Robbing Kids, the Dying and the Elderly to Pay Medicare HMOs

[McCamy Taylor]

Come and listen to a story ‘bout a Texas governor

Didn’t give a damn ‘bout the old, sick or poor,

Some lawmen down in Austin, fed up with HMO greed

Passed the Patient Protection Act, brought them to their knees.



Bush vetoed that sucker, killed it dead.



I guess if the Democrats in Congress were smarter, they would have known better than to mess with W.’s precious managed care industry. The first unpopular thing he ever did as governor in Texas was veto the Patient Protection Act after the legislature was out session, killing managed care reform in that state for two years. Next time around, he had to let it go into law without signing it, since he was considering a presidential run. In 2000, during a debate with Gore he lied and claimed credit for the bill. Later, he would have his Attorney General John Ashcroft successfully shoot it down in federal court. Managed care has always had a friend in George W. Bush.

So, when Congress proposed to finance SCHIP by taking back some of the extra money it is paying Medicare managed care or Advantage plans, that must have made W. see red. Or maybe, green. Lots of corporate giving from the health insurance industry. Lots of favors. Like the one Tom Kean Sr. former 9/11 Panel member and current United Health board member did when he vetted the Hindenburg of GOP propaganda The Path to 9/11. Funny how United Health’s problems with the SEC over backdated filings of options have sort of been put on a back burner ever since Kean did that work on The Path to 9/11. I never could take any Bush administration action against a health insurer too seriously.

First, here is what our tax money is being spent on. You ready? Our health care dollars, or rather Medicare’s health care dollars are going straight into the pockets of the health insurance industry, making their CEOs and stockholders rich, rich, rich. Even though they have been naughty, naughty, naughty. Santa is bringing them all lumps of coal this year.

How naughty have they been? Keep in mind, these are managed care plans, just like the old HMO horrors of the 1990s. They get one fee per member, and then they decide how to spend it. If they don't spend it, they pocket it. So, enrolling a lot of (not sick) members is important There has been an industry wide scandal in which the people who enroll Medicare members have lied and cheated to sign up members.

http://seniorjournal.com/NEWS/Medicare/2007/7-05-16-MedicareAdvantage.htm

“Seniors have been removed from traditional Medicare without their knowledge, signed onto plans they can’t afford, misled regarding coverage, and told their doctors accept these plans, when in reality they don’t. This is simply unacceptable.
“One of the most troubling problems we have seen involves insurance agents misrepresenting and marketing Medicare Advantage plans in inappropriate manners and places, such as within nursing homes.”

Think about it. People who are not looking for insurance are actually a good risk. These are people who do not spend a lot of time worrying about their health. These are the seniors who may never see a doctor from one year to the next.

It got to be so bad, that there was a moratorium for a while on Medicare Advantage plans signing up new members.

http://www.tcf.org/Publications/HealthCare/healthbeat2.pdf

They do not want just anyone mind you. This article explains how they cherry pick. They can not turn people away for having pre-existent conditions, since they are a kind of HMO. However, they are allowed to charge co payments. So, they charge exorbitant co payments for dialysis, chemotherapy, oxygen, radiation therapy, hospital care. At the same time, they load their plans with the kind of luxury services that traditional Medicare will not cover but which the healthy elderly will find attractive. Then, even though they pay out less per member for its unusually robust senior population, they manage to persuade the feds that they should be paid more per patient than fee for service doctors (remember, managed care started out as a way to save the government money).

A recent issue of the AMA weekly magazine reports that while fee for service Medicare providers face a 10% across the board fee cut, health insurance companies that with Medicare Advantage plans are making much more money from taxpayer—corporate welfare—than from their private products. Overall, the federal government is paying a handful of companies an excess of $54 billion a year.

http://www.ama-assn.org/amednews/2007/11/26/bisb1126.htm

$54 billion a year!

“Publicaly traded health plans reported gains for the third quarter of 2007 and generally cited Medicare Advantage and other government plan growth as the main driver.”

