Government-run Medicare incentives are overmedicating America’s seniors, turning healthcare into a profit-driven machine that burdens families and drains taxpayer dollars.
Story Snapshot
- Medicare Advantage plans profit from upcoding diagnoses, leading to overdiagnosis and polypharmacy among seniors.
- Deprescribing remains unrewarded, trapping patients on unnecessary medications despite decades of warnings like Beers Criteria.
- 2025 WSJ investigations exposed insurers like UnitedHealth using home nurses to inflate risk scores for higher payments.
- DOJ probes signal growing scrutiny, yet systemic incentives persist under bloated federal programs.
Systemic Incentives Fuel Overmedication
Medicare Advantage risk-adjustment payments reward plans for documenting more illnesses in seniors. Insurers receive higher reimbursements for sicker-coded patients, encouraging upcoding through home nurse visits. This government-designed system prioritizes billing over patient health, resulting in polypharmacy—patients on 5 or more medications. Cato Institute analysts highlight how third-party payers create moral hazard, shielding patients from costs while providers chase revenue. Persistent low-value drug use follows, as deprescribing offers no financial upside.
Recent Exposés Ignite Federal Probes
January 2025 Wall Street Journal reports detailed UnitedHealth Group’s tactics, dispatching nurses to uncover “missed” diagnoses for coding boosts. February 2025 Justice Department investigations followed, targeting upcoding practices confirmed by prior audits and settlements. These developments underscore how Medicare’s formulas, expanded since the 2000s, drive excess without accountability. Seniors in Medicare Advantage, now over 50% of enrollees, face heightened risks from this profit model. President Trump’s administration eyes reforms to curb such federal overreach.
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Harms to Seniors and Taxpayers Mount
Polypharmacy doubles medication-related problems for those on 11+ drugs, raising falls, fractures, and hospitalizations. Annual costs hit $2 billion from mismanaged prescriptions, burdening Medicare Part D beneficiaries with chronic conditions like diabetes and heart failure. Iatrogenic multimorbidity emerges from drug interactions and overtreatment. Caregivers shoulder added complexity, while taxpayers fund inflated payments. Limited patient price signals perpetuate the cycle, demanding incentive overhauls over mere guidelines.
Stakeholders Profit Amid Patient Risks
Medicare Advantage plans like UnitedHealth maximize revenue through risk scores, holding financial control. CMS sets payment formulas aiming for cost containment, yet mismatches incentivize complexity. Physicians and pharmacists prioritize time-efficient prescribing, as deprescribing remains unreimbursed. Seniors, shielded from costs, suffer low visibility into harms. Clinical bodies like Beers Criteria warn against inappropriate elderly drugs since 1991, but persistence endures.
2017 CMS Medication Therapy Management expansions target high-risk patients, reducing issues in diabetes and CHF, yet underutilize for polypharmacy. Cedars-Sinai pilots EHR risk models for pharmacist interventions. Experts urge payment redesigns to align with conservative principles of limited government and individual accountability. Ongoing DOJ outcomes remain uncertain, but probes pressure change.
Sources:
The System That Rewards Excess—the Incentives Behind Overdiagnosis, Overtreatment, and Polypharmacy
Polypharmacy and Medication-Related Problems Among Medicare Beneficiaries
Polypharmacy: Prescription for Better Interventions Needed to Reduce Risks
