Why payers are flocking to the Medicare Advantage market

https://www.healthcaredive.com/news/why-payers-are-flocking-to-the-medicare-advantage-market/510589/

Medicare Advantage (MA) and the Affordable Care Act (ACA) exchanges are both federal programs, but they couldn’t be more different in payers’ eyes. Insurance companies are entering or expanding their footprints in the MA market, while simultaneously pulling back or out of the ACA exchanges. They’ve found success in MA. Not so much in the ACA exchanges.

Payers see MA as a stable market. That’s evident in the fact that MA premiums are expected to decrease by 6% next year. Insurance companies like stability. Insurers increase premiums by double digits when there isn’t stability, which is the case with the ACA exchanges.

A large part of the ACA exchanges’ problems is linked to actions and inaction in Washington, D.C. President Donald Trump’s administration stopped paying cost-sharing reduction payments to insurers, cut the exchanges’ open enrollment in half, reduced the exchanges’ advertising budget by 90%, offered proposed rules and executive orders that hurt the ACA and threatened not to enforce the individual mandate that requires almost all Americans to have health insurance.

Congress, meanwhile, has tried and failed to repeal the ACA this year. All of this created an unstable exchanges market, which resulted in payers leaving the exchanges or jacking up premiums by 20% or more for 2018.

Meanwhile, the MA market is a picture of stability and payer success.

  • There is a steady stream of new people eligible for Medicare daily, and many choose MA.
  • People usually don’t switch back from MA plans after leaving traditional Medicare.
  • Payers can easily convert members from traditional Medicare to MA via marketing campaigns.
  • The MA demographics are usually people who once had an employer-based plan, so they know insurance and how healthcare works. That also means they usually don’t have pent-up healthcare needs.
  • The CMS pays MA plans upfront for covering people with high healthcare costs and payers have enjoyed stable MA payments from the CMS.

So, MA members are easier to get and keep, they usually have fewer health needs and payers like the MA payment structure better than the exchanges, which get compensated at the end of the year. All of that equals a stable market for payers.

One-third of Medicare beneficiaries are enrolled in an MA plan this year compared to 25% just six years ago. Enrollment grew by 8% between 2016 and 2017 and the CMS recently announced that MA membership will grow by 9% to 20.4 million members in 2018.

Gretchen Jacobson, associate director with the Kaiser Family Foundation’s (KFF) Program on Medicare Policy, told Healthcare Dive that more than half of those in Medicare will have MA plans in many counties next year.

That growth isn’t expected to slow — especially with Republicans controlling both houses of Congress and the White House, according to Steve Wiggins, founder and chairman of Remedy Partners.

“With Republican control of the federal government, it is conceivable that Medicare Advantage will become a centerpiece of CMS’ strategy to control spending growth,” Wiggins told Healthcare Dive.

What more MA members and payers mean for hospitals and providers

With more MA members expected next year, the continual shift to MA will have mixed benefits for providers. Jacobson said it’s not entirely clear how more MA members will affect hospitals and providers. “One of our studies recently showed that the provider networks for Medicare Advantage plans greatly varies and these networks will become even more important as enrollment in Medicare Advantage plans grows,” she said.

Fred Bentley, vice president at Avalere Health, told Healthcare Dive that MA’s growth will present a whole new set of challenges for hospitals and health systems.

Bentley listed two issues:

  • Narrow networks
  • Tighter utilization management compared to Medicare’s fee-for-service model

recent KFF report found that 35% of MA enrollees were in narrow-network plans in 2015. Payers have increasingly turned to narrow networks to control costs and improve quality of care. To take part in the narrower networks, physicians usually have to agree to payer demands concerning cost and quality.

“Differences across plans, including provider networks, pose challenges for Medicare beneficiaries in choosing among plans and in seeking care, and raise questions for policymakers about the potential for wide variations in the healthcare experience of Medicare Advantage enrollees across the country,” KFF said.

Another issue for hospitals and providers is that more payers involved in capitated plans like MA will result in more pressure on providers and hospitals to focus on the cost of care, Michael Abrams, partner at Numerof & Associates, told Healthcare Dive.

“With Republican control of the federal government, it is conceivable that Medicare Advantage will become a centerpiece of CMS’ strategy to control spending growth.”

There’s also the issue of having too few MA payers in some regions. Aneesh Krishna, partner in McKinsey & Company’s Silicon Valley office, told Healthcare Dive the concentration of MA plans in certain markets is a worry for providers. “This concern would be magnified in markets where there is a similarly high concentration in commercial segments from the same payers, and where overall MA penetration is high,” he said.

