Since the prominent killing of the CEO of UNITEDHEALTHCARE Brian Thompson Last year, health insurance companies faced severe scrutiny and increased dissatisfaction with the public. Now a New study You may encourage these fires. This is because it found that the differential coding patterns between Medicare Advantage plans (MA) and traditional medical care plans (TM) led to MA plans to receive an estimated 33 billion dollars of additional revenue – with $ 13.9 billion, or 42 % of the total, in the cabinet, UNITEDHELHELTH Group.
These results, from 2021, add a specific context to Past research This has found evidence of the highest diagnostic “intensity” of traditional medical care, which means that it records a more healthy diagnosis of traditional medical care for similar beneficiaries. For this reason, the Consultative Committee for Medical Care estimated to spend 13 % on the MA registrar than if they were registered in traditional medical care – with this difference, which represents 50 billion dollars in excessive payments in Master in 2024.
Medicare Advantage, according to the new results, plans more to patient members and less healthy organs, which provides MA plans to report many diagnoses as much as possible legally. But there is no research yet, as the authors say, the amount of additional revenues received by each insurance company.
“The most important ready -made meals are that some insurance companies on the Medicare Advantage feature are more powerful than other insurance companies, and they receive many dollars in additional payment as a result.” The author of the study, Richard Kronk, Professor of Family Medicine at Herbert Verteim Public Health, University of California San Diego. “As a result, many of what determines the successful insurance companies in the Medicare feature is not whether the insurance company provides high -quality care and done it efficiently, but simply an aggressive range of coding.” It refers to an additional $ 13.9 billion collected by UNITEDHELHELHELH GROUP, which is divided into $ 1863 per beneficial, compared to $ 0.5 billion, or $ 278 per beneficiary, for Cesar.
A spokesman for the UNITEDHELTH group refused to comment on luck Regarding the results, instead, indicating our publication to non -profit organizations The best medical care allianceWho is considered White Decker, the chief physician of the United Health Group, as a member of the Board of Directors.
“This is a defective analysis of apples to Orange.” luck. “He ignores the lack of coding known in medical care for service and does not adapt to clinical or demographic differences between the advantage of medical care and the beneficiaries of medical care for fees, which is an essential step for fair comparison. At the same time, this basic data is what is outdated and does not reflect the changes of modern risks.
However, Cronic says, “There is no perfect analysis, but we have done a precise work to measure the differences in the patterns of coding between the feature of medical care and traditional medical care, and most importantly, the very large differences between insurance companies in coding patterns … We have conclusively showed that some insurance company code is more powerful than others, and receives many dollars in additional revenue as positive.
More than half (54 %) of beneficiaries of qualified medical care in the medical care feature in 2024 were recorded, According to KFFAccounting to462 billion dollarsOf the total federal medical spending. Moreover, joining the MA is largely concentrated between a handful of companies, with united highhecare and Humana Nearly half (47 %) of all MA registrars represent the country.
Recently, there has been a shift towards. While usually, after the age of 65, you have Two options for medical careTraditional medical care (parts Afor forAnd DOften Medigap plan) Or a private health insurance company Medical care feature planIt is also called Part C, people with health advantages for retirees of their former employers are not given an option. Instead, they are told that they have to register in Medical care feature planWith its limited network of doctors and hospitals, or losing their health benefits completely retired.
At the same time, Recent research appears The MA registered is clearly healthier – because people who need more health care are less willing to accept restrictions (such as pre -empty and limited networks) imposed by MA plans.
How the researchers reached their findings on medical care
For the study, the researchers analyzed the risk degrees – the numbers that represent the expected cost of treating a specific patient or a group of patients compared to a patient with medium medical care, based on some health conditions. They also analyzed the effects of “stability” and “new injury” on the levels of risk over 24 months, with the definition of stability as the percentage of encrypted organs with a diagnosis in the first year that lasted in the second year, and a new light in reference to the percentage of members who suffer from a new diagnosis in the second year.
What they found is that the average MA (1.26) was 18.5 % higher than the average TM (1.07) risk.
The researchers found that the stability rates and new injury rates varied between insurance companies, as the average degree of risk in the UNITEDHELHELTH 2021 group was higher – greater than the average MA. 19 – even if it is if stability and the new satisfaction in TM levels.
Dr. C. Michael McWilloms of Harvard University Medical College, Brigham Hospital and Women, who responded to the study in “The results”. The accompanying editorialAlso published in Annals of internal medicine.
“Treating the risk adjustment system in the medical care feature (MA) is a huge problem,” he writes.
“It is well documented that the system’s dependence on diagnostic symbols that gain companies can affect the gains responsible for tens of billions of dollars from payments to MA plans are higher than what can be spent in traditional medical care (TM), which increases financial challenges for medical care,” continues. “But the problem works deeper, as the incentives of diagnosing the code more also distort competition and allocate resources within the MA.”
Among the many issues discovered by researchers, MCWilliams continues, because, because the best coding insurance companies tend to be larger, “local markets can become more focused, limiting insurance companies to pressure the sharing of their benefits and savings with registered people as a better cover.”
But fixing the problem, as noticed, will have hunting.
“Fishing is that the resulting payment discounts means higher installments or less generous benefits for registrants,” he writes Mcwilliams.
Because the Medicare Advantage companies retain a large part of their benefits and savings as profits, they pass along a large share to registrants. “Since the subsidies have grown more generous, MA has worked as a financing mechanism from the back door to treat gaps in the coverage that has long limited the value of TM (for example, the lack of the maximum extent),” adding that the records in the MA benefit from much lower costs of the pocket.
Therefore, where payment subsidies are reflected by repairing risk modification and other proposed measures, it indicates that “the lost benefits of registrants may be great. To the extent that socially it is advisable to provide the elderly with better coverage than traditional benefit, polycarbonate must give up this barter.”
More about medical care:
- Traditional Medicare or Medicare? Some retirees are not allowed to choose
- If you are not satisfied with your Medicare Advantage plan, experts offer these tips to find better benefits
- Native medical care does not cover most of the dental works, but there are 4 other ways to obtain coverage
This story was originally shown on Fortune.com
https://fortune.com/img-assets/wp-content/uploads/2025/04/GettyImages-2196335822-1-e1744050800369.jpg?resize=1200,600
Source link