The Dangers to Traditional Medicare from Medicare Advantage and ACO-REACH

-Libby Earle 12/14/22

If you are a senior citizen on Medicare, you are probably getting bombarded by phone calls from telemarketers implying they represent Medicare and they want to tell you about additional benefits.   What they are really doing is promoting Medicare Advantage (MA) which is no advantage to seniors or the health care system. What is now being promoted at the Center for Medicare and Medicaid Innovation (CMMI), an agency within HHS that tests and implements health payment models without congressional approval, is the transformation by 2030 OF all Traditional Medicare (TM) to a Medicare Advantage (MA) inspired private insurance-publicly funded program administered through a middleman? The program was initially piloted during the Trump administration and called a Direct Contracting Entity (DCE). The Biden Administration has rebranded it as ACO-REACH (Accountable Care Organization Realizing Equity, Access, and Community Health) but it is still a direct contracting entity.

Originally Medicare Advantage promised to fill the gaps of Traditional Medicare: services not covered, monthly premiums, deductibles, and cost sharing. However MA plans are private for profit entities receiving public funding.  MA plans can offer additional benefits not offered by traditional Medicare; however, the insured has a limited choice of providers and once switched they have difficulty getting out of a MA plan. If they do switch back, it is difficult to get supplemental insurance to fill in the gaps of traditional Medicare. 

These programs enroll 45% of Medicare eligible persons. Medicare overpaid these private health plans by more than $106 billion from 2010 through 2019 because of the way the private plans charge for sicker patients (Richard Kronick, the University of California-San Diego). MA insurance companies maximize their profits by how they construct reimbursements and utilization.

While Traditional Medicare must spend 98% of its budget on patient care and Medicare Advantage must spend 85% of the money received from the government Medicare Trust Fund, DCE and REACH middlemen are only required to spend 60% of the government money on patients realizing 40% as income. Both MA and DCE are paid based on an estimate of their potential needs.  They inflate the projected need by up-coding—increasing the patient’s risk score, including every possible diagnosis at the highest level possible regardless of the care given.

A landmark paper in 2017 reported that “Medicare Advantage (MA) insurer revenues are 30 percent higher than their healthcare spending. Healthcare spending is 25 percent lower for MA enrollees than for enrollees in Traditional Medicare (TM) in the same county with the same risk score. Spending differences between MA and TM are similar across sub-populations of enrollees and subcategories of care, with similar reductions for “high value” and “low value” care. Spending differences primarily reflect differences in healthcare utilization [with the most aggressive adjustment, the spending deference between MA and TM was 8%].”  There is suggestive evidence that MA restricted utilization for sicker individuals by discharging to home rather than post-acute care facilities, substituting less expensive types of care such as specialist visits and higher outpatient surgery rates.  [Healthcare Spending and Utilization in Public and Private Medicare Vilsa Curto, Liran Einav, Amy Finkelstein, Jonathan D. Levin, and Jay Bhattacharya NBER Working Paper No. 23090 January 2017 JEL No. H11,H42,H51,I11,I13]

Medicare Advantage programs have not saved money nor are they superior to traditional Medicare.  A report in JAMA “found no meaningful differences in the characteristics of patients or the quality of care received between those enrolled in MA vs those enrolled in FFS Medicare” but cautioned that utilization management strategies should not become factors that  adversely affect care. [JAMA Cardiol. 2020;5(12):1349-1357. doi:10.1001/jamacardio.2020.3638]

Additionally, the Office of the Inspector General found that nearly one in seven (13 percent) Medicare Advantage prior authorization denials were inappropriate. Medicare Advantage plans frequently denied requests for care that met Medicare coverage rules. Of the claim-payment denials in the study sample, 18% met Medicare coverage rules and Medicare Advantage plan billing rules. [AMA]

While MA as an accountable care organization was supposed to save money, at best these entities have either lost money or only saved Medicare a few tenths of a percent. [Promise vs. Practice: the Actual Financial Performance of Accountable Care Organizations J Gen Intern Med DOI: 10.1007/s11606-021-07089-6 © Society of General Internal Medicine 2021]

There is a close association between the middlemen who administer the direct contracting entities and Medicare Advantage insurance organizations. Many of the DCE are investor-owned startups or commercial insurers who also run Medicare Advantage plans.

