Health Care Reform Articles - October 10, 2022

 Editor's Note: 

I have occasionally described the American healthcare system as "the largest and most successful extortion racket ever invented" - much of it perfectly legal, and have been criticized for being hyperbolic.  Read the following NYT story about the profit-maximizing behaviour of Medicare Advantage plans (and soon Traditional Medicare as Designated Contractual Entities take over some of their management), and see whether or not you agree with me,  or agree with my critics.

But where does the fault lie? When you put the fox in charge of the chicken coop and the chickens begin to disappear, it seems a little misplaced to blame the fox for behaving like a fox.  

Who put the fox in charge anyway? Well - we all did - through our government.  

The Affordable Care Act put for-profit corporations, including publicly-traded and other investor-owned corporations including hedge-funds (poorly regulated private equity) in charge of much of our healthcare system, and asked them to use the tools of the market-place (such as choice of plans and competition among them) to provide accessible, affordable and high quality health care. This idea has resulted in the perfectly predictable behavior described in the following NYT clipping.

There is so much easy money sloshing around in the American healthcare system, and so many different actors in a position to be tempted to drink at the trough, that greed quickly overtakes the best of intentions. 

The fundamental mission of investor-owned corporations is to create wealth for their owners. This article rightly focuses on the insurance companies, but they are not alone. Many provider organizations are also complicit in cooperating by playing this pernicious game of up-coding - including physicians and other "providers" - many of them nominally non-profit.  Such complicit players have been described as "useful idiots".(see Kurt Andersen's excellent book "Evil Geniuses".

We need to abolish the participation of for-profit investor owned corporations from participating in our healthcare system if they are in a position to influence clinical decision-making, the documentation of those services, or the allocation of capital for the creation of the capacity to provide those services. 

Although it is true that many nominally non-profit entities behave in ways indistinguishable from their for-profit brethren, there is one important difference.  For a privately-owned company,  the amound of greed is optional.  In an investor-owned entity, including hedge funds or publicly-traded companies, it is baked into their mission - in other words, for them greed is mandatory.

I'm old enough to remember when doctors, hospitals and other providers of healthcare were overwhelmingly not for profit and motivated by putting the patient first.

It's way beyond time to put a stop to this chicanery, clean this mess up,and stop this perversion of the culture of our healthcare system. 

- SPC

‘The Cash Monster Was Insatiable’: How Insurers Exploited Medicare for Billions

By next year, half of Medicare beneficiaries will have a private Medicare Advantage plan. Most large insurers in the program have been accused in court of fraud.

by Reed Abolson and Margot Sanger-Katz - NYT - October 8, 2022

The health system Kaiser Permanente called doctors in during lunch and after work and urged them to add additional illnesses to the medical records of patients they hadn’t seen in weeks. Doctors who found enough new diagnoses could earn bottles of Champagne, or a bonus in their paycheck.

Anthem, a large insurer now called Elevance Health, paid more to doctors who said their patients were sicker. And executives at UnitedHealth Group, the country’s largest insurer, told their workers to mine old medical records for more illnesses — and when they couldn’t find enough, sent them back to try again.

Each of the strategies — which were described by the Justice Department in lawsuits against the companies — led to diagnoses of serious diseases that might have never existed. But the diagnoses had a lucrative side effect: They let the insurers collect more money from the federal government’s Medicare Advantage program.

Medicare Advantage, a private-sector alternative to traditional Medicare, was designed by Congress two decades ago to encourage health insurers to find innovative ways to provide better care at lower cost. If trends hold, by next year, more than half of Medicare recipients will be in a private plan.

But a New York Times review of dozens of fraud lawsuits, inspector general audits and investigations by watchdogs shows how major health insurers exploited the program to inflate their profits by billions of dollars.

The government pays Medicare Advantage insurers a set amount for each person who enrolls, with higher rates for sicker patients. And the insurers, among the largest and most prosperous American companies, have developed elaborate systems to make their patients appear as sick as possible, often without providing additional treatment, according to the lawsuits.

As a result, a program devised to help lower health care spending has instead become substantially more costly than the traditional government program it was meant to improve.

Eight of the 10 biggest Medicare Advantage insurers — representing more than two-thirds of the market — have submitted inflated bills, according to the federal audits. And four of the five largest players — UnitedHealth, Humana, Elevance and Kaiser — have faced federal lawsuits alleging that efforts to overdiagnose their customers crossed the line into fraud.

The fifth company, CVS Health, which owns Aetna, told investors its practices were being investigated by the Department of Justice.

In statements, most of the insurers disputed the allegations in the lawsuits and said the federal audits were flawed. They said their aim in documenting more conditions was to improve care by accurately describing their patients’ health.

Many of the accusations reflect missing documentation rather than any willful attempt to inflate diagnoses, said Mark Hamelburg, an executive at AHIP, an industry trade group. “Professionals can look at the same medical record in different ways,” he said.

The government now spends nearly as much on Medicare Advantage’s 29 million beneficiaries as on the Army and Navy combined. It’s enough money that even a small increase in the average patient’s bill adds up: The additional diagnoses led to $12 billion in overpayments in 2020, according to an estimate from the group that advises Medicare on payment policies — enough to cover hearing and vision care for every American over 65.

Another estimate, from a former top government health official, suggested the overpayments in 2020 were double that, more than $25 billion.

The increased privatization has come as Medicare’s finances have been strained by the aging of baby boomers. But for insurers that already dominate health care for workers, the program is strikingly lucrative: A study from the Kaiser Family Foundation, a research group unaffiliated with the insurer Kaiser, found the companies typically earn twice as much gross profit from their Medicare Advantage plans as from other types of insurance.

For people choosing between traditional Medicare and Medicare Advantage, there are trade-offs. Medicare Advantage plans can limit patients’ choice of doctors, and sometimes require jumping through more hoops before getting certain types of expensive care.

But they often have lower premiums or perks like dental benefits — extras that draw beneficiaries to the programs. The more the plans are overpaid by Medicare, the more generous to customers they can afford to be.

“Medicare Advantage is an important option for America’s seniors, but as Medicare Advantage adds more patients and spends billions of dollars of taxpayer money, aggressive oversight is needed,” said Senator Charles Grassley of Iowa, who has investigated the industry. The efforts to make patients look sicker and other abuses of the program have “resulted in billions of dollars in improper payments,” he said.

Many of the fraud lawsuits were initially brought by former employees under a federal whistle-blower law that allows them to get a percentage of any money repaid to the government if their suits prevail. But most have been joined by the Justice Department, a step the government takes only if it believes the fraud allegations have merit. Last year, the department’s civil division listed Medicare Advantage as one of its top areas of fraud recovery.

“It’s an extremely high priority for us,” said Michael Granston, a deputy assistant attorney general for the civil division.

