Medicare Is in Desperate Need of Modernization and Expansion -- Not Privatization

[Jilly_in_VA]

By Jamila Headley & Nicole Jorwic

For 58 years, Medicare and Medicaid have provided life-saving and life-sustaining care for millions of Americans, but they are rapidly being weakened by politicians who insist on inviting corporations to oversee their implementation.

Health insurance companies are creeping into Medicare and Medicaid via so-called “managed care.” Often proposed as a cost-saving measure, managed care is when patients agree to visit only certain doctors and hospitals, and the cost of treatment is monitored by a managing company. Here in the United States, these companies are often corporations focused on maximizing profit at the expense of patients.

Gary Bent — a man who spent his entire life faithfully paying into Medicare — was just one of the millions of patients who have been denied crucial care because of corporate intrusion into the administration of Medicare benefits.

When Bent finally became eligible for the Medicare benefits he paid into, his employer placed him on a Medicare Advantage plan — a plan administered by a private health insurance company, rather than on a traditional government-administered Medicare plan. But in 2022, when Gary was diagnosed with melanoma for the second time, prior-authorization denials led to delays in getting the rehabilitation services and skilled nursing care he needed. He died March 3, 2023, of complications due to melanoma.

“It has been hard for me not to dwell on how things might have been different for my father, for our family, if my dad had just received the care he needed when he needed it,” said Bent’s daughter, Megan Bent, as she spoke to a small crowd gathered in front of the United States Capitol to commemorate the 58th anniversary of Medicare on July 25, 2023.

https://truthout.org/articles/medicare-is-in-desperate-need-of-modernization-and-expansion-not-privatization/

Medicare Advantage is a goddam SCAM! I tried it for 6 weeks, but after a post-auth denial for desperately needed PT I dropped it and went back on straight Medicare. Single Payer for ALL!

[randr]

1. The predatory class has been after this pile of money for a long time

Reform and Privatization are the buzz words.

[Walleye]

2. I was the same, didn't know what to do.

Somehow got on Medicare advantage, didn't like it, although I guess it works for some people, they were making me pay for the colonoscopy that Medicare will pay for. I’m on straight Medicare now. It sucks, I feel like some companies are always trying to scam old people.

[yellowdogintexas]

21. A diagnostic colonoscopy should have been covered under ACA rules

If it was for treatment, it is subject to deductible and co insurance.

[dalton99a]

3. Kick

https://www.statnews.com/2023/03/13/medicare-advantage-plans-denial-artificial-intelligence/
https://archive.ph/QPCf0

Denied by AI: How Medicare Advantage plans use algorithms to cut off care for seniors in need
By Casey Ross and Bob Herman
March 13, 2023

...

Health insurance companies have rejected medical claims for as long as they’ve been around. But a STAT investigation found artificial intelligence is now driving their denials to new heights in Medicare Advantage, the taxpayer-funded alternative to traditional Medicare that covers more than 31 million people.

Behind the scenes, insurers are using unregulated predictive algorithms, under the guise of scientific rigor, to pinpoint the precise moment when they can plausibly cut off payment for an older patient’s treatment. The denials that follow are setting off heated disputes between doctors and insurers, often delaying treatment of seriously ill patients who are neither aware of the algorithms, nor able to question their calculations. ...

But even patients who win authorization for nursing home care must reckon with algorithms that insurers and care managers like NaviHealth use to help decide how long they are entitled to stay. Under traditional Medicare, patients who have a three-day hospital stay are typically entitled to up to 100 days in a nursing home.

With the use of the algorithms, however, Medicare Advantage insurers are cutting off payment in a fraction of that time.

“It happens in almost all these cases,” said Christine Huberty, a lawyer in Wisconsin who provides free legal assistance to Medicare beneficiaries. She said Medicare Advantage patients she represents rarely stay in a nursing home more than 14 days before they start receiving payment denials.

...

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https://www.washingtonpost.com/health/2023/10/01/medicare-advantage-algorithm-changes/
https://archive.ph/oqaDa

U.S. to rein in technology that limits Medicare Advantage care
By Susan Jaffe
October 1, 2023 at 7:00 a.m. EDT

...

“Advantage plans routinely cut patients’ stays short in nursing homes,” she said, including Humana, Aetna, Security Health Plan and UnitedHealthcare. “In all cases, we see their treating medical providers disagree with the denials.”