There’s also a potential payment issue. MA generally reimburses at a slightly higher level than traditional Medicare, but utilization is managed more tightly. Krishna said providers willing and capable of sharing medical cost savings are “likely to see more benefit from the shift to Medicare Advantage plans.” However, MA networks are often narrow, which means providers will need to weigh the relative price/volume trade-offs of accepting MA.

More MA growth in the coming years

MA will have more payers and members than ever next year and the two largest payers, UnitedHealth and Humana, are expected to increase their footprint. Despite new payers showing interest in the market, Jacobson expects the market break down will look similar in 2018. She said small payers entering the market will offset the plans exiting MA next year.

The Congressional Budget Office (CBO) and HHS both project MA enrollment will continue to grow over the next decade. The CBO estimated that about 41% of Medicare beneficiaries will have an MA plan in 2027. UnitedHealth even predicted half of Medicare beneficiaries will eventually have an MA plan.

MA’s popularity with payers is easy to understand — 10,000 people turn 65 every day. The CBO expects 80 million Americans will be eligible for Medicare by 2035.

There’s also an opportunity in the MA market to sign up members quickly. Rachel Sokol, practice manager of research at Advisory Board, told Healthcare Dive that utilizing a strong marketing engine allows payers to grow MA membership. This is quite different from the employer-based market, which relies on payers working with companies.

Potential MA barriers

The MA market is largely positive for payers, but it does face challenges, including:

  • A small number of payers dominate the market
  • The CMS expects improved efficiency and savings
  • There is increased federal oversight, especially concerning possible overpayments to MA insurers

CMS is all in supporting MA plans and its marketspace. The agency last week proposed a rule with an aim toward improving quality and affordability in contract year 2019. According to the agency, the number of plans available to individuals will increase from about 2,700 to more than 3,100.

The agency is proposing to expand the definition of quality improvement activity to include fraud reduction activities, changing the medical loss ratio (MLR) requirements for Medicare Advantage plans. This change should excite payers because they can add the administrative service to the MLR ratio they are required to spend on healthcare, which is at least 85%. CMS states it believes the service will help combat fraud.

For now, the MA market is consolidated around only a handful of payers. UnitedHealth and Humana have more than 40% of the market. UnitedHealth has one-quarter on its own. KFF said UnitedHealth, Humana and Blue Cross Blue Shield affiliates make up 57% of MA enrollment and the top eight MA payers constitute three-quarters of the market.

Also, CMS is imposing improved efficiency in the traditional Medicare program. This could ultimately affect MA. Accountable care organizations (ACO) and bundled payments will “put downward pressure on the benchmarks used to set payment rates for Medicare Advantage plans,” Wiggins said.

This pressure will result in MA payers needing to either cut costs or trim benefits. “The former is difficult, except through narrow networks, and the latter will diminish the attractiveness of Medicare Advantage plans,” he said.

Then there’s the 800-pound gorilla in the market — potential overpayments. The Department of Justice (DOJ) has joined whistleblower lawsuits against UnitedHealth Group concerning MA overpayments. The lawsuits allege that UnitedHealth changed diagnosis codes to make patients seem sicker, which resulted in higher reimbursements to the insurer. A federal judge threw out one of the lawsuits in October.

The DOJ is investigating other MA payers for the same reason, and Congress is also interested. Sen. Charles Grassley (R-Iowa), chairman of the Senate Judiciary Committee, sent a letter to CMS Administrator Seema Verma in April questioning what CMS is doing to “implement safeguards to reduce score fraud, waste and abuse.” Grassley said there was about $70 billion in improper Medicare Advantage payments between 2008 and 2013 because of “risk score gaming.”

It’s understandable that investigators and Congress have grown interested in MA payers. The federal government paid $160 billion to MA payers in 2014. The CMS estimated about 9.5% of those payments were improper.

The combination of billions being paid to insurers, the potential for fraud and growing membership numbers make MA ripe for oversight. The stability of the market, particularly compared to other options for payers, however, will mean growth continues.

 

Lawsuit: Epic’s software double-bills Medicare, Medicaid for anesthesia services

https://www.beckershospitalreview.com/finance/lawsuit-epic-s-software-double-bills-medicare-medicaid-for-anesthesia.html

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Health IT giant Verona, Wis.-based Epic Systems has been hit with a False Claims Act lawsuit that alleges the company’s software double-bills Medicare and Medicaid for anesthesia services, resulting in the government being overbilled by hundreds of millions of dollars.

