Yves here. Across the American economy, we are seeing the high cost of American rentierism, reflected among other things in a profit share to GDP that for year has been roughly twice the level Warren Buffett deemed unsustainably high in the early 2000s. We have an overpriced, underperforming military, an overpriced, underperforming higher education complex, and an overpriced, underperforming health care system, on the what appears to be unrealistic assumption that real world results matter. And a particularly disgraceful aspect our shoddy health care performance is the ruination of Medicare.
It’s isn’t just that the the Federal government has failed to use its ginormous buying power via Medicare, Medicaid, the VA and other programs, to rein in drug prices. Nor has it sought merely to set prices or limit price increases on drugs that use intellectual property funded by the Federal government. It is also that Medicare is being crapified directly.
The first way is via the standard of care being eroded even under traditional Medicare, for instance with wellness exams replacing annual physicals.1 But even worse is the Medicare Advantage scam, which pretends to be Medicare but offers a lower level o service (narrow networks, gotcha terms for surgeries and hospitalizations). Readers who advise the Medicare-eligible find that most people who can afford to pay the premiums opt for Medicare B and perhaps a supplemental program too, while the lower income choose Medicare Advantage. So Medicare Advantage is a vehicle for creating a two-tier program.
By Wendell Potter, the former vice president for corporate communications at Cigna. He is now president of Business for Medicare for All and author of bestselling books Deadly Spin and Nation on the Take. Originally published to Common Dreams
Right now, well-funded lobbyists from big health insurance companies are leading a campaign on Capitol Hill to get Members of Congress and Senators of both parties to sign on to a letter designed to put them on the record “expressing strong support” for the scam that is Medicare Advantage.
But here is the truth: Medicare Advantage is neither Medicare nor an advantage.
And I should know. I am a former health-care executive who helped develop PR and marketing schemes to sell these private insurance plans.
During my two decades in the industry, I was part of an annual collaborative effort to persuade lawmakers that Medicare Advantage was far superior to traditional Medicare—real Medicare. We knew that having Congressional support for Medicare Advantage was essential to ensuring ever-growing profits—at the expense of seniors and taxpayers. We even organized what we insiders derisively called “granny fly-ins.” We brought seniors enrolled in our Medicare replacement plans to Washington, equipped them with talking points, and had them fan out across Capitol Hill.
Instead of joining with the corporate lobbyists in extolling the benefits of Medicare Advantage while obscuring the program’s numerous problems… Congress should work to lower the cost of health care.
I regret my participation in those efforts. Over the 20 years since Congress passed the Medicare Modernization Act, the Medicare Advantage program has become an enormous cash cow for insurers, in large part because of the way they have rigged the risk-scoring system to maximize profits. As Kaiser Health News reported last month, the Center for Medicare and Medicaid Services estimated “net overpayments to Medicare Advantage plans by unconfirmed medical diagnoses at $11.4 billion for 2022.” That was for just one year. Imagine what the cumulative historical total would be.
The Medicare and Medicaid programs have become so lucrative and profitable for insurers that UnitedHealth Group, the nation’s largest health insurer and the biggest in terms of Medicare Advantage enrollment, got 72% of its health plan revenues in 2021 from taxpayers and seniors. In fact, all of UnitedHealth’s enrollment growth since 2012 has been in government programs. Enrollment in the company’s employer and individual health plans shrank by 370,000 between September 30, 2012, and September 30, 2022. Much of the $81 billion UnitedHealth collected in revenues in the third quarter of last year was subsidized by American tax dollars.
Members of Congress on both sides of the political aisle–and both sides of the Capitol–are at long last calling for more scrutiny of the Medicare Advantage program. Sen. Chuck Grassley has called for aggressive oversight of Medicare Advantage plans to recoup overcharges and was quoted in the Kaiser Health News story. As was Sen. Sherrod Brown, who said that fixing Medicare Advantage is not a partisan issue. And as Rep. Katie Porter commented, “When big insurance bills taxpayers for care it never intends to deliver, it is stealing our tax dollars.”