Now, here is the health care that you are not getting(for your $54 billion a year, that Aetna, Coventry, Cigna, Health Net, Humana, United Health and WellPoint require for the wellbeing of their financial health)

SCHIP Expansion: That $7 billion a year that the right wing groused so much about sure looks like small beans compared to the $54 billion in corporate welfare we are handing out to a handful of companies over and above their actual expenses. This $7 billion a year would have covered 4 million more uninsured children.

http://www.prnewswire.com/cgi-bin/stories.pl?ACCT=104&STORY=/www/story/07-25-2007/0004632408&EDATE=

According to the U.S. Census Bureau, more than eight million children
are still uninsured in the U.S., many of them eligible for the SCHIP
program but still not enrolled. Eight in ten voters surveyed said they
believe that such a high number of uninsured children represents a crisis
or very serious problem. More than six in ten voters said the current
health care system is not meeting the needs of children.

Wow. Covering half of the children who are still uninsured sounds pretty good to me. And most of America agrees with me. Hell. Maybe we should take $14 billion from the managed care plans and cover all of them.

Hospice Care: Guess who is asking for their money back? And guess who is going bankrupt? From the someone should have seen this coming files, Medicare is beginning to demand that Hospices refund hundreds of thousands of dollars in “over payments” for patients who are long dead. The problem? Look at what Congress did.

In 1998, Congress removed limits on the number of days that an individual could receive Medicare hospice coverage, encouraging physicians to refer terminal patients.
But lawmakers did not remove a cap on the aggregate amount that hospice providers could be reimbursed each year, a measure designed to contain the program's cost. A hospice's total annual reimbursement cannot exceed the product of the number of patients it serves and a per-patient allowance set by the government each year ($21,410 in 2007).

You got that? Congress said “You Hospices will now take care of anyone the doctor wants to refer for up to 365 days and we will only pay you $21,410.” Apparently, in the early days, Medicare did not really enforce it and some Hospices got paid more, but now Medicare wants its money back. I guess so that they can send it to Cigna and United and Wellpoint to cover that whopping $54 billion a year.

Never mind that the money is only a drop in the bucket to the HMOs. It can mean the difference between solvency and bankruptcy for the Hospices.

The commission, which analyzes Medicare issues for Congress, recently projected that 220 hospices -- about 1 of every 13 providers -- received 2005 repayment demands totaling $166 million. The National Alliance for Hospice Access, a providers group that is lobbying for a three-year moratorium on the collections, places the numbers at 250 hospices and $200 million.
However, it is enough to drive Hospices into bankruptcy.

http://www.star-telegram.com/national_news/story/326008.html

Who else can the federal government recoup some of its losses from? That’s right, the elderly! They are the ones costing them all the money in the first place. Let’s avoid fixing that donut hole in the Medicare prescription drug coverage. Not only does that save traditional Medicare a bundle. Medicare Advantage has its own prescription plan that does not contain a “hole”, which gives them an attractive sales point. Since they are a managed care plan, they can get their drugs for pennies on the dollar (unlike Medicare, which made a deal with the Devil with the pharmaceutical industry), meaning that drugs do not cost them much anyway.

What is the Medicare drug hole and how badly does it hurt seniors?

http://www.star-telegram.com/business/story/321887.html

The nickname given to the federal provision that older Americans love to hate describes a big financial gap in Medicare prescription-drug coverage.
In 2008, the gap in the standard Medicare drug benefit begins when a patient's total drug costs have reached $2,510, including the portion paid by Medicare and the patient's out-of-pocket deductibles and co-payments. The beneficiary must then absorb $3,216 in out-of-pocket costs until total drug costs have reached $5,726. Only then does the catastrophic coverage kick in, with prescriptions generally covered at 95 percent.
Snip

Although the poorest patients can get Medicare assistance for premiums, deductibles and co-pays, those who fall just above the poverty line and cannot get extra help sometimes simply stop taking their medications once they reach the doughnut hole or rack up big credit-card debt to pay for them.
A recent AARP survey found that 15 percent of Medicare beneficiaries who reached the doughnut hole did not get a prescription filled.
Dr. James King, a family physician in Selmer, Tenn., and president of the American Academy of Family Physicians, says 50 percent to 70 percent of his Medicare patients hit the doughnut hole, then switch to generics, ask for free samples or stop taking their medicine.

The article goes on to suggest generics. And using substandard “second best” therapies for the patent remedies you can not afford. That will definitely save the federal government an armload of money, and help them assure that their all important pals at Aetna and Humana and Coventry welcome the new year with happy smiles and big fat checks for their pals in DC.

http://www.prnewswire.com/cgi-bin/stories.pl?ACCT=109&STORY=/www/story/06-22-2007/0004613490&EDATE=

Massive spending by the healthcare
industry is swamping the nation's political process, according to the
findings of a new report issued today.

