How to get & stay rich - lie and cheat

http://www.pnhp.org/news/2012/june/oig-catches-pacificare-red-handed

Thursday, June 7, 2012

By Don McCanne, MD

As you know, Medicare beneficiaries have the option of leaving the traditional Medicare program and obtaining their care through private insurers offering Medicare Advantage plans. These private plans receive from the government monthly capitation payments (a set dollar amount for each beneficiary enrolled). To protect the private insurers from the higher spending required for sicker patients, the capitation payments are adjusted upward based on how ill the patients are. This is known as risk adjustment. Sounds reasonable. So what's the deal here?

Keep in mind that the traditional Medicare program is designed to serve patients whereas the private Medicare Advantage plans are private businesses designed primarily to make money. So how can these private plans meet their business obligation of keeping their spending down while increasing their revenues?

Quite simple. Game risk adjustment. Report many of the patients as having more serious disorders than they really do in order to increase the capitation payments. Although the insurers have denied that they do this, the Office of the Inspector General has caught them red-handed.

Based on this chicanery, UnitedHealth's PacifiCare was overpaid about $115 million for this one contract alone. That is almost $1000 excess for each of the 118,000 beneficiaries enrolled!

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Our own government stewards from the OIG (Office of the Inspector General), working for us, have exposed this scheme that is being used to skim off our tax dollars. So what are we going to do about it? Don't you think it's time to get rid of the amoral business ethic in health care financing and instead place in charge people dedicated to a service ethic? We can do this by establishing our own single payer national health program. But first we have to elect people who place public service above all. Supporting the 1 percent isn't working.