Opinion: Feeding time at the trough of Medicare


Published: 04-04-2023 7:00 AM

Robert S. Kiefner, MD of Concord is a retired family physician.

Salve Lucrum or “Hail Profit,” a mosaic discovered under 16 feet of volcanic ash, Pompei, c 79 A.D. 

“Greed is Good,” Gordon Gekko, from the film Wall Street, 1987.

“Agree with above, and fraud is fine,” Modus operandi of U.S. insurance companies offering Medicare Advantage Programs in 2023.

Much has been written recently regarding the financing of health care in America. One of the more insightful and comprehensive articles was offered by former CMS Administrator Dr. Don Berwick, entitled “Salve Lucrum: The Existential Threat of Greed in US Health Care,” (JAMA, Jan 30, 2023). He felt that the colorful mosaic from Pompei would be appropriate to the decor of the atria of many health care institutions today. He begins by stating that “The grip of financial self-interest is becoming a stranglehold, with dangerous and pervasive consequences. No sector of U.S. health care is immune from the immoderate pursuit of profit, neither drug companies, nor insurers, nor hospitals, nor investors, nor physician practices.”

Medicare Advantage programs have garnered the most scrutiny of late, as well they should, in light of their relatively unchecked exploitation of Medicare funds and the U.S. taxpayer. So, what could possibly go wrong with corporate takeover of a program which had been providing pretty good care at a reasonable cost to senior citizens and the disabled since 1965? Another movie title, Everything, Everywhere All at Once, nicely summarizes the answer.

Medicare Advantage has evolved from a managed care experiment within the realm of traditional Medicare into a monstrous multi-headed Hydra. Within the corporate, for-profit world of MA, the government pays the insurance company a monthly rate per beneficiary based on the number of diagnoses and the severity of illness, both of which are routinely fabricated and exaggerated to enhance payment. In fact, the average risk scores (measures of illness) for the generally healthier MA patients run some 20% greater than traditional Medicare patients (Richard Kronick, “Unpacking Controversy Over Medicare Advantage,” Kaiser Family Foundation, 3/21/23)

While the Department of Justice is investigating the fraudulent practices of the major insurers, the nonpartisan Medicare Payment Advisory Group estimates that taxpayers will fork over $25 billion in excess payments within the next year to insurers above and beyond the costs of traditional Medicare (“Biden Plan to Cut Billions in Medicare Fraud Ignites Lobbying Frenzy” Abelson and Sanger-Katz, New York Times, 3/23). With a portion of those ill-gotten gains, MA besieges Medicare-eligible patients with annoying has-been celebrities, bellowing promises of prescription drug coverage, dental care, and free eyeglasses. The celebrity endorsers do not routinely reveal the MA issues with limited provider networks, hidden copays, preauthorization hassles, and “managed” (limited) post-hospital skilled nursing care and rehabilitation.

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For every jaunty senior citizen enjoying MA health club benefits, there are several who spend hours arguing a denial of care with robotic AI entities on the phone. Over half of Medicare beneficiaries are enrolled in some sort of MA plan, and many are quite happy with the arrangement, but unbridled spending will deplete the Medicare Trust Fund in the near future. If we could upend the rush to privatization and outrageous profit, we might be able to apply additional benefits to traditional Medicare to cover many more beneficiaries.

It’s hard to discern the enablers from the enabled in this chaotic system, as all seem to be enjoying the bounty of the Medicare trough. Insurance companies have joined forces with pharmacy chains and large networks of primary care providers to assure that maximal billing occurs at all levels. Mega hospital systems have also bellied up to the buffet. It’s abundantly clear that mergers and integration of all of these networks do little to improve care, but certainly increase costs while consolidating corporate profit and power. Entire businesses have evolved to assist groups in coding to the max (Aledade, Change Healthcare) while pocketing a hefty portion of the enhanced billing. Less and less of the health care dollar is actually going towards health care. The Biden administration is trying to reign in fraud and abuse by focusing on fraudulent coding, forcing MA plans to assure network adequacy, and limiting pay raises to plans. In Greek mythology, Hercules attempted to slay the Hydra, but each severed head of the many-headed serpent was replaced by two more.

And so it is in Washington, as legions of obstreperous lobbyists are now desperately cornering lawmakers with tales of woe while assuring hefty contributions to those who have their sympathy. Dr. Patrick Conway, an executive with Optum (subsidiary of UnitedHealth), owner of one of the country’s largest physician groups, whined something to the effect that reducing payments for some of the most over-coded conditions will have direct impact on patients. Probably not, since there is so much profit built into the system. It seems, though, that he wants us to weep for any decrease in executive compensation or shareholder payout.

As far as the enablers go, look no further than AARP and our congressional delegation. I wrote to the director of AARP New Hampshire and leadership in Washington, voicing concerns about the AARP endorsement of United Health’s Medicare Advantage Plan. AARP, for all the good it might do, makes big bucks through endorsements of everything from cell phone plans to car rental agencies. Our congressional delegation wasn’t much more forthcoming. Our senators and representatives have all been on record as supporting Medicare Advantage. This is a delegation that has otherwise done great work, but you cannot support the privatization of Medicare and traditional Medicare at the same time. 

It’s time to back away from the feeding frenzy at the Medicare trough and finance a healthcare system and workforce to provide timely, high-quality, and compassionate care for all.