How they did it: STAT reporters expose how ailing seniors suffer when Medicare Advantage plans use algorithms to deny care
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In a call with a long-time source, what stood out most to STAT reporters Bob Herman and Casey Ross was just how viscerally frustrated and angry the source was about an algorithm used by insurance companies to decide how long patients should stay in a nursing home or rehab facility before being sent home.
The STAT stories had a far-reaching impact:
- The U.S. Senate Committee on Homeland Security and Government Affairs took a rare step of launching a formal investigation into the use of algorithms by the country’s three largest Medicare Advantage insurers.
- Thirty-two House members urged the Centers for Medicare and Medicaid Services to increase the oversight of algorithms that health insurers use to make coverage decisions.
- In a rare step, CMS launched its own investigation into UnitedHealth. It also stiffened its regulations on the use of proprietary algorithms and introduced plans to audit denials across Medicare Advantage plans in 2024.
- Based on STAT’s reporting, Medicare Advantage beneficiaries filed two class-action lawsuits against UnitedHealth and its NaviHealth subsidiary, the maker of the algorithm, and against Humana, another major health insurance company that was also using the algorithm.
- Amid scrutiny, UnitedHealth renamed NaviHealth.
The companies never allowed an on-the-record interview with their executives, but they acknowledged that STAT’s reporting was true, according to the news organization.
Ross and Herman spoke with The Journalist’s Resource about their project and shared the following eight tips.
1. Search public comments on proposed federal rules to find sources.
Herman and Ross knew that the Centers for Medicare and Medicaid Services had put out a request for public comments, asking stakeholders within the Medicare Advantage industry how the system could improve.
There are two main ways to get Medicare coverage: original Medicare, which is a fee-for-service health plan, and Medicare Advantage, which is a type of Medicare health plan offered by private insurance companies that contract with Medicare. Medicare Advantage plans have increasingly become popular in recent years.
Under the Social Security Act, the public has the opportunity to submit comments on Medicare’s proposed national coverage determinations. CMS uses public comments to inform its proposed and final decisions. It responds in detail to all public comments when issuing a final decision.
The reporters began combing through hundreds of public comments attached to a proposed Medicare Advantage rule that was undergoing federal review. NaviHealth, the UnitedHealth subsidiary and the maker of the algorithm, came up in many of the comments, which include the submitters’ information.
“These are screaming all-caps comments to federal regulators about YOU NEED TO SOMETHING ABOUT THIS BECAUSE IT’S DISGUSTING,” Ross says.
“The federal government is proposing rules and regulations all the time,” adds Herman, STAT’s business of health care reporter. “If someone’s going to take the time and effort to comment on them, they must have at least some knowledge of what’s going on. It’s just a great tool for any journalist to use to figure out more and who to contact.”
The reporters also found several attorneys who had complained in the comments. They began reaching out to them, eventually gaining access to confidential documents and intermediaries who put them in touch with patients to show the human impact of the algorithm.
2. Harness the power of the reader submission box.
At the suggestion of an editor, the reporters added a reader submission box at the bottom of their first story, asking them to share their own experiences with Medicare Advantage denials.
The floodgates opened. Hundreds of submissions arrived.
By the end of their first story, Herman and Ross had confidential records and some patients, but they had no internal sources in the companies they were investigating, including Navihealth. The submission box led them to their first internal source.
The journalists also combed through LinkedIn and reached out to former and current employees, but the response rate was much lower than what they received via the submission box.
The submission box “is just right there,” Herman says. “People who would want to reach out to us can do it right then and there after they read the story and it’s fresh in their minds.”
3. Mine podcasts relevant to your story.
The reporters weren’t sure if they could get interviews with some of the key figures in the story, including Tom Scully, the former head of the Centers for Medicare and Medicaid Services who drew up the initial plans for NaviHealth years before UnitedHealth acquired it.
But Herman and another colleague had written previously about Scully’s private equity firm and they had found a podcast where he talked about his work. So Herman went back to the podcast — where he discovered Scully had also discussed NaviHealth.
The reporters also used the podcast to get Scully on the phone for an interview.
“So we knew we had a good jumping off point there to be like, ‘OK, you’ve talked about NaviHealth on a podcast, let’s talk about this,’” Herman says. “I think that helped make him more willing to speak with us.”
4. When covering AI initiatives, proceed with caution.
“A source of mine once said to me, ‘AI is not magic,’” Ross says. “People need to just ask questions about it because AI has this aura about it that it’s objective, that it’s accurate, that it’s unquestionable, that it never fails. And that is not true.”
