Charles Everett MPH

📰 WSJ report: Medicare Advantage Misdiagnoses - A Costly Controversy Earlier this week, The Wall Street Journal reported that Medicare Advantage plans used questionable diagnoses to find “gaps in care,” which allowed plans to get an extra $50 billion in federal Medicare funds without doing any extra work. Insurers gave patients gift cards to agree to a home visit. During these visits, a clinician found – or, according to the WSJ article, sometimes made up – additional medical conditions to get more money from Medicare. A concrete example: over 66,000 Medicare Advantage members were diagnosed with diabetic cataracts, even though they had already had their damaged lenses replaced with plastic ones. It's "anatomically impossible" to have a diabetic cataract with a plastic lens. UnitedHealth members were 15 times more likely to be diagnosed with diabetic cataracts compared to those in traditional Medicare. The WSJ's analysis found that private insurers made hundreds of thousands of questionable diagnoses from 2018-2021. These incorrect diagnoses resulted in extra taxpayer-funded payments. Insurers benefited from these diagnoses even when patients didn’t need any treatment. The questionable diagnoses included some potentially deadly illnesses, like AIDS, for which patients received no follow-up care. There were also conditions that people couldn't possibly have. Often, neither the plan member nor their doctors knew about these false diagnoses. Medicare Advantage was supposed to save taxpayer money. The WSJ writes: "instead of saving taxpayers money, Medicare Advantage has added tens of billions of dollars in costs, researchers and some government officials have said." Insurers use home visits and medical chart reviews, sometimes with assistive software, to add diagnoses. While this approach was meant to catch missed conditions, the WSJ's analysis suggests it often leads to false diagnoses. My key takeaway: It’s critical for the Centers for Medicare & Medicaid Services (CMS) to make sure taxpayer dollars are spent appropriately and that seniors get proper care. Trust in America's healthcare system relies on it. The full article is at https://lnkd.in/gspMUPAh #Healthcare #MedicareAdvantage #WSJ

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Two seismic events this week in #MedicareAdvantage #marketing and #sales. As I pointed out at Medicarians in Vegas, #healthinsurance #brokers in #MedicareAdvantage will consolidate due to profiteering and noncompliance. Payers like Aetna, a CVS Health Company want to control the member experience from first contact and reduce their exposure to agents and FMOs operating outside the lines. Today they acquired one of their biggest brokerages. Then Prudential Financial shot its $3.5B brokerage Assurance IQ in the head and shut it down today for longstanding #compliance issues. https://lnkd.in/gBx5aaDP Expect a lot more of this.Evolve or die.

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Recent findings indicate that Medicare Advantage beneficiaries are less likely to receive aggressive (and unnecessary..?) treatments at the end of life as compared to those with traditional Medicare. As we move further from 2018, I anticipate these trends will become even more pronounced for this group. However, this raises important questions about the population seemingly left without appropriate resources noted in the article. If they aren't returning to the hospital (which on the surface is a good thing), where exactly are they going? Could also hint to the increased the burden on family caregivers. The authors of the study highlighted some critical caveats, including the challenges family caregivers face and the complexities of navigating both MA coverage and hospice benefits. This seems like a systemic issue that the CMS should address in collaboration w/ MA providers. Interestingly, while MA enrollment correlated with slightly higher hospice utilization rates, overall hospice election during the last 30 days before death was around 16%. It would be more impactful to examine hospice utilization 60-90 days before death. We’d want to see this number get smaller, contributing to an increase in rates at timelines more upstream. I'm eager to see how more recent data will influence value-based care plans for end-of-life care. What are your thoughts on these findings and their implications for future care models? https://lnkd.in/eJ3Qs53D

