thanks much for keeping up with issue, Mr. Conoboy, and keeping us informed!

 Kerry,

You are welcome!  Don’t forget to comment on the RFI site. STOP THE STEAL!

I found the hardest part of the ‘form’ was deciding what “category” my comment fit into.  I ended up choosing “other”.  (Any recommendations on this?)

I’m a little more radical than most folks that I know.  Here is what I submitted:

It’s difficult to write about this topic while remaining ‘civil’—the whole mindset and proposal are entirely wrongheaded, and ultimately anti-human.  We need a “national, universal health service”, and not even bother with any sort of ‘insurance’.  Those who cannot ‘see’ this obvious ‘solution’ are ‘well indoctrinated’, ‘entrenched’, and ignorant of economic dynamics, trends, and anti-social manipulation, and cannot fathom a future that is ‘beneficial for all’.  Please start these efforts over, beginning from a genuine understanding of human needs, and how a government can provide such.  I thank you.

 Kerry,

No recommendation as I have not yet filed my comment ... which is now being drafted.  If I find out anything more, I will let the readers know.

Thanks.

 To my readers,

 Kerry’s question is a valid one.  I would select Health Care Industry Pl015 as the category.

Within your commenting, refer to file code CMS-4203-NC.

Hi Dick, I will be crafting my response and submitting it tomorrow. I’ll post it here.

THANK YOU for alerting all of use to this opportunity to convey of our opinions (in my case disgust) about Medicare Advantage and ACO/REACH. 

Pat Britain

 Pat,

Remember that this is about Medicare Advantage.  ACO Reach is another program.

And THANKS!

I remember. Medicare Advantage is what got me started on this issue of privatization. It was Kaiser Medicare Advantage that declared all of the primary care physicians in Whatcom County that were not working for Peaceheath or Family Care Network as out of their network - and that included my primary care doc, Mitchell Kahn, the best doc that I ever had for primary care. As a result, I dumped MA for traditional Medicare, but Dr. Kahn closed his practice as so many of his patients were on Kaiser MA. The lesson I learned is that Medicare Advantage restricts their customers to a “preferred network” and there is no coverage for doctors, clinics or hospitals outside of their network. And Medicare Advantage insurers can, and do, change the entities that they declare “in network”, with a very limited amount of notice.

If you have Kaiser Medicare Advantage (as well as some other MA plans), some of the best providers in the state, such as Cancer Care Alliance (the best place in the Northwest to go if you have cancer) or University of Washington Medicine (tops in many catagories of heathcare), are out-of-network. I was really glad that when I needed to go to UW Medicine (because care in Bellingham was so limited), I had traditional Medicare and the cost of my care there was covered.

Yup, I have stuff to say about MA. ACO/REACH is just another iteration of the CMS drive to privatize Medicare. It’s just not enough that 48% of Medicare is privatized under MA; ACO/REACH is bent on privatizing the care of the 52% of us on traditional Medicare (where I am today).

Pat Britain

So, when you read this, one just has to wonder why CMS still appears to embrace Medicare Advantage which is clearly not getting their job done.

 The U.S. Department of Health and Human Services Office of the Inspector General put out a report on 4/27/22: 

Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care 

Here’s the link: https://oig.hhs.gov/oei/reports/OEI-09-18-00260.asp?hero=mao-report-04-28-2022

“Our case file reviews determined that MAOs sometimes delayed or denied Medicare Advantage beneficiaries’ access to services, even though the requests met Medicare coverage rules. MAOs also denied payments to providers for some services that met both Medicare coverage rules and MAO billing rules. Denied requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers. Although some of the denials that we reviewed were ultimately reversed by the MAOs, avoidable delays and extra steps create friction in the program and may create an administrative burden for beneficiaries, providers, and MAOs. Examples of health care services involved in denials that met Medicare coverage rules included advanced imaging services (e.g., MRIs) and post-acute facility stays (e.g., inpatient rehabilitation).

Prior authorization requests. We found that, among the prior authorization requests that MAOs denied, 13 percent met Medicare coverage rules; in other words, these services likely would have been approved for these beneficiaries under original Medicare (also known as Medicare fee-for-service). We identified two common causes of these denials. First, MAOs used clinical criteria that are not contained in Medicare coverage rules (e.g., requiring an x-ray before approving more advanced imaging), which led them to deny requests for services that our physician reviewers determined were medically necessary. Although our review determined that the requests in these cases did meet Medicare coverage rules, CMS guidance is not sufficiently detailed to determine whether MAOs may deny authorization based on internal MAO clinical criteria that go beyond Medicare coverage rules.

Second, MAOs indicated that some prior authorization requests did not have enough documentation to support approval, yet our reviewers found that the existing beneficiary medical records were sufficient to support the medical necessity of the services.