I know that Democrats and Republicans alike care about the financial stability of the Medicare program. Instead of joining with the corporate lobbyists in extolling the benefits of Medicare Advantage while obscuring the program’s numerous problems, and in the process helping Big Insurance make massive profits, Congress should work to lower the cost of health care.
Medicare Advantage is a money-making scam. I should know. I helped to sell it.
And I’m going to continue working alongside patients, caregivers, and elected officials to address the problems.
_______
1 Yes, there is an argument that annual physicals aren’t really necessary (erm, then why does insurance for younger people pay for them?). But IMHO an annual blood workup is a good idea.
64 comments
Comments are closed.
Yves, thank you for this.
I hope that the author can right some of the wrongs that he helped perpetuate.
When congress has to use the same benefits as the rest of us, then things will change. It should be a requirement do they know what’s happening in the real world.
the war against medicare is happening on many fronts. in nyc right now the mayor – with the complicity of important union leaders – is trying to switch all city worker retirees out of medicare. this is to save the city the 20% that the federal government isn’t responsible for. they’re working on a number of fronts. when their attempts are blocked by the courts as illegal they are now trying to change the law. this is also happening in other places.
meanwhile the biden people are promoting a trump initiative where the government can remove people from medicare to an “advantage” plan by fiat – without your permission and without even notifying you. it’s called ACO_REACH. the ACOs (accountable care organizations), are middle men between the patient and insurance. so far – they’re adding more as we write) – there are over 60 such, including private equity and hedge funds.
and now, with the fake debt limit “crisis,” the democrats are quite happy to complain while they allow the republicans to reduce and/or destroy medicare )and social security as well) to secure their votes for raising the debt ceiling. something they themselves could have done when they were still in the majority after the election. this is an extension of obama’s “great bargain,” where only the republicans greed for more kept social programs from taking a hit then.
against the wishes of even republicans the bought politicians of both parties are continuing to privatize everything they possibly can.
I’m pleased you have brought up the issue of ACO-REACH Program. This will be Medicare Advantage on steroids. Medicare pays the DCE or the REACH [ACO], and the DCE or REACH ACO pays your doctor or hospital. And the DCE keeps nearly all of what they don’t spend on your health care. So for the first time ever, there is a middleman in traditional Medicare making a profit from your health care. While Trump started shifting seniors to his program, the Biden administration have replaced the Trump plan with the REACH [ACO] with a big push to enroll seniors ( without their knowledge or consent) to the REACH program. The goal is to have all seniors in traditional Medicare shifted to the REACH program by 2030. Already nearly 1/2 million have already been shifted or should we say shafted. The lack of awareness of this radical change to completely eliminate traditional Medicare is startling. This is being done with little awareness of what’s happening by the people. Wendall Potter’s article is an example. While educating us as to the pitfalls of Medicare Advantage, there is no mention of REACH.
It should also be noted that the key to allowing this change comes from a little recognized provision in the ACA bill that establishes the Medicare Innovation Center that has the mission of developing the alternative payment plans. Liz Fowler, who came from the “Health Care Industry” to the the Max Baucus committee to play a large role in writing the ACA, was appointed by Biden to run the Medicare Innovation Committee which is proposing these privatization plans. Absolute treachery!
How does one avoid being shifted or shafted into the ACO-REACH Program?
According to
https://protectmedicare.net/wordpress/wp-content/uploads/2022/05/OnePager_DirectContractingREACH.pdf
But if the plan is to move everyone to REACH by 2030, then there will be no other place to go.
That crook Obama was perhaps the first to use ACO’s in his wretched Obamacare.
I probably would have signed up for Medicare Advantage were it not for NC and Yves. Several friends recommended Advantage to me. I read articles here which spurred me to research further and I ended up with regular Medicare and a gap policy, plan N, with Cigna. Thanks Naked Capitalism!