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Providers Are Fed Up With Medicare Advantage More and more health systems are parting ways with big-name Medicare Advantage plans for good reason. Hassles, denying care for inpatient level of care, denying authorization for outpatient scheduled procedures, putting up roadblocks for payment according to the negotiated contract terms, requesting more medical records prepayment to slow down payment, hiring contractors to steal back monies for paid claims one to two years earlier, second-guessing physicians clinical judgment and medical decision making in diagnosing through clinical validation denials, etc. This sums it up well: "Moreover, this trend could lead to even more scrutiny and potential reforms in Medicare Advantage policies. Stakeholders, including policymakers, may need to address the concerns raised by providers to ensure that MA plans can fulfill their promise of comprehensive, accessible care without imposing undue burdens on healthcare systems." I suggest : Moreover, this trend must lead to even more scrutiny and potential reforms in Medicare Advantage policies. Stakeholders, including policymakers, must address the concerns raised by providers to ensure that MA plans can fulfill their promise of comprehensive, accessible care without imposing undue burdens on healthcare systems. Medicare Advantage is leading the innovative use of value-based care — delivering better health outcomes, through better quality care at a better cost for Medicare beneficiaries according to the trade group for Medicare Advantage plans- Better Medicare Alliance. Mission of this organization- More than 33 million beneficiaries have made the choice to enroll in Medicare Advantage. Seniors and people with disabilities deserve quality health care — and we believe Medicare Advantage provides the opportunity for a healthier future. Medicare Advantage Plans provide for a healthier future for their C suites and shareholders through healthy profits and stock dividends paid on the backs of providers and beneficiaries who are denied needed care such as SNF and rehab, services Humana has a tendency to deny or if you are UHC, use AI to determine when to stop paying for inpatient rehab/SNF. #MedicareAdvantage, #Medicaredisadvantage, #profitfirst, #reininginMAplans https://lnkd.in/exujjGN6

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Allowing Medicare to negotiate drug prices on behalf of older Americans remains broadly popular across partisans, though many voters are unaware of the new law and the billions of dollars it is expected to save in 2026, a new KFF Health Tracking Poll finds. A large majority (85%) of voters say they support allowing the federal government to negotiate the price of some prescription drugs for people with Medicare. This includes at least three quarters of Republican (77%), independent (89%) and Democratic (92%) voters. The Inflation Reduction Act of 2022 authorized such negotiations, and the Biden administration recently completed the first round of negotiations on 10 drugs, resulting in an estimated $1.5 billion in lower out-of-pocket costs for Medicare beneficiaries in 2026. #kff #medicare #prescriptiondrugs

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In 2021, Medicare Advantage beneficiaries spent about $2,541 less in out-of-pocket costs and premiums than beneficiaries with fee-for-service Medicare, a new report discovered. Here is an organization funded by MA Plans, Better Medicare Allowance, promoting their sponsors with this misleading report. This organization claims Medicare beneficiaries have strong access to care and pay less for the care. This is partly bunk and misleading, the beneficiaries have less out-of-pocket costs because when they try to access their "great benefits" the plans deny the care as not medically necessary. The proof is Humana almost always denies SNF coverage for its members based on "Medical Necessity." This quote is spot on: Dr. Rick Gilfillan, an independent consultant who previously called the MA program a “failed experiment” during a panel discussion at the HLTH 2023 conference. “I say failed because for 35 years of its existence, privatized Medicare, now Subsidized Medicare Advantage, has cost more than traditional Medicare,” he said. “In 2023, those numbers are projected to be more than $75 billion to $120 billion in excess payments to MA over what the cost would be in traditional. From a quality standpoint, … what we can say is that [MA plans] put in place obstacles to care, made access to care more difficult.” Time to pull the plug on Medicare Advantage and save taxpayers from the failed Medicare Advantage experiment. #Medicareadvantageplans, #MAplans, #rippoff, #boondoggle, ##bettermedicareallowanceselfinterest https://lnkd.in/eWsNcZYJ

