health net

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</div><div><a href="https://www.alternet.org/how-republicans-sold-out-veterans-health-care-and-wastefully-funneled-money-private-companies">https://www.alternet.org/how-republicans-sold-out-veterans-health-care-and-wastefully-funneled-money-private-companies</a></div><div>
</div><div>For years, conservatives have assailed the U.S. Department of Veterans Affairs as a dysfunctional bureaucracy. They said private enterprise would mean better, easier-to-access health care for veterans. President Donald Trump embraced that position, enthusiastically moving to expand the private sector’s role.Here’s what has actually happened in the four years since the government began sending more veterans to private care: longer waits for appointments and, a new analysis of VA claims data by ProPublica and PolitiFact shows, higher costs for taxpayers.Since 2014, 1.9 million former service members have received private medical care through a program called Veterans Choice. It was supposed to give veterans a way around long wait times in the VA. But their average waits using the Choice Program were still longer than allowed by law, according to examinations by the VA inspector general and the Government Accountability Office. The watchdogs also found widespread blunders, such as booking a veteran in Idaho with a doctor in New York and telling a Florida veteran to see a specialist in California. Once, the VA referred a veteran to the Choice Program to see a urologist, but instead he got an appointment with a neurologist.The winners have been two private companies hired to run the program, which began under the Obama administration and is poised to grow significantly under Trump. ProPublica and PolitiFact obtained VA data showing how much the agency has paid in medical claims and administrative fees for the Choice program. Since 2014, the two companies have been paid nearly $2 billion for overhead, including profit. That’s about 24 percent of the companies’ total program expenses — a rate that would exceed the federal cap that governs how much most insurance plans can spend on administration in the private sector.<interaction data-token="5b96855f8198b4e625350260" data-context="true" data-tags="" data-fallback="true" style="background-color: rgb(255, 255, 255);" />According to the agency’s inspector general, the VA was paying the contractors at least $295 every time it authorized private care for a veteran. The fee was so high because the VA hurriedly launched the Choice Program as a short-term response to a crisis. Four years later, the fee never subsided — it went up to as much as $318 per referral.“This is what happens when people try and privatize the VA,” Sen. Jon Tester of Montana, the ranking Democrat on the Senate veterans committee, said in a statement responding to these findings. “The VA has an obligation to taxpayers to spend its limited resources on caring for veterans, not paying excessive fees to a government contractor. When VA does need the help of a middleman, it needs to do a better job of holding contractors accountable for missing the mark.”(<a href="https://www.propublica.org/article/how-we-crunched-the-numbers-on-the-vas-private-care-program" style="text-decoration-line: none;">Read more</a> about how ProPublica and PolitiFact did the analysis.)The Affordable Care Act prohibits large group insurance plans from spending more than 15 percent of their revenue on administration, including marketing and profit. The private sector standard is 10 percent to 12 percent, according to Andrew Naugle, who advises health insurers on administrative operations as a consultant at Milliman, one of the world’s largest actuarial firms. Overhead is even lower in the Defense Department’s Tricare health benefits program: only <a href="https://www.health.mil/Reference-Center/Reports/2018/05/09/Evaluation-of-the-TRICARE-Program-Fiscal-Year-2018-Report-to-Congress" style="text-decoration-line: none;">8 percent</a> last year.Even excluding the costs of setting up the new program, the Choice contractors’ overhead still amounts to 21 percent of revenue.“That’s just unacceptable,” Rick Weidman, the policy director of Vietnam Veterans of America, said in response to the figures. “There are people constantly banging on the VA, but this was the private sector that made a total muck of it.”Trump’s promises to veterans were a central message of his campaign. But his plans to shift their health care to the private sector <a href="https://www.propublica.org/article/the-trump-administration-goes-to-war-over-the-va" style="text-decoration-line: none;">put him on a collision course</a> with veterans groups, whose members generally support the VA’s medical system and don’t want to see it privatized. The <a href="https://www.propublica.org/article/trump-administration-plots-costly-private-care-expansion-for-veterans" style="text-decoration-line: none;">controversy around