Same here. I’m on traditional, classic rock Medicare. Very grateful to NC and Yves.
Kissy-kissy (virtually) and thank you too!
I had been on a Medicare Advantage program for eight years since I became eligible for Medicare.
Due to NC’s coverage and Wendell Potter’s posts, I switched back to traditional Medicare this year. Fortunately, I’m in good health so I should be able to get a Medicare Supplement policy.
Jack, one of my rules as a consumer is to avoid companies that advertise heavily.* Medicare Advantage gluts CNN (and other channels I presume) with non-stop advertisements. And who ultimately pays for all that expensive advertising? Not the companies. It is paid for by the consumer—you and me.
*There are a few other heavily-promoted scams out there. They’re easy to spot. Their common feature is that all seem too good to be true.
I wonder why you pay the regular Medicare premium plus a premium for a Medigap policy which makes it more expensive overall compared to MA. (I know that MA is rigged to be lower to suck people in). When I add up the two premiums plus my gym membership it becomes a lot more.
My gym membership is shoveling snow by hand and a putsch power mower. They both are named
Jim.
When you add up your medical bills from a serious medical event, the cost savings from traditional Medicare and a gap plan will offset the increase in annual premiums.
It is the Gap Plan that saves you from medical bankruptcy. My gap premium (Plan N) is $170/.mo., ~$2000/yr. I had to go to the emergency room for an ankle injury: $7000. Supplemental outpatient surgery: $11,000. The gap plan is to mitigate the very high cost of medical treatment.
Several years ago my mate and I visited a SHIIP (Senior Health Insurance Information Program) counselor. We already knew we wanted regular Medicare and a great gap policy and the counselor helped us decide by answering our questions. Our advice is the same: don’t sign up for Med Advtg. Thanks to NC for this good information.
But what if the cost of your gap policy would mean you could not pay rent or a house payment on your very small house plus groceries and utilities? My husband and I have always been frugal, not into spending for things we could do without or make ourselves. We no longer own a car because it was too expensive with gas and insurance costs increasing.
We both had self employment that we felt would help us make it the longer we could keep working. Then came Covid which effected the work we both did. (For instance my husband was contracted to care for and run a computerized water treatment system every day for a Public children’s splash park over five months every year which has not been open since Covid appeared.) So far we are healthy, and Medicare Advantage helps stretch our income but who knows what the future may bring?
I remember my Dad being amazed that Medicare took care of my Grandmother’s medical costs over a fairly long stay in the hospital ending in her death @ 1990. Twenty years later he and my sep-mom were rear-ended at a stoplight one night when he was @ 85 years old, by a driver who left the scene. My Dad had severe brain damage and did not recover but lived for many weeks in the hospital. Still, he was covered. I don’t know if my husband and I will do as well.
Beginning this month, there is an even greater threat to seniors that I don’t know why Wendell Porter did not address: the Biden administration has ramped up a Trump era pilot program under a new name: ACO-REACH (Accountable Care Organization Realizing Equity, Access and Community Health). Starting this year with a target of 100,000 elderly victims, ACO-REACH will insert profit-seeking middlemen by private financial interests into traditional Medicare.
It is the goal of the Center for Medicare and Medicaid Services (CMS) to see all of Medicare privatized by either “Advantage” or “REACH” by 2030.
https://www.times-standard.com/2023/01/14/my-word-private-entities-are-chiseling-away-at-medicare-as-we-know-it/
Since poor people count even less than old ones, I have seen no mention of Medicaid in the numerous articles about the dangers of REACH, but I think Medicaid is already entirely privatized… can any readers enlighten me further?