In contrast, regulators overseeing the plans at the Centers for Medicare and Medicaid Services, or C.M.S., have been less aggressive, even as the overpayments have been described in inspector general investigations, academic research, Government Accountability Office studies, MedPAC reports and numerous news articles, over the course of four presidential administrations.

Congress gave the agency the power to reduce the insurers’ rates in response to evidence of systematic overbilling, but C.M.S. has never chosen to do so. A regulation proposed in the Trump administration to force the plans to refund the government for more of the incorrect payments has not been finalized four years later. Several top officials have swapped jobs between the industry and the agency.

C.M.S. officials declined interview requests. In a statement, the C.M.S. administrator, Chiquita Brooks-LaSure, said the agency recently sought feedback on how to improve the program. “We are committed to making sure that Medicare dollars are used efficiently and effectively in Medicare Advantage,” she said.

The popularity of Medicare Advantage plans has helped them avoid legislative reforms. The plans have become popular in urban areas, and have been increasingly embraced by Democrats as well as Republicans. Nearly 80 percent of U.S. House members signed a letter this year saying they were “ready to protect the program from policies that would undermine” its stability.

“You have a powerful insurance lobby, and their lobbyists have built strong support for this in Congress,” said Representative Lloyd Doggett, a Texas Democrat who chairs the House Ways and Means Health subcommittee.

Some critics say the lack of oversight has encouraged the industry to compete over who can most effectively game the system rather than who can provide the best care.

“Even when they’re playing the game legally, we are lining the pockets of very wealthy corporations that are not improving patient care,” said Dr. Donald Berwick, a C.M.S. administrator under the Obama administration, who recently published a series of blog posts on the industry. “When you skate to the edge of the ice, sometimes you’re going to fall in.”

The program’s promise

Congress’s first attempt to design a privatized Medicare plan paid insurers the same amount for every patient with similar demographic characteristics.

In theory, if the insurers could do better than traditional Medicare — by better managing patients’ care, or otherwise improving their health — their patients would cost less and the insurers would make more money.

But some insurers engaged in strategies — like locating their enrollment offices upstairs, or offering gym memberships — to entice only the healthiest seniors, who would require less care, to join. To deter such tactics, Congress decided to pay more for sicker patients.

Almost immediately, companies saw ways to exploit that system. The traditional Medicare program provided no financial incentive to doctors to document every diagnosis, so many records were incomplete. Under the new program, insurers began rigorously documenting all of a patient’s health conditions — say depression, or a long-ago stroke — even when they had nothing to do with the patient’s current medical care.

In one early case, a Florida medical practice was accused of falsifying diagnoses to enrich its owner and Humana. When Humana told the doctor who owned the practice that his Medicare risk adjustment, or M.R.A., scores had increased significantly, he responded by email, according to the whistle-blower lawsuit: “Good, I am trying to buy that house based on M.R.A. scores.” The case was settled for more than $3 million.

The doctor denied any wrongdoing. Humana declined to comment on the lawsuit and said it takes compliance “seriously.” The company recently told investors it had been questioned by the Justice Department about its billing practices and expected additional litigation.

At conferences, companies pitched digital services to analyze insurers’ medical records and suggest additional codes. Such consultants were often paid on commission; the more money the analysis turned up, the more the companies kept.

The insurers also began hiring agencies that sent doctors or nurses to patients’ homes, where they could diagnose them with more diseases.

One company, Mobile Medical Examination Services, worked with Anthem and Molina, among others. Its doctors and nurses were pushed to document a range of diagnoses, including some — vertebral fractures, pneumonia and cancer — they lacked the equipment to detect, according to a whistle-blower lawsuit. According to the lawsuit, employees who drew patients’ blood often were not provided with a centrifuge or cooler; spoiled blood analyzed a day later produced strange results that could be used to justify valuable diagnoses, including kidney disease and leukemia. The company was acquired by Quest Diagnostics after the case was settled for an undisclosed amount in 2016; Quest said the company complies with all federal and state laws and regulations.

Anthem: The Justice Department suit quotes an executive describing her reluctance to change how it mined medical records for additional diagnoses. The case is continuing.

Cigna hired firms to perform similar at-home assessments that generated billions in extra payments, according to a 2017 whistle-blower lawsuit, which was recently joined by the Justice Department. The firms told nurses to document new diagnoses without adjusting medications, treating patients or sending them to a specialist.

According to the lawsuit, some patients were diagnosed with cancer and heart disease. Nurses were told to especially look for patients with a history of diabetes because it was not “curable,” even if the patient now had normal lab findings or had undergone surgery to treat the condition.

The company declined to comment. “We will vigorously defend our Medicare Advantage business against these allegations,” Cigna said in an earlier statement regarding the lawsuit.

Adding the code for a single diagnosis could yield a substantial payoff. In a 2020 lawsuit, the government said Anthem instructed programmers to scour patient charts for “revenue-generating” codes. One patient was diagnosed with bipolar disorder, although no other doctor reported the condition, and Anthem received an additional $2,693.27, the lawsuit said. Another patient was said to have been coded for “active lung cancer,” despite no evidence of the disease in other records; Anthem was paid an additional $7,080.74. The case is continuing.

The most common allegation against the companies was that they did not correct potentially invalid diagnoses after becoming aware of them. At Anthem, for example, the Justice Department said “thousands” of inaccurate diagnoses were not deleted. According to the lawsuit, a finance executive calculated that eliminating the inaccurate diagnoses would reduce the company’s 2017 earnings from reviewing medical charts by $86 million, or 72 percent.

In a statement, the company, now named Elevance, said it would “vigorously defend our Medicare risk adjustment practices” and accused the government of holding it to standards “that are not grounded in formal statutory and regulatory rules.”

Some of the companies took steps to ensure the extra diagnoses didn’t lead to expensive care. In an October 2021 lawsuit, the Justice Department estimated that Kaiser earned $1 billion between 2009 and 2018 from additional diagnoses, including roughly 100,000 findings of aortic atherosclerosis, or hardening of the arteries. But the plan stopped automatically enrolling those patients in a heart attack prevention program because doctors would be forced to follow up on too many people, the lawsuit said.

Kaiser, which both runs a health plan and provides medical care, is often seen as a model system. But its control over providers gave it additional leverage to demand additional diagnoses from the doctors themselves, according to the lawsuit.

“The cash monster was insatiable,” said Dr. James Taylor, a former coding expert at Kaiser who is one of 10 whistle-blowers to accuse the organization of fraud.

At meetings with supervisors, he was instructed to find additional conditions worth tens of millions of dollars. “It was an actual agenda item and how could we get this,” Dr. Taylor said.

Marc T. Brown, a Kaiser spokesman, said in a statement, “We are confident in our compliance with Medicare Advantage risk-adjustment program requirements,” and added, “Our policies and practices represent well-reasoned and good-faith interpretations of sometimes vague and incomplete guidance from C.M.S.”