AI is not a neutral, objective machine, Ross says. “It’s based on data that’s fed into it and people need to ask questions about that data.”
He suggests several questions to ask about the data behind AI tools:
- Where does the data come from?
- Who does it represent?
- How is this tool being applied?
- Do the people to whom the tool is being applied match the data on which it was trained? “If racial groups or genders or age of economic situations are not adequately represented in the training set, then there can be an awful lot of bias in the output of the tool and how it’s applied,” Ross says.
- How is the tool applied within the institution? Are people being forced to forsake their judgment and their own ability to do their jobs to follow the algorithm?
5. Localize the story.
More than half of all Medicare beneficiaries have Medicare Advantage and there’s a high likelihood that there are multiple Medicare Advantage plans in every county across the nation.
“So it’s worth looking to see how Medicare Advantage plans are growing in your area,” Herman says.
Finding out about AI use will most likely rely on shoe-leather reporting of speaking with providers, nursing homes and rehab facilities, attorneys and patients in your community, he says. Another source is home health agencies, which may be caring for patients who were kicked out of nursing homes and rehab facilities too soon because of a decision by an algorithm.
The anecdote that opens their first story involves a small regional health insurer in Wisconsin, which was using NaviHealth and a contractor to manage post-acute care services, Ross says.
“It’s happening to people in small communities who have no idea that this insurer they’ve signed up with is using this tool made by this other company that operates nationally,” Ross says.
There are also plenty of other companies like NaviHealth that are being used by Medicare Advantage plans, Herman says. “So it’s understanding which Medicare Advantage plans are being sold in your area and then which post-acute management companies they’re using,” he adds.
Some regional insurers have online documents that show which contractors they use to evaluate post-acute care services.
6. Get familiar with Medicare’s appeals databases
Medicare beneficiaries can contest Medicare Advantage denials through a five-stage process, which can last months to years. The appeals can be filed via the Office of Medicare Hearings and Appeals.
“Between 2020 and 2022, the number of appeals filed to contest Medicare Advantage denials shot up 58%, with nearly 150,000 requests to review a denial filed in 2022, according to a federal database,” Ross and Herman write in their first story. “Federal records show most denials for skilled nursing care are eventually overturned, either by the plan itself or an independent body that adjudicates Medicare appeals.”
There are several sources to find appeals data. Be mindful that the cases themselves are not public to protect patient privacy, but you can find the number of appeals filed and the rationale for decisions.
CMS has two quality improvement organizations, or QIOs, Livanta and Kepro, which are required to file free, publicly-available annual reports, about the cases they handle, Ross says.
Another company, Maximus, a Quality Improvement Contractor, also files reports on prior authorization cases it adjudicates for Medicare. The free annual reports include data on raw numbers of cases and basic information about the percentage denials either overturned or upheld on appeal, Ross explains.
CMS also maintains its own database on appeals for Medicare Part C (Medicare Advantage plans) and Part D, which covers prescription drugs, although the data is not complete, Ross explains.
7. Give your editor regular updates.
“Sprinkle the breadcrumbs in front of your editors,” Ross says.
“If you wrap your editors in the process, you’re more likely to be able to get to the end of [the story] before they say, ‘That’s it! Give me your copy,’” Ross says.
8. Get that first story out.
“You don’t have to know everything before you write that first story,” Ross says. “Because with that first story, if it has credibility and it resonates with people, sources will come forward and sources will continue to come forward.”
Read the stories
Denied by AI: How Medicare Advantage plans use algorithms to cut off care for seniors in need
UnitedHealth pushed employees to follow an algorithm to cut off Medicare patients’ rehab care
UnitedHealth used secret rules to restrict rehab care for seriously ill Medicare Advantage patients
This article first appeared on The Journalist’s Resource and is republished here under a Creative Commons license.
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Is still water better for you than sparkling water?
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Still or sparkling? It’s a question you’ll commonly hear in a café or restaurant and you probably have a preference. But is there any difference for your health?
If you love the fizz, here’s why you don’t have to pass on the sparkling water.
Brent Hofacker/Shutterstock What makes my water sparkle?
This article specifically focuses on comparing still filtered water to carbonated filtered water (called “sparkling water” or “unflavoured seltzer”). Soda water, mineral water, tonic water and flavoured water are similar, but not the same product.
