50 Comments
Apr 7, 2023Liked by Matt Stoller

Obamacare was a stopgap, not a goal. Incremental progress is better than none. We can do better. BTW - I'm reading GOLIATH and so should everybody else!

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Apr 7, 2023Liked by Matt Stoller

Optum has an interesting business model. They just don’t pay their bills. I’m not simply talking about providers’ bills. Other than landscaping and utilities, most of their vendors are reliant on them, so they just don’t pay them. Ever.

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Apr 8, 2023Liked by Matt Stoller

Almost all of my doctors had to close their practices and join large practices under the guise of Medstar hospital changed. Suddenly, getting an appointment with my GP went from 3 days to 2 weeks. During COVID, most of my doctors were forced to retire b/c their corporate masters feared the older docs would get sick and sue the system. The younger docs have too many patients and give care by rote. 10 minutes is about all you get. How many people will die because the docs didn't spend enough time with their patients? F Obama, Congress, and the vampire squid medical companies they helped create.

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Apr 8, 2023Liked by Matt Stoller

Another important read. Thanks for putting it together. In fact, I had to shudder a bit to read the part about Cigna, my insurer, and how it’s set up to automatically reject claims. It would seem to explain the administrative kabuki of a medical procedure I had done last year, in which my docs with UPMC - another fun subject on this topic, of course - told me the insurer would likely reject my procedure but then accept it on appeal, which is exactly what happened. Fingers crossed, Cigna has done relatively right by me....but certainly my radar is attuned to nonsense from both my insurer and my provider. It’s completely outside the scope of this topic, certainly, but your intro which delves into increasingly poor health outcomes and accurately attributes a good bit of it to our screwed up health care system, but another major contributor to this broader subject of general health outcomes is how surreally absurd our food system is and how wrong the federal government’s health guidelines are for nutrition, in which the comically awful food pyramid recommending to eat 8 to 12 servings of grains and other carbs a day has helped to put our country into a crisis of obesity and diabetes.

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Apr 7, 2023·edited Apr 7, 2023

"Medicare Advantage" is so named because it's the process whereby MEDICARE lets insurers take ADVANTAGE of seniors. Here's a nice little illustration: https://youtu.be/u5j1QyySdxM

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Apr 8, 2023·edited Apr 8, 2023

Healthcare Effectiveness and Data Set (HEDIS) is the measure set that is used by more than 90% of health plans to measure performance. STAR measure set, used to bonus Medicare Advantage Plans for quality, includes a subset of HEDIS measures. Given the recent MA ruling that phases in appropriate adjustments to the risk model used to determine capitation rate, payers may turn to quality measures bonuses, in addition to raising premiums or playing hard ball with health system price negotiation, to make up the difference.

The non-profit National Center for Quality Assurance designs and owns HEDIS, and is contracted by CMS to help establish STAR measures for Medicare Advantage bonusese.

Who sit on the board of NCQA? The United Healthcare CMO among others.

Who donates to the NCQA? Optum, Exact Sciences (the largest donor and the owner of the colorectal cancer screening that is now included in the HEDIS colorectal cancer screening measure), pharmaceutical companies, among others.

The HEDIS measures broadly require prescribing drugs and maintaining med adherence over non-pharmaceutical interventions for chronic conditions as it is diagnosis that qualifies a patient for the denominator (last I checked).

Cologuard, an Exact Sciences-owned fecal screening for colon cancer, is included as a way to meet the HEDIS colorectal cancer screening measure, despite the general public being confused about both the efficacy of the test (I am too!: https://www.gastroconsa.com/the-truth-about-cologuard-tests/), doctors being wary... as well as confusion over whether a colonoscopy is covered as preventative ($0 copay) if it becomes a diagnostic exam following a positive Cologuard test-- this is a real concern given the higher rate of false-positives. Maybe the latter concern becomes moot if $0 preventative services are under attack (https://www.cnn.com/2023/03/30/politics/affordable-care-act-preventive-care-reed-oconnor/index.html)

I honestly don't understand why CMS contracts with NCQA instead of designing the measures themselves via the AHRQ or some other agency. I assume there has to be a reason, but it frustrates me that they do.

Separately-- I think Multiplan, the large provider shadow network the top ten insurers use so that they don't have to do their own negotiating in every market, is also worth a review. (https://www.acutecondition.com/p/multiplan-the-secret-back-end-to). Multiplan is a monopoly that curates a national network of providers that the top ten health plans use. They blew up post-ACA and went public via SPAC a few years ago. And I haven't kept up with the story, but at one point Cali was going after them: https://www.nelsonhardiman.com/client-alert-multiplan-named-as-central-figure-in-antitrust-lawsuit-alleging-health-insurance-monopoly-scheme/.

Finally, I like that Congress is starting to pay attention to ghost networks, another byproduct of monopoly power and lack of oversight: https://bhbusiness.com/2023/01/31/senators-call-out-aetna-anthem-bcbs-humana-united-healthcare-for-mental-health-ghost-networks/.