New federal rules for Medicare Advantage plans beginning Jan. 1 will rein in their use of algorithms in coverage decisions. Insurance companies using such tools will be expected to “ensure that they are making medical necessity determinations based on the circumstances of the specific individual,” the requirements say, “as opposed to using an algorithm or software that doesn’t account for an individual’s circumstances.”

David Lipschutz, associate director of the Center for Medicare Advocacy, questions how CMS will enforce the rules, which don’t include specific penalties for violations.

...

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“When we did focus groups with brokers, many said they are paid more to put people into Medicare Advantage plans, sometimes much more,” Jacobson said. But “if they were going into Medicare tomorrow, most of them said they would choose to be in traditional Medicare.” These brokers do not get any commission for helping someone enroll in original Medicare. Likewise, they said most Part D prescription plans don’t offer commissions; for those that do, the rate is low. As for Medigap policies, an agent might get some money for signing people up, but agents say it’s not as much as what they get for a Medicare Advantage enrollment.

https://www.aarp.org/health/medicare-insurance/info-2023/will-original-medicare-survive-medicare-advantage.html

[RicROC]

4. When I became eligible for Medicare, I consulted with a broker.

She put me on 'Medicare'. A couple years later, I switched to another broker who put me on 'Medicare'.

Last year, I checked with both of them-I want to be sure that I'm still on 'Medicare' and both of them said,
'You're never been on Medicare, you're on an Advantage plan!"

Fortunately for me living in New York State, I could easily switch to the genuine traditional Medicare program, but in 47 other states, I understand if one has been on MAdvantage for over a year, it might not be possible. Depends on the whim of the Medicare underwriters.

YouTube videos have a wealth of information about the differences.

[dalton99a]

5. +1. Many brokers choose a plan that gives them the biggest commission from the insurance company

which is Medicare Advantage.

What kind of plan would they choose for themselves?

“When we did focus groups with brokers, many said they are paid more to put people into Medicare Advantage plans, sometimes much more,” Jacobson said. But “if they were going into Medicare tomorrow, most of them said they would choose to be in traditional Medicare.” These brokers do not get any commission for helping someone enroll in original Medicare. Likewise, they said most Part D prescription plans don’t offer commissions; for those that do, the rate is low. As for Medigap policies, an agent might get some money for signing people up, but agents say it’s not as much as what they get for a Medicare Advantage enrollment.

https://www.aarp.org/health/medicare-insurance/info-2023/will-original-medicare-survive-medicare-advantage.html

[Silent Type]

6. Anyone have a guess as to what decade they'll get around to modernizing Medicare? 2040, 2050?

Until then, Medicare Advantage is the best many people can afford.

As of 2023, the majority (51%) have chosen it. Incessant advertising has certainly helped growth, but it is the best many can afford on a monthly basis compared to traditional Medicare, a supplement, and a drug plan.

[PortTack]

7. End the Medicare advantage plans and Medicare would be fine

https://www.npr.org/sections/health-shots/2022/12/12/1141926550/medicare-advantage-plans-overcharged-taxpayers-dodged-auditors

[MichMan]

10. Telling millions of voters that like their MA plans that you plan on taking them away from them...

doesn't seem like a winning political strategy to me.

[Silent Type]

16. Yep, telling 31 Million (51% of Medicare beneficiaries) they are too stupid to choose what's best

for them will not go over very well.

While I don't have hard facts, I would bet at least half of those 31 Million are Democrats, maybe more.

[PortTack]

22. It's the truth

When something seems to good to be true it usually is.

These plans were designed to bankrupt and privatize Medicare, and so far it’s working

[Silent Type]

23. Lucky to have people who are smarter than 31 Million Medicare beneificiaries who decide MA is best

for them. Do I need a sarcams thingy?

Until we overhaul Medicare and entire healthcare structure, Medicare Advantage is best for a lot of people. I think we should criticize government for not doing something about it, rather than criticizing people forced into MA by cost.

[republianmushroom]

8. agree

[MichMan]

9. Why did his employer hsve anything to do with it?

When Bent finally became eligible for the Medicare benefits he paid into, his employer placed him on a Medicare Advantage plan — a plan administered by a private health insurance company, rather than on a traditional government-administered Medicare plan.

