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centers for medicare and medicaid services
Alarms Raised Over For-Profit Medicare Advantage Using AI to Deny Care to Seniors
"Insurers using AI to deny needed care to seniors and people with disabilities means sacrificing patient needs on the altar of corporate greed," said one campaigner.
Jun 25, 2024
Dozens of Democratic U.S. lawmakers joined consumer and patient advocates on Tuesday in sounding the alarm over the use of artificial intelligence by companies providing Medicare Advantage plans to deny healthcare to their senior customers.
Fifty-one Democratic members of Congress and Independent Sen. Bernie Sanders of Vermont wrote to Centers for Medicare and Medicaid Services (CMS) Administrator Chiquita Books LaSure on Tuesday expressing their concern over Medicare Advantage (MA) providers' increasing use of algorithmic systems to deny patient care.
"Plans continue to use AI tool to erroneously deny care and contradict provider assessment findings," the letter notes. "Last year, a class action lawsuit was filed alleging that UnitedHealth Group unlawfully used an AI algorithm, nH Predict, to deny rehabilitative care to sick Medicare Advantage patients."
"The lawsuit cites an investigation suggesting that UnitedHealth Group pressured employees to use the algorithm to issue payment denials to Medicare Advantage beneficiaries and set a goal for employees to keep patient rehabilitation stays within 1% of the length of stay predicted by nH Predict," the lawmakers continued.
MA plans are not part of Medicare. They are a private health insurance "scam" created by a Republican-controlled Congress and signed into law by then-President George W. Bush "as a way of routing hundreds of billions of taxpayer dollars into the pockets of for-profit insurance companies," according to frequent Common Dreams opinion contributor Thom Hartmann.
Advocates have warned about the use of AI in MA denials since at least last year, while imploring congressional and regulator action to protect seniors and people with disabilities from being preyed upon by what critics have called "Medicare disadvantage" companies.
In February, CMS "clarified that Medicare Advantage organizations may use algorithms, artificial intelligence, and related technologies to assist in making coverage determinations, but these technologies may not override standards related to medical necessity and other applicable rules for how coverage determinations by Medicare Advantage organizations are made."
Rights groups echoed the lawmakers' concerns about the use of AI for MA denials.
"Medicare Advantage insurers using AI to deny needed care to seniors and people with disabilities means sacrificing patient needs on the altar of corporate greed," Public Citizen executive vice president Lisa Gilbert said. "CMS must expand upon the steps it has already taken to improve oversight of companies using AI to deny care that would be covered by traditional Medicare."
"It is time to protect enrollees by cracking down on Medicare Advantage insurers using AI to deny needed care through additional reporting requirements and increased enforcement actions against bad actors," Gilbert added.
David Lipschutz, associate director of the Center for Medicare Advocacy, said in a statement that "in our experience, MA plans' use of AI or algorithmic software has led to more inappropriate denials and premature terminations of care—this must end."
A report published earlier this month revealed that MA plans have overcharged the federal government by $612 billion since 2007—and $82 billion last year alone. Another report published last year by Physicians for a National Health Program found that MA plans are also overcharging U.S. taxpayers by up to $140 billion per year, enough to erase all Medicare Part B premiums or fully fund Medicare's prescription drug program.
A 2022 U.S. Senate Finance Committee investigation found that insurance companies and other brokers are "running amok" with "fraudsters and scam artists" making false or misleading claims to dupe seniors into buying MA plans. In February 2023, Reps. Mark Pocan (D-Wis.), Ro Khanna (D-Calif.), and Jan Schakowsky (D-Ill.) reintroduced legislation to change the official name of MA to "alternative private health plan" to make clear that such coverage is offered by for-profit companies.
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'We Need Medicare for All Yesterday': US Healthcare Spending to Hit $7.7 Trillion
"The jaw-dropping figures," said one advocate, "highlight the need to move to Medicare for All immediately."
Jun 14, 2024
A federal analysis released this week projects that U.S. healthcare spending is set to rise to $7.7 trillion by 2032 and account for nearly 20% of the nation's economy, findings that single-payer advocates described as yet another indictment of the country's for-profit system and further evidence of the need for Medicare for All.
The Centers for Medicare and Medicaid Services' (CMS) Office of the Actuary said Wednesday that it expects national healthcare expenditures to outpace U.S. economic growth over roughly the next decade, "resulting in an increase in the health spending share of GDP from 17.3% in 2022 to 19.7% in 2032."
The CMS analysis showed that U.S. healthcare spending grew at a rate of 7.5% last year, with overall expenditures reaching $4.8 trillion. CMS said it projects health spending will rise by 5.6% annually over the coming years, with overall spending reaching $7.7 trillion by 2032.
Robert Weissman, president of the consumer advocacy group Public Citizen, said in a statement Thursday that the coming surge in healthcare spending "has nothing to do with improving care and everything to do with price-gouging, monopolization, and wealth extraction by insurance corporations, Big Pharma, and for-profit hospitals."
Despite spending more on healthcare per capita than any other rich nation, the U.S. consistently ranks last among its peers in health outcomes.