Snip

"These staggering sums have a crushing impact on policy and are
drowning out the voices of patients and other ordinary Americans who can't begin to match the financial clout of the big drug companies, insurers, and other healthcare industry giants," said CNA/NNOC President Deborah Burger, RN.

Something has got to give, and one thing is the nation's health insurance industry which must be forced to give up the tax money which it is being fed by the Bush administration. I do not want to hear that $54 billion is nothing compared to what we spend in Iraq. Iraq is Iraq, and sick kids receiving inadequate care in the ER and dying people having no where to go and the elderly being forced to choose between their heart meds and foods after Labor Day while a bunch of CEOs brag about what great businessmen they are because they know how to get rich off corporate welfare like some cabal of GOP caricature unwed moms eating steak they bought with food stamps in their cadillacs while their kids play in traffic---

that ain't the American dream. That is the American nightmare.

Addendum: Just in case any of you have forgotten how managed care works, here is a link to a book I wrote in the 1990’s Damaged Care, Damaged Caregiver, about how HMOs and PPOs operated back then. Although this refers to the way things were a decade ago, there are only so many ways to make money under a capitated system, so some of it will be applicable now. It is all about volume enrollment of a cherry picked healthy population which has in place a system to encourage those who actually need health care to bail and go back to fee for service. This is done by throwing up roadblocks to care----long waits on the phone, lots of paperwork, no specialists in the area, long waits for certain specialists, red tape for certain procedures—--for people whom the managed care plan identifies as money sinks. You know. The needy ones. The ones most deserving of compassion.

http://home.earthlink.net/~suzannetolbert/

[Trailrider1951]

1. K & R, Mr. Taylor

This won't die that soon. Sometimes I am Sooooooo ashamed of my fellow Texans, present company excepted, of course. :kick: :kick: :kick: :kick: :kick:

[flashl]

2. K&R & bookmarked n/t

[eridani]

3. Put it in the research section, pretty please

That way it won't get archived into oblivion.

[lame54]

4. Hmo's killed the patient

or in my son's case un-necessary crippling for life. He was diagnosed with Dermatomyositis in Jan. of 1991 it took my hmo nearly a year to do the simple blood test I requested (I had lupus in the family and recognized many of his symptoms). Most in the 1990's who had never dealt with a long term or catastrophic illness thought hmo's were just great. I was able to "manage" my hmo for over 10 years and have three large boxes of correspondence to prove it(not to mention endless hours on the phone). I was able to do so because of books like "Fighting the Blues" and the one stated above. I met many parents at Children's over the years that my son's illness was active, who just gave up the fight and went on medical. I have told my story to many who are against a one payor health care system some have seen the light others do not. I heard over and over again from the one's who were happy with their hmo's if my story was true than I should have just sued. Little do they know the many laws that were put in place to prevent any chance of holding them accountable. In 1991 California passed the "Fair Claims Practice Act". I used it many times when dealing with my Hmo but it gives the company time (thirty days) time you don't have. The industry found their way around that law very quickly, it was called putting your case in "review". The Insurance Industry is very good at the game of keeping the money for as long as possible, the only problem with that is people die while they play their game of greed. Universal Health Care is long over due, when we take the Insurance Companies out of the equation only then will we truly be able to manage our health care cost.

Time to take them out of the game.

patty lame's wife

[McCamy Taylor]

5. So sad! How is your son now? Re suing check out "Who is ERISA

and why won't she let me sue my HMO" a chapter in the book which is the last link in my post. Unless Congress has repealed or modified ERISA (something I can not imagine that the insurance industry would allow) this old piece of legislation designed to protect pensions has been used by HMOs and other health insurance plans to protect them from liability when they play doctor and mess up people's lives.

Another favorite game is giving authorization before the procedure and then taking it back afterwards. That way the patient gets the care but then the HMO doesn't pay the bill. No pesky medical malpractice case and the HMO saves money and the patient is left with a gazillion dollars in debt. I saw this a fair amount while in practice.