Thank you for your comment drawing attention to REACH. While the PNHP is well aware and trying to do something about it, there seems to be a blind spot in recognizing the total privatization of traditional Medicare. This is such a radical change that will send up to 40% of the Medicare funds to Wall Street. Why is there so little awareness and recognition of this massive treachery? Not even Wendall Potter seems to know what is happening or if he knows he didn’t seem to feel it was important to mention it.
wendell potter has a substack and the june newsletter addressed this—I’ll try to link it here
https://wendellpotter.substack.com/p/biden-is-continuing-trumps-privatization
when I was a hospice social worker some 10 years ago the state of Illinois at least forced everyone on Medicaid to sign up for narrow-network plans administered by for-profit insurance companies allegedly to improve care but actually to save money. those who didn’t choose from the choices offered were summarily dumped into one. this happens state by state and I know in Oregon they only recently started privatizing the OHP, which is what Medicaid there is called.
Does anyone here have some perspective on the history of those who have made a living apologizing for their profession while wearing a hair shirt?
What Jack said. I signed up for Part A only and now we’re waiting for my husband to retire (2 years, 10 months and counting down). We’re probably going to look into the Aspen Club to narrow down the choices. We’ve had Aetna for years via his employer.
Got sent off to seek a PT and handed a sheet of PT’s the orthopod liked. None of them took Aetna; they are all ‘out-of-network’ now. Why? Aetna either won’t pay or takes months (as much as a year). Since Covid, a lot of the PT’s have closed their doors. Those still in operation can’t afford to wait that long for payment, so they no longer contract with Aetna. The orthopod’s office may not know this… but they will. It’s on my to-do list
Our dentist, having been bought by private equity two years ago, sent us a we are now out of network notice last month.
WHY do things have to get SO bad before “we” can make them better? WHY?
Just a cri de coeur…
My dentist is pushing 70. His (tiny) office is on the second floor of a 1920’s “shopping center.” It was his dentist father’s office before him. There is no receptionist or dental technician. He does all the dental work himself, with his wife answering the phone and making appointments remotely from home. I’m just hoping I die before he does.
Because not enough people have been burned (yet) by the system. There are still too many people who haven’t had the “pleasure” of limited networks, denied coverage, and high deductibles.
jmo
Actually, we think little attention has been paid to this financial corruption called “Private Health Care in the US” is mainly because millions of Americans have simply given up trying to make changes.
According to some figures, US citizens are in debt up to their ears: approximately $14 or 15 billion worth “of debt.” This is personal debt X how many adults there are in the US.
We thank this site for sharing both this news and, in particular, the article on NW Natural Gas. It appears those financiers are making vast profits off the backs of average citizens in Oregon and Washington State.
Is that the editorial “we” or the royal “we” or the familial “we”?
I agree, in any case, that Americans have given up. Not sure how many ever knew they could even try to change things. I mean, how would they know? And then, so many people just don’t have the disposition to try…
aetna is the (dis)service that mayor adams and uft union leader mulgrew want to switch us to in nyc. the fix is in and no one in the democratic party is calling them on it.
“The first way is via the standard of care being eroded even under traditional Medicare, for instance with wellness exams replacing annual physicals.”
No they do not.
Wellness for all, annual physicals for most patients of Medicare age. They are separate and complimentary.
Wellness is more of a general questionnaire and overview of the patients general medical, mental, social and lifestyle conditions. The physical is hands on, may include testing, and more closely addresses the patients specifics.
With a streamlined approach they can be done together at the same visit, with no extra charge to the patient.
You obviously have not had an “annual” “checkup” by a Medicare Adjacent doctor lately. The basic appeoach is Gresham’s Dynamic as applied to medicine. The Bad drives out the Good. Gresham is very appropriate to this situation. The original Gresham was a financial advisor to the English monarchy back in the days of Queen Elizabeth 1. His Rule was originally applied to coinage, money. Since modern American everything has been financialized, the rules pertaining to money apply. So, as Medicine becomes increasingly financialized, fraud and abuse increase.
You are partially correct in that I have not.
As a recently retired internist, I cover most all my own bases.