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Healthcare spending and insurance coverage - Colliding trend projections In the past few weeks, the nonpartisan Congressional Budget Office (CBO) released their projections for insurance coverage trends from 2024-2034 and CMS released their projections on healthcare spending through 2032. The insurance coverage projections show an increase in the uninsured from the recent low point of 7.7% to 8.9% by 2034, representing an additional 4 million uninsured persons.  The increased number is based on current laws unwinding the Covid-19 Medicaid stabilization rules, the rollback of expanded advanced premium tax credit (APTC) subsidies for Health Benefit exchange plans and an increase in undocumented immigrants unable to access health insurance.  CMS projects that healthcare spending will increase to over $7 trillion by 2032 taking up 19.7% of the total gross domestic product. The increases are driven predominantly by price increases and an ageing population with Medicare spending rising from $14,226 in 2021 to $24,921 per enrollee per year by 2032.    There are some additional issues and impacts created by the collision of higher healthcare costs per person and more uninsured people, that may not have been taken into consideration: As healthcare costs increase there may be a tipping point where some employers, employees and independent purchasers may find that commercial insurance premiums are not affordable. For the past decade insurers have been mitigating the premium costs by adding high deductibles, copays and coinsurances which lower premium costs while shifting these costs to families. Without significant wage growth, the increased healthcare insurance expenses can exceed many families’ financial capabilities. This impact could lead to a higher rate of uninsured persons 1. CMS has planned to have all beneficiaries under accountable care relationships by 2030 in hopes that these programs will reduce spending. The largest incentives for providers to engage in these programs is the ability to generate financial savings that come back to them. In the near future all of the reasonable savings might be wrung out of the system and their will be little incentive for providers to participate 2. As the number of uninsured patients grows, this group will likely defer early preventive interventions, become sicker, develop more costly end stage complications of chronic diseases, and result in increases in uncompensated care. This will ultimately pass the costs of that care onto other payers. This is the trajectory based on current policies. Who we elect to lead our states and the nation will influence the future policy direction. If our leaders preserve the APTCs, expand Medicaid, and invest wisely and sufficiently in prevention, primary care and public health; we may have a better long-term result. What do you think will happen with healthcare spending over the next decade? What do you think will happen to insurance coverage? Yours in health Howard

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Here's Part Two! While the TRT market presents lucrative opportunities, it also comes with challenges: 1: Regulatory Landscape: Adherence to regulations and guidelines governing hormone therapy is crucial to ensure patient safety and compliance. 2: Clinical Expertise: Offering TRT requires specialized knowledge and expertise in hormone optimization, necessitating ongoing education and training for healthcare providers. 3: Patient Education: Educating patients about the benefits, risks, and expectations of TRT is essential for informed decision-making and treatment adherence. 4: Competitive Landscape: With the growing popularity of TRT, competition among cash-pay medical practices offering these services is increasing, requiring differentiation strategies to stand out. Opportunities for Growth: Despite challenges, the TRT market in cash-pay medical practices presents promising opportunities for growth: 1: Diversification of Services: Incorporating comprehensive men's health services beyond TRT, such as sexual health treatments and wellness programs, can attract a broader patient base. 2: Technological Advancements: Embracing innovative technologies and treatment modalities, such as telemedicine and precision medicine, can enhance the delivery and efficacy of TRT services. 3: Strategic Partnerships: Collaborating with industry partners, including pharmaceutical companies and compounding pharmacies, can expand service offerings and access to resources. 4: Market Differentiation: Establishing a unique brand identity and value proposition based on quality of care, patient experience, and outcomes can position cash-pay medical practices as leaders in the TRT market. By understanding the market landscape, addressing challenges, and seizing strategic opportunities for growth, practitioners can successfully navigate the TRT landscape and meet the needs of their patients effectively.

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It strikes me as very important that the court did not rule on geographic restrictions for #340B covered entities. Contract Pharmacy geographic restrictions will: 1. Reduce access for patients 2. Restrict innovation related to patient engagement and access, 3. Likely increase costs to patients, and 4. Create a non-competitive business environment that will likely result in higher dispensing fees. There is no evidence that “remote” pharmacies harm program integrity. More detail on follow on posts on each of these points. Health Resources and Services Administration (HRSAgov), HHS Centers for Medicare & Medicaid Services National Association of Community Health Centers (NACHC) PhRMA #340B #CoveredEntities Advocates for Community Health

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