Will All Seniors Eventually Have No Choice but Medicare Advantage?

[Duaine]

The interview has been edited for clarity and brevity.

Cheryl Clark: Medicare Advantage plans have been enrolling beneficiaries at astonishing rates, and plans now cover 52% of eligible lives, or almost 32 million people -- up from 11 million in 2010 and 33% in 2016. At this pace, 70% or 80% of eligible people will be in an MA plan in a few more years. Eventually, will everyone be required to enroll in a Medicare Advantage plan to access benefits?

Michael Chernew, PhD: For the foreseeable future, I think traditional Medicare will still be an option, but just one that fewer people choose. The pace will slow as fewer people are left to convert. But there are now markets that -- in Puerto Rico for example -- 92% are in Medicare Advantage plans. There are already other markets outside of Puerto Rico that are 70% and 80%.

Clark: But are you saying it's worked out the way it's supposed to? Your staff studyopens in a new tab or window noted that MA plans have cost the Medicare program $613 billion more than beneficiaries in fee-for-service over the last 18 years, and $353 billion of that is in just the last 5 years, $88 billion more expected in 2024 alone. These private plans have been using the risk adjustment factor to score patients 20% sicker than their counterparts in fee-for-service, which means higher capitated revenue. And some people are concerned that we really don't know if those extra benefits -- that free transportation to the doctor or that lower copay for a dental visit that some of this money is paying for -- have improved health status.

Chernew: I believe the Medicare Advantage program has successfully changed patterns of care in ways that have reduced overall utilization. They have enabled plans to offer better benefits to beneficiaries, financed by the plans' efficiencies as well as the payments they've received. And there's a range of technical things -- changing the risk adjustment models, which we have already done -- and making changes to the quality bonus program. There's a lot of strategies one could take if one wanted to improve the balance of payments between Medicare Advantage and fee-for-service.


[EXTERNAL LINK] - Will All Seniors Eventually Have No Choice but Medicare Advantage?

 

[somarco]

Quoted from the same article . . . addresses limited access to care.


Clark: Let's shift to some of the unintended or perhaps unappreciated consequences of majority MA enrollment. Physicians at large academic hospitals that specialize in certain conditions or diseases are excluded from MA networks. Patients can't get a consult at the Mayo Clinic in Arizona and Florida, and they can't get cancer care at Sloan Kettering. I have friends who have had symptoms that doctors in their MA networks couldn't diagnose, but the expert was at UC San Diego. They had to fork over $900 for an out-of-network visit. What do we say to these centers when 70% or 80% of the Medicare population can't benefit from their expertise? I don't think many realize that when they enroll.

Chernew: This is a complicated question. Medicare Advantage involves a trade-off. Individuals choose to have a narrow network. The challenge is for CMS to make sure people have good quality care outside of academic medical centers. It's not the case that if you don't go to an academic medical center, you'll get substandard care. But it is complicated when it's a rare diagnosis.

And academic medical centers could be in network if they negotiate with the plans. But I have a hard time seeing how one accomplishes what one wants to accomplish in the Medicare Advantage space if one requires all the academic medical centers to be in a network, or some version of that.

That said, there are some areas that merit some attention; there's a penalty if you try to switch out of a Medicare Advantage plan because you could be underwritten in the Medigap market and it may be more expensive to get a Medigap plan.



You can't pick and choose once your health changes because Medigap plans underwrite.

How is this different from any other insurance product?

 

[StephanieCJ]

I have an MA client at MD Anderson in Houston as I type this...

 

[sman]

I have an MA client at MD Anderson in Houston as I type this...

I have a client here in Georgia who has traveled to MD Anderson in Houston for cancer treatments in the past. When discussing Medicare plan options his MAIN concern was, "I want to be able to go to MD Anderson if cancer ever comes back".

I have two clients who are two hours north of Jacksonville here in Georgia. Both were adamant that they be able to go to Mayo in Jacksonville One just went last week for a surgery related to prior bladder cancer.

While these clients may be the exception and not the norm, it's important that we listen to our clients and make sure we offer the best solution for them. Of course you already know that.

 

[somarco]

If you are enrolled in a managed care plan (HMO, PPO or POS), your treatment at MD Anderson may be covered by insurance. Before scheduling an initial appointment, please call your health plan/insurance company and ask if you have access to health care services at MD Anderson. We encourage you to refer to Questions to Ask Your Insurance Company when speaking to your insurance provider.

If MD Anderson is not a participating provider, you may still be able to receive treatment here. Contact your insurance company and ask about obtaining authorization. It is important to note that some benefit plans utilize what are referred to as "narrow" or "limited" networks; that is, they further narrow or limit the choices of doctors and hospitals that their customers can use. Often, these networks exclude MD Anderson. Additionally, some plans, such as HMO's, have primary care physician referral and/or other authorization guidelines.

