STAT Opinion Piece By MA Opponents Uses Misleading Statistics
A STAT opinion piece written by two well-known opponents of Medicare Advantage (MA), Paul Ginzburg and Steve Lieberman, again uses misleading statistics to attack the program and argues MA is exorbitantly overpaid.
The authors have some recommendations, such as a move to standardization and delinking MA rate setting from the traditional fee-for-service (FFS) program over time, that could be considered with a more dispassionate discourse on the program overall. But their misleading statistics on the overpayment issue makes it difficult to take their recommendations seriously.
They argue the MA overpayment is more than $80 billion or 22%, generated by “beneficial selection” and “upcoding.” I have argued there is some over-reimbursement and that some reforms need to be made on risk adjustment. And many others have dispelled what the critics here say and what MedPAC, the congressional policy arm, constantly reports. Another misleading statistic from the authors: they argue MA profits are more than double the employer-based market. We know this is just not the case right now given the publicly disclosed financials of MA plans.
It is ironic that, just as the STAT editorial was written, another study from management consulting firm BRG finds that the new risk model being phased in MA from 2024 to 2026 will actually lead to lower MA payments vs. FFS. I peg the risk model changes as worth about 7% of revenue once fully in. There are other reforms that should be made, such as ending diagnosis code submissions in risk adjustment tied only to health risk assessments and manual chart reviews. But all of this in toto is far less than the critics’ $80 million plus overpayment numbers. BRG also pokes holes in MedPAC’s calculations and approach, which are similar to the critics.
In essence, some of the MA overpayment is being programmed out already through the risk model change, yet critics of MA look past this in favor of political arguments. It is clear that the goal of critics is to undermine MA and augment benefits in and grow the tired, fraud-ridden, and inefficient FFS system. That would be a hugely costly mistake.
(Some articles may require a subscription.)
Additional articles: https://www.statnews.com/2024/09/25/medicare-advantage-reform-cms-election-trump-harris/ and https://insidehealthpolicy.com/daily-news/brg-analysis-ma-pay-declines-compared-ffs-when-accounting-ra-change
#medicareadvantage #riskadjustment #overpayments
Hospital-Friendly Study Falsely Says Non-Profit Charity Care Exceeds Tax Benefits
A new American Hospital Association (AHA) study from Ernst & Young (E&Y) finds that non-profit hospitals provided $129 billion in community benefits in 2020, nearly 10 times the $13.2 billion in federal tax revenue uncollected from nonprofit hospitals that year.
Of course, the study is simply singing from AHA’s lobbying hymnal. Other studies and analyses show that hospitals’ broad tax exemptions are being abused as many hospitals provide minimal levels of charity care and sue their patients for exorbitant charges. A bipartisan group of lawmakers have it right when they argue that tax exemption is being abused and reforms are needed. The non-partisan Committee for a Responsible Federal Budget (CRFB) sees it this way too.
E&Y and the AHA twist the facts in a number of ways:
- It uses unreasonable and exorbitant hospital costs in calculations.
- It includes all so-called bad debt on charity care, much of which is based on the ridiculous costs above.
- It includes supposed Medicare under-reimbursement.
- It includes supposed under-reimbursement in Medicaid.
- It includes mission critical spending like education, research, and other community spending.
- It includes only federal tax exemption costs.
Including all tax exemption benefits against true community care as other studies do tells the true story – one that is not pretty and the AHA hides. (Note a much higher estimate of tax benefits in a study published in JAMA below — over $37 billion across all levels of government.) The study, which amounts to propaganda, was concocted by the AHA because the heat is turning up on hospitals in Congress. E&Y should be embarrassed.
See some of my blogs on the truth about hospital costs and exorbitant fees: https://www.healthcarelabyrinth.com/the-truth-about-hospital-costs-and-payments/ and https://www.healthcarelabyrinth.com/hospitals-drive-up-overall-healthcare-costs-considerably/
Additional article: https://jamanetwork.com/journals/jama/article-abstract/2824116?utm_campaign=articlePDF&utm_medium=articlePDFlink&utm_source=articlePDF&utm_content=jama.2024.13413
#hospitals #charitycare
Democrats Have House and Senate Bill To Make Exchanges’ Enhanced Premium Subsidies Permanent
Democrats have proposed a bill in each house of Congress to make the enhanced premium subsidies in the Exchanges permanent. They are set to expire at the end of 2025. Making them permanent would increase the deficit by $335 billion over the next 10 years. At the same time, 3.4 million more people annually would have health insurance. The bill is not expected to be called up in the GOP-controlled House in 2024.
Additional article: https://www.fiercehealthcare.com/payers/democrats-introduce-aca-subsidy-permanency-legislation
#aca #obamacare #exchanges
Zing Health Has Successful Capital Raise
Zing Health, a Chicago-based Medicare Advantage (MA) plan has raised $140 million from investors as it seeks to enroll patients in new markets. The company launched in 2019 and currently has about 14,000 enrollees in three states.
(Article may require a subscription.)
#zinghealth #medicareadvantage
New CMS Rule Requires Reporting On Age-Friendly Services And Grants Future Incentives
With aging in America, the Centers for Medicare and Medicaid Services (CMS) is focusing on ensuring age-friendly services in hospitals in the traditional Medicare program. Beginning in 2025, hospitals will report on new measures to ascertain whether they have appropriate care for seniors in emergency rooms and hospitals. The services include medication reconciliation, following living wills, frailty screenings, and assessing for social vulnerabilities. Incentives will begin in 2027.
(Article may require a subscription.)
#medicare #hospitals #compliance
https://www.modernhealthcare.com/policy/medicare-quality-measures-senior-age-friendly-care-2025
Another Survey Complains about Plan Claims Denial
Yet another provider survey complains about health plan claims denials. Almost 75% say claims denials have increased. Nearly 40% say their claims are denied at least 10% of the time, with 11% saying claims were denied at least 15% of the time. More than two-thirds say wait times for claims payment are increasing.
The survey also says that providers are not rushing to automation or AI. This is the case in part due to the pandemic disruption.
#healthplans #providers #claimsdenials
California Joins Other States In Barring Medical Debt From Credit Reports
Gov. Gavin Newsom signed a bill that will ensure Californians with medical debt will no longer have to worry huge debts show up on their credit reports. The bill blocks healthcare providers as well as collection agencies from reporting medical debt to credit reporting agencies. At least eight states have similar measures. More states have passed legislation on surprise billing reforms.
#medicaldebt #ca
— Marc S. Ryan