But for as long as these programs have run, I have most often combined a Wellness with at least a partial physical when appropriate for the patient.
Ah, yes. You seem to have had some autonomy in your practice. That’s to the good.
However, my GP has hinted at being constrained as to what she can do by ‘Orders From Above.’ In other words, my GP is a tool of the Medical Industrial Complex. [I’m not casting aspersions at the woman. She worked hard to get the training and knowledge to carry out the function of healer. It’s not her fault that the entire system shifted under her. It makes me wonder just how many MDs are giving up in frustration.]
Many are, and most docs these days join with a hospital, academic institution or large group since overheads have killed off most solo or small group private practice.
Ex Kaiser Permanente employee here, 13 years. In the biannual town halls / all hands meetings when they’d show financial results, it was mentioned on numerous occasions that our Medicare Advantage members brought 5 times the revenue of other members (HMO – the majority of KP’s membership as well as Self Funded, PPO, POS, OOA plans, the latter being slice “products”). 5 times the revenue.
So, it never occurred to me that Kaiser DIDN’T exploit seniors AND the taxpayers. But I guess I didn’t realize they would actually regularly BRAG about it.
I have been on Medicare Advantage for eight years. Fortunately, I am relatively healthy and have not needed to worry about what might be in network. My husband is not so healthy and is on Medicare with a medigap policy. This is not cheap. He pays over $5000 a year currently for the medigap policy, and that will undoubtedly increase as he ages. Neither of us has had an annual physical since being on Medicare, but we do get the “wellness” exams; my comment on these is that if my doctor did any less, she would wave as she passed the door. My husband gets additional monitoring since he regularly sees an oncologist and a cardiologist. I know many people who have Medicare Advantage; most seem satisfied, and, since this is a middle/upper middle class neighborhood, I would say that many people who are on Medicare Advantage are not lower income. I would love to see the government pass Medicare for all, but with changes that will ensure better care, such as requiring annual physicals.
Medicare savings programs (there are four kinds) are available for Medicare costs if one meets certain income and resource limits. They are described on pages 94-95 of the 2023 Medicare & You manual. They are State specific so the income and resource limits are not described therein, though they have been more fully in previous years. The income limits relate to each State’s Medicaid requirements, the resource limits are separate. Medicaid for Seniors contains Estate Recovery provisions which, upon one’s demise, will claw back additional assistance provided. That, as I understand it, is not the case under the ACA Medicaid Expansion provisions, which does not include seniors.
The Medicare & You manual is riddled with Medicare DisAdvantage promo, natch.
The Medicare & You manual is riddled with Medicare DisAdvantage promo, natch.
Here Here! Or is it Hear Hear. In any case, the (sadly) funniest part is that there are even pages 94 & 95. I’d rather read NC instead of nearly 100 pages of propaganda.
It is hear, hear, originally from hear him, hear him, to express agreement with a speaker, or writer I suppose.
Well, it was never hear her, hear her, so, though I’d opt for that, the shortened form will have to do!
:-)
Here, Here or Hear, Hear?
Anyway, Medicare DisAdvantage is a travesty.
For years I have been pestered with phone calls and emails to sell me on it. I actually did get one caller to agree that I was better off with my traditional Medicare and QMB (Medicare Savings program). QMB pays my monthly part B premium, deductibles and co-pays, which is good because I couldn’t pay anything. My heirs will have to sort it out later, hopefully much later.
Gadzooks. another ‘thing’ we have to keep an eye on, the REACH program.
My question; if one is “switched” to the REACH program, is there a way to reverse that?
[This stealth ‘switching’ is just like the old telecoms trick of “slamming” that used to be such a big problem. The short take here is that there can easily be rules instituted against such a tactic. It was done by the FCC for the telecoms.]