To be clear we could all list a million more issues, but these are the ones that I thought to mention today since Matt's post riled me up per usual :)

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Apr 8, 2023Liked by Matt Stoller

You had me at Glass-Steagall.

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Apr 8, 2023Liked by Matt Stoller

Indeed, Thanks Matt.

I just want to add one more bit of absurdity. I formerly lived in the land of The Cleveland Clinic and now live in the land of Mass General, both of which claim world wide GOAT status in healthcare. And one of the things they use their claims of greatness for is to obtain large charitable contributions. So wouldn’t you be honored to put your family name on the wing of a building or, hey, why not the whole building, where the hospital can attract even more patients that they can over charge at patient or government expense, even though they are now freed from the building expense that you so graciously covered with your contribution. And, maybe the building already had a name from when it was a modest but honest stand alone community hospital that was swallowed up whole by the healthcare behemoth but that was in the dark ages of our modern healthcare world so let’s rename it for even more money.

And hospitals are ‘not for profits’ ... right?

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Apr 8, 2023Liked by Matt Stoller

your article in prospect is absolutely brilliant. i can just imagine the apoplectic response in "the economist" ....

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What you mean the whole "we worked together with the medical industry and the insurance industry" should have maybe raised a red flag or two? Who knows? Maybe that whole "repeal and replace" turning out to be complete bullshit from day one should have been another one?

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This is a really great explanation of the perverse incentives of the healthcare system, including the role Obamacare played, and how it all ties to monopoly consolidation. I always learn something from the BIG newsletter.

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> In 2004, the average insured family of four paid $11,192 in health care costs, by 2022 that amount was $30,260.

Slight correction. Looking at the referenced docs, those appear to be total cost not employee share. In 2022, the employee share was $12,683 and for 2005 it was $4,119 (couldn't find it for 2004). Your point holds of course, those numbers just seemed impossible.

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Apr 7, 2023·edited Apr 7, 2023

UPDATED COMMENT: GOOD THING I PROOFREAD, LOL. If anyone previously read my comment they would have found some bad links and not been able to read certain articles. Apologies. My VPN was set abroad when I absentmindedly copied the links, so they all said ‘access denied’. (I hadn’t eaten dinner yet, if that can be called an excuse.) The affected links have been corrected and are now accessible.

Here’s some recent reads of mine. Atlanta area hospitals have been taken over by Wellstar and Emory (the latter keeps the original hospital name so no one will notice until the bills roll in). Also the ‘nonprofit’ charade. Grady revenues were small but up about 1%. Their much larger losses, however, were the result of risky investments, but now they want to stick it to their customers to make up for their poor decision making. (A few years ago they had to fire the head of billing who managed to embezzle over half a million dollars before anyone noticed.) A friend recently realized he’s now being charged a facility fee in addition to each visit he makes at Grady, which has DOUBLED his bill - per visit. That’s when I started looking into it. Below are some links. Hope someone finds them useful.

https://www.beckershospitalreview.com/hospital-finance/taxpayers-shouldnt-foot-the-bill-for-nonprofit-hospitals-investment-losses-health-economists.html

https://www.healthaffairs.org/content/forefront/s-behind-losses-large-nonprofit-health-systems

https://www.11alive.com/article/news/health/metro-atlanta-georgia-hospitals-price-transparency-law/85-0f10d555-b92b-48b1-88bb-083155499fe2

https://www.11alive.com/article/news/local/wellstar-federal-complaints-georgia/85-ace571d0-9e7b-4bf7-9aaa-9f1ad4e77d32

https://www.11alive.com/article/news/local/grady-new-expansion-largest-investment-generation/85-4b13b892-34aa-4076-bf63-df42b188d97f

https://www.11alive.com/article/news/health/metro-atlanta-georgia-hospitals-price-transparency-law/85-0f10d555-b92b-48b1-88bb-083155499fe2

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The main reason Obamacare became such a mess was because the Democrats and Republicans alike didn't back up what President Obama wanted for it in the first place. It was never his intention for healthcare to be an industry moneymaker, but to provide healthcare for all Americans without such a nonsense bureaucracy. Biden was part of the problem, and it was right along with the general conservative idea that approving Obama's candidacy was just a way to push the message to America that, "see, America isn't a racist country, we have a black man for president!" And then to do everything possible to assure there would never be another one. We are the richest nation (supposedly) in the world, but we can't provide healthcare for people unless some industry makes huge profits from it? In North Korea, people get sick, they go to the doctor, and they go home (or to the hospital) and that's all there is to it. Can't we be better than North Korea?

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When I was a kid real doctors actually made house calls. Real vaccines were developed and actually prevented things like polio. Today doctors are mostly prima donnas who think their time is much more valuable than yours and worry more about whether they have the latest BMW in their garage. Pharma is only interested in things for which they can charge ridiculous prices. And our deep state government changed the definition of a “vaccine” to cover a fraud they themselves perpetrated. We have fallen a long way down into the sewer.

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Just one more crumbling stone in the foundation of what was once a great country.

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