The bubbles in sparkling water are created by adding carbon dioxide to filtered water. It reacts to produce carbonic acid, which makes sparkling water more acidic (a pH of about 3.5) than still (closer to neutral, with a pH around 6.5-8.5).
Which drink is healthiest?
Water is the best way to hydrate our bodies. Research shows when it comes to hydration, still and sparkling water are equally effective.
Some people believe water is healthier when it comes from a sealed bottle. But in Australia, tap water is monitored very carefully. Unlike bottled water, it also has the added benefit of fluoride, which can help protect young children against tooth decay and cavities.
Sparkling or still water is always better than artificially sweetened flavoured drinks or juices.
Isn’t soda water bad for my teeth and bones?
There’s no evidence sparkling water damages your bones. While drinking a lot of soft drinks is linked to increased fractures, this is largely due to their association with higher rates of obesity.
Sparkling water is more acidic than still water, and acidity can soften the teeth’s enamel. Usually this is not something to be too worried about, unless it is mixed with sugar or citrus, which has much higher levels of acidity and can harm teeth.
However, if you grind your teeth often, the softening could enhance the damage it causes. If you’re undertaking a home whitening process, sparkling water might discolour your teeth.
In most other cases, it would take a lot of sparkling water to pass by the teeth, for a long period of time, to cause any noticeable damage.
How does drinking water affect digestion?
There is a misconception drinking water (of any kind) with a meal is bad for digestion.
While theoretically water could dilute stomach acid (which breaks down food), the practice of drinking it doesn’t appear to have any negative effect. Your digestive system simply adapts to the consistency of the meal.
Some people do find that carbonated beverages cause some stomach upset. This is due to the build-up of gases, which can cause bloating, cramping and discomfort. For people with an overactive bladder, the acidity might also aggravate the urinary system.
Interestingly, the fizzy “buzz” you feel in your mouth from sparkling water fades the more you drink it.
Is cold water harder to digest?
You’ve chosen still or sparkling water. What about its temperature?
There are surprisingly few studies about the effect of drinking cold water compared to room temperature. There is some evidence colder water (at two degrees Celsius) might inhibit gastric contractions and slow down digestion. Ice water may constrict blood vessels and cause cramping.
However other research suggests drinking cold water might temporarily boost metabolism, as the body needs to expend energy to warm it up to body temperature. This effect is minimal and unlikely to lead to significant weight loss.
Which water wins?
The bottom line is water is essential, hydrates us and has countless other health benefits. Water, with carbonated bubbles or without, will always be the healthiest drink to choose.
And if you’re concerned about any impact to teeth enamel, one trick is to follow sparkling water with a glass of still. This helps rinse the teeth and return your mouth’s acidity back to normal.
Christian Moro, Associate Professor of Science & Medicine, Bond University and Charlotte Phelps, Senior Teaching Fellow, Medical Program, Bond University
This article is republished from The Conversation under a Creative Commons license. Read the original article.
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Cordyceps: Friend Or Foe?
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Cordyceps: friend or foe?
Cordyceps is a famously frightening fungus. It’s the one responsible for “zombie ants” and other zombie creatures, and it’s the basis for the existential threat to humanity in the TV show The Last of Us.
It’s a parasitic fungus that controls the central and peripheral nervous systems of its host, slowly replacing the host’s body, as well as growing distinctive spines that erupt out of the host’s body. Taking over motor functions, it compels the host to do two main things, which are to eat more food, and climb to a position that will be good to release spores from.
Fortunately, none of that matters to humans. Cordyceps does not (unlike in the TV show) affect humans that way.
What does Cordyceps do in humans?
Cordyceps (in various strains) is enjoyed as a health supplement, based on a long history of use in Traditional Chinese Medicine, and nowadays it’s coming under a scientific spotlight too.
The main health claims for it are:
- Against inflammation
- Against aging
- Against cancer
- For blood sugar management
- For heart health
- For exercise performance
Sounds great! What does the science say?
There’s a lot more science for the first three (which are all closely related to each other, and often overlapping in mechanism and effect).
