Wednesday, November 1, 2023

Whose Advantage?

Letting private insurance run Medicare Advantage cost us dearly

By Philip Mattera, director of the Corporate Research Project for the Dirt Diggers Digest 

Fraud Magazine illustration by Jonathan Bartlett

Progressive Democrats such as Bernie Sanders have long promoted Medicare for All as the solution to the country’s health insurance problems. 

Given the popularity of Medicare among the seniors it serves, extending the program to other age groups has a great deal of appeal.

The problem, though, is that Medicare is not a single program. It is an assortment of coverage options that can be bewildering to those turning 65 and to participants during the open enrollment period each year when they must decide whether to stick with their current plan or jump to another. The 2024 open enrollment period began on October 15th and ends December 7th.

Seniors are currently being bombarded with coverage offers, not from the federal government, which oversees Medicare, but from the private insurance companies which have gained a significant foothold in a nominally public program.

That involvement may take the form of supplemental coverage for the 20 percent of medical costs Medicare does not cover. Prescription drugs coverage, which was not part of traditional Medicare, was added in 2006 through a system that requires most participants to purchase plans from private insurers.

Most problematic is the coverage designated as Medicare Part C, which is more commonly known as Medicare Advantage (MA). Whereas traditional Medicare operates much like the fee-for-service health insurance many Americans receive through their employer, MA is more akin to a health maintenance organization or HMO. 

Instead of paying doctors and others for providing service, MA gives plan providers, which are usually commercial insurers, a lump sum for each beneficiary. They are then responsible for managing patient care. Around half of Medicare participants are in MA plans.

MA providers claim that they can offer improved care, including services such as dental and vision which are not included in traditional Medicare. They also depict themselves as the solution to runaway medical costs. To the extent this is true, the MA providers achieve these results through many of the same ruthless practices that gave HMOs and managed care a bad name starting in the 1990s.

That means erecting roadblocks to care by limiting beneficiaries’ choice of providers, requiring prior authorization for many procedures and refusing authorization at a high rate.

It turns out that MA also fails to deliver on the promise of reducing healthcare costs for the Medicare program. A recent report from Physicians for a National Health Program estimates that the way MA’s capitated system is structured causes taxpayers to overpay the plans at least $88 billion per year and perhaps as much as $140 billion.

Along with these technical reasons is old-fashioned fraud. The Justice Department recently announced that Cigna  would be paying $172 million to settle allegations that it submitted “inaccurate and untruthful” diagnosis codes to the federal government to inflate risk adjustments and thus boost the MA payments it received.

Cigna is not alone. As shown in Violation Tracker, Sutter Health paid $90 million to resolve allegations of submitting inaccurate information about the health status of its MA beneficiaries in order to get its payments increased. It had previously paid $30 million for similar misconduct.

An analysis last year by the New York Times found that all but one of the top ten MA providers had been accused by the federal government of fraud or overbilling.

When we talk of Medicare for All, we need to be clear that means an extension and ideally an enhancement of traditional Medicare–not the false promise of Medicare Advantage.

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