Part of the strategy to move traditional Medicare to DCE is to switch Traditional Medicare patients to Direct Contracting Entities. Medicare can automatically transfer a client to MA by searching two years of each senior’s claims history to see if the senior has gotten care from a primary care provider who is aligned with a DC or REACH middleman. 350,000 seniors were in DCE plans as of January 2022 — none of whom elected to sign up voluntarily (Rep. Pramila Jayapal). 

Rebranding DCE does not remove the incentive for Wall Street investors and insurance companies from profiteering. There are major conflicts of interest existing within the CMMI, the architect of direct contracting. The Center for Medicare and Medicaid Services is a department within the Department of Health and Human Services. The Center for Medicare and Medicaid Innovation ((CMMI) exists as an agency of the DHS charged with piloting new programs but is outside of congressional control. The CMMI leaderships’ connections with health care insurance, lobbying and venture capital is alarming:

CMMI Leadership:

Adam Boehler (2020)

  • 2020 Previous position: startup company, Landmark Health which was awarded contract to be a DCE under Boehler.
  • Former roommate of Jared Kushner.
  • 2021 left to form Rubicon Founders, a new firm based in Nashville, Tennessee, focused on growing “transformational” health care companies

Brad Smith, former Anthem Executive (2021)

  • 2021, leaves to be executive chairman of CareBridge, a home- and community-based services company.
  • 2021, Forms “Russell Street Ventures, “an innovative healthcare firm focused on launching and scaling companies that serve some of our nation’s most vulnerable patient populations” and “Main Street Health,” a new company “focused exclusively on delivering value-based healthcare in rural America.”

Liz Fowler, director  (2022)            

  • Past employment: Johnson & Johnson; Former Sp Asst to President-Health/Econ Policy, National Economic Council
  • She predicts Traditional Medicare will transition to payments through Direct Contracting Entities by 2030.    

Nor does direct contracting insure any cost saving, improvement in health outcomes or equitable access to care.  The current group of DC middle men, with all their entanglements with investors and insurance companies, do not have to re-apply for the new (rebranded) program. And REACH allows any company to apply, including private equity and commercial insurers.  Penalties for middlemen who increased costs or significantly reduced quality have been reduced.

The focus on improving health equity is encouraged by using incentives.   Middlemen receive financial bonuses simply for reporting enrollee’s demographic data, like race and income, giving a bonus of $360 per year for each senior that is considered underserved (based on residence and income), regardless of how much care that senior receives.  Also middlemen are allowed to use demographic factors like race and income to increase enrollees’ risk scores regardless of how much care provided.  These incentives provide invitations for profiteering as much as the practice of up-coding.

This is not a Republican or Democratic issue.  Both parties are heavily influenced by campaign donations.  “In 2020, the leadership of DCE contractor Clover Health donated $500,000 to the main super PAC for Senate Democrats, while the company’s financier Chamath Palihapitiya donated $750,000 to the same super PAC plus $250,000 to the Biden Victory Fund. ( Mar 24, 2022•Matthew Cunningham-Cook  https://www.levernews.com/seniors-medicare-benefits-are-being-privatized-without-consent).

Healthcare consumers are confronted with confusing information about health insurance.  If the cost of health care is going to be controlled, the driving force of an unregulated health care industry must become the responsibility of Congress backed by an informed electorate.

Social Justice December Update

Second-Sunday Collection on December 11 will benefit Oxford Citizens for Peace and Justice. Since 1979, OCPJ has worked to construct a world of peace with social, economic, and environmental justice. They organize speakers, public education forums, demonstrations, and other community events in response to important issues and to their commitment to support peace and justice. OCPJ has a community forum at https://www.facebook.com/groups/185403008216446/. For this collection, please make the checks out to HUUC and put “OCPJ” in the memo line.

Oxford Citizens for Peace and Justice Bread Not Bombs community dinner is on December 3 from 5:00 – 7:00 p.m. at Holy Trinity Church in Oxford. The event features delicious homemade food, live music, presentation of the annual Peace and Justice Award, and a Holiday Peace Market. Tickets are $10 for adults; $5 for students and those with limited income. Children under 12 are FREE – no reservations needed.