The lawsuit, which was filed under the qui tam provision of the False Claims Act in 2015 and made public Thursday, alleges Epic’s billing software’s default protocol is to charge for both the applicable base units for anesthesia provided on a procedure and the actual time taken for the procedure. This results in the provider being reimbursed twice for the base unit component, according to the lawsuit.

The whistle-blower who filed the lawsuit, Geraldine Petrowski, worked at Raleigh, N.C.-based WakeMed Health from September 2008 through June 2014. In her role as supervisor of physician’s coding, Ms. Petrowski served as the hospital liaison for Epic’s implementation of its software at WakeMed Health.

Ms. Petrowski claims she provided examples to Epic representatives illustrating the double-billing practice, and the company initially ignored her complaints. “It was only after relator, Petrowski, reiterated her direction to fix this software setting that [Epic] relented and fixed it only for the WakeMed Health facility,” according to the lawsuit.

The lawsuit alleges the unlawful billing protocol has resulted “in the presentation of hundreds of millions of dollars in fraudulent bills for anesthesia services being submitted to Medicare and Medicaid as false claims.”

In a statement to Healthcare IT News, an Epic spokeswoman said, “The plaintiff’s assertions represent a fundamental misunderstanding of how claims software works.”

The Department of Justice declined to intervene in the case, and the whistle-blower will move forward in the case without the government.

Another Health-Care Fraud Judgment Includes Personal Liability

https://www.bna.com/healthcare-fraud-judgment-b73014471303/?utm_campaign=LEGAL_NWSLTR_Health%20Care%20Update_102717&utm_medium=email&utm_source=Eloqua&elqTrackId=b4c0d096790e4f62a8a465ccca33d352&elq=3924f09b80454e158ead21b0e1788481&elqaid=9961&elqat=1&elqCampaignId=7532

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The Department of Justice has put another notch on its Yates memo belt in securing a $2 million judgment against a home health provider and its owner personally.

A federal district judge issued the judgment Oct. 20 against Dynamic Visions Inc. and its owner Isaiah Bongam. The court previously granted the DOJ judgment on the issue of liability against Dynamic, and agreed that Bongam should be held personally responsible for Dynamic’s activities, which included forging physician signatures on patient care plans that were submitted to the District of Columbia’s Medicaid program.

The DOJ’s litigation strategy in the False Claims Act lawsuit aligned firmly with the 2015 Yates memo directive to hold individuals personally responsible for corporate fraud. While the court said there wasn’t sufficient evidence to tie Bongam to the forged signatures directly, it instead ruled that Bongam should be held personally liable for Dynamic’s actions because he was in sole control of the corporation.

Holding a person responsible for corporate liability, known as “piercing the corporate veil,” is available when the corporation is determined to be a mere shell or alter ego of a person, and therefore not deserving of the legal protection generally accorded the corporate form.

In this case, the court said not piercing the corporate veil to reach Bongam personally would be an “inequitable result,” citing Bongam’s disregard for corporate formalities and intermingling of personal funds with Dynamic’s accounts.

The judgment itself consisted of $1.5 million in damages and an additional $517,000 in fines for each alleged false claims submission. The DOJ asked for, and the court gave, the maximum $11,000 per claim damages for the 47 false claims that Dynamic submitted to Medicaid based on Dynamic’s egregious behavior.

Bongam is now on the hook for that judgment, unless it’s overturned on appeal. Bongam’s attorney told me that he intends to file an appeal, so stay tuned for an update.

DOJ: Personal trainer posed as physician in $25M scheme

https://www.beckershospitalreview.com/legal-regulatory-issues/doj-personal-trainer-posed-as-physician-in-25m-scheme.html

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A 54-year-old personal trainer was arrested in Fort Worth, Texas, Oct. 12, and charged with engaging in a scheme to defraud insurance companies by submitting more than $25 million in false claims for medical services, according to the Department of Justice.

The government claims David Williams, the personal trainer, identified himself as “Dr. Dave” on his website and said he offered in-home fitness training and therapy. Mr. Williams’ website stated he accepted most health insurance plans, according to the DOJ.

To bill health insurance companies for his fitness and exercise training services, Mr. Williams allegedly registered as a healthcare provider with CMS and then billed insurance companies as if he were a physician. He allegedly used different names to enroll as a healthcare provider at least 19 times.

The government alleges Mr. Williams used inaccurate codes to bill for the services he and his staff provided, and he sometimes billed for services that had not been provided.

From November 2012 through August 2017, Mr. Williams submitted $25 million in false claims to UnitedHealthcare, Aetna and Cigna, and he was paid more than $3.9 million in relation to those claims.