Payment requests. We found that, among the payment requests that MAOs denied, 18 percent of the requests met Medicare coverage rules and MAO billing rules. Most of these payment denials in our sample were caused by human error during manual claims processing reviews (e.g., overlooking a document) and system processing errors (e.g., the MAO’s system was not programmed or updated correctly).

We also found that MAOs reversed some of the denied prior authorization and payment requests that met Medicare coverage and MAO billing rules. Often the reversals occurred when a beneficiary or provider appealed or disputed the denial, and in some cases MAOs identified their own errors.”

 Pat,

Thanks for those revelatory comments.  I am still in Traditional Medicare and intend to stay there.

One of the big concerns about Medicare advantage plans here in the islands is the possibility that they could deny coverage for an emergency helicopter or plane flight to a mainland hospital if the insurer later deems that it was medically unnecessary. Last I looked, that would stick the poor patient with a whopping $15,000 bill, and it’s probably (a lot) more now. Talk about cost savings!

After some digging and calling, I was told that such decisions are ultimately made by Medicare officials, not the plan officials, but I could easily see the latter stepping in and denying coverage at first—in the interests of maximizing profits—leaving the hapless patient to battle it out.

This is one reason I recently switched to a Medicare Supplement plan, but I’m not sure that gives me any added protection.

Michael,

“After some digging and calling, I was told that such decisions are ultimately made by Medicare officials, not the plan officials…

I am not sure what you mean by Medicare officials vs. plan officials. 

Easy, Dick. Government officials from the DHHS versus Medicare Advantage plan employees. But in cases of appeal, which I am currently doing, Medicare apparently offloads the responsibility of at least replying to a private firm in South Dakota. Not sure how the actual decision is made.

Michael,

Not excited.  Medicare is used in various ways by many entities.  Just trying to figure out what the “plan” meant to you. 

The machinations are opaque as you have discovered.  If you are in a “plan” allied to Medicare like Advantage or some other private insurance or DCE/ACO REACH, then the plan gets to decide as far as I know. I suppose Medicare can act as a referee. 

I just go to Traditional Medicare directly and after they make payment, I go to Blue Cross FEHP to pick up remaining costs, if any.  But I am in a federal health plan due to my retirement under FERS which is not available to non-retirees.

It all should be single payer/Medicare for all.  None of this nonsense would then exist.

This was my comment:

The best way to improve Medicare Advantage is to abolish it.  The fact that it includes “Medicare” in its name is disingenuous at best and, in reality, false advertising, which is illegal.  MA is private insurance period. 

Despite having the most expensive health care system, the United States ranks last overall compared with six other industrialized countries, Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom on measures of quality, efficiency, access to care, equity, and the ability to lead long, healthy, and productive lives, according to a new Commonwealth Fund report.

Our disjointed, complex and financially-driven system is responsible for our poor outcomes.  So why would the US allow the private sector to destroy our most successful health coverage system for seniors?

Unlike traditional Medicare, business interests get to decide what is medically necessary, what doctors you can see, which hospitals you can visit.  Cost, rather than doctor recommended treatment, becomes the primary determinant.

Traditional Medicare allows a patient to go to any doctor or hospital that takes Medicare without referral or permission.  Advantage programs usually require a referral from your primary care physician or the private insurance company that administers the plan. 

Medicare allows you to buy a Medigap policy to cover copays and deductibles; Advantage plans do not. 

The current Advantage plans advertise by implying they are Medicare plans, only better, by dangling additional benefits - dental, hearing, gym memberships, etc.  In reality, limits on choice can cause financial hardship.  If a doctor or hospital is out-of-network, you can be hit with unexpected bills that far outweigh the so-called Advantage benefits.  In emergency situations, you don’t have time to check these out-of-network restrictions.

In addition, Advantage programs place additional burden and costs on health care professionals.  Doctors need to hire staff to deal with the multitude of private insurance plans, that profit from denying or delaying payment.  Again, our system does not reward efficiency; but it does reward those companies offering Advantage plans.

The New York Times published an article on April 28, 2022, which includes this opening paragraph:  “Every year, tens of thousands of people enrolled in private Medicare Advantage plans are denied necessary care that should be covered under the program, federal investigators concluded in a report published on Thursday.”

https://www.nytimes.com/2022/04/28/health/medicare-advantage-plans-report.html

Advantage programs try to find the healthiest “customers” and will drop those who are the sickest.  And they have been caught inflating or cheating on diagnoses in order to make more money off the government.  What is happening is that they are draining money from the Medicare Trust fund.

Advantage programs are designed to make profits for private industry; traditional Medicare was created to improve the health of senior citizens.  

LBJ provided the political impetus to create a successful, popular government program that has controlled the cost of health care, while protecting seniors from bankruptcy and giving them a wider choice over their own health care. 

Why would a Democratic administration facilitate the destruction of a program created by a previous Democratic administration?

Embracing neo-liberal policies has gotten us to today’s environment where we are worried about Democrats controlling the next Congress.  Maybe acting more like Democrats is a better approach!

Carol Kemp