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Friday, 13 June 2014 08:03

What is Medicare Advantage?

Written by  Dan Woodard, Center for Public Integrity, Team SCPA

UPDATED June 18, 2014, 4:30pm

June 18, 2014

Dr. Woodard responds to DWB email dtd June 14:
More about Medicare Advantage

By Dr. Dan Woodard

I am all for senior citizens, as my wife is one and I will be as well in a few short years.

I did not say that Medicare Part C limits "coverage."

I said that, like all managed care plans, it limits "access," and it certainly does.

"Persons who enroll in a Medicare Advantage HMO cannot use certain specialist physicians or out-of-network providers without prior authorization from the HMO, except in emergencies. This can be a problem for people who need to use specialists or who are hospitalized and are forced to use out-of-network doctors while in the hospital." -- Wikipedia, "Medicare Advantage."

This is always an element of managed care; costs are held in check by requiring the patient to see only providers who work for the plan, and who are given incentives to minimize costs. Only tests, referrals, treatments and medications that are actually ordered by the plan's physicians are paid for. This limits the care actually available to the patient, regardless of what the plan may "cover".

As stated in the annual Medicare reports to Congress, the 2003-law payment formulas purposely overcompensated Part C plans by 12 percent or more on average compared to what Original Medicare beneficiaries received in the same county on average, in order to increase the availability of Part C plans in rural and inner-city geographies. (Wikipedia, "Medicare").

This constitutes a subsidy.

By 2017, when the new benchmarks (the standard federal payments to insurers) are fully phased-in, the benchmarks will range from 95% of traditional Medicare costs in the top quartile of counties with relatively high per capita Medicare costs (e.g., Miami-Dade), to 115% of traditional Medicare costs in the bottom quartile of counties with relatively low Medicare costs (e.g., Boise). However the insurer may charge both an additional premium and copayments for each visit or prescription.


June 16, 2014

see About Medicare Advantage, by Dr. Stephen Blythe


June 14, 2014

reader DWB writes: re: Your article: "What Is Medicare Advantage"

Your article about the public Part C Medicare Advantage health plan program crosses over from the usual left-wing lies to actual hate speech against senior citizens. Don't let you readers see the truth though: the description of who Part C is paid for is wrong; the description of what the "subsidy" does is wrong; and it is an absolute despicable lie by the author of this article to say there is any limit on treatments in Part C as compared to Parts A and B.


June 13, 2014

What is Medicare Advantage?

by Dr. Dan Woodard

[Ed. note: You may have seen promotion of Medicare Advantage. So, what IS Medicare Advantage? Knowing Dr. Woodard speaks in straight language, we asked hime to explain Medicare Advantage to us.]

Medicare Advantage uses Medicare tax dollars to provide a rather generous subsidy for an insurer (in this case Health First), which in turn replaces Medicare with an HMO-like health plan. This allows the insurer to rather easily limit the patient's access to providers and treatments and thus is a lot more profitable than traditional Medicare. In fairness the patient does get full coverage for medications but this could have easily been provided for everyone under traditional Medicare if our representatives in Congress had permitted the government to negotiate drug prices, an inexplicable restriction which Congress did not choose to apply to the insurance companies.

The Obama Administration is trying to limit the growth of Medicare Advantage for the simple reason that it costs the taxpayers more than traditional Medicare, and the difference goes mainly to the insurance companies, not doctors, nurses, or patients. For the same reason the insurance industry is using its lobbying muscle to maintain the status quo and convince seniors that the additional drug coverage under the plan comes from their efficiency and generosity.

Dr. Daniel Woodard is a board certified emergency physician who has practiced in Brevard County for the past twenty-five years. He also works in the space program -- he has supported over one hundred shuttle launches -- in medical research, where he studies the biochemistry of Alzheimer's disease.



Why Medicare Advantage costs taxpayers billions more than it should
Center for Public Integrity, by Fred Schulte / First in a series


In South Florida, one of the nation’s top privately-run Medicare insurance plans faces a federal investigation into allegations that it overbilled the government by exaggerating how sick some of its patients were.

In the Las Vegas area, private health care plans for seniors ran up more than $100 million in added Medicare charges after asserting patients they signed up also were much sicker than normal — a claim many experts have challenged.

In Rochester, New York, a Medicare plan was paid $41 million to treat people with serious diseases — even though the plan couldn’t prove the patients in fact had those diseases.

These health plans and hundreds of others are part of Medicare Advantage, a program created by Congress in 2003 to help stabilize health care spending on the elderly. But the plans have sharply driven up costs in many parts of the United States — larding on tens of billions of dollars in overcharges and other suspect billings based in part on inflated assessments of how sick patients are, an investigation by the Center for Public Integrity has found.

Dominated by private insurers, Medicare Advantage now covers nearly 16 million Americans at a cost expected to top $150 billion this year. Many seniors choose the managed-care Medicare Advantage option instead of the traditional government-run Medicare program because it fills gaps in coverage, can cost less in out-of-pocket expenses and offers extra benefits, such as dental and eye care.

But billions of tax dollars are misspent every year through billing errors linked to a payment tool called a “risk score,” which is supposed to pay Medicare Advantage plans higher rates for sicker patients and less for those in good health.

Government officials have struggled for years to halt health plans from running up patient risk scores and, in many cases, wresting higher Medicare payments than they deserve, records show. …


Medicare Advantage Lobbying Machine Steamrolls Congress
Center for Public Integrity, by Fred Schulte


… Some of the nation’s mightiest insurance carriers -- UnitedHealth Group and Humana Inc. are two of the biggest -- dominate the market and are deeply invested in keeping Medicare Advantage alive and thriving. The health insurance industry’s main trade group, America’s Health Insurance Plans, or AHIP, funds its own “grassroots” lobbying group and its members dole out millions of dollars in federal campaign contributions.

The top 10 Medicare Advantage companies in terms of enrollment unleashed as many as 145 lobbyists in 2013, according to Senate Office of Public Records data. AHIP spent nearly $2.5 million in the first quarter of 2013 lobbying senators and congressmen on health care issues, according to Senate filings. Ultimately, their assertion that cuts to the insurers would harm seniors trumped criticism that the health plans can be a poor value for taxpayers.

The magnitude of Medicare Advantage overcharges is staggering by any measure. An investigation by the Center for Public Integrity found that by the government's own calculations, Medicare paid the health plans nearly $70 billion in “improper” payments -- mostly inflated charges from overstating the health risks of patients -- from 2008 through 2013 alone.

The health plans, which are paid a varying fee for each person they enroll, also have driven up Medicare costs in many parts of the country. The Center’s analysis of Medicare enrollment data uncovered more than 550 counties where payments to Medicare Advantage plans have been at least 25 percent higher than the average costs of treating seniors who remain on standard Medicare. ...


Accepting Medicaid expansion in Florida would save money, by Dr. Woodard; and If Gov. Scott is can-do guy, why doesn't Florida have Medicaid expansion?


Series by The Center for Public Integrity focuses on Medicare Advantage Money Grab



Dr. Daniel Woodard is a board certified emergency physician who has practiced in Brevard County for the past twenty-five years. He also works in the space program -- he has supported over one hundred shuttle launches -- in medical research, where he studies the biochemistry of Alzheimer's disease.

The Center for Public Integrity. The Center’s mission is to serve democracy by revealing abuses of power, corruption and betrayal of public trust by powerful public and private institutions, using the tools of investigative journalism.

-- compiled by Team SCPA.


Last modified on Tuesday, 05 August 2014 09:58
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