Group items tagged

But the diagnoses had a lucrative side effect: They let the insurers collect more money from the federal government’s Medicare Advantage program.

Medicare Advantage, a private-sector alternative to traditional Medicare, was designed by Congress two decades ago to encourage health insurers to find innovative ways to provide better care at lower cost.

by next year, more than half of Medicare recipients will be in a private plan.

a New York Times review of dozens of fraud lawsuits, inspector general audits and investigations by watchdogs shows how major health insurers exploited the program to inflate their profits by billions of dollars.

The government pays Medicare Advantage insurers a set amount for each person who enrolls, with higher rates for sicker patients. And the insurers, among the largest and most prosperous American companies, have developed elaborate systems to make their patients appear as sick as possible, often without providing additional treatment, according to the lawsuits.

As a result, a program devised to help lower health care spending has instead become substantially more costly than the traditional government program it was meant to improve.

Eight of the 10 biggest Medicare Advantage insurers — representing more than two-thirds of the market — have submitted inflated bills, according to the federal audits. And four of the five largest players — UnitedHealth, Humana, Elevance and Kaiser — have faced federal lawsuits alleging that efforts to overdiagnose their customers crossed the line into fraud.

The government now spends nearly as much on Medicare Advantage’s 29 million beneficiaries as on the Army and Navy combined. It’s enough money that even a small increase in the average patient’s bill adds up: The additional diagnoses led to $12 billion in overpayments in 2020, according to an estimate from the group that advises Medicare on payment policies — enough to cover hearing and vision care for every American over 65.

Another estimate, from a former top government health official, suggested the overpayments in 2020 were double that, more than $25 billion.

The increased privatization has come as Medicare’s finances have been strained by the aging of baby boomers

Medicare Advantage plans can limit patients’ choice of doctors, and sometimes require jumping through more hoops before getting certain types of expensive care.

At conferences, companies pitched digital services to analyze insurers’ medical records and suggest additional codes. Such consultants were often paid on commission; the more money the analysis turned up, the more the companies kept.

they often have lower premiums or perks like dental benefits — extras that draw beneficiaries to the programs. The more the plans are overpaid by Medicare, the more generous to customers they can afford to be.

Many of the fraud lawsuits were initially brought by former employees under a federal whistle-blower law that allows them to get a percentage of any money repaid to the government if their suits prevail. But most have been joined by the Justice Department, a step the government takes only if it believes the fraud allegations have merit. Last year, the department’s civil division listed Medicare Advantage as one of its top areas of fraud recovery.

In contrast, regulators overseeing the plans at the Centers for Medicare and Medicaid Services, or C.M.S., have been less aggressive, even as the overpayments have been described in inspector general investigations, academic research, Government Accountability Office studies, MedPAC reports and numerous news articles,

Congress gave the agency the power to reduce the insurers’ rates in response to evidence of systematic overbilling, but C.M.S. has never chosen to do so. A regulation proposed in the Trump administration to force the plans to refund the government for more of the incorrect payments has not been finalized four years later. Several top officials have swapped jobs between the industry and the agency.

The popularity of Medicare Advantage plans has helped them avoid legislative reforms. The plans have become popular in urban areas, and have been increasingly embraced by Democrats as well as Republicans.

“You have a powerful insurance lobby, and their lobbyists have built strong support for this in Congress,”

Some critics say the lack of oversight has encouraged the industry to compete over who can most effectively game the system rather than who can provide the best care.

“Even when they’re playing the game legally, we are lining the pockets of very wealthy corporations that are not improving patient care,”

In theory, if the insurers could do better than traditional Medicare — by better managing patients’ care, or otherwise improving their health — their patients would cost less and the insurers would make more money.

But some insurers engaged in strategies — like locating their enrollment offices upstairs, or offering gym memberships — to entice only the healthiest seniors, who would require less care, to join. To deter such tactics, Congress decided to pay more for sicker patients.

Almost immediately, companies saw ways to exploit that system. The traditional Medicare program provided no financial incentive to doctors to document every diagnosis, so many records were incomplete

Under the new program, insurers began rigorously documenting all of a patient’s health conditions — say depression, or a long-ago stroke — even when they had nothing to do with the patient’s current medical care.

But for insurers that already dominate health care for workers, the program is strikingly lucrative: A study from the Kaiser Family Foundation, a research group unaffiliated with the insurer Kaiser, found the companies typically earn twice as much gross profit from their Medicare Advantage plans as from other types of insurance.

The insurers also began hiring agencies that sent doctors or nurses to patients’ homes, where they could diagnose them with more diseases.