Last year, the inspector general’s office noted that one company “stood out” for collecting 40 percent of all Medicare Advantage’s payments from chart reviews and home assessments despite serving only 22 percent of the program’s beneficiaries. It recommended Medicare pay extra attention to the company, which it did not name, but the enrollment figure matched UnitedHealth’s.

A civil trial accusing UnitedHealth of fraudulent overbilling is scheduled for next year. The company’s internal audits found numerous mistakes, according to the lawsuit, which was joined by the Justice Department. Some doctors diagnosed problems like drug and alcohol dependence or severe malnutrition at three times the national rate. But UnitedHealth declined to investigate those patterns, according to the suit.

UnitedHealth Group: A whistle-blower complaint quotes an executive’s email to a firm that was helping the company review patient medical records. A trial is scheduled for next year.

Matthew Wiggin, a spokesman for the company, called the inspector general’s report “misleading.” He said the company uses diagnostic coding to improve patient care, and noted that the whistle-blower in the lawsuit had not worked for the company in nearly a decade. “Our chart review process complies with regulatory standards,” he said, adding, “Our robust compliance program also proactively seeks to identify fraud, waste and abuse in the system.”

The company countered by suing Medicare, arguing that it wasn’t required to fix inaccurate records before regulations changed in 2014. It won at first, then lost on appeal. In June, the Supreme Court declined to hear the case.

Inaction at Medicare

Even before the first lawsuits were filed, regulators and government watchdogs could see the number of profitable diagnoses escalating. But Medicare has done little to tamp down overcharging.

Several experts, including Medicare’s advisory commission, have recommended reducing all the plans’ payments. Congress has ordered several rounds of cuts and gave C.M.S. the power to make additional reductions if the plans continued to overbill. The agency has not exercised that power.

The agency does periodically audit insurers by looking at a few hundred of their customers’ cases. But insurers are fined for billing mistakes found only in those specific patients. A rule proposed during the Trump administration to extrapolate the fines to the rest of the plan’s customers has not been finalized.

Some of the agency’s top leaders have had close ties to industry. Marilyn Tavenner, a former C.M.S. administrator, left in 2015, then ran the main trade group for health insurers; she was replaced by Andy Slavitt, a former executive at UnitedHealth. Jonathan Blum, the agency’s current chief operating officer, worked for an insurer after leaving the agency in 2014, then became an industry consultant, before returning to Medicare last year.

Ted Doolittle, who served as a senior official for the agency’s Center for Program Integrity from 2011 to 2014, said officials at Medicare seemed uninterested in confronting the industry over these practices. “It was clear that there was some resistance coming from inside” the agency, he said. “There was foot dragging.”

There are signs the problem is continuing.

“We are hearing about it more and more,” said Jacqualine Reid, a government research analyst at the Office of Inspector General who has analyzed Medicare Advantage overbilling.

Kaiser Permanente: An executive discussed punishing doctors who failed to review patient records for more diseases, according to a Justice Department lawsuit. The case is continuing.

The Justice Department has brought or joined 12 of the 21 cases that have been made public. But whistle-blower cases remain secret until the department has evaluated them. “We’re aware of other cases that are under seal,” said Mary Inman, a partner at the firm Constantine Cannon, which represents many of the whistle-blowers.

But few analysts expect major legislative or regulatory changes to the program.

“Medicare Advantage overpayments are a political third rail,” said Dr. Richard Gilfillan, a former hospital and insurance executive and a former top regulator at Medicare, in an email. “The big health care plans know it’s wrong, and they know how to fix it, but they’re making too much money to stop. Their C.E.O.s should come to the table with Medicare as they did for the Affordable Care Act, end the coding frenzy, and let providers focus on better care, not more dollars for plans.”

https://www.nytimes.com/2022/10/08/upshot/medicare-advantage-fraud-allegations.html

  

Medical Debt Makes the Sick Sicker

by David U. Himmelstein, MD, and Steffie Woolhandler, MD, MPH

Most physicians have sworn an oath to "abstain from whatever is deleterious" to our patients. Yet our medical institutions harm patients daily. They dun them for medical bills they can't afford, often leaving them unable to pay their rent or mortgage, or buy enough to eat.

That accusation isn't hyperbole, it's a finding from our analysis -- published this month in JAMA Network Open -- of Census Bureau surveys on medical indebtedness. We found that more than one in 10 U.S. adults -- and nearly one in five households -- incurred a medical debt they couldn't pay. And it wasn't just the poor or uninsured who were at risk. Adults who had gone to college were just as likely to have medical debts as those who hadn't finished high school, and middle-income individuals had the same risk as the poor. While the uninsured had the highest rate (15.3%) of medical indebtedness, 10.5% of individuals with private coverage had medical debts -- presumably due to high copayments, deductibles, and coverage denials -- with Medicare Advantage enrollees having a particularly high rate. And the debts weren't trivial: they averaged $21,687 per debtor in 2018.

Our findings add to a growing litany of studies showing that medical bills are a huge problem for Americans. Back in 2001, we (together with then-Harvard law professor Elizabeth Warren and sociologist Deborah Thorne) found that illness and medical bills contributed to more than half of all personal bankruptcies, a figure that climbed to 62% in 2007. A Kaiser/NPR survey this year suggests that our estimates of medical indebtedness (based on 2017-2019 surveys) may be too conservative; Kaiser/NPR estimates that 100 million Americans are dealing with medical debt.

But whatever the number, the consequences are often grave. Because the Census Bureau repeatedly surveyed the same individuals over 3 years, we, unlike previous analysts (who used one-time surveys), could assess the consequences of newly acquiring medical debt. Among individuals with no medical debts in 2017, those who newly incurred such debt in subsequent years were more than twice as likely to newly become food insecure or unable to pay their rent, mortgage, or utility bill, and to be evicted or suffer foreclosure in subsequent years.

Moreover, the detailed income and asset data that the Census Bureau collected enabled us to isolate the effects of medical bills. It was medical bills, not lost income due to illness or depleted assets from non-medical bills, that drove people from their homes and left them struggling to afford groceries. In policy parlance, medical bills often worsened patients' Social Determinants of Health -- non-medical factors that affect health outcomes.

Medical leaders and policy makers like to blame those non-medical factors for the yawning disparities in health outcomes in our nation, and our life-expectancy that lags 3 to 4 years behind other wealthy nations. They're right. Poverty and all of the woes that come with it undermine health. But while in 80% of hospitals the "leadership is committed to establishing and developing processes to systematically address social needs as part of clinical care," they studiously avoid acknowledging that they're part of the problem. The bills they send often contribute to a downward spiral of worsening poverty that we know causes deteriorating health.

That leaves doctors trying to clean up the mess that our healthcare system creates. Our patients get sick and their medical bills too often make them sicker, or add to their trauma (as we found in another recent study led by Sam Dickman, MD).