Bottom line is it is unethical to pay an insurer money to not provide care. This will inevitably result in the same thing every time: an organization which does business by signing up those who do not have health problems. Sick people will be driven away. Doctors who actually dare to provide treatment for sick people will be fired from the plan. Since the HMO can not exclude those with pre-existing medical conditions (the way traditional insurance makes money) and since no one stays on one plan long for disease prevention to pay off in cost saver, cherry picking becomes the preferred money making strategy under the capitation model.

[lame54]

6. He is doing better then we thought he would

at 28 he has finally got to a point where he believes his life has a purpose and he can get off of disability and medical. He is going to the Art Institute of San Francisco and living with a wonderful woman and her son. They would love to get married but then he would lose medi-cal and most of his disability (a whooping $800.00 a month). The sad part is if he had been treated earlier he might not have suffered for so long and lost so much muscle. The problem with holding the HMO and the one doctor who helped them, is no doctor will say for certain earlier treatment would have stopped the progression of his disease. I still remember the hmo's doctor's statement to me in early July of 1990, when I requested a blood test for lupus. He patted me on the hand and stated "now, now mother. Quit playing detective and let me be the doctor." He was treating my son for possible allergy's because of the rashes. Like I stated in my earlier comment I have a family history of lupus and was well acquainted with rashes on the face and joints. After a summer of treating his illness like an allergy, I wanted to get a second opinion not so easily done with an HMO. The muscle weakness progresses slowly, than wham over night it hits and hits hard. My child could barley walk more than a few feet before becoming exhausted was having trouble swallowing. I had to threaten a mal-practice suit in order to get that simple test for antibodies in the blood stream and then wait for almost a week for the results. After my son's first stay at Children's I started reading everything I could including the book mentioned above and "Fighting the Blues". I know all too well about ERISA Act and California Fair Claims Practice Act.
Thanks for your post and concern
patty lame's wife

[McCamy Taylor]

7. Patronizing doctors burn me up (and I'm a doctor).

:mad:

I remember the time a mom from India brought her daughter into the office with chief complaint "I think she has malaria." If I had been a patronizing doctor I would have said something like "I'm the doctor, you are the mom. This is the United States. We don't have malaria here." However, a mom from India knows a lot more about malaria than a doctor from the U.S. (And the daughter had malaria)

[lame54]

10. Did you write the book mentioned in your Post?

If so thank you. William Shernoff's book "Fighting the Blues" is another good one written in the late 80's earlie 90's. His office was located near where I lived in California. I went to see them about filing a lawsuit against my HMO for continually delaying treatment. He was quite impressed with what I had already accomplished (two years of in-home physical therapy) that's when I learned about Ms. ERISA. I was better informed than most (worked for an Insurance Broker and handled our commercial accounts) and it was still a 15 year nightmare. I only met one doctor who I thought didn't need to be in medicine and that was the original hmo doctor. If he had his way my son would have been released for Childrens after a week and sent home to die. I thank god for Dr. Shaham because she refused to release my son and helped me fight my insurance company. That is also when I learned how to "qualify" an out of network Hospital and Doctor, but not before being stuck with a huge share of cost for the first stay (three months).
Thanks again for a great post hopefully more will read it and get a better understanding of the Insurance Industry. We need to lobby our reps. in DC for a one payor system, or at least go back to pre-reagan days in regards to regulating this very greedy industry.
patty lame's wife

[nightrain]

8. Americans have crappy healthcare coverage

Thanks for the article. I appreciate the information. I am coordinating hospice care for elderly mother, and someday for my father as well. Mother's meds are now in the doughnut hole. ~$900 for October. We desperately need to revamp Medicare to include ALL meds and get rid of the doughnut hole that the med companies love.

I support a single payor, Kucinich-style health care SERVICE.

[McCamy Taylor]

9. Good luck with your mom. The administration changes do not directly

target hospice patients--i.e. they do not demand that the families of the dying or dead fork over refunds. However, the effect will be to force Hospice Agencies to become more strict in who they allow into Hospice facilities. People will have to be within days to a few weeks of dying rather than within a few months of death to be admitted, even though some, especially the poor elderly without caretakers, need some form of terminal care to have decent quality life in their final days. The effect will be a hastening of their deaths from starvation, neglect, suicide--no doubt saving the federal government tons of money in Social Security payments and Medicare benefits. It is genocide of the elderly.