So let’s take a look:
Against inflammation
The science looks promising for this, but studies so far have either been in vitro (cell cultures in petri dishes), or else murine in vivo (mouse studies), for example:
- Anti-inflammatory effects of Cordyceps mycelium in murine macrophages
- Cordyceps sinensis as an immunomodulatory agent
- Immunomodulatory functions of extracts from Cordyceps cicadae
- Cordyceps pruinosa inhibits in vitro and in vivo inflammatory mediators
In summary: we can see that it has anti-inflammatory properties for mice and in the lab; we’d love to see the results of studies done on humans, though. Also, while it has anti-inflammatory properties, it performed less well than commonly-prescribed anti-inflammatory drugs, for example:
❝C. militaris can modulate airway inflammation in asthma, but it is less effective than prednisolone or montelukast.❞
Against aging
Because examining the anti-aging effects of a substance requires measuring lifespans and repeating the experiment, anti-aging studies do not tend to be done on humans, because they would take lifetimes to perform. To this end, it’s inconvenient, but not a criticism of Cordyceps, that studies have been either mouse studies (short lifespan, mammals like us) or fruit fly studies (very short lifespan, genetically surprisingly similar to us).
The studies have had positive results, with typical lifespan extensions of 15–20%:
- The lifespan-extending effect of Cordyceps sinensis in normal mice
- Cordyceps sinensis oral liquid prolongs the lifespan of the fruit fly, Drosophila melanogaster
- Anti-aging activity of polysaccharides from Cordyceps militaris
- Anti-aging effect of Cordyceps sinensis extract
Against cancer
Once again, the studies here have been in vitro, or murine in vivo. They do look good though:
In vitro (human cell cultures in a lab):
In vivo (mouse studies):
Summary of these is: Cordyceps quite reliably inhibits tumor growth in vitro (human cell cultures) and in vivo (mouse studies). However, trials in human cancer patients are so far conspicuous by their absence.
For blood sugar management
Cordyceps appears to mimic the action of insulin, without triggering insulin sensitivity. For example:
The anti-hyperglycemic activity of the fruiting body of Cordyceps in diabetic rats
There were some other rat/mouse studies with similar results. No studies in humans yet.
For heart health
Cordyceps contains adenosine. You may remember that caffeine owes part of its stimulant effect to blocking adenosine, the hormone that makes us feel sleepy. So in this way, Cordyceps partially does the opposite of what caffeine does, and may be useful against arrhythmia:
Cardiovascular protection of Cordyceps sinensis act partially via adenosine receptors
For exercise performance
A small (30 elderly participants) study found that Cordyceps supplementation improved VO2 max by 7% over the course of six weeks:
However, another small study (22 young athletes) failed to reproduce those results:
Cordyceps Sinensis supplementation does not improve endurance exercise performance
In summary…
Cordyceps almost certainly has anti-inflammation, anti-aging, and anti-cancer benefits.
Cordyceps may have other benefits too, but the evidence is thinner on the ground for those, so far.
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The Five Invitations – by Frank Ostaseski
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This book covers exactly what its subtitle promises, and encourages the reader to truly live life fully, something that Ostaseski believes cannot be done in ignorance of death.
Instead, he argues from his experience of decades working at a hospice, we must be mindful of death not only to appreciate life, but also to make the right decisions in life—which means responding well to what he calls, as per the title of this book, “the five invitations”.
We will not keep them a mystery; they are:
- Don’t wait; do the important things now
- Welcome everything; push away nothing
- Bring your whole self to the experience
- Find a place in the middle of things
- Cultivate a “don’t know” mind
Note, for example, that “do the important things now” requires knowing what is important. For example, ensuring a loved one knows how you feel about them, might be more important than scratching some item off a bucket list. And “push away nothing” does mean bad things too; rather, of course try to make life better rather than worse, but accept the lessons and learnings of the bad too, and see the beauty that can be found in contrast to it. Enjoying the fullness of life without getting lost in it; carrying consciousness through the highs and lows. And yes, approaching the unknown (which means not only death, but also the large majority of life) with open-minded curiosity and wonder.
The style of the book is narrative and personal, without feeling like a collection of anecdotes, but rather, taking the reader on a journey, prompting reflection and introspection along the way.
Bottom line: if you’d like to minimize the regrets you have in life, this book is a fine choice.
Click here to check out The Five Invitations, and answer with a “yes” to the call of life!
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7 Ways To Boost Mitochondrial Health To Fight Disease
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Fatigue and a general lack of energy can be symptoms of many things, and for most of them, looking after our mitochondrial health can at least help, if not outright fix the issue.
The Seven Ways
Dr. Jonas Kuene suggests that we…
- Enjoy a good diet: especially, limiting simple sugars, reducing overall carbohydrate intake, and swapping seed oils for healthier oils like avocado oil and olive oil.