If proven guilty, Mr. Williams faces up to 10 years in federal prison and a $250,000 fine.

California Suing Trump Administration Over Rollback Of Birth Control Rule

https://www.huffingtonpost.com/entry/california-trump-birth-control_us_59d80b87e4b0f6eed35065d4

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“The California Department of Justice will fight to protect every woman’s right to healthcare, including reproductive healthcare.”

Becerra’s suit comes hours after Trump’s administration announced a new rule that will allow all employers to opt out of including birth control in their health care plans, rolling back an Obama-era mandate that guaranteed 62 million women access to contraception at no cost.

“Donald Trump wants businesses and corporations to control family planning decisions rather than a woman in consultation with her doctor. These anti-women’s health regulations prove once again that the Trump Administration is willing to trample on people’s rights,” Becerra said in a statement Friday. “The California Department of Justice will fight to protect every woman’s right to healthcare, including reproductive healthcare. We’ll see the Trump Administration in court.”

In announcing the decision, the administration argued the coverage requirement created a “substantial burden” on employers’ free exercise of religion as protected by the U.S. Constitution. The new regulations will allow any employer to deny coverage for contraception on religious and/or moral grounds.

This, Becerra argues, violates the Constitution as well as federal law.

The complaint makes the case that the rollback violates the First Amendment’s Establishment Clause by allowing employers to use their religious beliefs to deny women a health care benefit.

Becerra also argues the regulations violate the Fifth Amendment’s Equal Protection Clause.

The new rules “specifically target and harm women,” reads the complaint. “The [Affordable Care Act] specifically contemplated disparities in health care costs between women and men, and specifically sought to rectify this problem by giving women cost-free preventative services. The new [regulations] undermine this action and is discriminatory to women.”

 The suit also contends the rules violate the federal Administrative Procedure Act, which requires a notice and comment period for major policy changes, and that the new rules will harm the state of California by burdening it with additional costs to fill coverage gaps.

“Millions of women in California may be left without access to contraceptives and counseling and the State will be shouldering that additional fiscal and administrative burden as women seek access for this coverage through state-funded programs,” reads the complaint.

Becerra filed the suit Friday in the U.S. District Court for the Northern District of California.

The American Civil Liberties Union filed a similar suit Friday, also arguing the rules violate the Establishment and Equal Protection clauses.

“The Trump administration is forcing women to pay for their boss’s religious beliefs,” ACLU senior staff attorney Brigitte Amiri said in a statement.

Women’s health groups have also pushed back on the move, noting the low unintended pregnancy rates, as well as low abortion rates, since the birth control coverage mandate went into place.

Medicare Advantage will have more enrollment, lower premiums in 2018

http://www.healthcaredive.com/news/medicare-advantage-will-have-more-enrollment-lower-premiums-in-2018/506293/

Dive Brief:

  •  The CMS says Medicare Advantage (MA) members will have more choices and lower premiums in 2018. Medicare open enrollment starts on Oct. 15.
  • The average MA monthly premium is expected to decrease by about 6% from $31.91 in 2017 to $30 in 2018. The CMS said 77% of MA enrollees who stay with their current plan will have the same or lower premiums in 2018.
  • MA’s enrollment is expected to increase by 9% to 20.4 million in 2018. The CMS expects that slightly more than one-third of Medicare enrollees will have an MA plan next year.

Dive Insight:

While the CMS has talked negatively about the Affordable Care Act (ACA), CMS Administrator Seema Verma is a big fan of MA. Verma (a candidate for HHS secretary in the wake of Tom Price’s departure) said MA and Medicare Part D “demonstrate what a strong and transparent health market can do — increase quality while lowering costs.”

Payers are enjoying positive financial numbers in the MA market. UnitedHealth Group said recently that it believes eventually half of all Medicare beneficiaries will have an MA plan. Payers are looking at the MA market for growth opportunities. In some cases, payers, such as Humana, are cutting back on ACA plans and investing more in MA.

Despite the CMS’ overall support of MA, the agency still sees one way to improve the program. The CMS wants MA payers to provide current and accurate information about their providers. The CMS found that 45% of MA provider directories had incorrect information, such as listing which providers are taking new patients, or providing the wrong phone numbers and addresses.

Currently, the CMS can only review MA plans’ provider networks when there is a triggering event. This can include when the insurance company starts in MA or extends its coverage, or the CMS receives a complaint about provider network issues. The CMS wants to have more oversight over provider network information, so that it can ensure the information is up to date.