Slamming: https://en.wikipedia.org/wiki/Telephone_slamming
Ye FCC speaks: https://datcp.wi.gov/Pages/Publications/CrammingSlamming172.aspx#:~:text=If%20your%20authorized%20telephone%20company,30%20days%20of%20its%20service.
Employers are saving money by moving retirees to Medicare Advantage—but the switch may disrupt care
https://fortune.com/2022/03/02/employers-medicare-advantage-health-insurance-retirees/
antidlc–too much thanks to you for the insight
I’m am now in the NC State Employees Retirement System where for 30+ years I have utilized the BlueCross BlueShield 70/30 HealthPlan.
For the past 15 years, if I wanted it I did NOTHING–being designed to ‘roll-over’ w/o another selection.
It is, and was then, FREE. I considered it a Perk for anchoring decades of low wage Educators salaries.
As a Retiree, that Plan is my Medicare backup–with the VA backing all that up.
It worked well–I never was looking for a free lunch and had been really healthy and well most all that time.
Times change-Diagnosed with a disease (happy new year) and the brand new Medical Team helping me get through it.
Plans Change–2023 BCBS 7030 Medicare had to go to HUMANA Medicare Advantage–well that is what the Enrollment Literature says (I kept it). Because I read the NC, this made me very nervous and skeptical and the wife couldn’t understand it either –but TINA. So I did nothing again and HUMANA became my roll over destiny on 1/1/23.
The thought of Shifting Insurers, in the middle of a course of treatments, isn’t confidence inspiring for me.
However–
Things were not as they seemed.
My NC Retiree newsletter received and read just before Christmas had a note from Dale Folwell, State Treasurer of NC. That note said there had been some ‘confusion’ in the Retiree Community surrounding that mando Humana Medicare Advantage shift—call this number if this is you.
I called 12/27, and within two hours was actually speaking with a State Health Plan representative. They were nice and soon offered to establish a Case # –explaining that she had been very very busy with calls like mine for the past month and that NC was going to ‘RE-OPEN’ the Medicare Enrollment Period in January.
But I needed to call another number and give them my Case # and Preference asap.
Which I did as soon as we finished setting up the Case. But one can only stay on Hold so long–so I left my number.
And someone with the Title of Vice President of the NC State Health Plan called back the next day. However i missed the call (of course) but did call that number back a few times.
About four days later that VP of the NCSHP and I did speak for as long as I could hold him.
He’d been very very busy the past month with people like me. He was sorry there was so much confusion.
He agreed the Enrollment Literature may not have been as clear as it could have been.
And this is what he did while I was on the phone:
On 1/4/23 I was reenrolled in the familiar BCBS 7030 Medicare Plan starting 2/1/23 at no charge.
WTF
spits
WTF
And, Who’s paying the bills for January?
https://www.wfmynews2.com/article/news/local/changes-coming-to-the-state-health-plan-bcbs-of-nc-united-healthcare-appeal-the-decision-treasury-folwell/83-9217ae8b-84b4-4c1e-99bf-711d1783f843
Here is what McKinsey has to say:
https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/looking-ahead-to-the-next-decade-of-accountability-for-care-delivery
Looking ahead to the next decade of accountability for care delivery
I also found this interesting…
Agent Broker Compensation
https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/AgentBroker
Isn’t Mrs Obama also a “former healthcare executive”?
Yes she is. ISTR that she was a hospital executive in Chicago.
Michelle got that <s/job sweetheart appointment at the Univ of Chicago Hospital with a lucrative salary. It pays to have connections.
MO got a promotion shortly after O’s ascension to the senate. MO’s new job with the U of C was to negotiate the move of unprofitable medicaid patients from U of C to local community hospitals. Consequent to this new appointment, her salary tripled.( I am a former U of C medical school faculty member.) :)
.
Last year when I was hospitalized for pneumonia, a woman came to my room wanting to know if I would be interested in finding out if I qualified for a Medicare Advantage policy. I was shocked (isn’t this solicitation)? I emphatically said – no – and she acted like I insulted her. I had no idea a hospital would allow this sort of activity.
