2017-03-30 Update: Physicians for a National Health Program (PNHP)

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Justice Department joins in Medicare fraud lawsuit against UnitedHealth Justice Department Joins Lawsuit Alleging Massive Medicare Fraud By UnitedHealth By Fred Schulte Kaiser Health News, March 28, 2017 The Justice Department has joined a California whistleblower's lawsuit that accuses insurance giant UnitedHealth Group of fraud in its popular Medicare Advantage health plans. Justice officials filed legal papers to intervene in the suit, first brought by whistleblower James Swoben in 2009, on Friday in federal court in Los Angeles. On Monday, they sought a court order to combine Swoben's case with that of another whistleblower. Swoben has accused the insurer of the Medicare Advantage payment system by patients look sicker than they are," said his attorney, William K. Hanagami. Hanagami said the combined cases could prove to be among the frauds" ever against Medicare, with damages that he speculates could top $1 billion. is a very big development and sends a strong signal that the Trump administration is very serious when it comes to fighting fraud in the health care arena," said Patrick Burns, associate director of Taxpayers Against Fraud in Washington, a nonprofit supported by whistleblowers and their lawyers. is not one company engaged in episodic bad behavior, but a lucrative business plan that appears to be national in scope," Burns said. When Congress created the current Medicare Advantage program in 2003, it expected to pay higher rates for sicker patients than for people in good health using a formula called a risk score. But overspending tied to inflated risk scores has repeatedly been cited by government auditors, including the Government Accountability Office. A series of articles published in 2014 by the Center for Public Integrity found that these improper payments have cost taxpayers tens of billions of dollars. khn.org‚… Regular readers know that the private Medicare Advantage plans have been cheating the taxpayers by upcoding the diagnoses of insured patients to make them appear …

Can more Republicans support single payer? Republicans for Single-Payer Health Care By David Leonhardt The New York Times, March 28, 2017 Without a viable health care agenda of their own, Republicans now face a choice between two options: Obamacare and a gradual shift toward a single-payer system. The early signs suggest they will choose single payer. That would be the height of political irony, of course. Donald Trump, Paul Ryan and Tom Price may succeed where left-wing dreamers have long failed and move the country toward socialized medicine. And they would do it unwittingly, by undermining the most conservative health care system that Americans are willing to accept. You've no doubt heard of that conservative system. It's called Obamacare. So if voters like government-provided health care and Republicans are going to undermine private markets, what should Democrats do? When they are next in charge, they should expand government health care. www.nytimes.com‚… *** The Republican Waterloo By David Frum The Atlantic, March 24, 2017 Seven years and three days ago, the House of Representatives grumblingly voted to approve the Senate's version of the Affordable Care Act. Democrats in the House were displeased by many of the changes introduced by Senate Democrats. But in the interval after Senate passage, the Republicans had gained a 41st seat in the Senate. Any further tinkering with the law could trigger a Republican filibuster. Rather than lose the whole thing, the House swallowed hard and accepted a bill that liberals regarded as a giveaway to insurance companies and other interest groups. The finished law proceeded to President Obama for signature on March 23, 2010. Over the next seven years, Republicans would vote again and again to repeal the Affordable Care Act. Total and permanent opposition to the law would become the absolute touchstone of Republican loyalty. Some of the conservatives who voted to the House leadership's version of repeal may yet imagine that they will have some other opport …

