Do Not Resuscitate (This System) #330 Jan 12 2024

I review health news in the mainstream and specialty media about how we spend trillions of dollars making intermediaries rich instead of making ourselves healthier. This week's topics are: the crazy way we pay for our healthcare; the Medicaid disenrollment debacle; good news on the antitrust front against further concentration in healthcare; some short pharmaceutical updates; and two sad tales about systemic breakdown in psychiatric care for veterans and minors. The full archive can be found at NYPAN.org under "single payer news." The script follows (not verbatim as I can't resist making wisecracks). 

 

12 JAN 2024

Hello and welcome to “Do Not Resuscitate (This System”) for the week ending January 12, 2024. I’m Tim Frasca, and every week I tell you about what’s in the mainstream and specialty healthcare news media about how we spend trillions of dollars making intermediaries rich instead of making ourselves healthier. This week we’ll discuss news about the crazy way we pay for our healthcare; more on the Medicaid disenrollment debacle; good news on the antitrust front against further concentration in healthcare; some short pharmaceutical updates; and some sad tales about systemic breakdown in psychiatric care for veterans and minors.

Let’s start with some general news about our crazy-ass payment system. Sarah Jane Tribble writes for KFF Health News that “Older Americans say they feel trapped in Medicare Advantage plans.” Well, news flash, they are. Seniors are lured into signing up for MA plans with bells and whistles like gym memberships and eyeglasses, all hustled in those ads with Joe Namath and Captain Kirk. Then, when they have any kind of major episode and start costing the insurance company money, guess what? They act like an insurance company! Limited the available networks and subject patients to prior authorization hell with frequent denials and red tape. When enrollees want to go back to traditional Medicare and add a supplemental to absorb the 20% Medicare doesn’t cover, those companies can reject them for pre-existing conditions—except for four states.

And I’m not making that up about the automated denials. Jakob Emerson at Becker’s Payer Issues writes about a lawsuit over the use of artificial intelligence to issue mass denials of MA claims. Emerson describes how any provider who deviated from the strict limits on post-acute facility stays faced “discipline and termination.” We need a federal crackdown with teeth.

Michael Osso from the Dallas Morning News gives some helpful advice on “How to fight back if your health insurance claim is denied.” I almost hate to read these admittedly useful details because WHY DO WE HAVE TO DO THIS IN THE FIRST PLACE? And denial rates are increasing—they’re up to 11% of all claims from users of ACA marketplace plans. Only 0.2% of these denials are appealed—that’s 1 in 500. Yes, we should learn to appeal and fight these SOBs and clog up their admin pipelines. And appeals are successful, says Osso, 82% of the time. So we should do it while reminding ourselves that this time-sink is an abuse.

Now here’s an interesting piece with an unacknowledged conceptual error, or you could say even an ideological one: Dylan Scott at Vox writes that, “The US doesn’t have universal health care—but these states (almost) do.” But wait: let’s define “universal”—Scott thinks it means everyone has something called “insurance.” Now, any listener to this podcast knows that being insured doesn’t mean you actually get medical care when you need it and without going bankrupt. That a state’s uninsured rate is under 5% tells us next to nothing. “The country is inching toward universal coverage,” Scott claims but without any discussion of premiums, deductibles, copays, or prior authorization. Compare U.S.-style “universal” care to Canada’s where you show your health card at any doctor’s office and then forget about it.

An excellent example comes from NC Health News and the Charlotte Ledger where Michelle Crouch tells the incredible tale of how “Charlotte hospitals say ‘no thanks’ to charity’s efforts to erase medical debt.” These hospital CEOs are auditioning for The Grinch, I swear. This church group wants to buy up people’s medical debt and then forgive it, and the city’s hospitals refuse to sell it to them. Charlotte’s Mecklenburg County, 18% of families have medical debt in collections; 57% of them were insured when they incurred it. Paging Dylan Scott @ Vox: Is Charlotte “inching toward universal coverage”? All these people on the hook for thousands in hospital debt—are they really insured? What does that even mean?

From the provider side, things are even worse. Andrew Popper told his story in STAT with the headline, “Insurance companies are forcing psychiatrists like me to stop accepting their coverage.” This poor guy tried his best to deal with insurance companies, finally gave up, and now earns less but spends all that wasted reimbursement-pursuit time with patients. Here’s what his prior life was like: “The paper claims simply disappeared into the ether or were rejected. Slight deviations from the insurer’s opaque and ever-changing protocol would necessitate resubmitting the claim. My administrative time started exceeding my clinical time.” Popper wonders why we put up with it all and winds up with a memorable phrase. “This is the business model—customers pay for the right to be deprived of the product they’re purchasing.”