While MA plans have been popular with the CMS, members and payers, there is a concern about a small number of payers monopolizing the market. The Kaiser Family Foundation said UnitedHealth controls nearly one-quarter of the MA market and is a major MA player in 42 states and the District of Columbia. KFF found UnitedHealth, Humana and Blue Cross Blue Shield affiliates make up 57% of MA enrollment and the top eight MA payers comprise three-quarters of the market.

Another issue for MA payers is that federal investigators are concerned about how much MA is paying insurers. The Department of Justice (DOJ) is investigating payments to insurance companies involved with MA.

Two of the bigger cases involve UnitedHealth. The payer is involved in two whistleblower lawsuits that allege MA overpaid the insurer by billions. The DOJ joined the lawsuits, which allege that UnitedHealth changed diagnosis codes to make patients seem sicker, which resulted in higher reimbursements to the insurer.

The CMS estimated that it overpaid $14.1 billion in 2013 to MA organizations. Medicare Advantage payers received about $160 billion in 2014. The CMS estimated about 9.5% of those payments were improper.

Right After Trump Blamed High Drug Prices On Campaign Cash, Drugmakers Gave More

Right After Trump Blamed High Drug Prices On Campaign Cash, Drugmakers Gave More

“The cost of medicine in this country is outrageous,” President Donald Trump said at a rally in Louisville, Ky., two months after his inauguration. He went on about how identical pills have vastly lower price tags in Europe.

“You know why?” the president asked, before spreading his hands wide. “Campaign contributions, who knows. But somebody is getting very rich.”

It was March 20, 2017.

The next day, drugmakers donated more money to political campaigns than they had on any other day in 2017 so far, according to a Kaiser Health News analysis of campaign spending in the first half of the year reported in Federal Election Commission filings.

Eight pharmaceutical political action committees made 134 contributions, spread over 77 politicians, on March 21. They spent $279,400 in all, showering Republicans and Democrats in both legislative bodies with campaign cash, according to FEC filings. The second-highest one-day contribution tally was $203,500, on June 20.

Brendan Fischer, who directs election reform programs at the Campaign Legal Center, said he found the timing of the contributions interesting: “I think it’s entirely possible that the drug companies sought to curry favor with members of Congress in order to head off any sort of potential attack on their industry by the press or by the federal government.”

During the Louisville rally, Trump also promised to lower drug prices, and pharmaceutical stocks tumbled afterward.

Although drug industry PACs have different structures and protocols, they are equipped to mobilize quickly to disperse funds to legislators.

“Writing a check doesn’t require much beyond putting pen to paper,” Fischer said.

FEC records show Merck’s PAC led the way that day, donating $148,000 to 60 candidates on March 21. House Speaker Paul Ryan (R-Wis.) received three maximum contributions to his various PACs from the drugmaker, totaling $15,000. Behind him with $7,500 was Sen. Tom Carper (D-Del.), who sits on the Senate Finance Committee.

Merck spokeswoman Claire Gillepsie said the contributions were “not tied to specific events.”

“Decisions on contributions are made at the beginning of a cycle and are approved by a contributions committee,” she said. A White House official referred requests for comment to the presidential campaign, which did not respond.

Companies may donate funds or lobby ahead of impending legislative issues and executive orders, or they may react to something a politician says.

“Presidents get a lot of attention to what they say,” said former congressman Lee Hamilton, who founded the Indiana University Center on Representative Government after three decades in the House of Representatives. “[Companies] have to react to that and defend the drug prices.”

Overall, FEC records show Merck spent $242,500 on campaign contributions and $3.7 million on lobbying in the first half of 2017.

The drugmaker, which makes diabetes pill Januvia, cancer drug Keytruda and shingles vaccine Zostavax, responded to outrage over drug prices earlier this year by revealing on its website that the average list prices of its drugs increased from 7.4 percent to 10.5 percent each year since 2010. Merck said discounts and rebates also increased, meaning it took home less money. But Thomson Reuters pointed out that the price increases outpaced inflation.

FEC records don’t indicate why a company donated to a politician or what that contribution led to, but when House Democrats accused Rep. Jason Chaffetz (R-Utah) of failing to schedule a hearing on prescription drug price hikes in 2015, The Intercept pointed out that the pharmaceutical industry had been among Chaffetz’s top campaign contributors.

Pharmaceutical lobbying dollars have also swelled in 2017, Kaiser Health News previously reported. In their disclosures, drug companies listed tax reform and drug pricing among issues on which they lobbied Congress.

March 21 was also the date of the National Republican Congressional Committee’s annual fundraising dinner, featuring Trump as keynote speaker. The event, which raises money for House Republicans, drew a record-breaking $30 million from a variety of industries, the NRCC reported.