The UU Council of Greater Cincinnati elected Hopedale’s Genevieve O’Malley Knight to a two-year term as Secretary.

“Transgender Inclusion in Congregations” is an online course by the Transforming Hearts Collective (https://tinyurl.com/3yauyu4e) facilitated by Hopedale’s Social Justice and Religious Education Committees. Members and Friends of Hopedale are invited to join the course and participate in person during the final session on January 29, 2023 from 1:00 – 3:00 p.m. This class is part of our efforts to renew our Welcoming Congregation status.

Next meeting of the Social Justice Committee – over Zoom – will be Thursday, January 12th 7:00 – 8:00 pm. Contact Liz Woedl at liz.woedl@gmail.com for the Zoom link.

TRANS AWARENESS WEEK 2022

November 13-19 this year has been Trans Awareness Week.  This week honors and celebrates the achievements and resiliency of transgender individuals and communities.  In March of 2021, President Joe Biden signed an historic proclamation on Transgender Day of Visibility, recognizing the struggle, activism, and courage of trans*, transgender and gender non-binary people in the United States and around the world to live openly and authentically.  

Trans Awareness Week culminates today, November 20, with a Trans Day of Remembrance vigil at 6:00 at the outdoor seal at Miami University.  The annual TDOR honors the memory of the transgender people whose lives were lost this year to acts of anti-transgender violence.  All LGBTQIA+ community and affirming allies are welcome to attend.

Sadly, 2022 has already seen at least 32 transgender people fatally shot or killed by other violent means.  The Human Rights Campaign says “at least” because too often these stories go unreported—or misreported.  In previous years, the majority of these people were Black and Latinx transgender women.  In 2021, the Campaign tracked a record number of violent fatal incidents against transgender and gender non-conforming people—with 50 fatalities tracked.  These victims, like all people, are loving partners, parents, family members, friends and community members.  They worked, went to school and attended houses of worship.  They were real people—people who did not deserve to have their lives taken from them.  

 

Social Justice November Update

The Social Justice committee is sponsoring will be a Second Sunday Collection on Sunday, November 13 to benefit Talawanda Oxford Pantry & Social Services and will match contributions up to the first $100 of the donations. TOPSS serve their clients’ food needs by honoring shoppers’ dignity, allowing them to choose their food items according to their household size and preference. Please make checks out to “HUUC’ and put “TOPSS” in the memo line. 

Member and Friends of HUUC are invited to participate in “Transgender Inclusion in Congregations” an online course by the Transforming Hearts Collective, https://tinyurl.com/3yauyu4e and facilitated by the Social Justice Committee, HUUC and the Hopedale Adult Religious Education as part of renewing our Welcoming Congregation Status. The course has two remaining sessions and will be taught in person at the HUUC building at 3870 Millville Oxford Rd, Oxford, Ohio with remote access for those who wish to attend virtually. The remaining dates are Nov. 13, 2022 and Jan. 29, 2023, 1pm-3pm.

Voting Information:
• Vote! The polls are open on Election Day from 6:30AM to 7:30PM.
• The Butler County Board of Elections at https://elections.bcohio.gov/, Check your registration!
• The League of Women Voters of Oxford website is a great place to check on elections, issues, and voter education. We have the League of Women Voters’ election guides at Hopedale in the entry area. https://my.lwv.org/ohio/oxford/voting-elections-info.

Read the Action of Immediate Witness Statements chosen for at the June 2022 UUA General Assembly. These links are HOT:

We Do Not Consent: Taking Action to Ensure Access to Abortion  
Stop the Privatization of Medicare 
Anti-Racism and Reparations Via Restorative Justice

Calendar Dates:
• Thu, Nov 10, HUUC Social Justice Zoom mtg. 7 pm
• Sat, Nov 12, UU Council of Greater Cincinnati, Zoom mtg, 9:30-11:30 am
• Sun, Nov 13, Second Sunday Collection
• Sun, Nov 13, Adult RE/Trans Inclusion, 1-3 pm

Be an Informed Voter!