Cigna hired firms to perform similar at-home assessments that generated billions in extra payments, according to a 2017 whistle-blower lawsuit, which was recently joined by the Justice Department. The firms told nurses to document new diagnoses without adjusting medications, treating patients or sending them to a specialist

Nurses were told to especially look for patients with a history of diabetes because it was not “curable,” even if the patient now had normal lab findings or had undergone surgery to treat the condition.

Adding the code for a single diagnosis could yield a substantial payoff. In a 2020 lawsuit, the government said Anthem instructed programmers to scour patient charts for “revenue-generating” codes. One patient was diagnosed with bipolar disorder, although no other doctor reported the condition, and Anthem received an additional $2,693.27, the lawsuit said. Another patient was said to have been coded for “active lung cancer,” despite no evidence of the disease in other records; Anthem was paid an additional $7,080.74. The case is continuing.

The most common allegation against the companies was that they did not correct potentially invalid diagnoses after becoming aware of them. At Anthem, for example, the Justice Department said “thousands” of inaccurate diagnoses were not deleted. According to the lawsuit, a finance executive calculated that eliminating the inaccurate diagnoses would reduce the company’s 2017 earnings from reviewing medical charts by $86 million, or 72 percent.

Some of the companies took steps to ensure the extra diagnoses didn’t lead to expensive care. In an October 2021 lawsuit, the Justice Department estimated that Kaiser earned $1 billion between 2009 and 2018 from additional diagnoses, including roughly 100,000 findings of aortic atherosclerosis, or hardening of the arteries. But the plan stopped automatically enrolling those patients in a heart attack prevention program because doctors would be forced to follow up on too many people, the lawsuit said.

Kaiser, which both runs a health plan and provides medical care, is often seen as a model system. But its control over providers gave it additional leverage to demand additional diagnoses from the doctors themselves, according to the lawsuit.

At meetings with supervisors, he was instructed to find additional conditions worth tens of millions of dollars. “It was an actual agenda item and how could we get this,” Dr. Taylor said.

Last year, the inspector general’s office noted that one company “stood out” for collecting 40 percent of all Medicare Advantage’s payments from chart reviews and home assessments despite serving only 22 percent of the program’s beneficiaries. It recommended Medicare pay extra attention to the company, which it did not name, but the enrollment figure matched UnitedHealth’s.

Even before the first lawsuits were filed, regulators and government watchdogs could see the number of profitable diagnoses escalating. But Medicare has done little to tamp down overcharging.

Several experts, including Medicare’s advisory commission, have recommended reducing all the plans’ payments.

Congress has ordered several rounds of cuts and gave C.M.S. the power to make additional reductions if the plans continued to overbill. The agency has not exercised that power.

The agency does periodically audit insurers by looking at a few hundred of their customers’ cases. But insurers are fined for billing mistakes found only in those specific patients. A rule proposed during the Trump administration to extrapolate the fines to the rest of the plan’s customers has not been finalized.

Ted Doolittle, who served as a senior official for the agency’s Center for Program Integrity from 2011 to 2014, said officials at Medicare seemed uninterested in confronting the industry over these practices. “It was clear that there was some resistance coming from inside” the agency, he said. “There was foot dragging.”

few analysts expect major legislative or regulatory changes to the program.

“Medicare Advantage overpayments are a political third rail,” said Dr. Richard Gilfillan, a former hospital and insurance executive and a former top regulator at Medicare, in an email. “The big health care plans know it’s wrong, and they know how to fix it, but they’re making too much money to stop. Their C.E.O.s should come to the table with Medicare as they did for the Affordable Care Act, end the coding frenzy, and let providers focus on better care, not more dollars for plans.”

The JHU team automates its data uploads and regularly checks them for anomalies. This may result in occasional data discrepancies on this page as the JHU team resolves anomalies and updates its feeds. State-by-state recovery data are unavailable at this time. There may be discrepancies between what you see here and what you see on your local health department's website. Figures shown do not include cases on cruise ships.

In his 2013 paper, Burkhauser and his two co-authors have completely upended the thrust of Figures 1 and 2.

Burkhauser’s 2011 methodology worked to make the pattern appear far less extreme, as illustrated by Figure 2:

First, take a look at Figure 1, a 2011 Congressional Budget Office chart showing significant inequality in the distribution of income gains from 1979 to 2007. Many on the left consider work done by the C.B.O. to be the gold standard of inequality measurement:

The Burkhauser approach does a number of things. First, it spreads and flattens income from capital gains over the duration of ownership. For a wealthy individual who makes a huge killing selling stock or a businesses, his or her income does not spike in the year of the sale, but emerges instead as a series of yearly incremental gains.