But on that day, drugmakers also gave generously to Democrats and senators, according to FEC filings.

Pfizer and Novo Nordisk PACs donated $76,900 and $38,500 on March 21, respectively, to several dozen candidates on March 21, according to their filings. Five additional pharmaceutical PACs spent between $1,000 and $5,000 on contributions that day.

The companies say the timing was coincidental. A Novo Nordisk spokesman said the March 21 contributions from its PAC had been scheduled in advance “and in no way were tied to any specific statement.”

Pfizer spokeswoman Sharon Castillo said it takes three to four weeks to orchestrate and approve a PAC contribution.

“Pfizer’s political contributions to candidates and elected officials from both parties are led by two guiding principles — preserve and further the incentives for innovation, and protect and expand access to medicines and vaccines for the patients we serve,” Castillo said.

Pfizer’s PAC donated more than any pharmaceutical PAC in the first half of 2017, contributing $418,400 in all — nearly 70 percent more than the first six months of the 2015 election cycle, according to FEC records. In February of this year, the company’s CEO was among several executives from drugmaking firms and other global companies to pen a letter to Congress in support of tax reform. In December 2016, Pfizer received a letter from the Senate Special Committee on Aging, asking it to explain its price increases for the opioid overdose reversal drug, naloxone.

“Pfizer is committed to addressing the prevention, treatment and effective response to the growing opioid abuse in the United States,” Castillo said, adding that the company is donating up to 1 million naloxone doses and $1 million in grants toward opioid addiction awareness efforts.

Novo Nordisk has spent $178,000 on campaign contributions so far this year, or nearly four times more than it spent the first six months of 2015, according to its filings with the FEC. The company is one of the top three insulin makers, and in July, Sen. Amy Klobuchar (D-Minn.) sent the companies letters asking them to justify their price increases. In November, Sen. Bernie Sanders (I-Vt.) and Rep. Elijah Cummings (D-Md.) asked the Justice Department and the Federal Trade Commission to investigate the insulin makers for possible price collusion. The companies have denied the allegations.

“We’re certainly aware of policymakers’ concerns about the price of insulin, and we’re committed to collaborate with all those involved in the healthcare supply chain to ensure patient access,” said Novo Nordisk spokesman Ken Inchausti.

“From the public record, you can’t tell for sure” what prompted the spike in political contributions from pharmaceutical companies, said Tony Raymond, a former analyst at the Federal Election Commission who founded Political Money Line to track campaign finance. The PACs could have been “killing two birds with one stone” by donating to legislators across the board on the night of the NRCC fundraiser, or they could have been responding to what Trump said.

“We’re talking about a couple phone calls and then they could courier a check over to someone,” he said.

Antitrust in the Labor Market: Protectionist, or Pro-Competitive?

https://promarket.org/antitrust-labor-market-protectionist-pro-competitive/

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Redirecting antitrust enforcement to confront monopsony power would be a substantial departure from the way it has been conducted in recent decades, but just because a policy has been in place for a long time does not mean it is a success, and recent evidence implies a significant policy change is necessary and justified.

The very first sentence of the United States submission to the OECD’s “Global Forum on Competition” in 2015 reads “The U.S. Federal Trade Commission and the Antitrust Division of the Department of Justice do not consider employment or other non-competition factors in their antitrust analysis.”

Employment isn’t a “competition factor?” A growing body of evidence, drawn from both micro and macro sources, implies that the labor market has been slack since the Great Recession thanks to an aggregate demand shortfall. The employment-to-population ratio, labor force participation, job-to-job and geographic mobility, and the job ladder as a whole have all stagnated for almost a decade, and even before 2008 these indicators had barely made up ground since the recession of the early 2000s. Wages have been stagnant, and thus the labor share of national income has been in decline.

Over an even longer period, worker compensation has failed to keep pace with productivity gains per capita. The broadening literature on the rise of earnings inequality between firms, controlling for worker characteristics, implies that workers do not receive sufficient job offers to equalize the earnings they receive across firms. All of these phenomena are explained by rising monopsony power in the labor market.

The recent paper by De Loecker and Eeckhout makes this point explicit: the ability of employers to extract rents in the labor market causes a reduction in the market demand for labor, and this in turn motivates all of the manifestations of a slack labor market just described, as well as the rising markups that are the central finding of that paper. Profits have risen, reflecting rising market power in both labor and product markets—a finding that is consistent with the aggregate analysis done by Barkai.

