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

The New York Times | By Reed Abelson and Margot Sanger-Katz

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.

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.

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BPC Recommends Two-Year Extension Of Pandemic-Era Telehealth Policies

Inside Health Policy | By Jessica Karins
  
The Bipartisan Policy Center has released a wide-ranging slate of recommendations for telehealth policy after the COVID-19 public health emergency, including calling for a two-year extension of most telehealth flexibilities, which the group says would offer time for policymakers to further study the most-effective approaches to virtual care.
 
The recommendation could boost efforts by stakeholders to convince the Senate to pass by year’s end the two-year telehealth extension bill that cleared the House.
 
But BPC also calls for Congress to require that HHS and Congress’ Medicare payment advisers study hot-button issues before permanently expanding telehealth.
 
Researchers should use the time to study the benefits of hybrid care and what specialties and conditions it is most effective for, asses the value of audio-only care, and consider how telehealth flexibilities can fit into value-based care models, the report says.
 
In the Oct. 11 report titled “The Future of Telehealth After COVID-19: New Opportunities and Challenges,” the think tank issues numerous recommendations for how policymakers can preserve the benefits of telehealth after the end of the PHE.
 
“For starters, Congress and the Biden administration should extend most of the telehealth flexibilities for Medicare beneficiaries for two years after the end of the PHE, and formally evaluate their impact,” BPC wrote.
 
It says a two-year extension of flexibilities to further study their impact and efficacy would maintain patients’ access to care while minimizing risks.

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One in 4 Clinicians Want to Leave Healthcare, Citing Burnout. Here's What Providers Can Do to Stem the Tide

Fierce Healthcare | By Heather Landi
 
About one out of four clinicians in the U.S. are considering leaving healthcare, primarily due to unrelenting burnout.
 
Even among doctors and nurses who want to stay in healthcare, about a third are considering switching employers, according to a Bain and Company survey. Research shows that around half of clinicians surveyed report their mental health has declined since the start of the pandemic.
 
Of those considering leaving the field entirely, 89% cite burnout as the main cause, the consultancy firm's survey of nearly 600 clinicians found. Additionally, around 40% of all clinicians surveyed say they don’t have the resources they need to operate at full potential. They report a lack of effective processes and workflows, supplies and equipment. And 59% don’t believe their teams are adequately staffed.
 
Clinicians' dissatisfaction is also illustrated by drastically dropping Net Promoter Scores (NPS), a measure of their likelihood to recommend their employer. U.S. physicians’ NPS dropped 17 points from 36 points in 2020 to 19 points and this year, nurses weighed in with a dissatisfied NPS of 11 points, according to the company.
 
These challenges, including turnover and potential departure from the industry, come as the healthcare industry is already facing a tight labor market that is on track to be short 38,000 to 124,000 physicians by 2034, according to data from the Association of American Medical Colleges.
 
Aligned with the low NPS scores, hospital-based staff has the highest turnover rate, which increased 6.4 percentage points in the past year alone, according to NSI’s National Health Care Retention & RN Staffing Report. The staff RN turnover rate has reached 27%, exceeding the turnover rate for hospital staff overall (26%) for the first time…

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Dementia- When Does the Dying Process Begin?

By Barbara Karnes

Dear Barbara, what do you think about a patient who has been in hospice for months. He has dementia. I thought when patient’s got on hospice they would die soon yet I hear there are patients here in this nursing facility that have been here a year or more. I heard a saying, “dementia patients forget to die”. Is that true?

I'm glad you reached out to me about dementia at end of life. I'll start by saying I have a booklet How Do I Know You?, which goes into detail about how dementia at the end of life is different from other diseases. You may find it helpful.

I have not heard the statement "dementia patients forget to die" and I do not agree with it. They die, it's just that it generally takes them a lot longer.

They don't however play by the "rules” of how the body generally dies from a disease (withdrawal, sleeping more, eating less). With dementia as the main diagnosis, they don’t really enter the actively dying process until eating is problematic (choking, holding food in their mouth, not swallowing).

About being on hospice longer than expected: in my opinion you cannot determine a person with dementia has entered the dying process until the difficulty with eating signs occurs. YET more and more hospices are admitting patients way before that happens. Hospices are filling a need that is otherwise missing in our health care system —support, care, and guidance during the very long deteriorating disease process.

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