THIS TIME ON CODE WACK!
This time on Code WACK! What’s the latest on efforts to rein in Medicare Advantage insurers and their questionable practices? What hurdles do patients face with Medicare Advantage plans when it comes to their care? Is Medicare Advantage a better deal for patients, or for insurers? And is Medicare Advantage actually fixable?
To find out, we spoke to Diane Archer, founder and president of Just Care USA, an independent digital media hub, covering health and financial issues facing boomers and their families. Miss Archer is the past chair of the Board of Consumer Reports, currently serves as a senior advisor at Social Security Works and as a member of the board of the Center for Health and Democracy.
SHOW NOTES
WE DISCUSS
When it comes to benefits, how do Medicare Advantage plans compare to traditional Medicare?
“…the (U.S. Health and Human Services’) Office of the Inspector General has found … that most Medicare Advantage plans, if not all, are not delivering the benefits that you would get in traditional Medicare.
“And part of the reason they’re not is because they’re using prior authorization requirements and putting in place rules about what care is medically reasonable and necessary that are more restrictive than the rules in traditional Medicare.” – Diane Archer
Are there other roadblocks to getting care that Medicare Advantage insurers commonly use?
“So in a Medicare Advantage HMO – and most Medicare Advantage plans are HMOs – … you usually need a referral from your primary care doctor before you can see a specialist. So that’s another hurdle because as we all know, accessing a primary care doctor can take weeks, right? They’re just not enough primary care doctors and they don’t have the time to schedule you quickly as a general rule.
“So in a Medicare Advantage plan HMO you could be waiting weeks to see a specialist because you need the primary care physician first to approve that specialty care.” – Diane Archer
What about out-of-pocket costs and Medicare Advantage?
“With Medicare Advantage plans … you are responsible … up to the out of pocket limit for in-network care – so up to as much as $7,550.
“So if you think you need to go to the emergency room, you’re saying to yourself, do I want to spend $1,000 or $2,000? I don’t know what this is going to cost me, or do I want to pray this isn’t an emergency and stay home?” – Diane Archer
Looking at the big picture, how does permitting private health insurers in Medicare affect our ability to manage public health?
“…one thing that traditional Medicare offers that we’re losing as more people enroll in Medicare Advantage, is a window into who’s getting care, where, when, how.
“It’s a window accessible only to the researchers but what it then allows us to do, in a moment when we’re in a pandemic, is to see where are people being hospitalized? What are the needs of those hospitals? How can we better ensure that people are getting the care they need?
“Because we can see what’s going on. Right now, again with Medicare Advantage, it’s a big black box. We don’t know what they’re paying for or how, and so we’re really at a loss.” – Diane Archer
Helpful Links
Letter to CMS on Prior Authorization and more, American Medical Association
Prior Authorization Physician Survey, American Medical Association
‘End the Scam’: Democrats Unveil Bill to Change Name of Medicare Advantage, Common Dreams
Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care, Office of Inspector General
Addressing Commercial Health Plan Challenges to Ensure Fair Coverage for Patients and Providers, American Hospital Association
Medicare Advantage: A Policy Primer, The Commonwealth Fund
Pitfalls of Medicare Advantage Plans, Investopedia
Many Patients Can’t Afford Health Costs Even With Insurance, Pew Trusts
Medicare vs. Medicare Advantage: Ill Health Often Leads to Plan Switch, Kiplinger
Episode Transcript
Read the full episode transcript.
Biography: Diane Archer
Diane Archer is founder and president of Just Care USA, an independent digital media hub covering health and financial issues facing boomers and their families.
Ms. Archer is the past chair of the Board of Consumer Reports. She began her career in health advocacy in 1989 as founder and president of the Medicare Rights Center, a national consumer service organization dedicated to ensuring that older and disabled Americans get the health care they need.
She served as director of the Health Care for All project for the Institute for America’s Future and currently serves as a senior advisor at Social Security Works. She is a member of the Board of the Center for Health and Democracy.
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