So if monopsony power constrains employment, why not consider it a factor in antitrust analysis? After all, the premise of economic analysis in antitrust is that market power threatens welfare by restricting output and raising prices. Why doesn’t market power threaten welfare by reducing demand for labor and lowering wages?

Existing antitrust policy treats maximizing consumer welfare as the ultimate end goal of antitrust policy, and that policy aim makes sense in a world of little market power, where profits are low and the economy is assumed to be on its production possibility frontier. In that world, maximizing consumer welfare is a suitable summary statistic for overall wellbeing.

Moreover, since the revolution in antitrust policy associated with Robert Bork put such an emphasis on sustaining an “economies” defense—meaning that potentially efficiency-enhancing aspects of corporate mergers and conduct must be weighed against inefficiencies arising from market power—the potential for monopsony power has been considered a plus. After all, enforcers and courts generally assumed that any gains at the expense of workers would be passed to consumers in the form of lower prices, since product markets would be competitive (and if not, the potential for entry would exert a disciplining influence). In that world, caring about employment, wages, or other labor market outcomes looks like protectionism, impeding the competitive pressure that yields the best outcomes for consumers, and favoring certain privileged “insider” workers at the expense of others.

We know now that we don’t live in that world, and that revelation calls for a wholesale re-think of the proper goals of antitrust policy, very much including whether the sole focus on consumer welfare makes sense when powerful corporations squeeze workers and then pocket the gains for themselves and their shareholders.

What would it actually look like to bring antitrust into the labor market?

As with any enforcement regime, antitrust often starts with the lowest-hanging fruit: out-and-out written evidence of anti-competitive practices, such as the Justice Department’s 2010 lawsuit against Silicon Valley employers for colluding not to hire one another’s programmers. This is partly why the recent increase in the use of non-compete clauses has drawn attention in antitrust circles. As a would-be vertical restraint, non-compete clauses aren’t as easy to target under antitrust as horizontal collusion, but they are there, in writing—prohibitions on competition in the labor market, to the benefit of employers. And they should be banned, or at the very least subjected to a high burden of proof requiring a substantive defense on the part of employers who impose them, plus an affirmative finding that they do not act to reduce wages or restrict job offers.

The same dynamic is at play in prohibitions on poaching in franchising agreements, which Alan Krueger and Orley Ashenfelter recently found to be prevalent in franchising contracts and which, to my knowledge, the federal competition regulators have never touched—even though they do regulate other provisions of those contracts. Franchising networks are a hybrid beast, somewhere between horizontal and vertical, but a blanket prohibition on poaching throughout a franchisor’s network certainly starts to look like a horizontal agreement not to compete.

It’s important to understand, though, that these written restraints of trade are symptoms of the broader decline in worker power, and meaningful antitrust enforcement should go after the causes. Reclassification of workers as independent contractors is a broader concern—not only anti-competitive in itself, but as a means to engage in other coercive conduct and corporate structures. Studies show that reclassifications result in immediate wage reductions and no other changes in terms of employment, suggesting that they amount to employer’s exploiting their wage-setting power by changing the legal structure of their business.

And beyond the act itself, classifying workers as independent contractors allows employers to avoid liability for minimum wage, maximum hours, workplace safety, and a host of other entitlements associated with statutory employment. The idea was that employment inherently signifies control, and with control ought to come responsibility—and by extension, if employers do not bear responsibility, then they should not be able to exercise control. What employers have realized now, as enforcement regimes in both labor and antitrust have weakened, is that they can have the control without the responsibility. For example, contracting terms often prevent workers from simultaneously working for others—an exercise of control if ever there was one, and an anti-competitive vertical restraint in the context of an independent contractor.

Employers can have that control without first establishing themselves as a monopoly—in fact, reclassification is increasingly standard operating procedure in many industries, which means that treating it as a violation of Section 2 of the Sherman Act should not require that outright monopolization must first be shown.

This is the fundamental issue behind the litigation over whether Uber’s drivers ought to be considered employees, and if not, whether the business amounts to a price-fixing conspiracy between the company and hundreds of thousands of independent businesses who drive for it. I’ve written before about the antitrust lawsuit against Uber on these grounds. The case was recently dealt a severe blow in the form of an appellate ruling that upheld the company’s mandatory arbitration clause—meaning that if the lower court decides Uber did not itself void the arbitration clause by hastening the case with a move to summary judgment, then the case will likely be thrown out of court.