The Dickman study examined the ED records of sexual assault victims across the nation. More than 17,000 of those survivors were uninsured; the charges for their ED care averaged $3,600. Moreover, even rape victims with private insurance are stuck paying (on average) 14% of the costs for their rape-related care -- nearly $1,000. That's a particularly steep price for the lower-income women and girls who face the greatest risk of a sexual assault. Fear of the cost is undoubtedly part of the reason that only one in five rape victims seeks medical care.

Doctors can take some small steps that might reduce patients' financial risks. We can remind veterans to check if they're eligible for VA services, help our poor patients enroll in Medicaid, or connect them to hospitals' financial assistance programs. In some practice settings, physicians can forgive copayments and deductibles that cause hardships. But those measures would still leave millions of Americans, insured and uninsured, submerged in debt once they get sick.

The hard truth is that unless you're Elon Musk, you could be only one serious illness away from financial disaster, even if you have coverage, because health insurance is a defective product.

Our healthcare system's infliction of financial (and hence medical) harm is a uniquely American policy choice. In most wealthy nations, national health insurance or a national health service protects patients from that harm; taxpayers foot the bill for everyone's care so the sick don't suffer doubly. That's an approach -- generally known as Medicare for All -- that more than half of American voters and about half of all doctors support. It would let doctors do good without worrying that they're doing harm.

David U. Himmelstein, MD, and Steffie Woolhandler, MD, MPH, are both distinguished professors at CUNY's Hunter College in New York City, lecturers in medicine at Harvard Medical School in Boston, and research associates for Public Citizen's Health Research Group.

 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2796358

 

Some hospitals rake in high profits while their patients are loaded with medical debt

  By Noam Levey - Kaiser Health News - September 28, 2022 

 

PROSPER, Texas — Almost everything about the opening of the 2019 Prosper High School Eagles' football season was big.

The game in this Dallas-Fort Worth suburb began with fireworks and a four-airplane flyover. A trained eagle soared over the field. And some 12,000 fans filled the team's new stadium, a $53 million colossus with the largest video screen of any high school venue in Texas. Atop the stadium was also a big name: Children's Health.

Business has been good for the billion-dollar pediatric hospital system, which agreed to pay $2.5 million to put its name on the Prosper stadium. Other Dallas-Fort Worth medical systems have also thrived. Though exempt from taxes as nonprofit institutions, several, including Children's, notched double-digit margins in recent years, outperforming many of the area's Fortune 500 companies.

But patients aren't sharing in the good times. Of the nation's 20 most populous counties, none has a higher concentration of medical debt than Tarrant County, home to Fort Worth. Second is Dallas County, credit bureau data show.

The mismatched fortunes of hospitals and their patients reach well beyond this corner of Texas. Nationwide, many hospitals have grown wealthy, spending lavishly on advertising, team sponsorships, and even spas, while patients are squeezed by skyrocketing medical prices and rising deductibles.

A KHN review of hospital finances in the country's 306 hospital markets found that several of the most profitable markets also have some of the highest levels of patient debt.

Overall, about a third of the 100 million adults in the U.S. with health care debt owe money for a hospitalization, according to a poll conducted by KFF for this project. Close to half of those owe at least $5,000. About a quarter owe $10,000 or more.

Many are pursued by collectors when they can't pay their bills or hospitals sell the debt.

"The fact is, if you walk into a hospital today, chances are you are going to walk out with debt, even if you have insurance," said Allison Sesso, chief executive of RIP Medical Debt, a nonprofit that buys debt from hospitals and debt collectors so patients won't have to pay it.

A community shadowed by debt

Across the Dallas-Fort Worth metro area — the nation's fourth-largest — the impact has been devastating.

"Medical debt is forcing people here to make incredibly agonizing choices," said Toby Savitz, programs director at Pathfinders, a Fort Worth nonprofit that assists people with credit problems. Savitz estimated that at least half their clients have medical debt. Many are scrimping on food, neglecting rent, even ending up homeless, she said, "and this is not just low-income people."

David Zipprich, a Fort Worth businessman and grandfather, was forced out of retirement after hospitalizations left him owing more than $200,000.

Zipprich, 64, had spent a career in financial consulting. He owned a small bungalow in a historical neighborhood near the Fort Worth rail yards. His daughters, both teachers, and his four grandchildren lived nearby. He had health insurance and some savings, and he'd paid off his mortgage.

Then in early 2020, Zipprich landed in the hospital. While driving, his blood sugar dropped precipitously, causing him to black out and crash his car.

Three months later, after he was diagnosed with diabetes, another complication led to another hospitalization. In December 2020, covid-19 put him there yet again. "I look back at that year and feel lucky I even survived," Zipprich said. 

But even with insurance, Zipprich was inundated with debt notices and calls from collectors. His credit score plummeted below 600, and he had to refinance his home. "My stress was off the charts," he said, sitting in his neatly kept living room with his Shih Tzu, Murphy.

Overall in Tarrant County, 27% of residents with credit reports have medical debt on their records, credit bureau data analyzed by KHN and the nonprofit Urban Institute shows. In Dallas County, it's 22%.

That's more than five times the rate in the largest counties in New York, data shows. The Texans also owe a lot more — the median amount of medical debt on credit records in Tarrant and Dallas counties is nearly $1,000, compared with $400 or less in New York.

Last year, Zipprich returned to work, taking a job in New Jersey that required he commute back and forth to Texas. He recently quit, citing the strain of so much travel. He's now job hunting again. "I never thought this would happen to me," he said.

Who is responsible?

Even small debts can have potentially dangerous consequences, discouraging patients from seeking needed care. Angie Johnson, a 28-year-old schoolteacher, cut short her honeymoon so she and her husband could pay off more than $1,100 she owed a physical therapy center owned by Baylor Scott & White, a mammoth Dallas-based hospital system.

Johnson said the center, where she'd gone after a knee injury, initially said her visits would cost $60. "Then they billed me hundreds," she said. "I don't go to the doctor unless I absolutely have to because it's so expensive." 

Hospital industry leaders blame the patient debt on health insurers, citing the rise of high-deductible plans and other efforts that limit coverage. "The last thing that hospitals want is for their patients to face financial barriers," said Molly Smith who leads public policy at the American Hospital Association. "Hospitals are in there trying to work on behalf of patients."

Despite repeated requests from KHN, none of the medical systems around Dallas-Fort Worth would discuss their finances or the debt carried by patients.

But Smith and other hospital leaders point to billions of dollars of free or discounted care that hospitals nationwide provide every year. "Hospitals have been pretty darn generous," said Stephen Love, president of the Dallas-Fort Worth Hospital Council. "If other parts of the community did as much as hospitals, we wouldn't be in this problem."

Unlike drug companies, device makers, and many physician practices, most U.S. hospitals are nonprofit and must provide charity care as a condition of their tax-exempt status.