Now What, After the Demise of The Republicans' Health Care Plan? The death of the or die" GOP health care plan, as the bill was pulled from a floor vote in the House on March 24, 2017, comes as no surprise. It was a non-coherent bill that depended entirely on votes from a large Republican majority in the House, but exposed bitter divisions between the hard-right Freedom caucus and more moderate Republicans. Despite the addition of many late amendments intended to address the concerns of the opposing groups, they often lost as many votes as were gained. This became a momentous defeat for the House Speaker Paul Ryan, President Donald Trump, and the Republican Party on what was intended to be its signature and opening domestic success. Despite the Republicans having had seven years to develop their own health care plan, the American Health Care Act (AHCA) was a hastily drafted assemblage of ideas, largely based on Paul Ryan's 37-page white paper in 2016, Better Way, and the proposed Empowering Patients First Act by Dr. Tom Price, now the Secretary of Health and Human Services. As a replacement for a repealed Affordable Care Act (ACA) (1), the plan would have done away with the individual mandate, promoted a free market approach, deregulated the private health insurance industry, eliminated the ACA's requirement for coverage of essential services, added tax credits and given insurers wide latitude to charge older enrollees higher prices, fully repeal Medicaid expansion, and cut back women's health care. Their longer-term goal was to privatize both Medicare and Medicaid. Unfortunately and predictably, the debate in the media was superficially covered, disinformation and false promises were common, and legislators at the end did not know what was actually in the bill. As Republicans retreated from the issue, they were unpersuasive as to what they would do next. One day after the defeat of the repeal and replace bill in the House, President Trump declared that will explode. We will all get together and piece together a p …

Krugman needs to study up on‚…Krugman and single payer How to Build on Obamacare By Paul Krugman The New York Times, March 27, 2017 knew that health care could be so complicated." So declared Donald Trump three weeks before wimping out on his promise to repeal Obamacare. But put politics aside for a minute, and ask, what could be done to make health care work better going forward? One important answer would be to spend a bit more money. A report from the nonpartisan Urban Institute argues that the A.C.A. is underfunded," and would work much better in particular, it could offer policies with much lower deductibles if it provided somewhat more generous subsidies. What about the problem of inadequate insurance industry competition? Better subsidies would help enrollments, which in turn would probably bring in more insurers. But just in case, why not revive the idea of a public option insurance sold directly by the government, for those who choose it? There are other more technical things we should do too, like extending reinsurance: compensation for insurers whose risk pool turned out worse than expected. Some analysts also argue that there would be big gains from moving plans onto the government-administered marketplaces. www.nytimes.com‚… *** NYT Reader Comment: By Don McCanne, M.D. San Juan Capistrano, CA Paul Krugman had it right: would argue that good economics is also good politics: reformers will do best with a straightforward single-payer plan, which offers maximum savings and, unlike the Clinton plan, can easily be explained" (NYT, 6/13/05). Studies have shown that the most expensive model of health care financing is a fragmented, multi-payer, public and private system such as we have in the United States. Incremental patches increase costs even more and always fall short on universality, equity, and access while increasing the profound waste of administrative inefficiency (currently over $500 billion per year in recoverable waste Annals of Internal Medicine, 2 …

ACA and AHCA fall short, but so does the Commonwealth Fund solution Where Both the ACA and AHCA Fall Short, and What the Health Insurance Market Really Needs By David Blumenthal and Sara Collins Harvard Business Review, March 21, 2017 To understand the ongoing battles about the individual, or non-group, markets and their reform, three points should be kept in mind. First, these insurance markets were distressed before the enactment of the Affordable Care Act. Second, the ACA improved their functioning but was not sufficient as passed and implemented to stabilize all of them. Neither, however, is the American Health Care Act (AHCA), the repeal and replacement legislation proposed by House Republicans and embraced by President Trump. Third, the reforms that will improve individual markets, which we discuss below, are known. They include greater balance between premium subsidies and penalties for not taking up coverage, using proven mechanisms for stabilizing risks such as reinsurance, and accelerating efforts to control the costs of health care services. To date, the United States has just lacked the political will to adopt them. What to do There is no great mystery about how to shore up private insurance markets. First, we need to create balanced risk pools that include both healthy and less healthy persons in individual insurance markets. This will require two types of actions. Subsidies for young healthy consumers must be increased without decreasing those for older Americans so that so-called young invincibles find the prices of insurance less off-putting but the neediest customers in individual markets can still afford to participate. However, reducing financial barriers for good risks will not suffice. Unlike many other purchases in our lives, buying insurance is difficult, confusing, and provides little short-term gratification; so healthy young people will always tend to avoid it. That is why creating healthy risk pools for individual markets will require something like the individual mandate that has been so unpopular with co …