If Burkhauser’s approach was accepted, it would render moot the basic political and philosophical tenets of the Obama presidency

Not only would Burkhauser lay waste to a core liberal argument — inequality is worsening — but his claim that a declining share of income is going to the wealthy could be used to justify further tax cuts for the affluent in order to foster top-down investment and growt

Burkhauser et al. achieve their reversal of past income distribution data by amending the definition of income developed in their 2012 paper — “post-tax, post-transfer, size-adjusted household income including the ex-ante value of in-kind health insurance benefits” — to incorporate another accounting tool: “yearly-accrued capital gains to measure yearly changes in wealth.”

it is a game changer.

Burkhauser attempts to measure the year-to-year increase in taxpayers’ assets — stocks and bonds, housing and privately held businesses – and to count those annual increases as income. Increases in the value of such assets do not show up in tax data because they are taxed by the federal government only when the asset in question is sold and the increased value is realized as taxable gains.

If — a virtually impossible if — the economic and policy-making community were to reach even a rough consensus in support of Burkhauser’s 2013 analysis, the victory for the right would be hard to overestimate.

For assets that have been held for a long time, the Burkhauser system effectively backdates much of currently realized capital gains onto earlier years. This is especially significant in calculating income gains from the current sale of assets purchased in the 1980s and 1990s, since much of the added value was acquired in those earlier decades.

I raised the following question: Is it a fair measure of a person’s well-being to include unrealized capital gains? Their house or other assets may have increased in value, but their standard of living has not changed.

The unfairness of Burkhauser’s approach is clearly acute at the bottom and middle of income distribution. The most common large asset for those on the bottom rungs is a house. Burkhauser would increase the income of those below the median lucky enough to own a home by the annual appreciation in the value of the home through 2007. For many of these families, however, selling their home is not an option. In Burkhauser’s view, their income goes up even if their living conditions remain unchanged.

Burkhauser is respected by his peers; his critics, including some friends, do not accuse him of ideological bias. In addition to A.E.I, he has received support from such center-left institutions as the Pew Foundation, Brookings Institution and the Russell Sage Foundation.

the “problem is that in such things, especially when it is a difficult task based on lots of new data sources, the devil is in the details. It’s pretty hard to judge those details without doing a substantial amount of work.” Acemoglu’s conclusion: “Bottom line: conceptually there is a valid point here, and this is a serious paper. The rest is to be determined.”

“Rich Burkhauser’s work is really the state of the art — the most important research on inequality being done, in my view,” Scott Winship, of the Brookings Institution, e-mailed me. Winship voiced some concern over the reliability of the statistical data used by Burkhauser, but concluded:All that said, I think Rich’s paper is incredibly disruptive for many fields of research in labor economics and other social sciences, and potentially it could change our entire view about rising inequality over the past few decades.

Burtless continued:The problem with the authors’ estimates of accruing capital gains is that those numbers are wholly made up based on a prediction that everyone is equally successful in finding homes, stocks, bonds and other assets to invest in.  But they’re not:  Some people are wildly successful, and get into the 1%; others are horribly unsuccessful and become paupers (or receive foreclosure papers); and most earn mediocre returns that are — surprise! — a bit lower than the economy-wide average.

Burkhauser et al. measure the period from 1989 to 2007 because those are both peak years in the business cycle. This timing results in a failure to account for the consequences of the 2008-9 financial crisis and the subsequent struggle toward recovery accompanied by persistent high levels of unemployment.

During the post-crisis years 2009-11, according to the Pew Center, the wealthiest mean of the nation saw the value of their assets grow by 28 percent, to $3.17 million from $2.48 million, while the bottom 93 percent saw their net worth drop by 4 percent, to $133,816 from $139,896.

Wealth trends since the 2008 crash, shown in Figure 5, demonstrate an extraordinary growth in inequality, suggesting that Burkhauser’s findings — restricted to his carefully tailored definition of income — are fatally flawed as an instrument to assess the current real-world position of the poor and middle class compared with the very rich:

A key purpose in measuring both wealth and income is to determine what kind of standard of living is possible for those at the top, the middle and the bottom. Do individuals, families and households have enough to provide for themselves, perhaps most importantly for their children? Do they have the financial resources to enter the highly competitive global marketplace?On that score, Burkhauser’s use of “yearly accrued capital gains” fails the test of measuring what is most significant to know in policy making and in assessing the true quality of life in America.