Regardless of tax status, medical centers in markets with high medical debt do provide more charity care, according to an analysis by KHN and the Urban Institute, a Washington think tank. That's important, said Dr. Vikas Saini, president of the Lown Institute, a nonprofit that grades hospitals on their quality and community benefits.

But Saini asked: "Is a hospital truly serving its community if it's pushing so many into debt?"

Around Dallas-Fort Worth, major medical systems frequently tout their commitment to the region and its patients.

When Texas Health Resources, a Dallas-based nonprofit system with more than $5 billion in annual revenue, opened a new hospital tower in Fort Worth earlier this year, Barclay Berdan, the system's chief executive, said the building "reinforces Texas Health's long-standing commitment to the Fort Worth community." The nine-story, $300 million tower is one of more than a half-dozen new hospitals and major expansions around the Dallas-Fort Worth area since 2018.

The big building spree has been accompanied by big bottom lines.

From 2018 to 2021, Texas Health, which owns hospitals in North Texas, had an average operating margin of almost 6%, according to a KHN analysis of publicly available financial reports.

Other major systems in the area, including Baylor, Children's Health, and HCA, the nation's largest for-profit hospital company, did even better, KHN found. Cook Children's, the region's second major pediatric system, had an average operating margin of nearly 12%.

By comparison, profits at most of the 25 Fortune 500 companies based around Dallas-Fort Worth, such as ExxonMobil, were less than 6% in 2019, according to Fortune data.

Approaching a tipping point

Hospitals have thrived in other markets with high patient debt, KHN found.

In Charlotte, N.C., where a quarter of residents have medical debt on their credit reports, hospitals recorded an average operating margin of 13.6% from 2017 to 2019.

The average margin at hospitals in and around Gainesville and Lakeland, two central Florida markets where a quarter of residents also carry medical debt, topped 9%. In Tulsa, Okla., which has the same level of debt, margins have averaged 8.5%.

Overall, U.S. hospitals recorded their most profitable year on record in 2019, with an aggregate operating margin of 6.5%, according to the federal Medicare Payment Advisory Commission. Total margins, which include income from investments, were even higher.

"You might think that hospitals in communities where patients have a lot of debt would be less profitable, but that doesn't seem to be the case," said Anuj Gangopadhyaya, a senior Urban Institute researcher who worked with KHN on an analysis of hospital finance and consumer debt data in U.S. hospital markets.

In fact, the analysis found, there is no apparent relationship between the profits of hospitals in a market and how much medical debt residents have. So while hospitals in places like Charlotte and Tulsa may be comfortably in the black, in other places with high patient debt such as Amarillo, Texas, and Columbia, S.C., hospitals are struggling, data shows.

Industry experts say the most profitable medical centers — like those around Dallas-Fort Worth — have developed business models that allow them to prosper even if their patients can't pay.

One key is prices. These hospitals maximize what they charge for everything from a complex surgery to a dose of aspirin. Most of those charges are picked up by health insurers, which still pay a much larger share of hospital bills than patients do, even those with the highest deductibles.

Across the country, many medical systems have strengthened their market power in recent years by consolidating, buying up smaller hospitals and physician practices, which enable the hospital systems to charge even more.

Dallas-Fort Worth has the highest medical prices in Texas, according to the Health Care Cost Institute, a nonprofit that tracks costs nationwide. And in a state where most markets have relatively low medical prices, in-patient care at Dallas-Fort Worth hospitals was 13% more expensive than the national median in 2020.

In addition to charging more, the most profitable hospitals frequently squeeze more savings from their operations, holding down what they pay workers, for example, and securing better contracts from suppliers. "Hospitals have had to get leaner and meaner," said Kevin Holloran, a senior director at Fitch Ratings who tracks nonprofit health systems for the bond rating firm.

It's unclear how much longer this business model can endure.

Across the country, many small and rural hospitals have closed in recent years. Even some larger systems are now losing money, as inflation and rising labor costs put new pressure on bottom lines.

As bills rise, hospitals are having a harder time collecting. Last year, nearly 1 in 5 patient bills generated by hospitals for people with insurance topped $7,500, according to an analysis of hospital billing records by Crowe LLP, a Chicago-based accounting and consulting firm. That was more than triple the rate in 2018.

"These are bills that fewer and fewer patients out there can afford," said Brian Sanderson, a senior Crowe health care consultant and former hospital executive. Indeed, hospitals manage to collect less than 17% of patient balances that exceed $7,500, according to Crowe's analysis.

"The rates at which patient balances are growing is just unsustainable for our health systems," Sanderson said, predicting that most will never be able to collect bills of this size. "It's trending to the ridiculous."

Robert Earley, a former Texas state legislator who used to head Fort Worth's public health system, compared today's hospitals to shrimpers in the Gulf Coast district he once represented.

"They wanted to pull so much shrimp out of the bay that they didn't think about whether there'd be any there long term," Earley said, recalling his constituents' struggles. "I worry that those of us in health care aren't asking ourselves enough if this system is sustainable." 

https://www.mainepublic.org/npr-news/2022-09-28/some-hospitals-rake-in-high-profits-while-their-patients-are-loaded-with

 

Physician Burnout Has Reached Distressing Levels, New Research Finds

Nearly two-thirds of doctors are experiencing at least one symptom of burnout, a huge increase from before the pandemic. But the situation is not irreparable, researchers say.

by Oliver Whang - NYT - September 29, 2022

Ten years of data from a nationwide survey of physicians confirm another trend that’s worsened through the pandemic: Burnout rates among doctors in the United States, which were already high a decade ago, have risen to alarming levels.

Results released this month and published in Mayo Clinic Proceedings, a peer-reviewed journal, show that 63 percent of physicians surveyed reported at least one symptom of burnout at the end of 2021 and the beginning of 2022, an increase from 44 percent in 2017 and 46 percent in 2011. Only 30 percent felt satisfied with their work-life balance, compared with 43 percent five years earlier.

“This is the biggest increase of emotional exhaustion that I’ve ever seen, anywhere in the literature,” said Bryan Sexton, the director of Duke University’s Center for Healthcare Safety and Quality, who was not involved in the survey efforts.

The most recent numbers also compare starkly with data from 2020, when the survey was run during the early stages of the pandemic. Then, 38 percent of doctors surveyed reported one or more symptoms of burnout while 46 percent were satisfied with their work-life balance.

“It’s just so stark how dramatically the scores have increased over the last 12 months,” said Dr. Tait Shanafelt, an oncologist at Stanford University who has led the research efforts.

Burnout among physicians has been linked to higher rates of alcohol abuse and suicidal ideation, as well as increased medical errors and worse patient outcomes. In May, the U.S. Surgeon General, Dr. Vivek Murthy, issued an advisory.

“Covid-19 has been a uniquely traumatic experience for the health work force and for their families,” he said, adding, “if we fail to act, we will place our nation’s health at risk.”