privatization</a>, and the <a href="https://www.propublica.org/article/ike-perlmutter-bruce-moskowitz-marc-sherman-shadow-rulers-of-the-va" style="text-decoration-line: none;">outsize influence of three Trump associates at Mar-a-Lago</a>, has sown turmoil at the VA, endangering critical services from <a href="https://www.nbcnews.com/news/us-news/veterans-haven-t-receive-gi-bill-benefits-months-due-ongoing-n934696?cid=sm_npd_nn_tw_ma" style="text-decoration-line: none;">paying student stipends</a> to <a href="https://www.stripes.com/news/va-leaves-nearly-5-million-unused-in-2018-campaign-to-battle-suicide-watchdog-finds-1.561146" style="text-decoration-line: none;">preventing suicides</a> and <a href="https://www.propublica.org/article/va-shadow-rulers-program-is-trending-towards-red" style="text-decoration-line: none;">upgrading electronic medical records</a>.A spokesman for the VA, Curt Cashour, declined to provide an interview with key officials and declined to answer a detailed list of written questions.One of the contractors, Health Net, stopped working on the program in September. Health Net didn’t respond to requests for comment.The other contractor, TriWest Healthcare Alliance, said it has worked closely with the VA to improve the program and has made major investments of its own. “We believe supporting VA in ensuring the delivery of quality care to our nation’s veterans is a moral responsibility, even while others have avoided making these investments or have withdrawn from the market,” the company said in a <a href="https://www.documentcloud.org/documents/5628647-Response-to-Inquiry-From-PolitiFact.html" style="text-decoration-line: none;">statement</a>.TriWest did not dispute ProPublica and PolitiFact’s estimated overhead rate, which used total costs, but suggested an alternate calculation, using an average cost, that yielded a rate of 13 percent to 15 percent. The company defended the $295-plus fee by saying it covers “highly manual” services such as scheduling appointments and coordinating medical files. Such functions are not typically part of the contracts for other programs, such as the military’s Tricare. But Tricare’s contractors perform other duties, such as adjudicating claims and monitoring quality, that Health Net and TriWest do not. In a <a href="https://www.rand.org/pubs/research_reports/RR2762.html" style="text-decoration-line: none;">recent study</a> comparing the programs, researchers from the Rand Corporation concluded that the role of the Choice Program’s contractors is “much narrower than in the private sector or in Tricare.”Before the Choice Program, TriWest and Health Net performed essentially the same functions for about a sixth of the price, according to the VA inspector general. TriWest declined to break down how much of the fee goes to each service it provides.Because of what the GAO called the contractors’ “inadequate” performance, the VA increasingly took over doing the Choice Program’s referrals and claims itself.In many cases, the contractors’ $295-plus processing fee for every referral was bigger than the doctor’s bill for services rendered, the analysis of agency data showed. In the three months ending Jan. 31, 2018, the Choice Program made 49,144 referrals for primary care totaling $9.9 million in medical costs, for an average cost per referral of $201.16. A few other types of care also cost less on average than the handling fee: chiropractic care ($286.32 per referral) and optometry ($189.25). There were certainly other instances where the medical services cost much more than the handling fee: TriWest said its average cost per referral was about $2,100 in the past six months.Beyond what the contractors were entitled to, <a href="https://www.va.gov/oig/pubs/VAOIG-17-02713-231.pdf" style="text-decoration-line: none;">audits</a> by the VA inspector general found that they overcharged the government by $140 million from November 2014 to March 2017. Both companies are now under federal investigation arising from these overpayments. Health Net’s parent company, Centene, <a href="https://investors.centene.com/node/23336/html" style="text-decoration-line: none;">disclosed</a> a Justice Department civil investigation into “excessive, duplicative or otherwise improper claims.” A federal grand jury in Arizona is investigating TriWest for “wire fraud and misused government funds,” according to a <a href="https://www.documentcloud.org/documents/5498679-17-16221-2017-11-08.html" style="text-decoration-line: none;">court decision</a> on a subpoena connected to the case. Both companies said they are cooperating with the inquiries.Despite the criminal investigation into TriWest’s management of the Choice Program, the Trump administration recently expanded the company’s contract without competitive bidding. Now, TriWest stands to collect even more fees as the administration prepares to fulfill Trump’s campaign promise to send more veterans to private doctors....</div>