Medicare Advantage is not Medicare!

MedicareCMS the parent organization of Medicare has gone to the private sector and contracted with private health insurance companies including United Healthcare, Blue Cross Blue Shield, Aetna, Cigna and others to offer a private managed care insurance product to Medicare age recipients.  CMS or “Uncle Sam” is supposed to pay a flat fee for all the services rendered to a Medicare recipient to the private insurer to cover their enrollees’ medical needs. The fee was originally 95% of what Medicare paid on the average for a Medicare patient annually. This was supposed to save the government money.  In exchange for that annual fee the insurer or Medicare Advantage plan is supposed to cover your health care, provide pharmaceutical coverage and products and provide a set of extras or enhancements such as eye glasses, sneakers, gym memberships for wellness programs. It is managed care. There are strict rules and regulations about who you can and cannot see as a physician. There is a strict formulary of medications and there are contracted institutions you must go to such as hospitals, labs and imaging centers to receive appropriate tests. For the coverage to apply you must see a physician contracted to that insurance company’s panel. Non-emergency hospital admissions, trips to the emergency room and post illness care are all subject to the approval and review of non-physician personnel before the insurance company will pay for it. You lose your choice of going to the best institution or practitioner in exchange for lower up front monthly costs, minimal or no co-pays, no out of pocket pharmaceutical donut hole costs and the extras, glasses, sneakers, gym memberships.  You are issued a Medicare identification card that is virtually indistinguishable from the card a traditional Medicare patient uses. It is less expensive to the patient and works wonderfully if you are healthy and do not need health care.  Unfortunately individuals over 65 years old usually have or develop medical issues frequently.

B.J. is an 89 year old retired physician who got his Medicare Advantage plan through his medical society in the NY metropolitan area. He suffered a series of small strokes and was hospitalized for four days after being brought to the hospital by the paramedics on an urgent basis. His speech was impaired, his strength and balance did not allow him to walk without assistance. He was swallowing poorly with food as likely to end up going down the wrong pipe and choking him as it was to get into his stomach, so nutrition was an issue.  His wife and daughter did not feel he could go from the hospital directly home because he was too weak to walk.  His elderly wife could not handle him in this weakened state.  I suggested a short stay in a skilled nursing facility for strengthening, gait and balance training and speech therapy to rejuvenate his swallowing process safely.  We checked on the bed availability at three of the facilities in our area that did a nice job with this type of problem and there was bed availability. His health insurance was a Medicare Advantage plan, the Empire plan. They wanted him to be placed in a facility that I would not send my worst enemy to. They wanted him to go home from the hospital. The hospital case manager and I spent two days arguing with them about the need for placement, extending the patient’s hospital stay by two days and then they only approved a two day stay with a reassessment to be done on the third day which was a Saturday.   Had he been a traditional Medicare patient we would have sent him to the best place for his problem and he would have been eligible to stay for 21-30 days with full coverage. Post illness care can be a problem with Medicare Advantage plans.

Then there was H.B. a 69 year old overweight hypertensive man, still running his business, with new onset of significant shortness of breath and chest heaviness when walking a short distance.  We called the cardiologist “on the plan” who set up an appointment two weeks later. I called him to discuss the need for a timelier visit but it is managed care and that is the best he could do. . The cardiologist ordered a nuclear stress test after seeing him. This required approval again and this took his staff three more days. The test was scheduled for a week after that.  He flunked that test. The cardiologist wished to perform an angiogram to look for blockages. He referred the patient to an interventional cardiologist on the plan who could not see the patient for three weeks.  He saw the patient three weeks later and recommended doing a cardiac catheterization or angiogram.  It was scheduled for the next week instead of the next day as it should have been. When the patient arrived early in the morning for his catheterization as an outpatient he was told that the insurance company had not yet approved the procedure. He lay on a gurney from 7am until 2:35 PM without getting approval, or fluids, or a meal.  At 2:40 PM they sent him home. This occurred two more times on two separate days before the approval was obtained. The angiogram showed a 97% blockage of a left main coronary artery which they could not pass a stent through.  Try as they might they could not get it through. The interventional cardiologist was the practitioner under contract to the plan not necessarily one of my top choices or the most skilled in our area for that problem. He called in a cardiovascular surgeon to bypass the lesion surgically.  He took him to the ER later that day and successfully bypassed the blockage.  He approached me after the procedure and asked me, “Why did you guys wait so long to get him tested and some treatment. He was lucky with that “widow maker lesion that he didn’t drop dead. Why did it take eight weeks to get him fixed? ”

The next few months are the open enrollment period for individuals who qualify for Medicare to either stay in the traditional program or switch to a Medicare Advantage plan.  Managed care Medicare Advantage plans work well if you are healthy and if your budget does not allow you to buy a co- insurance policy and pay any portion of your prescription medication costs. If you sign up for the Medicare Advantage plan you to relinquish your choices. Think twice before you give up your freedom and choice to save a few dollars per month.

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