 Open Secrets lists candidates and their donors.  There is a lot of ways to search the site because it is extensive!  https://www.opensecrets.org/
League of Conservation Voters Scorecard looks at voting records on conservation-related legislation for national office holders by state.  https://scorecard.lcv.org/
Ohio Environmental Council Scorecard posts environmental voting records of state-level elected officials and uses this and other information to make candidate endorsements. http://www.theoecactionfund.org/

Garden Report


The recent drainage work at Hopedale’s property has pointed out the need to revamp the flower garden by the entrance. That is one of the targets of the regular outdoor workdays.  As plants are moved and subdivided extra plants are available, especially irises and black-eyed susans. Fall is a great time to add plants to your garden at home. Black-eyed susans are native plants that support native insects and birds. Help is greatly appreciated!
 
There are lots of herbs in our garden that can be picked and used fresh or dried for winter use. Help yourself to Basil, Parsley, Sage, Oregano and Rosemary. The cherry and grape tomatoes are still producing, and there are three kinds of hot peppers – ancho (serrano), jalapeno, and sugar rush peach. The latter make great “jalapeno poppers,” i.e., stuffed pepper appetizers. Removing seeds and membranes reduces the heat. Just be sure to wear gloves and a mask when working with hot peppers! The aerosols can be irritating.

Welcoming Congregation Renewal

Welcoming Congregation
As part of renewing Hopedale’s Welcoming Congregation status, the Social Justice Committee and Adult RE are sponsoring a course, “Transgender Inclusion in Congregations,” by the Transforming Hearts Collective https://tinyurl.com/3yauyu4e. This course will be taught in person at the HUUC building at 3870 Millville Oxford Rd, Oxford, Ohio, and will offer remote access for those who wish to attend virtually. The first session was held September 25; two more sessions are planned for November 13 and January 29 (Sundays) from 1:00 – 3:00 pm. Registration information was emailed in mid-September.  Contact Libby Earle if you are interested at mearle1945@gmail.com.  

Journeying Toward Spiritual Wholeness

October 16th, 10:30am at Hopedale UU Community – “Journeying toward Spiritual Wholeness in Beloved Community:  Renewing Welcoming Congregation Status”  Hopedale member Ann Fuehrer will outline this year’s process of renewing Hopedale’s Welcoming Congregation status.  She will frame welcoming practices within the context of the core of the UUA’s 8th Principle, journeying toward spiritual wholeness in Beloved Community.  Service leader: Kathleen Carels. Children’s RE:  Activity in lower level during the service.

UUs to Honor Leslie Edwards at Walk to Defeat ALS 2022



The Social Justice Committee, HUUC will be part of the UU Council of Greater Cincinnati’s (UUCGC) participation in the Walk to Defeat ALS 2022 on Sept 25 at Winton Woods. The UUCGC participation will honor Leslie Edwards, a member of The Gathering at Northern Hills, who prior to his death in 2019 was the oldest living Tuskegee airman in the Greater Cincinnati area. Mr. Edwards was also a grandson of Rev. W.H.G. Carter, was pastor of the Church of the Unitarian Brotherhood in the West End of Cincinnati during the 1920s and 1930s, and Rev. Carter’s wife was Beulah Carter. Mr. Edwards suffered from ALS (amyotrophic lateral sclerosis), a disease that especially affects veterans. Funds raised by the walk will have a direct effect on the quality of life of those living with ALS today by making local care and services available.
 
The Social Justice Committee, HUUC will match contributions made during the Rainbow Basket Second Sunday Collection on September 11. Those who will not be at the service may send a check donation (write ALS in the memo) to HUUC by way of the Hopedale Treasurer,  P.O. Box 625, Oxford, OH 45056.

If you would like to know more about participating in the two-mile walk, visit the Walk to Defeat ALS Cincinnati web site (bit.ly/2022WalkToDefeatALS ). You can register by joining the Leslie Edwards Unitarian Universalist Team. The UU Council of Greater Cincinnati will match the first $250 raised by the Leslie Edwards UU Team. Daniel Schneider (UUCGC President) is listed as the team captain.