Your MD Anderson patient access specialist will help you obtain the full benefit from your insurance plan by:

• Answering your questions about insurance verification and/or prepayment requirement
• Responding to insurer requests for additional medical information.

DISCLAIMER: MD Anderson's participation with any product or insurance plan is subject to change without notice. Additionally, insurance companies offer a variety of plans and may change the names and benefits at any point. A patient's level of coverage depends on the specific benefits outlined in their plan.

To ensure that MD Anderson and its physicians are in-network, it is the patient's responsibility to verify that MD Anderson is a participating provider and their benefit plan allows them access as of the day of a visit and/or admission. Please contact your insurance plan to obtain this information.

Insurance Plans

If you are enrolled in a managed care plan (HMO, PPO or POS), your treatment at MD Anderson may be covered by insurance. See the list of accepted insurance plans here.

www.mdanderson.org

Seems like a patient MAY be admitted for care at MD Anderson (or Mayo, or SK, or any other specialty hospital) but MAY have to jump through hoops to get there.

That is expecting a lot for someone who is 65+ and fighting cancer PLUS have to get PERMISSION from their PPO/HMO plan so they can get treatment.

Those with OM don't have to ask permission . . . they just go.

 

[axeman462]

I have a client here in Georgia who has traveled to MD Anderson in Houston for cancer treatments in the past. When discussing Medicare plan options his MAIN concern was, "I want to be able to go to MD Anderson if cancer ever comes back".

I have two clients who are two hours north of Jacksonville here in Georgia. Both were adamant that they be able to go to Mayo in Jacksonville One just went last week for a surgery related to prior bladder cancer.

While these clients may be the exception and not the norm, it's important that we listen to our clients and make sure we offer the best solution for them. Of course you already know that.

Thats the key. and I can tell by a lot of the posts on this forum, many agents here don't do that.

 

[axeman462]

The interview has been edited for clarity and brevity.

Cheryl Clark: Medicare Advantage plans have been enrolling beneficiaries at astonishing rates, and plans now cover 52% of eligible lives, or almost 32 million people -- up from 11 million in 2010 and 33% in 2016. At this pace, 70% or 80% of eligible people will be in an MA plan in a few more years. Eventually, will everyone be required to enroll in a Medicare Advantage plan to access benefits?

Michael Chernew, PhD: For the foreseeable future, I think traditional Medicare will still be an option, but just one that fewer people choose. The pace will slow as fewer people are left to convert. But there are now markets that -- in Puerto Rico for example -- 92% are in Medicare Advantage plans. There are already other markets outside of Puerto Rico that are 70% and 80%.

Clark: But are you saying it's worked out the way it's supposed to? Your staff studyopens in a new tab or window noted that MA plans have cost the Medicare program $613 billion more than beneficiaries in fee-for-service over the last 18 years, and $353 billion of that is in just the last 5 years, $88 billion more expected in 2024 alone. These private plans have been using the risk adjustment factor to score patients 20% sicker than their counterparts in fee-for-service, which means higher capitated revenue. And some people are concerned that we really don't know if those extra benefits -- that free transportation to the doctor or that lower copay for a dental visit that some of this money is paying for -- have improved health status.

Chernew: I believe the Medicare Advantage program has successfully changed patterns of care in ways that have reduced overall utilization. They have enabled plans to offer better benefits to beneficiaries, financed by the plans' efficiencies as well as the payments they've received. And there's a range of technical things -- changing the risk adjustment models, which we have already done -- and making changes to the quality bonus program. There's a lot of strategies one could take if one wanted to improve the balance of payments between Medicare Advantage and fee-for-service.


[EXTERNAL LINK] - Will All Seniors Eventually Have No Choice but Medicare Advantage?

I've been saying on this forum for a few years now, that MA is not only the future of Medicare, but the future of all health insurance in the USA.

 

[rousemark]

What?! You mean my client in Sulligent Alabama can't go to "Mayo Clinic in Arizona and Florida, and they can't get cancer care at Sloan Kettering"?

Don't have a horsevin this debatevother than as a consumer.

You make fun of yhe fact someone in AL might want to go to AZ for the best possibility of saving their life. I have known folks in this small TN town in which I live that have travelled to MD Anderson and Mayo Florida for treatment. I would hate to have been the agent who robbed them of that choice without them being fully informed.

 

[somarco]

Logic and reason completely baffle the immature, irrational mind that only sees dollars and cents in the decision making progress.

 

[rousemark]

Overall, the median straight-line patient-hospital travel distance was 6.6 miles, with 75 percent of distances less than 15 miles and 90 percent of distances less than 30 miles. The median driving distance was 8.7 miles.

Methods for Calculating Patient Travel Distance to Hospital in HCUP Data

hcup-us.ahrq.gov

So… 90% of people drove less than 30 miles for hospital care.

Facts and all.

Yeah, people don't travel far to be treated for the flu, Tonsillectmies, etc. If you you include only very serious conditions that small town and rural hospitals are not equiped to handle, that will be an entirely different story.