I’m wondering why people who are being shifted (shafted) onto MA policies without their consent and knowledge, how this is even legal. In my opinion, one must give consent to make a legal, binding contract. No consent is given for these MA policies. I don’t know if there has ever been a legal challenge on this point.
I was shocked when I received the 2023 Medicare book – half of it was dedicated to MA programs. It’s almost like medicare wants to encourage people to buy them. I hope I live long enough to see this country have enhanced medicare 4all.
Gonna have to live for evah.
And from the older old folks I know, longevity is not at all what it may be cracked up to be by some.
This article will most definitely be sent to my rep in the federal govt. The whole article. My rep is a war-mongering CIA democrat who probably doesn’t even know a darn thing about this.
@responseTwo: Please, please, please send your CIA democrat rep the article I linked above about ACO-REACH. The Biden administration took a Trump administration program and just slapped a new woke-sounding name and acronym on it. It’s the same P.O.S. it was when the Trumpsters introduced it.
responseTwo: Please send it to multiple executives at AARP as they are currently funded (per an article here at NC that I canot locate) to the tune of $800 million dollars a year through kickbacks from allowing AARP to use their name and subscriber list to sell these Medicare (dis)Advantage plans and other rip-off offerings.
They also need to be brow beaten into advocating for Single Payer.
There are a couple catchphrases we all need to be aware of that describe the same healthcare “innovations”; value based medicine, population health management, integrated health networks and alternative payment arrangements. All phrases speak to the economic models that enrich the large industry players: large so-called nonprofit health systems, providers (MDs) employed by large health systems in integrated delivery networks to service Medicare Advantage members, and government sponsored privatized health plans (UHC, Cigna, CVS Health) There is big money to be made here!
CVS health aquired Signify Health last summer for $8 billion. Signify Perfected the value-based medicine / ACO revenue stream to perfection.
https://www.cvshealth.com/news/company-news/cvs-health-to-acquire-signify-health.html
Lastly, from the dubious public health experts at UPENN. As an aside, the UPENN affiliated HealthSystem UPMC profits heavily from alternative payment models.
Fun fact, Obama advisor Dr. Ezekiel Emanuel is listed as an author.
https://ldi.upenn.edu/our-work/research-updates/the-future-of-value-based-payment-a-road-map-to-2030/
The money quote from authors with MD/PHD credentials who all appear to have mastered MBA financial speak: “To support its strategic vision, CMS should bring a portfolio-based approach to its value-based payment initiatives. The portfolio approach treats new payment models as a series of investments across APM programs, with specific allotments based on desired high-level goals, such as reducing per-beneficiary costs, improving value, and addressing health equity. Such a division of investments would guide how CMS allocates resources and measures success. The benefits to a long-term portfolio approach are manifold. First, a long-term commitment to a specific set of investments helps guard against shifting political goals. Second, it provides clarity to providers about the types of value-based program initiatives that are most suitable for investment. Finally, it allows for a clear accounting of success and failures in value-based payment, separating wheat from chaff.”
UPMC in my comment should be PENN Medicine. Example reference link of how Health Systems partner with a health plans to invest in for-profit value based medicine provider orgs.
https://www.beckerspayer.com/m-and-a/independence-blue-cross-penn-medicine-partner-on-value-based-care-through-co-ownership-of-tandigm-health.html
IIRC the teaching of “value-based medicine” to medical students is now part of their Medical Practice curriculum. The older clinicians scoff at its importance. The directive may come from the highest levels of academic medicine, who should be ignored as much as possible. Which unfortunately is not very much.
But I am hearing more and more first-year medical students calling bullshit on the entire edifice of American medicine…hope is not dead and there are still a few subversive teachers in the weeds other than yours truly. I remember a justifiably well known biochemist, a non-practicing MD, at one of the very best medical schools in the US greet his first-year students after a short presentation from the AMA before his class biochemistry class: “That was all well and good, but the American Medical Associations need you a lot more than you need them.” From that moment forward he ceased being the minor pill in my eyes that he remained in others.