But for Tom Price & Elaine Parker writing an op ed in Newsweek, we need more of the same. They criticize Biden’s health care agenda as not being sufficiently friendly to free enterprise. Price, we should recall, was Trump’s disastrous HHS chief who had to resign after racking up $1 million in private jet travel. Now, he works for the libertarian “Job Creators Network.” He denounces government regulation in favor of “free-market competition and patient choice” [yawn]. But under the broken-clock rule, Price accidentally lands on a fact about Obamacare subsidies for people buying private insurance: he says it’s “a temporary Band-Aid that does nothing to quell long-term inflationary pressures within health care. [true] Middle-class families who don’t qualify for subsidies will continue to be financially squeezed while others are blindfolded to the real problem.”

Kristen Hwang at Cal Matters describes how that free market in healthcare is working on planet Earth, as opposed to the ideological Fantasyland where Tom Price lives. Her article entitled, “A market failure” tells us about Monterey County where insured Californians can’t use local hospitals because of their monopoly prices, which run four to five times Medicare rates, such as $12,000 a night for a hospital room and double-digit annual price increases for premiums. But hey, reality doesn’t intrude too much in the Tom Price world.  

Now, there’s a subtler version of the market worship in Ezekiel Emanuel’s STAT piece purporting to tell us, “Why health care costs haven’t exceeded inflation in recent years?” Emanuel was an insider involved in crafting the ACA (Obamacare), so not surprisingly he says that value-based care, such as that used by the Medicare Disadvantage system, created incentives to keep costs down, so that’s the way forward, privatize Medicare and get those free-market incentives to work. But Emanuel doesn’t address how “value-based” translates as “if we don’t spend money on patient care, we get to keep more of the money.” How is that not a perverse incentive? Emanuel wants us all to have to fight rigged prior authorization procedures because that’s going to produce cost savings. Yeah, and who gets that saved cash? Three guesses. Emanuel’s neoliberal market-worship is the Democrats’ version of what Tom Price is peddling.

Now, let’s move on to the Medicaid disenrollment debacle. Bryce Covert asks in the New York Times, “What happened to my health insurance?” and tells us about people being surprised at the ER or the pharmacy when they find out they were kicked them off Medicaid. During Covid, people were guaranteed continued coverage, which meant people could take on better-paying jobs and not worry about losing their eligibility for making too much money. Well, that went out with the window, and now 30 million people are set to lose Medicaid; 13 million already have. Are these millions going to show up in 2024 to vote for the Democrats who presided over this nightmare? Asking for a friend.

There is a slew of stories of the Medicaid nightmare in various states. Texas is the worst with 1.7 million people thrown off so far. Neelam Bohra at the Texas Tribune quotes one Texas Congress member who complained about “an incredible amount of incompetence and indifference to poor people” as if that were an accident. Texas has a “backlog of hundreds of thousands of applications” for Medicaid and other benefits, which provides convenient excuses for kicking people off who actually remain eligible.

The enforcement from the Feds who actually stump up the cash to pay states for their Medicaid programs has been pretty pathetic. Benjamin Hardy in the Arkansas Times writes that the “Biden administration [is] ‘deeply alarmed’ by Arkansas’s rush to kick kids off Medicaid.” Oh, they’re “deeply alarmed,” isn’t that skeery for Governor Cruella de Ville who takes delight in dumping her state’s poor. Arkansas so far has tossed 18% of child enrollees off Medicaid after they refused to work in chicken slaughtering plants (ha, just kidding!)

Chelsea Cirruzzo at Politico has a similar tale: “Biden administration pleads with states after millions of kids lose Medicaid coverage.” Pleading, that’s the regulatory response. Yes, we will send you a stern letter! With the subject line: “Please don’t be so mean!”

There’s some good news on the market concentration & antitrust front. Matt Stoller writes at his very informative and really must-read blog BIG, “Out with a bang as FTC beats the Pharma Bros.” This is a story about Lina Khan’s tenure at the Federal Trade Commission, which used to be one of those Federal agencies you never heard about because they never did anything important. But she and her team are addressing vertical integration in healthcare, which is crucial for us because it threatens the healthcare cartels’ business model. Stoller relates how a medical data behemoth named IQVIA was “trying to monopolize the business of advertising to doctors” by buying out a competitor, exactly the way Google monopolized online advertising, successfully, to our detriment. But Khan sued IQVIA and beat them in court, the first challenge to a vertical integration merger in 40 years. We should pay attention to this fight because it is extremely important for the future of the entire $4 trillion a year industry.