- Take supplements: including coenzyme Q10, alpha-lipoic acid, and vitamins
- Decrease exposure to toxins: limit alcohol consumption (10almonds tip: limit it to zero if you can), avoid foods that are likely high in heavy metals or pesticides, and check you’re not being overmedicated (there can be a bit of a “meds creep” over time if left unchecked, so it’s good to periodically do a meds review in case something is no longer needed)
- Practice intermittent fasting: Dr. Kuene suggests a modest 16–18 hours fast per week; doing so daily is generally considered good advice, for those for whom this is a reasonable option
- Build muscle: exercise in general is good for mitochondria, but body composition itself counts for a lot too
- Sleep: aiming for 7–9 hours, and if that’s not possible at night, add a nap during the day to make up the lost time
- Get near-infrared radiation: from the sun, and/or made-for-purpose IR health devices.
For more info on these (including the referenced science), enjoy:
Click Here If The Embedded Video Doesn’t Load Automatically!
Want to learn more?
You might also like to read:
- Coenzyme Q10 From Foods & Supplements
- How To Reduce Or Quit Alcohol
- Intermittent Fasting: What’s the truth?
- Build Muscle (Healthily!)
- Red Light, Go!
Take care!
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Stretching to Stay Young – by Jessica Matthews
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A lot of stretching gurus (especially the Instagrammable kind) offer advices like “if you can’t do the splits balanced between two chairs to start with, that’s fine… just practise by doing the splits against a wall first!”
Jessica Matthews, meanwhile, takes a more grounded approach. A lot of this is less like yoga and more like physiotherapy—it’s uncomplicated and functional. There’s nothing flashy here… just the promise of being able to thrive in your body; supple and comfortable, doing the activities that matter to you.
On which note: the book gives advices about stretches for before and after common activities, for example:
- a bedtime routine set
- a pre-gardening set
- a post-phonecall set
- a level-up-your golf set
- a get ready for dancing set
…and many more. Whether “your thing” is cross-country skiing or knitting, she’s got you covered.
The book covers the whole body from head to toe. Whether you want to be sure to stretch everything, or just work on a particular part of your body that needs special attention, it’s there… with beautifully clear illustrations (the front cover illustration is indicative of the style—note how the muscle being stretched is highlighted in orange, too) and simple, easy-to-understand instructions.
All in all, we’re none of us getting any younger, but we sure can take some of our youth into whatever years come next. This is the stuff that life is made of!
Get your copy of “Stretching To Stay Young” from Amazon today!
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Be A Plant-Based Woman Warrior – by Jane Esselstyn & Ann Esselstyn
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Notwithstanding the title, this book is not about being a woman or a warrior, but let us share what one reviewer on Amazon wrote:
❝I don’t want to become a plant based woman warrior. The sex change would be traumatic for me. However, as a man who proudly takes ballet classes and Pilates, I am old enough not to worry about stereotypes. When I see a good thing, I am going to use it❞
The authors, a mother-and-daughter team in their 80s and 50s respectively, do give a focus on things that disproportionally affect women, and rectifying those things with diet, especially in one of the opening chapters.
Most the book, however, is about preventing/reversing things that can affect everyone, such as heart disease, diabetes, inflammation and the autoimmune diseases associated with such, and cancer in general, hence the dietary advice being good for most people (unless you have an unusually restrictive diet).
We get an overview of the pantry we should cultivate and curate, as well as some basic kitchen skills that will see us well for the rest of the book, such as how to make oat flour and other similar mini-recipes, before getting into the main recipes themselves.
About the recipes: they are mostly quite simple, though often rely on having pre-prepared items from the mini-recipes we mentioned earlier. They’re all vegan, mostly but not all gluten-free, whole foods, no added sugar, and as for oil… Well, it seems to be not necessarily oil-free, but rather oil-taboo. You see, they just don’t mention it. For example, when they say to caramelize onions, they say to heat a skillet, and when it is hot, add the onions, and stir until browned. They don’t mention any oil in the ingredients or in the steps. It is a mystery. 10almonds note: we recommend olive oil, or avocado oil if you prefer a milder taste and/or need a higher smoke point.
Bottom line: the odd oil taboo aside, this is a good book of simple recipes that teaches some good plant-based kitchen skills while working with a healthy, whole food pantry.
Click here to check out Be A Plant-Based Woman Warrior, and be a plant-based woman warrior!
Or at the very least: be a plant-based cook regardless of gender, hopefully without war, and enjoy the additions to your culinary repertoire
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