Customized health insurance benefits do not pool risk Late G.O.P. Proposal Could Mean Plans That Cover Aromatherapy but Not Chemotherapy By Margot Sanger-Katz The New York Times, March 23, 2017 Most Republicans in Congress prefer the type of health insurance market in which everyone could the plan that's right for them." Why should a 60-year-old man have to buy a plan that includes maternity benefits he'll never use? (This is an example that comes up a lot.) In contrast, the Affordable Care Act includes a list of benefits that have to be in every plan, a reality that makes insurance comprehensive, but often costly. Now, a group of conservative House members is trying to cut a deal to get those benefit requirements eliminated as part of the bill to repeal and replace the Affordable Care Act moving through Congress. (The vote in the House is expected later today.) At first glance, this may sound like a wonderful policy. Why should that 60-year-old man have to pay for maternity benefits he will never use? If 60-year-old men don't need to pay for benefits they won't use, the price of insurance will come down, and more people will be able to afford that coverage, the thinking goes. And people who want fancy coverage with extra benefits can just pay a little more for the plan that's right for them. But there are two main problems with stripping away minimum benefit rules. One is that the meaning of insurance" can start to become a little murky. The second is that, in a world in which no one has to offer maternity coverage, no insurance company wants to be the only one that offers it. David Cutler, a professor at Harvard who helped advise the Obama administration on the Affordable Care Act, said he thinks the kind of insurance products that would be offered under the proposed mix of policies could become much more bare-bones than plans before Obamacare. He envisioned an environment in which a typical plan might cover only emergency care and basic preventive services, with everything else as an add-on product, …

AJPH Editorial: or Transformation' By David U. Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H. American Journal of Public Health, March 21, 2017 Democrats as well as Republicans have offered too little that inspires and too much that appeases the rich and powerful. Trump won by attacking a status quo that is disastrous for many. In health care, the Affordable Care Act (ACA) extended coverage to 20 million and boosted funding for public health and community health centers. But it offered little help to 90% of the population, perpetuated a dysfunctional health care financing system, left 26 million uninsured, saddled covered families with unaffordable deductibles and narrow provider networks, and enriched drug firms, medical conglomerates, and insurers. Mobilizing for a reform that would fix these defects is a far better defense against Trump's health-damaging plans than calls to retain the pre-Trump order. Even before the inauguration, congressional Republicans initiated repeal of key pillars of the ACA. But although Republicans are unified in their desire to destroy what Obama wrought, crafting the replacement is more complicated. Unfortunately, going halfway repealing without replacing would likely cost thousands of lives (see numbers in PNHP release, below). Potential Devastation The health impacts of the administration's antiscience bent are hard to gauge, but potentially devastating. Public health advance requires accurate data and honest assessment. When politicians threaten and muzzle scientists studying the environment, label inconvenient truths news," and propagate falsehoods under the guise of facts," they chip at the foundations of scientific progress. This grim litany reflects what President Trump and his allies want to do. But their agenda is already fraying under the pressure of popular opposition. Backlash Perhaps as important, Democratic politicians are feeling pressed and emboldened to embrace progressive policies. Moving forward from the ACA to single p …

