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This commentary is by Marvin Malek, M.D. and MPH, an internist who lives in Berlin.
Anyone who tunes into commercial television will find it impossible to avoid the deluge of TV ads promoting Medicare Advantage plans. The advertising is funded by the lavish profits these companies are raking in.
Joe Namath, the great New York Jets’ quarterback, among other well-paid geriatric opinion leaders, extol these plans, asserting that they cover everything in traditional Medicare and more, and for a lower price.
My mom taught me that if something sounds too good to be true, it probably is just that.
Here’s the rest of the Medicare Advantage story:
1. The networks: Unlike traditional Medicare, which covers care from nearly every physician and surgeon in the country, Medicare Advantage plans confine you to a limited network of physicians. This may work out if all your health problems turn out to be common ones. But if you’re traveling out of the area, or if your illness is serious and less common, there’s a good chance that the designated network will not meet your needs.
2. The copays.
If you buy traditional Medicare Supplemental Insurance, you’re responsible for minimal out-of-pocket payments. This is not the case for Medicare Advantage: You can expect significant copays with nearly all the medical services you receive.
If you use a service that generally healthy people receive — vaccines, primary care visits, screening mammography — copays will be minimal. But when you become ill, well. that’s a different story. Medicare Advantage plans are permitted to charge up to $8,300 annually — and considerably more if you dare to stray from the plan’s network of physicians.
3. The payment denials.
The rule that Medicare Advantage plans are required to follow is not that they cover all of Medicare’s services, but rather that they cover all medically necessary services available through the Medicare benefit.
When you sign up for an Medicare Advantage plan, who decides which services are medically necessary? You guessed it — the plan decides.
This is not a mere theoretical concern: During my six years working at Springfield Hospital, Medicare Advantage plans were denying payment frequently and almost at random — often for entire hospitalizations.
Some of these denials left me speechless: A Medicare Advantage plan denied payment for an agitated, delirious woman whose spinal tap showed clear evidence of a brain infection. The same occurred to an elderly patient with advanced dementia, who had fallen and broken her shoulder and hip. Given her poor prognosis, the family opted for comfort care. Her Medicare Advantage plan wanted her discharged the same day she was admitted, offering to pay only if that care occurred at home. Her nearly 90-year-old husband couldn’t possibly have cared for her at home. We did not even consider attempting to discharge her. And we were not paid. No leeway was granted. There are no exceptions.
Under traditional Medicare, patients who require rehabilitative physical therapy generally receive that service the day they’re ready. Rehab stays for patients in Medicare Advantage plans rarely begin before three days have passed, and are often never approved at all.
On the outpatient side, practitioners who order anything other than a routine test or treatment — especially primary care providers — can expect a time-consuming flurry of paperwork known as “prior authorization.” In this process, a Medicare Advantage employee sitting in a cubicle in a Dallas suburb gets to decide whether the plan will cover the treatment plan the doctor has proposed. It doesn’t matter that the individual sitting in the cubicle may have no medical training whatever, has never met your patient, and knows nothing of the issue your patient is facing.
According to Medicare data, Medicare Advantage plans required 35 million prior authorization procedures in 2021, and denied 2 million of them. This entire process imposes a great deal of stress and often materially worse outcomes for patients whose treatment was delayed, and is time-consuming and frustrating to primary care physicians who are in short supply and stressed out even without this gratuitous imposition.
Last year, the federal Office of the Inspector General found that at least 13% of prior authorization denials were inappropriate and 18% of payment denials were unjustifiable.
4. Getting out of Medicare Advantage.
Given these issues, it isn’t surprising that people are especially likely to exit Medicare Advantage plans and return to traditional Medicare when they become more significantly ill. When this occurs, the Medicare Supplemental plan you’ll want to purchase is allowed to review your medical record, and if your preexisting conditions appear to be costly, they can decide not to cover you, or charge you considerably more to buy the insurance.
5. Depleting the Medicare Trust Fund.
Given the above, you might get the impression that the taxpayers are saving money when Medicare beneficiaries sign on to a Medicare Advantage plan. But this is not the case: Medicare loses approximately $310 each time a Medicare enrollee signs up for a Medicare Advantage plan rather than traditional Medicare, depleting the Medicare Trust Fund of $10 billion-plus every year.
The Medicare program was founded in 1965 after years of grassroots public pressure following the demise of President Truman’s proposed universal, single-payer plan, leaving the elderly and the poor without health coverage. By contrast, there was never public pressure to privatize Medicare. The Medicare Advantage program was created in 1985 and expanded thereafter exclusively due to the pressure of powerful lobbyists — not the public.
The fundamental problem, however, is that traditional Medicare leaves its beneficiaries with large and potentially unlimited copays and deductibles. This reality has forced beneficiaries who wish to maintain control over their health care to pay the $175 or so monthly cost of purchasing Medigap and Part D pharmacy plans. Alternatively, one must accept the uncertainties, loss of control, and potentially high copays that are features of being a Medicare Advantage customer.
This is not a choice we should have to accept. Send a letter to all three members of our federal delegation, insisting that Congress improve the coverage in traditional Medicare, eliminating the potentially bankrupting deductibles and copayments so that there will be no further need for Medicare beneficiaries to contend with the expense and risk of these private plans.
And someone should arrange a tutorial on the Medicare Advantage program for members of the Scott administration who concocted the idea of shoving Vermont’s retirees into one of these Medicare replacement schemes.