He could have chosen regular Medicare just like anyone else does.

[yellowdogintexas]

12. Most likely he was still working, and transitioning from the regular company

plan to Medicare. The rules when I became eligible allowed one to delay moving to Medicare without late enrollment penalty.

It is possible that the Advantage plan is underwritten and managed by the same insurance company which managed his original coverage. Somewhere buried in the fine print there may be a clause which authorizes the company to automatically transition the employee to that plan.

At least we have the option under Medicare rules to change plans during open enrollment. I think that if you start out with Advantage, then change to Part B and later decide to go back to Advantage you become subject to underwriting. Part B does not do underwriting.

It's a mess!

When my brother in law went from Farm Bureau to Medicare, the local agent emphatically told him to not even bother with anything other than Medicare B with a supplement and Part D because the networks in their area are sparse and do not go across state lines. (They are on the state line between Ky and Tn and all their doctors are in Tn)

[Auggie]

11. Like anything these days, do your research.

If you’re unable to, ask trusted friends and family for help.

[GoneOffShore]

13. When I was signing up 10 years ago, my insurance person called it Medicare Disadvantage

Now I am completely out of the system and am covered under the French system.

[erronis]

14. I'm surprised the usual suspects haven't chimed in about how fine MA is.

There have been some regulars that jump into these types of conversations and give us their "unbiased" anecdotes about how they got fantastic coverage along with dental, vision, etc. I'll update my post when I see one of them....

[Silent Type]

17. Here's one. Although I am on traditional Medicare now, if Kaiser comes my way, I'm signing up.

Even if not, I suspect MA will become all I can afford when my savings run out in a few years.

It is nice to have such smart people telling me -- and 31 Million Medicare beneficiaries, the majority -- how stupid we are.

[PoindexterOglethorpe]

15. Actually, it's our entire "health care system" that needs modernization

and expansion, not just Medicare.

I suspect that Advantage Plans vary every bit as much as regular health insurance plans. I've never experienced a problem with being denied care on either system. For what it's worth, I have Humana.

About 14 years ago I worked at the local hospital doing outpatient registration. I learned to despise Blue Cross Blue Shield. There are countless, several thousand different versions, and each one was worse and more restrictive than the other.

A few years ago after my heart attack the $80,000 plus bill was completely paid for. As was my more recent $7,000 ER visit with a broken arm. I had, if I recall correctly, no co-pay for the first, and a $25.00 copay with the second. Various follow-up visits have all been just the $25.00 copay.

I know, terrible, isn't it? Oh, and the three prescription medications I currently take have zero copay, but I think that has nothing to do with my Advantage Plan, but some other changes that have been made under Biden.

At least with Advantage Plans, if you choose that route, you will probably have several to choose from. With an employer plan, you almost never have a choice, although I'm under the impression that federal government employees do get to choose from a large set of options. I've been where my husband's company decided to change plans, I had to find us new doctors, which was a royal pain. Fortunately, after a year they went back to the old plan and I could get us back to our familiar providers.

[Silent Type]

18. Exactly.

[Bayard]

19. K&R

[AncientOfDays]

20. Not all MA the same?

I have Kaiser Medicare Advantage - I have NEVER needed pre-authorization that I know of. Just referral from GP pr Urgent Care as is standard everywhere.

[Silent Type]

24. I had Kaiser when employed. I liked it. They were big on preventive care and made sure you got it.

I remember when I started they made me take a different version of a drug I had been on for many years.

Their explanation made a lot of sense. I had been taking a newfangled drug that you take only once a day vs. the version Kaiser approved, requiring 2 a day.

I called and the pharmacist explained it to me. The new drug cost Kaiser $400 a month, yet it wasn't a bit different than the drug they approved, except it had to be taken twice a day. The old -- twice a day drug -- was about $20. I thanked them for actually giving a damn about the cost. I am no longer on Kaiser, but continue to take the cheap drug.

I also like not having to go look for a doctor. If you needed a colonoscopy, prostate surgery, cardiac surgery, etc., they set you up. They actually coordinate care, something the patient has to do under some Plans and traditional Medicare. Adminttedly, someone who has to choose from a big list of docs might be disappointed. I'm not.