Susanna Vogel at Healthcare Dive notes that “Antitrust enforcements hit a high in 2022 with health deals impacted.” The FTC blocked three big proposed health system mergers in 2023, and although they didn’t always win, at least they’re fighting and shaking up the giants.

For example, Dan Primack at Axios notes that drugmaker Sanofi had to scrap its attempt to buy out a company that was developing a potential competitor drug. This is known as “killer acquisitions,” which obviously destroy innovation in the pharmaceuticals, which is supposedly the reason these companies have to make so much dough, right? In a killer acquisition, a drugmaker buys up anything that might come along to compete with its blockbuster sellers to make sure that we have no alternative. Primack writes, “This must be raising eyebrows among biotech venture capitalists, who often generate returns via these sorts of bio-bucks deals.” Couldn’t happen to a nicer bunch.

There were some sad tales about systemic failures as well, such as Gretchen Morgenson’s long piece for NBC News entitled, “Vital signs vs. dollar signs: At HCA hospitals, the person monitoring your heart may monitor 79 other patients, too.” This is a chilling tale about how the person watching your heart rhythms, blood pressure, or respiratory functions when you’re hospitalized might be a low-paid techie sitting in another building watching dozens of screens simultaneously. Why would a hospital do this? “Technician salaries are significantly lower than those of registered nurses.” Ah. So those precious seconds when your heart stops can and is easily missed by someone whose eyes glazed over in front of a bank of beeping screens.

Kathleen McGrory & Neil Bedi investigated the Veterans Administration’s mental health services and, not surprisingly, found them lacking in a ProPublica piece, “When veterans in crisis can’t get help.” Here’s the key statement: “The military has long drawn recruits from remote towns across America, promising them a lifetime of health care in return for their service. But the VA has seldom staffed those same communities with the mental health professionals needed to help them once they return home.” You’d think in that $800-plus billion-dollar Pentagon budget there might be a line for enough psychiatrists, but apparently not. “We were abandoned,” said one VA social worker. “We kept saying, there is going to be a problem. This is going to blow up.” Then it did.

ProPublica did a joint investigation with The City, a wonderful online new source for us New Yorkers, “New York closed psych beds for youth in crisis. Now, foster care programs and host town are being pushed to the limit.” This one’s about the overstretched acute care facilities for minors, specifically one in Westchester County that is drawing ire from locals because they can’t control their residents. This goes back to Gov. Cuomo’s closure of half of psychiatric care beds in the state, which the current administration apparently wants to reverse, and none too soon. It’s a heartbreaking story of how suicidal kids wait for months on wait lists for a treatment program, part of a larger ProPublica series called “How New York Wrecked Mental Health Care for Kids.”

Finally, two items about pharmaceuticals: Adam Cancryn at Politico reports that the Biden Administration is “targeting costly meds and asserts authority to seize certain drug patents.” Yeah, I’ve heard this one before, but it falls into the category of All Hat, No Cattle. I recall very well from the HIV/AIDS wars some heady rhetoric about defying Pharma over patents, but it almost never happened. But it does make good copy for an election campaign. And Cancryn notes that “Biden officials now plan to make a fresh push to put health care at the center of Biden’s reelection platform.” So I’ll wait for action and ignore speeches, but that’s just me.

And I could not leave out this marvel from Ned Pagliarulo at Healthcare Dive, “Lilly launches online service for home delivery of weight loss drug.” So yes, now you can not only get your expensive fat meds paid for by the government, but Lilly will even drop them on your doorstep. To stave off criticism, Lilly added a virtue signaling statement that its product should not be used for “cosmetic weight loss.” Oh no, we totally do NOT want you to see our ads and then clamor for our slimming product from your doctor! Perish that thought.

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That’s it for Do Not Resuscitate (This System) for the week ending January 12, 2024. I’m Tim Frasca, and each week I compile news and commentary about how the lack of a single-payer system is giving us lousy services for a ton of money. All these articles and more are in my written digest, and you can look that up at the website of the New York Progressive Action Network, that’s NYPAN.org N-Y-P-A-N and search for Single Payer News—I’ll put a link in the program notes along with my email in case you would like to receive my written digest to your inbox. I’ll be back next Friday with more news about our ongoing national project to squander trillions and make intermediaries rich. Thank you for listening.