Sticking points with multi-payer contracting in health care Common-Agency Problems and Contracting in the U.S. Healthcare System By Brigham Frandsen, Michael Powell, and James B. Rebitzer National Bureau of Economic Research, NBER Working Paper No. 23177, February 2017 Abstract We propose a model for explaining inefficient contracting in the U.S. healthcare system. In our setting, common-agency problems arise when multiple payers seek to motivate a shared provider to invest in improved care coordination. Our approach differs from other common-agency models in that we analyze points," that is, equilibria in which payers coordinate around Pareto-dominated contracts that do not offer providers incentives to implement efficient investments. These sticking points offer a straightforward explanation for three long observed but hard to explain features of the U.S. healthcare system: the ubiquity of fee-for-service contracting arrangements outside of Medicare; problematic care coordination; and the historic reliance on small, single specialty practices rather than larger multi-specialty group practices to deliver care. The common-agency model also provides insights on the effects of policies, such as Accountable Care Organizations, that aim to promote more efficient forms of contracting between payers and providers. From the Conclusion In this paper we have developed a common-agency model for explaining inefficient contracting in the U.S. healthcare system. In our setting, common agency problems arise when multiple payers seek to motivate a shared provider to invest in improved care coordination. Our approach differs from other common-agency models in that we analyze sticking points, that is, equilibria in which payers coordinate around Pareto dominated contracts that do not offer providers incentives to implement efficient investments. These sticking points offer a straightforward explanation for three long-observed but hard to explain features of the US healthcare system: the ubiquity of fee-for-service c …

Mayo discriminates against Medicaid patients Mayo to give preference to privately insured patients over Medicaid patients By Jeremy Olson StarTribune, March 15, 2017 Mayo Clinic's chief executive made a startling announcement in a recent speech to employees: The Rochester-based health system will give preference to patients with private insurance over those with lower-paying Medicaid or Medicare coverage, if they seek care at the same time and have comparable conditions. Mayo will always take patients, regardless of payer source, when it has medical expertise that they can't find elsewhere, said Dr. John Noseworthy, Mayo's CEO. But when two patients are referred with equivalent conditions, he said the health system should those with private insurance. asking ‚… if the patient has commercial insurance, or they're Medicaid or Medicare patients and they're equal, that we prioritize the commercial insured patients enough so ‚… we can be financially strong at the end of the year to continue to advance, advance our mission," Noseworthy said in a videotaped speech to staff late last year. Mayo reported a sharp increase in the amount of unreimbursed costs related to Medicaid patients, from $321 million in 2012 to $548 million in 2016. The figures include its campuses in Arizona and Florida. Mayo nonetheless remained profitable in 2016, with income of $475 million. (Allan Baumgarten, a Twin Cities health analyst) added that complaints about the rise in Medicaid patients should be tempered by the corresponding decline in uninsured patients. you better off having bad payment through Medicaid compared to next to nothing from a patient who is uninsured?" he asked. www.startribune.com‚… *** Cherry-picking patients? Mayo Clinic aims to privately insured By Elizabeth Whitman Modern Healthcare, March 20, 2017 Late last year, CEO John Noseworthy had a message for the staff of the Mayo Clinic: We want patients with commercial insurance over Medicare or Medicaid. For the Mayo Clinic he …

CRISIS IN U.S. HEALTH CARE: Corporate Power vs. The Common Good By John Geyman, M.D. March 15, 2017 Excerpts from the Preface There is widespread acknowledgement today that our current health care system is dysfunctional and broken, and I believe that we have reached a crisis point in U.S. health care. We need to better understand why this has come to pass if we are to avoid continuing in the same directions. The sixty years we will discuss have had many policy choices in how we finance and deliver care in this country. It is still a pervasive myth that U.S. health care is the best in the world part of the American exceptionalism argument but, as we will see, this is far from the case. Technology does not necessarily make things better, and we will look at how the traditional values of medicine as a profession have held up over the years. How our health care system is organized and conducted should be above politics as a non-partisan issue, but we know that that is certainly not the case today nor has it been in earlier years. Despite ongoing national debates, we still have been unable to answer, as a society, even the most basic questions about health care, such as Should we establish universal access to care for all Americans? Should health care be for-profit or not-foe-profit? Is health care a right or a privilege based on ability to pay? The results of the 2016 election cycle, which turned over the White House and both chambers of Congress to the Republicans, has placed our already broken health care system in continuing crisis. This book is organized in three parts. Part One includes reflections on system changes over sixty years. Part Two, then and now, gives my personal perspective from direct experience over those sixty years. In Part Three, today's realities are described, as are lessons that can be learned from the evolution of health care, three major alternatives for financing health care, and projections for future health care reform. As the ongoing debates over the future of health care continue across the po …

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