By: Marion Mass, M.D. and Craig M. Wax, D.O.
Insurers, Pharmacy Benefit Managers(PBM), advocacy groups such as AARP, and others are using their amassed wealth and influence to game the over-complicated and burdensome healthcare system for their own profit on the backs of the American taxpaying patient while fragmenting their care. Let’s follow one pathway of corporate profiteering that results in a poorer quality of patient care:
United Healthcare’s subsidiary Optum (the company formerly known as Inginex) is one of the three big PBM… companies that control what drugs your insurance company pays for and how much, while having the government given right to receive kickbacks from pharma manufacturers (conflict of interest much?). These kickbacks are costing Americans $200 BILLION PER YEAR and a prime reason why Optum got so rich. Their 2018 profits put them at the 100 billion mark.
How did a company with a history of fraud get so rich? Round up the usual suspects of the government/corporate cronyism.
After the fraud charges, Ingenix rebranded itself as Optum, it’s CEO Andy Slavitt left and in 2015 became the Head of Center for Medicare and Medicaid Services(CMS) while the former head of CMS, nurse Marilyn Tavenner, left to become the president of the insurance industry’s lobby group AHIP. Slavitt was able to cash out stock options TAX FREE, getting a $4 million windfall.
Curiously, in 2015, while Slavitt is running CMS, Optum seems to take over the publication and administration of the CPT and ICD coding, their logo appearing on the coding material.
As if kickbacks, and coding are not enough, Optum finds another revenue stream via home visits. They send clinicians to medicare advantage patient’s homes often incentivizing the patients with gift cards. ( apparently they discovered that kickbacks work) These “wellness visits” prevent patients from being able to see their primary care physician for an annual physical, thus fragmenting care, while failing to forward critical information to the patients’ physicians.
These visits seem designed for Optum to be able to increase risk scores, and thus collect more from Medicare. A possible scenario: order protein levels, often low in elderly patients, increase the patients risk score, and viola! Optum collects more from Medicare, and thus from the pockets of TAXPAYERS. Apparently, someone in the Justice Department is paying attention, as United looks to be in the hot waters of fraud yet again.
All this money-making benefits the AARP, a formidable lobby force in DC. The AARP gets nearly 50% of its income from royalties the big insurance companies pay them to peddle Medicare advantage plans, the bulk from United/Optum. A mere 17% of AARP’s collections come from membership fees from its 37 million members.
There you have it: big insurance and their PBM henchmen, hired by our government, teaming up with the AARP all getting rich gaming the system while Medicare patients get fragmented care and taxpayers pay more. Medicare advantage plans? They ought to call them “taking advantage of taxpayers plans. ”
Marion Mass, MD is co-chair of Practicing Physicians of America (PPA) and Craig M. Wax, DO is PPA’s VP of Health Care Policy. Learn more: https://practicingphysician.org