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Dr. Shanafelt noted that most of the studies on burnout among physicians and health care workers at this stage of the pandemic have been focused on certain specialties and geographic hot spots, not on the profession as a whole. With the new data set, he said, “We have, for the first time, real context.”

While the idea of burnout has become ubiquitous, the condition has a definition in medical literature. The Maslach Burnout Inventory, first published in 1981, measures burnout on three dimensions: emotional exhaustion, depersonalization from work and sense of personal accomplishment.

When the metric was first proposed, a widely held belief was that burnout could be blamed on the dispositions of individual physicians — “that these are just weaklings,” explained Dr. Colin West, a physician at the Mayo Clinic who helped conceive of the survey efforts. Over time, though, the problem persisted and that belief became outdated.

“This couldn’t just be pawned off as a handful of people who couldn’t handle the career,” Dr. West said.

In 2019, the National Academy of Medicine released a 312-page report on physician burnout, carefully laying out the current understanding of the issue and steps that people in the medical profession could take to address it. Dr. Shanafelt, who helped write the report, said that evidence suggested that many doctors’ dissatisfaction with their work could be caused by an incongruence between what they cared about and what they were incentivized to do by the health care system.

“We cared about quality of patients’ experience, building relationships with them, and then there were all these things we got paid for,” Dr. Shanafelt said. A doctor may stop looking forward to patient visits if each one is accompanied by a large amount of paperwork; they may feel as if their time is being wasted by an inefficient process.

“Even something that was once a good thing can become tarnished,” he added.

The researchers noted that the most recent survey’s broad scope has limitations. About 2,500 physicians participated by responding to a mass email, a fraction of the estimated one million practicing physicians in the United States. And the factors that might lead someone to complete a survey on burnout — such as the need for an outlet to express frustration or the lack of time to complete one — could have had complicating effects.

Doctors also exist within an ecosystem of other health workers. Dr. Sexton published a study of more than 70 hospitals this month that showed burnout is often a local phenomenon. “A lot of a person’s exhaustion score is connected to who they work with,” he said. “There’s a social contagion in burnout. If your colleagues are fried and you’re not, give it six months and you’ll look just like them.”

Doctors were unevenly affected by the early stages of the pandemic. While emergency physicians and family physicians worked around the clock, constantly exposed to Covid-19, many physicians in other specialties were able to reach their patients through telehealth appointments and spend more time with their families. Combined with a possible optimism that the worst of the pandemic was over, the rise of remote work might explain why emotional exhaustion rates actually fell among surveyed physicians in mid-2020 to the lowest point since the survey began in 2011.

But two and a half years into the pandemic, the most recent survey pointed to an overall decline in mental health.

The survey also suggested that some physicians were at higher risk of burnout, including those practicing emergency medicine, family medicine and pediatrics, as well as women physicians in general. Dr. Shanafelt said this might be because of the shortage of mental health services. “They’ve got 10 minutes to take care of their patients. There’s no psychiatrist or therapist to refer them to because our health care system is overwhelmed,” he said.

The increase in burnout is most likely a mix of new problems and exacerbated old ones, Dr. Shanafelt said. For instance, the high number of messages doctors received about patients’ electronic health records was closely linked to increased burnout before the pandemic. After the pandemic, the number of messages from patients coming into physicians’ In Baskets, a health care closed messaging system, increased by 157 percent.

And physicians pointed to the politicization of science, labor shortages and the vilification of health care workers as significant issues. In one survey published in 2021, 23 percent of physicians reported being bullied, threatened or harassed by their patients at work in the past year.

Dr. Sexton added: “On a hopeful note, we know that there are simple interventions that can have as much a positive effect on well-being as the pandemic had a negative effect. So, yes, things are worse during the pandemic, but they’re not so bad that we don’t know how to fix it.”

Dr. West, who has done research on how to combat burnout among health care workers, said that “all the solutions run through a common pathway”: They connect people with their most meaningful activities.

“What that means is it’s less important what the specific tactic is,” he said, “and more important to make sure that, whatever the solution is, it’s aligned with our basic, fundamental goals.”

But Dr. West emphasized the need for data to know the prevalence of burnout and how to combat it.

“This really provides a 30,000-foot view pulse check,” he said of the survey. “So that we’re not just guided by our feelings and our intuition.”

https://www.nytimes.com/2022/09/29/health/doctor-burnout-pandemic.html 

 

For 20-Somethings, a Confusing Rite of Passage: Finding Health Insurance

Whether you’re turning 26 and about to age out of a parent’s plan or just landing a job with benefits, finding coverage is a tricky task.

by Isabella Simonetti - NYT - September 30, 2022

Ahead of Cal Treichler’s 26th birthday in June, he faced a common challenge for 20-somethings fortunate enough to have parents with health insurance: He had to get off their plan and find his own coverage.

Mr. Treichler, who lives near Minneapolis, cannot obtain health insurance through his employer, a small financial planning firm. His company does, however, provide a stipend to pay for insurance. So Mr. Treichler considered two options: joining his wife’s plan through her teaching job or finding coverage on Minnesota’s health insurance marketplace, where residents can search for affordable plans.

Whether they are 25 and about to age out of a parent’s plan or entering the work force for the first time, young Americans are tasked with making crucial decisions about their health care at a time when they may have little understanding of how insurance works.

Luckily, Mr. Treichler’s training and knowledge as a financial planner helped him weigh his options. His wife’s plan offered advantages like lower deductibles (the amount of money you need to pay each year before coverage kicks in) and out-of-pocket maximums (the most you have to pay for covered services each year). But he calculated that her plan would be more expensive month to month than the plan he found on the marketplace.

“I typically, personally, haven’t had a lot of health care needs,” Mr. Treichler said. “I decided to go with the lower-paying option with the expectation that I wouldn’t need as much care and would likely be better off going with the lower-premium plan.” (A premium is what you pay to buy an insurance policy, separate from a deductible.)

Nearly 15 percent of Americans ages 19 to 25 were uninsured in 2021, according to data from the Census Bureau, the highest portion of any age group. That number fell from 31.4 percent in 2010, when the Affordable Care Act (nicknamed Obamacare) required insurers to cover families’ dependent children until age 26. Since then, many young people who have the benefit of insured parents have not had to research their own coverage options. Finding a suitable plan for the first time as an adult can present some pitfalls. And a lot of questions.

“You can see your 26th birthday coming,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation. “You know when that’s going to be. Don’t wait until a week or two before to start looking into your options.”

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What’s out there?

Depending on the situation, a young adult might weigh these choices: staying on a parent’s plan till 26, joining an employer-sponsored health insurance plan or buying coverage on their state’s marketplace. Someone with an income up to 138 percent of the federal poverty level may even qualify for Medicaid, which offers free or inexpensive health care for low-income Americans, including pregnant women and seniors. The next open enrollment period (the period when you can sign up for coverage) for marketplace plans that comply with the A.C.A. runs from Nov. 1 to Jan. 15, 2023 for most states. Many employers offer open enrollment periods, too, that are typically in the fall, but the timing varies from company to company.

