Christopher Weaver
Appearances
The Journal.
Medicare, Inc. Part 1: How Insurers Make Billions From Medicare
There were no physician claims. There were no drugs prescribed to them. And 100% of those people, ideally, if they actually have HIV, would be getting antiretroviral therapy. And in reality, fewer than one in five were.
The Journal.
Medicare, Inc. Part 1: How Insurers Make Billions From Medicare
Yeah, right. That's right. We interviewed a bunch of experts about this particular finding, you know, AIDS specialists. And they almost universally concluded that those people didn't really have HIV. What they surmised is basically that they were getting tested for HIV, screened for HIV, and that... However, the insurers were reviewing charts to add diagnoses on the back end.
The Journal.
Medicare, Inc. Part 1: How Insurers Make Billions From Medicare
They were picking up those screening exams and just like inferring a diagnosis out of it.
The Journal.
Medicare, Inc. Part 1: How Insurers Make Billions From Medicare
In total, what we determined was that Medicare Advantage insurers over a three-year period had got paid $50 billion for diagnoses that they alone added to patients' records. And what astounded me was basically the magnitude and just the total amount of dollars that they were getting from sort of chasing that incentive to make people be sicker on paper.
The Journal.
Medicare, Inc. Part 1: How Insurers Make Billions From Medicare
That's us, right? It's a taxpayer-funded program. You pay Medicare taxes with each of your paychecks, and that's where it goes.
The Journal.
Medicare, Inc. Part 1: How Insurers Make Billions From Medicare
I mean, the problem here is that insurers are layering diagnoses on patients, generating billions and billions and billions of dollars more in taxpayer-funded reimbursement. And in many cases, the patients don't have them, aren't getting treated for them, and that's waste. That's waste for taxpayers.
The Journal.
Medicare, Inc. Part 1: How Insurers Make Billions From Medicare
For private insurers, Medicare Advantage has driven a huge amount of growth in that industry and vast changes in the way health care is provided and paid for. It's added to the kind of the runaway cost of American health care.
The Journal.
Medicare, Inc. Part 1: How Insurers Make Billions From Medicare
Yeah, I mean, there's a lot of ways to make money in Medicare. And, you know, that's fueled a lot of growth in the industry. And, you know, our stories are just some of the strategies that, you know, these companies have embraced.
The Journal.
Medicare, Inc. Part 1: How Insurers Make Billions From Medicare
Yeah, that's right. So we decided to dip into this area, which is just a huge portion of the federal budget, so we could see how these giant insurers were operating, what kind of care they were providing, and how much they were getting paid.
The Journal.
Medicare, Inc. Part 1: How Insurers Make Billions From Medicare
Yeah, there's more than 60 million people in Medicare, and more than half of those are in Medicare Advantage at this point.
The Journal.
Medicare, Inc. Part 1: How Insurers Make Billions From Medicare
So we paired that with extensive interviews of doctors, medical providers, patients, and other people who interact with the system.
The Journal.
Medicare, Inc. Part 1: How Insurers Make Billions From Medicare
The federal government pays insurers essentially monthly lump sums to cover all of their care. And those lump sums go up when people are sicker. So like an example would be somebody who's obese might generate like a 30% higher payment for the insurer than the same person who's not. Or somebody who has diabetes might generate for the insurer like a 10% higher payment than somebody who doesn't.
The Journal.
Medicare, Inc. Part 1: How Insurers Make Billions From Medicare
And in Medicare Advantage, the incentives are basically to make patients look sicker on paper because insurance get paid more when they do that.
The Journal.
Medicare, Inc. Part 1: How Insurers Make Billions From Medicare
Insurers have defended their practices. They've argued that some of their practices lead to diagnosing patients with serious conditions sooner so they can get the treatment that they need. They argue that their practices lead to better outcomes for patients and end up costing beneficiaries less than traditional Medicare.
The Journal.
Medicare, Inc. Part 1: How Insurers Make Billions From Medicare
Medicare Advantage is sort of dominated by these huge insurance companies like United Health Group, Humana, Aetna, and Elevens.
The Journal.
Medicare, Inc. Part 1: How Insurers Make Billions From Medicare
I'm an investigative reporter at The Wall Street Journal.
The Journal.
Medicare, Inc. Part 1: How Insurers Make Billions From Medicare
These are conditions that no doctor or hospital treated, and that insurers basically went behind the scenes to add or dispatch nurses to patients' houses to sort of work them over, do a bunch of tests, that kind of thing, but for which they were getting no care. And it was astounding, and UnitedHealth, more than any other insurer, engaged in those practices.
The Journal.
Medicare, Inc. Part 1: How Insurers Make Billions From Medicare
What we found was that Medicare Advantage insurers were basically gaming the system to get paid billions of dollars more and at the same time creating barriers to accessing care.
The Journal.
Medicare, Inc. Part 1: How Insurers Make Billions From Medicare
They had already had the lenses of both eyes surgically removed and replaced during routine cataract surgeries. And it's literally impossible to get cataracts again after you've had cataract surgery in both eyes.
The Journal.
Medicare, Inc. Part 1: How Insurers Make Billions From Medicare
the quanta flow, it wasn't very specific. Basically, it had a relatively high rate of false positives. And under certain circumstances, nurses who used it would say cold in the room or something that might produce an inaccurate result.
The Journal.
Medicare, Inc. Part 1: How Insurers Make Billions From Medicare
And one nurse said she used it on herself because she was so concerned about the readings that it was producing and found that she herself apparently had peripheral artery disease, even though Like, actually, she has no signs of it.