She is, for instance, the first Democratic nominee in more than 20 years to be leading among those making over $100,000, according to a Bloomberg News poll. She clobbered Trump among millionaires by 13 points in a CNBC poll. She also has a 20-to-1 fundraising edge among billionaires, and an even bigger one among top corporate earners.

if we’re going by proposed tax policies alone, there really is no dispute about which candidate promises to most advance the interests of America’s 1 percent.

As the graphic shows, Clinton’s plan would raise taxes for the top 1 percent — those making over $730,000 — by an average of $123,570 a year. That number is a little misleading —

Overall, Clinton’s tax increases on the top 1 percent would increase revenue by somewhere in the order of $140 billion in 2017 alone. That money would then be funneled into an ambitious and extensive array of social welfare programs and other policy initiatives,

Among them include raising capital gains taxes, imposing a 4 percent surcharge on incomes over $5 million, advancing a new tax for incomes that surpass $1 million

Trump, meanwhile, would give the top 1 percent an extra cash cushion in the range of $162,000 a year.

Goldwein’s analysis is based on one think tank’s estimate of incomes for 2017, though Trump’s plan is based on a different think tank’s estimate of incomes for 2016.

Is this film accurate? I asked Schmidt directly. “I felt as if I were having an out-of-body experience as I watched,” he said. In other words: yes.

The Census Bureau, in creating the S.P.M., corrected these failings, and it also took a more comprehensive view of what types of outlays are necessary for a decent life. Rather than basing everything on food, it included clothing, shelter (rent or mortgage payments), utilities, medical expenses, and child care. And, recognizing that poverty is partly relative, it tied the new poverty threshold to the expenditures of a family that is a third of the way up the income distribution. By recognizing non-market sources of income, the new poverty measure increases the estimated resources of the poor. In taking account of things like rent and medical expenses, it broadens the concept of the household budget. As far as the poverty rate goes, these adjustments work in opposite directions: the increased measure of incomes reduces the poverty rate; the acknowledgement that more must be spent to secure life’s essentials increases it. When the Census Bureau compared its new poverty metric to its old one, it found that the S.P.M. gave a slightly higher rate for 2012: sixteen per cent, compared to fifteen per cent for the O.P.M.

By 2012, the pre-tax/pre-transfer poverty rate is twenty-nine per cent, and the post-tax/post-transfer poverty rate is sixteen percent. To put it another way, by 2012, government anti-poverty programs were reducing the poverty rate by thirteen percentage points.

“Our estimates…show that historical trends in poverty have been more favorable—and that government programs have played a larger role—than [previous] estimates suggest… Government programs today are cutting poverty nearly in half (from 29% to 16%) while in 1967 they only cut poverty by about one percentage point.” The next time Paul Ryan (or any other Republican luminary) starts talking about poverty, and anti-poverty programs, somebody should ask him if he knows what he is talking about. The evidence suggests he doesn’t.

The economics community just hasn't spent much time over the past couple of decades focusing on the effect that machine intelligence is likely to have on the labor marke

The Digital Revolution is different because computers can perform cognitive tasks too, and that means machines will eventually be able to run themselves. When that happens, they won't just put individuals out of work temporarily. Entire classes of workers will be out of work permanently. In other words, the Luddites weren't wrong. They were just 200 years too early

while it's easy to believe that some jobs can never be done by machines—do the elderly really want to be tended by robots?—that may not be true.

Robotic pets are growing so popular that Sherry Turkle, an MIT professor who studies the way we interact with technology, is uneasy about it: "The idea of some kind of artificial companionship," she says, "is already becoming the new normal."

robots will take over more and more jobs. And guess who will own all these robots? People with money, of course. As this happens, capital will become ever more powerful and labor will become ever more worthless. Those without money—most of us—will live on whatever crumbs the owners of capital allow us.

Economist Paul Krugman recently remarked that our long-standing belief in skills and education as the keys to financial success may well be outdated. In a blog post titled "Rise of the Robots," he reviewed some recent economic data and predicted that we're entering an era where the prime cause of income inequality will be something else entirely: capital vs. labor.

We're already seeing them, and not just because of the crash of 2008. They started showing up in the statistics more than a decade ago. For a while, though, they were masked by the dot-com and housing bubbles, so when the financial crisis hit, years' worth of decline was compressed into 24 months. The trend lines dropped off the cliff.

In the economics literature, the increase in the share of income going to capital owners is known as capital-biased technological change

The question we want to answer is simple: If CBTC is already happening—not a lot, but just a little bit—what trends would we expect to see? What are the signs of a computer-driven economy?

if automation were displacing labor, we'd expect to see a steady decline in the share of the population that's employed.

