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Monday, 16 June 2014 17:21

About Medicare Advantage

Written by  Dr. Stephen Blythe

About Medicare Advantage
by Dr. Stephen Blythe

The idea of Medicare Advantage plans (also known as a "Medicare HMO") was to encourage cost savings by shifting risk to the insurance companies. Instead of billing Medicare in the typical "fee-for-service" manner, the Medicare Advantage Plans would be given an amount that should cover the care of the Medicare patient -- if the providers for the Medicare Advantage plan spent more, it was a loss for the plan. So the plans generally utilize networks of providers (physicians, labs, imaging facilities, and hospitals) all of whom offer discounts for their services. The risk to the plans is made more palatable by the fact that these plans are given more than the average cost to provide care to Medicare patients. Therein the controversy...
It is a good-news, bad-news scenario. These plans compete with each other by offering seniors services which may not ordinarily be covered by Medicare -- annual physicals (which until recently were not covered), no donut-hole in prescription coverage, etc. On the other hand, patients do not have free reign to seek care anywhere they wish -- they technically no longer "have Medicare." They must stick within the network and often must obtain authorization for referrals and services, especially expensive services such as MRI scans. This is no different than patients with coverage under many commercial insurances, but is much more restrictive than standard Medicare. This benefits the taxpayer and the Medicare Program by putting some not unreasonable brakes on runaway costs from excessive and duplicate testing. With straight Medicare, for example, I can order an MRI on a patient with back pain simply to more clearly define their problem. While this is very informative, it does not necessarily change my treatment plan. When the patient sees the back specialist, that specialist can order ANOTHER MRI just because they like their machine better than the on at my hospital. With a Medicare HMO, just like a commercial HMO, I have to document that the patient is a candidate for a treatment such as injections or surgery, for which the MRI is a necessary prerequisite, before it will be authorized. To me this is not inappropriate. At times the Medicare Program seems like a blank check (although they certainly don't pay generous amounts for the services they cover!).
I participated in the past not only as a provider but also as a member of the physician advisory board for the Health First Medicare Advantage plan. My impression was that they were very dedicated to providing excellent care to their member patients. Denials of services could be appealed -- I don't know that I was ever witness to a reasonable request being denied. They focused on and pushed preventive services long before ObamaCare came along emphasizing and paying for these services.
Problems for the patients center on accessibility -- especially with a regional insurer such as Health First, if you travel out of the area you have no coverage other than an emergency room (unless they have changed that). It is also difficult to see a specialist who is out of network. Snowbirds could not have a physician in Maine where they lived for four months out of the year under this plan.
But problems for the system in general stem from two issues -- how much they are reimbursed, which has always been MORE than the average Medicare expense. Many argue that the costs of managing this care are more than paid for by the savings generated. These plans have been very profitable for the insurance companies. The second problem can be more subtle. These plans are often accused of using subtle ways of cherry-picking the healthier seniors. Having general information luncheons at restaurants (especially those not on a bus line in big cities) helps weed out seniors who are too frail to come to lunch. While offering a gym membership as part of the HF Medicare Advantage Plan is a fantastic benefit for seniors, it also serves to attract the healthier seniors -- the non-smokers and the ones who take care of themselves -- to the HMO. This means that although reimbursement may be based on the "average" senior, the plans try to enroll more "healthier-than-average" seniors.
I see these as problems that need to be monitored and corrected, more than as an indictment of the general concept. We have to find ways to reign in health care costs, and currently with Medicaid and Medicare there is no real oversight to services performed. In the "fee-for-service" world where the more you do, the more you get paid, costs get higher and higher. While we are not necessarily to the point of rationing care, we do need to apply some reasonable resistance.
A good example -- several major studies have shown that cardiac catheterization and stenting does not reduce the risk of heart attacks and does not extend the life of people with heart disease if they are maximally treated medically (baby aspirin, statin for cholesterol, blood pressure control, exercise, and stop smoking). The main benefit of cardiac catheterization and implanting stents in narrowed arteries is to reduce chest pain and associated symptoms. So in reality, unless someone with heart disease is having major symptoms, they do not need a visit to the cardiac cath lab -- they just need "aggressive medical management."  But with more and more (fee-for-service) cardiologists making more and more money by cathing everyone in sight, there is no slowdown in sight of the cath-lab assembly line. Fortunately, the Affordable Care Act includes new ways of reducing fraud, but until we get to a single-payer system, regulate drug costs, and pay physicians NOT through fee-for-service, our health care costs will continue to escalate to the point of bankruptcy.
Stephen Blythe, D.O., Down East Community Hospital Family Medicine, 229 Main St., Suite 2, Machias, ME 04654. Dr. Blythe is a former resident of Brevard County.



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Compiled by Team SCPA


Last modified on Tuesday, 05 August 2014 10:00
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