The marketplace plans offer different tiered private insurance options with government subsidies for people whose income falls below a certain threshold. While the service is mainly available through Healthcare.gov, some states, including California and Pennsylvania, operate their own websites. Although the open enrollment period is fixed, those who have experienced a so-called qualifying event, like losing insurance through an employer or being forced off a parent’s insurance after a 26th birthday, have 60 days from that event to enroll in a marketplace plan. If you miss the cutoff, you will have to wait until the next enrollment period, unless there has been a major event like a natural disaster.

For those deciding whether or not to join an employer plan, it is wise to compare its cost and coverage with that of a parent’s plan. If a parent’s plan is cheaper and offers better coverage, asking your parents if they will share the cost with you might be the best solution.

Among employer plans, there may be the option to choose between a Preferred Provider Organization plan and a Health Maintenance Organization plan. A P.P.O. plan generally is more expensive on a monthly basis but may offer more out-of-network coverage, which could be necessary if you have specific medical needs. An H.M.O., though, is typically less expensive and includes a smaller group of providers.

“It’s just really a math problem,” said Robert Persichitte, a financial planner at Delagify Financial. “It’s figuring out how much would your parents pay for the insurance versus how much would you pay for the insurance, and you pick.”

Mr. Persichitte teaches a volunteer income tax assistance class at the Metropolitan State University of Denver in which accounting students help prepare tax returns for people who have annual incomes of less than $57,000. A student in the class, Deborah Son, was able to use what she learned to help prepare her father’s 2021 tax return. When they prepared the return, the family, of Aurora, Colo., got an expensive surprise.

As a college student, Ms. Son, 25, had opted to stay on her father’s plan rather than pay extra for her university health insurance. That worked for a while — until the money she earned as an intern in 2021 increased her family’s income. With the extra income, they no longer qualified for subsidized coverage through the A.C.A., requiring them to pay an unexpected additional premium of $3,000.

“We were all pretty shocked,” Ms. Son said.

Ms. Son’s case was more complicated than most, Mr. Persichitte said. Still, a multitude of varied situations can create confusion and uncertainty.

Georgia Lee Hussey, the chief executive of Modernist Financial, a planning firm in Portland, Ore., that helps clients make financial decisions aligned with their progressive values, noted that some young people who are working as independent contractors or interns may qualify for Medicaid. She said it was important for young adults to aim for financial independence, if possible.

“If you have the means, get your own health care coverage,” Ms. Hussey said.

Talking to your family

Conversations about financial decisions like health insurance can provoke tension between parents and grandparents and their children, sometimes because of generational differences. Ms. Hussey said people should focus on cultivating understanding and empathy when sensitive issues arise.

“What we don’t talk about as often as I would like is the financial realities for younger folks and the changing expectations,” Ms. Hussey said. “There’s a place for compassion between generations and understanding between generations.”

And it helps to remember that everyone has unique health needs that factor into making the right decision about insurance.

“There’s really no one size fits all, especially when it comes to something as sensitive as health care,” said Noah Damsky, a co-founder of Marina Wealth Advisors in Los Angeles.

A good place to get started, though, is educating yourself on health insurance vocabulary. Alexis Plicque, who recently went from being insured under two plans at once, to being covered by only her employer’s plan, said navigating insurance for the first time was a challenge — and it felt like a stride into adulthood.

“I really am paying for my own stuff now,” she said. “It’s kind of crazy.”

Ms. Plicque, who lives in Jacksonville, Fla., added that she leaned on her parents to teach her about terms like deductibles and co-pays (a co-pay is the fee you pay for a doctor visit or procedure after insurance). “A lot of it is very dependent on how much you want to pay per month and what your plan covers and what your employer will give you, so it’s not something you can just Google and figure it out on your own,” she said.

If like her, you have employer-sponsored coverage, Ms. Plicque offered this bit of advice: Be careful about taking on the cheapest plan an employer offers, because often that will mean having to pay a higher annual deductible before coverage kicks in.

“It is confusing, and I feel like it’s kind of confusing on purpose,” Ms. Plicque said. “And so it’s OK to ask for help and ask for other people to explain it to you, because how would you know? Because you’ve never paid for it before.”

https://www.nytimes.com/2022/09/30/business/health-insurance-obamacare-young-adults.html 

 

Medical Care Alone Won’t Halt the Spread of Diabetes, Scientists Say

Now experts are calling for walkable communities, improved housing, and access to health care and better food, particularly in minority communities.

by Roni Caryn Rabin - NYT - October 5, 2022

Over the past 50 years, medical advances have led to a more sophisticated understanding of the causes of Type 2 diabetes and to an abundance of new tools for managing it. But better treatments have done little to stem the rise of the disease.

One in seven American adults has Type 2 diabetes now, up from one in 20 in the 1970s. Many teenagers are developing what was once considered to be a disease of older people; 40 percent of young adults will be diagnosed with it at some point in their lives.

Researchers who study Type 2 diabetes have reached a stark conclusion: There is no device, no drug powerful enough to counter the effects of poverty, pollution, stress, a broken food system, cities that are hard to navigate on foot and inequitable access to health care, particularly in minority communities.

“Our entire society is perfectly designed to create Type 2 diabetes,” said Dr. Dean Schillinger, a professor of medicine at University of California, San Francisco. “We have to disrupt that.”

Dr. Schillinger and nearly two dozen other experts laid out a road-map for doing so earlier this year in a comprehensive national report to Congress on diabetes, the first of its kind since 1975.

It calls for reframing the epidemic as a social, economic and environmental problem, and offers a series of detailed fixes, ranging from improving access to healthy food and clean water to rethinking the designs of communities, housing and transportation networks.

“It’s about massive federal subsidies that support producing ingredients that go into low-cost, energy-dense, ultra-processed and sugar-loaded foods, the unfettered marketing of junk food to children, suburban sprawl that demands driving over walking or biking — all the forces in the environment that some of us have the resources to buffer ourselves against, but people with low incomes don’t,” Dr. Schillinger said.

“We feel impotent as doctors because we don’t have the tools to tackle the social conditions people are grappling with,” he added.

The report, issued in January, calls for setting up a national policy office to roll out a far-reaching strategy to prevent and control diabetes. The document also pushes for a greater involvement of federal agencies, like those regulating housing and urban growth, that may seem to have little to do with health but could play a role in reducing the spread of the disease.

The recommendations are intended to tackle the so-called social determinants of health, said Felicia Hill-Briggs, vice president for prevention at Northwell Health.