That brings us to yet another way in which employers exercise monopsony power: mandatory arbitration and class action waivers for employment claims, about which the Supreme Court is set to hear a case this term. The issue there is that expansive readings of the Federal Arbitration Act have essentially said that individual rights protected by both the constitution and federal statute can be voided by bilateral waivers—as though the parties are equally situated and at liberty to reject such provisions in employment agreements and elsewhere. Of course, the whole point of monopsony is that jobs are scarce, and hence employers have leverage with which to extract concessions, be they out-and-out wage reductions or agreements not to litigate disputes. Thus, another aim of antitrust enforcement in labor markets ought to be bans on litigation waivers between parties that are not similarly situated economically as restraints of trade—and the competition authorities ought to make their views known to the Supreme Court on this issue. After all, private action is a pillar of federal antitrust policy, and so arbitration clauses are not just themselves restraints of trade, but they also inhibit enforcement against other restraints, as the fate of the Uber antitrust case shows.

Finally, there’s the elephant in the room when it comes to antitrust: merger review, the bulk of what the agencies do about enforcing the laws they’re entrusted to carry out. Claims that mergers reduce employment are not entertained as arguments against them—in fact, they are likely to be considered arguments in favor, as they show some motivation for the transaction beyond raising prices for consumers. And yet we know anecdotally that recently-consummated mergers have in fact had adverse employment impacts. A systematic study of the labor market impact of past mergers has yet to be conducted, to my knowledge—such an exercise would be a valuable component of assessing the impact and success of the current competition policy regime, including whether these job losses do actually end up benefiting consumers in the form of lower prices, as merging parties invariably claim, versus their shareholders and executives.

In conclusion, the view that the competition authorities expressed to the OECD in 2015 looks increasingly out of touch with the labor market and the broader macroeconomic conditions that currently exist. It is true that redirecting antitrust enforcement to confront monopsony power would be a substantial departure from the way it has been conducted in recent decades, and as such there are both court decisions and agency policies that go against it. But just because a policy has been in place for a long time does not mean it is a success, and recent evidence implies a significant policy change is necessary and justified—much as an intellectual movement in academia once shifted antitrust policy substantially, it’s time for new evidence to change it once again.

Physician who claimed to have 11k patients sentenced to 35 years in prison

http://www.beckershospitalreview.com/legal-regulatory-issues/physician-who-claimed-to-have-11k-patients-sentenced-to-35-years-in-prison.html

Image result for physician in handcuffs

A 60-year-old Texas physician was sentenced Aug. 9 to 35 years in prison for orchestrating a $375 million healthcare fraud scheme, according to the Department of Justice.

Federal prosecutors said Jacques Roy, MD, and his cohorts used promises of cash, groceries and food stamps to recruit patients, including some of Dallas’ homeless, as part of the fraud scheme.

From January 2006 to November 2011, Dr. Roy’s office, Medistat Group Associates in DeSoto, Texas, handled more home healthcare visits than any physician’s office in the country. Dr. Roy allegedly certified or directed the certification of more than 11,000 individual patients from more than 500 home healthcare agencies for home health services during that time, according to the DOJ.

“A doctor cannot care for 11,000 patients at once,” Assistant U.S. Attorney P.J. Meitl said during the trial, according to The Dallas Morning News

In April 2016, Dr. Roy, who has lost his medical license, was found guilty on eight counts of healthcare fraud, two counts of making a false statement relating to healthcare matters, one count of obstruction of justice and one count of conspiracy to commit healthcare fraud. Three owners of home healthcare agencies were also convicted on various felony offenses.

In addition to his 35-year prison term, Dr. Roy was ordered to pay $268.15 million in restitution.

BCBS of Michigan faces more than 30 lawsuits alleging hidden health plan fees

http://www.beckershospitalreview.com/legal-regulatory-issues/bcbs-of-michigan-faces-more-than-30-lawsuits-alleging-hidden-health-plan-fees.html

Image result for blue cross blue shield of michigan

More than 30 lawsuits filed against Detroit-based Blue Cross Blue Shield of Michigan in the past week claim the insurer charged employers unauthorized and hidden fees for their health plans, Bloomberg BNA reports.

Filed between Aug. 9 and Aug. 11 in Michigan’s federal court, the lawsuits allege BCBSM issued hidden markups to employers’ health plan assets to shore up its finances, the report states. The allegations stem from a 2014 appeals court decision finding the payer responsible for the unauthorized fees under the Employee Retirement Income Security Act. The decision also upheld a $6 million judgment against BCBSM.

More than 200 ERISA lawsuits alleging hidden health plan fees were filed against the payer since the 2014 decision, the report states. A college, an auto parts maker, a plastics manufacturer and a car dealer are among the employers suing BCBSM.

BCBSM did not respond to Bloomberg BNA‘s request for comment.