IN THIS EPISODE
What are the major differences between Original Medicare and Medicare Advantage? How do the two programs compare when it comes to accessing care?
To get the facts, join host Brenda Gazzar and Ed Weisbart, MD, a retired family physician, former chief medical officer of Express Scripts and a national board member of Physicians for a National Health Program.
From narrow provider networks to pre-authorizations and claims denials, Dr. Weisbart shares the nitty-gritty on Medicare Advantage. What is the Medicare Advantage business model? Why are so many Medicare Advantage insurers being accused of fraud?
SHOW NOTES
WE DISCUSS
One key difference between traditional Medicare and Medicare Advantage is who pays the claims. Why is this difference so important?
“…when Medicare pays your claims …, that’s their only job … They don’t get in the way, they’re not not trying to make money off of you … But if you have opted into Medicare Advantage, Medicare itself is no longer paying your claims at all. Instead, Medicare is paying an insurance company to pay your claims and the insurance company, as we all learned from having employer-based insurance and other things, is really not out to just pay your claims. They’re out to make money …” – Ed Weisbart, MD
99% of Medicare Advantage plans impose pre-authorizations. How does this affect access to health care?
“There’s an awful lot of things that you just simply can’t go get, even if you and your doctor think it’s important and medically necessary and appropriate, there’s this, you know, set of bureaucrats in a Medicare Advantage company, an insurance company that knows if it’s expensive, that’s less profit for them. And so they require the physician to get it prior authorized.” – Ed Weisbart, MD
Is there a particular good reason to choose Medicare Advantage?
“No, the only reason to pick Medicare Advantage is that the upfront short term costs, if you’re healthy, can be lower … than they would be in traditional Medicare, particularly if you have to buy a supplement, which you should. So the upfront short term costs are lower. But once you get even a little bit sick, the personal financial advantage of being in Medicare Advantage disappears. And I am unaware of any evidence of better health outcomes or, or a subpopulation that Medicare Advantage does a splendid job at [covering].” – Ed Weisbart, MD
Helpful Links
Differences between Original Medicare and Medicare Advantage, Medicare Rights Center
Pitfalls of Medicare Advantage Plans, Investopedia
‘Straight Up Fraud’: Data Confirms Private Insurers Use Medicare Advantage to Steal Billions, Common Dreams
Switching Between Medicare Advantage And Traditional Medicare Before And After The Onset Of Functional Disability, National Library of Medicine
Medicare vs. Medicare Advantage: Ill Health Often Leads to Plan Switch, Kiplinger
Episode Transcript
Read the full episode transcript.
Biography: Ed Weisbart, MD
Ed Weisbart, MD, is a national board member of Physicians for a National Health Program and health policy advisor for Code WACK!
He practiced family medicine for 20 years at Rush Medical Center in Chicago and spent seven years as chief medical officer of Express Scripts until retiring in 2010 to devote his time to advocating for healthcare justice.
He is an author and popular speaker about single-payer health care, the ongoing attacks on today’s Medicare program, and how to find common ground across political chasms.
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