“When we move beyond thinking of health as just biological disease, then we’re able to see that the conditions in which people are born, grow, work, live and age play a very, very key role in influencing who gets disease and what the outcomes of the disease are,” Dr. Hill-Briggs said.

“Being born into poverty should not determine whether you have access to food, or green space, or an educational system that works.”

Each patient with Type 2 diabetes faces a cascade of risks, including painful nerve damage, vision loss, kidney disease and heart disease, as well as foot and toe amputations. (Type 1 diabetes, once called juvenile diabetes, carries many of the same risks but is believed to be an autoimmune condition.)

As of 2019, more than 14 percent of Native American and Alaska Native adults had diabetes, according to the Centers for Disease Control and Prevention. The figure for Black and Hispanic adults was about 12 percent, compared with 7.4 percent for white adults.

Maria Garcia, a 58-year-old restaurant worker in San Francisco, developed Type 2 diabetes after a pregnancy almost 30 years ago. She has developed numerous complications over the years, including digestive problems, vision loss and nerve damage so severe that she has trouble walking. At night, her legs feel as if they were “on fire,” she said.

She has given up sweetened soda but said she can’t afford to purchase healthy foods like lean meat, fish and vegetables on a regular basis. It was very different in the small village in Mexico where she was born, she recalled.

“Fresh food was really cheap, and sweets and candies were expensive,” she said, adding, “We walked everywhere, even just to go to the store.”

Many of the recommendations now urged by diabetes researchers are both politically unpalatable and costly. But they could save money in the long run: One in four health care dollars goes to treat diabetes, and that costs the nation $237 billion annually (most of it paid for by government health plans), along with $90 billion in reduced productivity.

Among the proposals:

• Subsidies for farmers to grow healthy foods like fruits, vegetables and nuts in order to make them more affordable.

• Paid maternity leave for working mothers so they can breastfeed, a practice associated with a lower risk of obesity and Type 2 diabetes for both mother and child.

• Clear guidance from the government about the strong link between sugar-sweetened beverages and Type 2 diabetes. Almost one in 10 nutrition-program dollars is spent on sweetened drinks, and the researchers recommend that government programs no longer pay for them.

• Improved nutrition labels that specify the amounts of sugar in drinks in teaspoons, a measure that consumers can easily grasp, rather than grams. A 16-ounce Starbucks frappuccino contains 11 teaspoons of sugar; a 16-ounce bottle of Snapple raspberry ice tea has nine teaspoons.

The report also proposes hefty taxes of 10 percent to 20 percent on the price of sugary drinks. The beverage industry has aggressively fought similar efforts in the past.

William Dermody Jr., a spokesman for the American Beverage Association, pointed to studies showing drops in the consumption of soda and other sugary beverages, not counting tea and coffee drinks. But taxes have had little effect on consumption, he said.

Even the American Diabetes Association prefers more public education about the risks of sugary drinks to taxes or “punitive measures,” said Dr. Robert Gabbay, the association’s chief scientific and medical officer.

Healthy, unprocessed food is more costly, which has led some providers to open their own free pantries so that patients with “food prescriptions” can pick up produce, beans and items like cans of low-sodium turnip greens.

The food pantry at Nashville General Hospital helps Arleen Hicks, 59, who is unemployed and has diabetes, prepare healthy dinners. For her first two meals of the day, she eats as cheaply as possible, usually knockoff toaster pastries that are filled with sugar, which she follows with two tablespoons of peanut butter to bring her blood sugar back down.

She knows that toaster pastries are not nutritious, but they’re cheap. She lives on a monthly income of $607 and $100 in food stamps.

“I get coupons for them in the mail,” Ms. Hicks said, as she picked up zucchini, tomatoes and easy-to-follow recipes at the hospital’s food pantry. “This place has been heaven-sent.”

Some of the concerns expressed by diabetes researchers have been addressed in recent federal legislation. The Inflation Reduction Act, for example, capped the co-payments that Medicare patients shell out for insulin at $35 a month and included $50 billion to strengthen the nation’s drinking water and wastewater systems.

The report’s authors also want to make it easier for patients and people at risk for Type 2 diabetes to take in-depth courses to learn how to manage and prevent the disease. Doctors often say that managing diabetes is like having a full-time job.

Loretta Fleming, 53, who lives in New York City, didn’t know how to keep her blood sugar under control until she enrolled in peer education classes through Health People, a nonprofit, at a community center in her neighborhood in the Bronx.

“I saw dietitians and nutritionists at the hospital, but their education didn’t match what I got from the program,” Ms. Fleming said. Though the classes, she has learned to limit bread and sugary drinks and to check her feet every day for sores that could become infected. She has lost over 100 pounds and has also become a peer educator.

“I used to drink a three-liter soda every day,” she said. “It was a ritual. I had to have my soda. So I had to get rid of that. I didn’t know it was bad for me.”

https://www.nytimes.com/2022/10/05/health/diabetes-prevention-diet.html 

 

Anthem must face U.S. government lawsuit alleging Medicare Advantage fraud

by Jonathan Stempel - Reuters - October 1, 2022

NEW YORK, Oct 3 (Reuters) - A federal judge ordered Anthem Inc to face a U.S. government lawsuit claiming it submitted inaccurate diagnosis data, enabling the health insurer to fraudulently collect tens of millions of dollars in annual overpayments from Medicare.

In a decision released on Monday, U.S. District Judge Andrew Carter in Manhattan said the total alleged overpayment to Anthem appeared to be well over $100 million, making the government's financial costs "substantial and not merely administrative."

A lawyer for Anthem declined to comment. The Indianapolis-based insurer did not immediately respond to a request for comment.

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The Department of Justice lawsuit filed in March 2020 stemmed from Anthem's operation of dozens of Medicare Part C plans, also known as Medicare Advantage, a privatized system that insures Americans who opt out of traditional Medicare.

Anthem was accused of not checking the accuracy of diagnosis codes it submitted when seeking reimbursements between early 2014 and early 2018, because deleting invalid codes would have reduced revenue.

One company executive was quoted in 2016 as saying Anthem viewed its "retrospective chart review," which supplemented codes it had already collected from doctors, as a "cash cow."

The Justice Department sued Anthem under the federal False Claims Act, which prohibits submitting false payment claims, and sought civil fines and triple damages. Carter's decision is dated Sept. 30.

Anthem's case is one of multiple Justice Department civil lawsuits against companies that participate in Medicare Advantage.

The government watchdog MedPac said excess Medicare Advantage billing linked to what it calls "coding intensity" reached $12 billion in 2020.

Enrollment in Medicare Advantage has doubled since 2013 to about 28.7 million, or approximately 49% of all eligible Medicare beneficiaries, MedPac said in July.

The case is U.S. v. Anthem Inc, U.S. District Court, Southern District of New York, No. 20-02593.

https://www.reuters.com/legal/anthem-must-face-us-government-lawsuit-alleging-medicare-advantage-fraud-2022-10-03/