Weissman on Thursday pointed to an academic analysis published earlier this week in JAMA Internal Medicine detailing the massive costs of Medicare Advantage, a federally funded program run by private insurance companies. The paper notes that private Medicare Advantage plans have overcharged the federal government to the tune of $612 billion since 2007—much of which insurers pocket as profit.
"We have known for decades that healthcare costs in the U.S. are out of control," said Weissman. "The jaw-dropping figures from CMS highlight the need to move to Medicare for All immediately so that we can finally start to make healthcare more affordable for taxpayers, while ensuring everyone in America can access the care and medicines they need."
Studies have repeatedly shown that transitioning to a Medicare for All system—as proposed by Sen. Bernie Sanders (I-Vt.) and more than 120 other members of Congress—would save the U.S. hundreds of billions of dollars a year and countless lives compared to the status quo, which leaves tens of millions of people uninsured, underinsured, and unable to afford lifesaving treatments and medications.
Peer-reviewed research published in 2022 estimated that more than 338,000 coronavirus-related deaths could have been prevented in the U.S. if the country had a single-payer system that guaranteed coverage to all people as a right.
"Other countries spend far less per capita on healthcare while guaranteeing coverage and providing higher quality care," Weissman said Thursday. "It is time that we do the same."
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Campaigners Beat 'Greedy' Insurance Giants Exploiting Medicare Advantage
"The private insurance industry is used to getting its way, but this year we out-organized them," said one People's Action leader.
Apr 02, 2024
As insurance companies' stock fell 6-12% on Tuesday in response to the Biden administration's Medicare Advantage announcement, one healthcare campaigner celebrated that the U.S. government didn't cave to the "greedy" industry's pressure.
"The private insurance industry is used to getting its way, but this year we out-organized them," declared Aija Nemer-Aanerud, the People's Action Health Care for All campaign director.
Medicare Advantage (MA) plans are an alternative to traditional coverage under the federal health insurance program for people with disabilities and those age 65 or older. They are administered by private insurance companies known for denying patients necessary care and overcharging the government, which costs taxpayers up to $140 billion extra each year.
"We urge President Biden to do more to rein in abuse of the Medicare program by private corporations."
The Centers for Medicare & Medicaid Services (CMS) announced Monday that "payments from the government to MA plans are expected to increase on average by 3.7%, or over $16 billion, from 2024 to 2025. The federal government is projected to pay between $500 and $600 billion in Medicare Advantage payments to private health plans in 2025."
First unveiled in January, the 3.7% is higher than what campaigners wanted. Last week, Alex Lawson of Social Security Works and Brittany Shannahan of Public Citizen delivered to the White House around 28,000 petition signatures urging President Joe Biden to "reduce MA rates to a level commensurate with traditional Medicare and recoup all overpayments."
However, the rate is also far less than what insurers and industry groups were demanding—and, as Reutersnoted Tuesday, the decision was a departure from the norm, as CMS "typically raises the final reimbursement from the advanced notice."
"Medicare is one of the most popular government programs because it delivers healthcare to people when and where they need it," said Nemer-Aanerud. "Private insurance companies like UnitedHealthcare spent millions in advertising and lobbying in Washington to demand more of our public money for privatized, so-called 'Medicare Advantage' plans."
The People's Action leader pointed out that "we countered their lobbying by helping people share their stories with lawmakers about how Medicare Advantage plans harmed them by denying care when they needed it most."
"We commend the Biden administration for listening to our people and refusing to cave to the insurance lobby's demands," the campaigner added. "We urge President Biden to do more to rein in abuse of the Medicare program by private corporations and reinvest public funds into expanding and strengthening traditional Medicare."
As private insurers have grown their MA businesses, "concerns about the cost of the program have been rising for years from wonkier corners of Washington," Bloomberg's John Tozzi reported Tuesday. According to his newsletter:
"We went years without the advocacy community really paying attention to it," says Wendell Potter, who left a career doing public relations for health insurers to become an outspoken critic of the industry.
That shifted over the last year or two, he said, as a loose group of advocates coalesced around the issue... Potter said advocates now get face-to-face meetings with top Biden administration officials about the issue.
Potter partnered with Congresswoman Pramila Jayapal (D-Wash.)—a leader in the fight for Medicare for All, a single-payer healthcare system that would cover everyone nationwide—for a Newsweek op-ed published just before the CMS announcement.
The pair took aim at the insurance industry's "disinformation campaign" about what they call "Medicare (Dis)Advantage."
"First off, the industry claims that Medicare Advantage plans reduce costs. But this is simply not true," Potter and Jayapal explained. "And it gets worse. While Big Insurance touts the coverage Medicare Advantage plans provide, the reality is Medicare Advantage plans often provide worse coverage than traditional Medicare."
They wrote that "another important characteristic of Medicare Advantage plans is their aggressive use of tools to delay and deny care such as prior authorization, which is seldom used in traditional Medicare, and rarely for services like physician-administered cancer treatments (no one wants chemotherapy if they don't need it)."
"Medicare Advantage plans also drive health inequalities, contrary to Big Insurance claims," they continued. "And the industry's biggest and boldest piece of disinformation is that Medicare Advantage plans will be forced to cut benefits if the government stops massive overpayments that have been padding corporate profits for decades."
"This is wholly false," they stressed. "And you want to know how we know? Because we have reduced overpayments before."
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