugs, the situation will change.
Novo-Nordisk, the maker of the medicine Dr. Apovian prescribed, and patient advocacy groups have been aggressively lobbying insurers to pay for weight-loss drugs. They also have been lobbying Congress to pass a bill that has languished through three administrations that would require Medicare to pay for the drugs.
But for now, the status quo has not budged.
No one disputes the problem — more than 40 percent of Americans have obesity, and most have tried repeatedly to lose weight and keep it off, only to fail. Many suffer from medical conditions that are linked to obesity, including diabetes, joint and back pain and heart disease, and those conditions often improve with weight loss.
“The evidence is now overwhelming that there are physical changes in weight regulating pathways that make it difficult for people to lose weight and maintain their weight loss,” said Dr. Louis Aronne, an obesity medicine specialist who directs the comprehensive weight control center at Weill Cornell Medicine. “It’s not that they don’t have willpower. Something physical is holding them back.”
“Access to medicines for the treatment of obesity is dismal in this country,” said Dr. Fatima Cody Stanford, an obesity medicine specialist at Massachusetts General Hospital and Harvard Medical School.
But even if a patient’s insurer will cover weight loss drugs, most doctors do not suggest the drugs and most patients do not ask for them, as they fail to realize there are good treatment options, said Dr. Scott Kahan, an obesity medicine specialist in Washington, D.C. And, he added, even if doctors and patients know there are F.D.A. approved drugs, many think they are “unsafe or not well studied and that everyone regains their weight.”
The medical system bears much of the blame, Dr. Stanford said. Just 1 percent of doctors in the United States are trained in obesity medicine. “It’s the biggest chronic disease of our time, and no one is learning anything about it,” she said.
Data on medication use by patients predate the newer, more effective and safe drugs made by Novo Nordisk and Eli Lilly. Still, obesity medicine doctors say, they doubt that the number has changed much from the earlier studies that found that less than 1 percent who are eligible obtained one of these drugs. That is about the same percentage as those who get bariatric surgery, which most insurers, including Medicare, pay for.
“The perception is, ‘If you are heavy, pull yourself up from your bootstraps and try harder,’” Dr. Kahan said.
And that, he adds, is a perception many patients, as well as doctors, share, making them reluctant to seek medical help or prescription medications.
Then there is the problem Ms. Cohen ran into: Insurers that do not cover weight-loss drugs.
But some obesity specialists have found a strange workaround to get an effective but expensive Novo Nordisk drug for patients with obesity whose insurers will not pay.
The workaround exploits quirks in the way Novo Nordisk markets its drugs. The company sells a drug, semaglutide, for both diabetes and for obesity. As a diabetes drug, it is called Ozempic and has a list price of $892 for four weeks. It is easily available at pharmacies, and insurance companies cover it for people with diabetes.
Novo Nordisk sells two weight loss drugs that are of the same class in two doses — liraglutide as Saxenda, and semaglutide at a higher and more effective dose as Wegovy. The list price — the suggested retail price — for both is about $1,350 a month. That means the same drug costs 51 percent more if it is used to treat obesity than if it is used for diabetes.
But as an obesity drug, it is hard to get.
Not only do most U.S. insurers decline to pay for Saxenda or Wegovy because they are weight-loss drugs, but Wegovy supplies are so limited that the company has asked doctors not to start new patients on it.
Eli Lilly has a similar and seemingly more powerful weight-loss drug, tirzepatide, which it hopes to get approved for people with obesity. It was recently approved to treat diabetes under the name Mounjaro. As a diabetes drug, its retail price is $974 a month.
Douglas Langa, an executive vice president at Novo Nordisk, said the Wegovy supply problem was caused by a manufacturing issue that should be resolved later this year.
He also said that diabetes and obesity were “separate categories, separate marketplaces” to explain the difference in price between the companies’ two drugs that were based on the same medicine, semaglutide. He said Wegovy’s price “reflects efficacy and clinical value in this area of unmet need.”
Dr. Stanford was appalled.
“It’s unbelievable,” she said, adding that it was a gross inequity to charge people more for the same drug because of their obesity. She finds herself in an untenable situation: getting excited when her patients with obesity also have diabetes because their insurers pay for the drug.
Dr. Apovian says she too finds herself rejoicing when patients have high blood sugar levels — and that was what ultimately resolved Ms. Cohen’s problem.
Her insurance company would cover Ozempic, but it would not cover Saxenda. So she started taking Ozempic, with a $70 a month copay.
Ms. Cohen — who measured at five feet tall and weighed 192 pounds when she saw Dr. Apovian — had a dramatic response to Ozempic. She has lost 54 pounds and now weighs 138 pounds. Her waist size, which was 46 inches, is now 33 inches. She has more energy and her joints do not hurt.
“It has absolutely changed my life,” Ms. Cohen said.
No comments:
Post a Comment