Second, we'd expect to see fewer job openings than in the past.

Third, as more people compete for fewer jobs, we'd expect to see middle-class incomes flatten in a race to the bottom.

Fourth, with consumption stagnant, we'd expect to see corporations stockpile more cash and, fearing weaker sales, invest less in new products and new factories

Fifth, as a result of all this, we'd expect to see labor's share of national income decline and capital's share rise.

There will be no place to go but the unemployment line.

The modern economy is complex, and most of these trends have multiple causes.

in another sense, we should be very alarmed. It's one thing to suggest that robots are going to cause mass unemployment starting in 2030 or so. We'd have some time to come to grips with that. But the evidence suggests that—slowly, haltingly—it's happening already, and we're simply not prepared for it.

the first jobs to go will be middle-skill jobs. Despite impressive advances, robots still don't have the dexterity to perform many common kinds of manual labor that are simple for humans—digging ditches, changing bedpans. Nor are they any good at jobs that require a lot of cognitive skill—teaching classes, writing magazine articles

in the middle you have jobs that are both fairly routine and require no manual dexterity. So that may be where the hollowing out starts: with desk jobs in places like accounting or customer support.

In fact, there's even a digital sports writer. It's true that a human being wrote this story—ask my mother if you're not sure—but in a decade or two I might be out of a job too

Doctors should probably be worried as well. Remember Watson, the Jeopardy!-playing computer? It's now being fed millions of pages of medical information so that it can help physicians do a better job of diagnosing diseases. In another decade, there's a good chance that Watson will be able to do this without any human help at all.

Take driverless cars.

Most likely, owners of capital would strongly resist higher taxes, as they always have, while workers would be unhappy with their enforced idleness. Still, the ancient Romans managed to get used to it—with slave labor playing the role of robots—and we might have to, as well.

There will be no place to go but the unemployment lin

we'll need to let go of some familiar convictions. Left-leaning observers may continue to think that stagnating incomes can be improved with better education and equality of opportunity. Conservatives will continue to insist that people without jobs are lazy bums who shouldn't be coddled. They'll both be wrong.

Corporate executives should worry too. For a while, everything will seem great for them: Falling labor costs will produce heftier profits and bigger bonuses. But then it will all come crashing down. After all, robots might be able to produce goods and services, but they can't consume them

we'll probably have only a few options open to us. The simplest, because it's relatively familiar, is to tax capital at high rates and use the money to support displaced workers. In other words, as The Economist's Ryan Avent puts it, "redistribution, and a lot of it."

would we be happy in a society that offers real work to a dwindling few and bread and circuses for the rest?

The next step might be passenger vehicles on fixed routes, like airport shuttles. Then long-haul trucks. Then buses and taxis. There are 2.5 million workers who drive trucks, buses, and taxis for a living, and there's a good chance that, one by one, all of them will be displaced

 economist Noah Smith suggests that we might have to fundamentally change the way we think about how we share economic growth. Right now, he points out, everyone is born with an endowment of labor by virtue of having a body and a brain that can be traded for income. But what to do when that endowment is worth a fraction of what it is today? Smith's suggestion: "Why not also an endowment of capital? What if, when each citizen turns 18, the government bought him or her a diversified portfolio of equity?"

In simple terms, if owners of capital are capturing an increasing fraction of national income, then that capital needs to be shared more widely if we want to maintain a middle-class society.

it's time to start thinking about our automated future in earnest. The history of mass economic displacement isn't encouraging—fascists in the '20s, Nazis in the '30s—and recent high levels of unemployment in Greece and Italy have already produced rioting in the streets and larger followings for right-wing populist parties. And that's after only a few years of misery.

When the robot revolution finally starts to happen, it's going to happen fast, and it's going to turn our world upside down. It's easy to joke about our future robot overlords—R2-D2 or the Terminator?—but the challenge that machine intelligence presents really isn't science fiction anymore. Like Lake Michigan with an inch of water in it, it's happening around us right now even if it's hard to see

A robotic paradise of leisure and contemplation eventually awaits us, but we have a long and dimly lit tunnel to navigate before we get there.

Scalia declared that “a person who is required to put his name to a document is much less likely to lie than one who can lie anonymously.”Scalia concluded: “I can imagine no reason why an anonymous leaflet is any more honorable, as a general matter, than an anonymous phone call or an anonymous letter. It facilitates wrong by eliminating accountability, which is ordinarily the very purpose of the anonymity.”