After wading through the literature at some length, I chose a Medicare Advantage program because it claimed to have an upper limit on out-of-pocket payments. I have made a practice of avoiding doctors most of my life (I’m now 83) so what I was interested in was not insuring against small to medium charges (if there are any such any more) but catastrophic ones, such as those from getting hit by a truck or acquiring an interestingly dire disease, which could easily wipe out my “net worth” as the financier set call it. Perhaps I have read too much Taleb, but for me it is catastrophes, total wipeouts, that are most interesting. Medicare Advantage has these upper limits, or so they say, but Medicare apparently doesn’t. Many of you disagree with my approach. Am I reading things wrong? My experience with the medical industry and fraternity is that, when it comes to sucking up money, they have no limits and no shame. Of course I know that doctors, lawyers, and insurance companies will always have more lawyers than I will, so maybe it doesn’t matter?
I don’t have all the answers. But the really big bucks are at the hospital, and with ordinary Medicare your max out of pocket is low.
The problem with your small and medium expenses with an MA, is related to your ability to access their included docs and facilities. If you have to travel far or out of town for this stuff, it can quickly escalate into a much more serious problem.
With ACO-REACH, the Centers for Medicare and Medicaid plan to eliminate all “traditional” or “ordinary” Medicare by 2030, handing the whole kit & kaboodle to Wall Street.
Why Wendell Potter did not mention ACO-REACH in his article, I cannot imagine, or don’t want to.
he addresses it in the June newsletter from his substack
https://wendellpotter.substack.com/p/biden-is-continuing-trumps-privatization
I’m with Starry, but for completely different reasons. I know I’m going to have catastrophic level expenses every year. So I want something that caps out of pocket costs or I’m not getting treatment and I die much faster (I’ve reached acceptance on my five stages of grief today).
So I’m in an advantage program that is literally keeping me going. My out of pocket to my advantage program is a couple hundred a year (yes, year). I’d have to find another program to deal with hundreds in meds monthly, and tens of thousands for treatment, semiannually.
I’m not saying the program doesn’t have problems, but it works for me.
skorn,
Re your UPMC typo, versus UPenn (Non-Profit University of Pennsylvania, in Philadelphia), whose medical/medical insurer branch is, UPHS, wouldn’t worry too much, UPMC (Non-Profit University of Pittsburgh Medical Center and Insurer) is nefarious in its own right, has been for over two decades, much like way too many of the other large “Non Profit Hospitals”.
12/24/21 New Documentary, InHospitable, Details The Big Profits In “Non-Profit” Healthcare
Adam Andrzejewski
(Note to ddt, above, the piece gives mention to Non-Profit Kaiser Hospital CEO pay also)
Having stayed in contact with Pittsburghers, for decades, haven’t talked to a one that has nice things to say about UPMC’s insurance policies.
Policy Primer: Medicare Direct Contracting & REACH
Medicare Direct Contracting & REACH Policy Primer:
A Threat to Seniors and to Medicare’s Future
https://docs.google.com/document/d/1vh16zgdhytDYJPlPek-T8VKLOsbnvGn7c4jk1YKwCV4/edit
Thank you! PNHP (Physicians for a National Health Program), who provided this primer, is the best thing going in terms of working for actual, real healthcare. I’m a dues-paying member at $50 a year, and highly recommend that all other members of the commentariat who can afford to, join up as well. And if you can send more than $50, please do. (heart emoji)
Slide set on DC/REACH — Physicians for National Health Care
https://docs.google.com/presentation/d/1BRqewrxCkJCwZKg6NVncMhJkFtnypcJUR2Fz-PPrB-c/edit
Privatizing Medicare through
Direct Contracting & REACH