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Medical “Advantage” for my indigent patients

Despite the aggressive marketing, Medicare Advantage plans offer little benefit for poor and vulnerable patients.

Consider my patient C, who was in pain from her knee arthritis. She was often in pain, but now her new pain medication helped her less than her previous one. She also wanted her old asthma inhaler back as the new one was harder to use. We had changed all her medications since her new Medicare Advantage insurance plan’s formulary (list of medications covered by a plan) was different. Patient W, with recently treated throat cancer, had to leave the longtime doctor he liked to a practice that worked with his new Medicare Advantage plan. There are countless more stories.

I have served as a physician for over fourteen years. My patients are mostly indigent, not employed as a result of disability, and have serious mental illnesses. Most of them qualify for Medicaid. Those who are over 65 or who have certain health conditions also qualify for Medicare. It is this subset that is getting on the Medicare Advantage plans. For most physicians, our knowledge about insurance comes from frustration over medication denials and prior authorization requests for patients. Only when I started navigating the system for my parents did I understand the different Medicare plans.

Traditional Medicare has existed since 1965 and pays for hospital and outpatient care. Medicare pays for 80 percent of costs, and most people need to get an additional supplemental Medigap insurance to pay the 20 percent “gap.” Medigap plans are aligned with traditional Medicare for coverage. Medicare Advantage plans are separate from Medigap plans. These plans, managed by insurance companies, came into being to improve efficiency and cut costs. They typically include Part D drug plans that pay for medications (these drug plans can be obtained as stand-alone plans with traditional Medicare). The “advantage “over traditional Medicare is potentially lower costs for the consumer. But most of my patients are dually eligible for Medicaid and Medicare, and their Qualifying Medicaid Benefits (QMB) pay for the 20 percent gap in Medicare. Since they do not need supplemental insurance, they gain nothing in the cost analysis.

My experience with traditional Medicare is through my parents. It has been uniformly good. We were never denied payment for tests or procedures. And Medicare is accepted just about anywhere in the country. I was never more thankful for traditional Medicare than when my mother needed specialty treatment, and I moved her care to an out-of-state hospital with the world’s leading specialist in that field. It spared us so much stress to expediently transfer her care without any need for insurance approval. That peace of mind was priceless. Medicare Advantage plans present more barriers and out-of-network restrictions. In contrast, Medigap plans will pay the 20 percent “gap” for anything traditional Medicare covers and in any facility where Medicare is accepted.

We are all subject to the relentless advertising of Medicare Advantage plans through television, robocalls, emails, and flyers. These efforts have been successful. To date, close to 50 percent of Medicare-eligible people are on Medicare Advantage. These plans have not reduced health care costs as was hoped or effectively insured low-income enrollees. There are concerns about overcharges and business models designed to inflate profits.

Medicare Advantage enrollees reported more affordability problems compared to traditional Medicare beneficiaries with supplemental insurance, even though Advantage plans usually have a cap on out-of-pocket expenses. Advantage plans tout access to dental and vision plans as a benefit that traditional Medicare does not offer. But it turns out many enrollees end up paying a majority of expenses out of pocket.

What about quality of care? Medicare Advantage enrollees were more likely to receive preventive care. But they were less likely to get care at high-quality hospitals and top-ranked cancer centers.

Enrollees in Medicare Advantage plans and traditional Medicare report no difference in satisfaction with their health care. To be sure, that is a favorable sign. However, people with complex health needs and those who are dually eligible are more likely to switch to traditional Medicare. This suggests that Medicare Advantage may not meet the needs of sicker people with increased health care needs and those who do not have to worry about the “gap” in Medicare coverage. My patients would belong to both categories.

Newly eligible Medicare enrollees are subject to aggressive Medicare Advantage marketing and very little marketing or information for traditional Medicare with Medigap. Poor patients with mental illness or cognitive problems are among the most vulnerable to disingenuous marketing. Shepherding them toward a health care plan without informed decision-making worsens the inequality they already experience. As a society, we should help our most vulnerable people make choices that are right for them.

This is open enrollment time. It is not open season for exploitation.

Aniyizhai Annamalai is an internal medicine-psychiatry physician.


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